Gait training Strategies to Optimize Walking Ability in

People with Stroke: A Synthesis of the Evidence

Steve Chmielewski, SPT

Purpose

To analyze novel and emerging gait training strategies and propose research directed treatments to enable optimal recovery and maintenance of walking in stroke patients.

Stroke Characteristics

• Increasing in incidents in older adult population

• Increasing in stroke pts due to an increase in older populations and an increase in acute phase survival rate

• 75-85% of stroke pts are discharged home and 90% claim mobility to be their primary impairment.

• Gains in functional recovery tend to plateau around a year post-stroke.

Major Stroke Impairments

• Muscle weakness

• Pain

• Spasticity

• Poor balance

• Reduced activity tolerance- most difficult to address

* 65-85% of stroke patient learn to walk independently by 6 months post stroke, but gait abnormalities still persist.

Walking Implications

• Average Adults• Ability/time to ambulate 400m

• Predictor of mortality, CVD, Disability

• Slow walking speeds, Inability to ambulate 1mile (1609m), Inability to walk a flight of stairs• Predictor of Frailty and Disability

• Health of Stroke Patients• Inability to walk independently

• Predictor of being discharged to a nursing home and correlated with an increase chance of mortality

• 6 Minute walk test correlates to community reintegration

• Ambulation may prevent or postpone secondary complications such as osteoporosis and heart disease

Common Regression

Selected Walking Speed and the 6 Minute Walk Test are excellent predictors of a patient’s VO2 max, a

criterion measurement of one’s cardiovascular fitness.

Major Determinants of Ambulation in Stroke patients

Muscle Strength

• Paretic Limb- PFs, Hip Flexors, Knee Extensors, Knee Flexors• Dorsi Flexors?

• Non-Paretic Limb- Knee Flexors, PFs

Motor Control

Balance

• Postural control while performing functional activities• Ex. Walking around/over objects

• Standing postural exercises were lowly correlated as determinants of walking

Minor Determinants of Ambulation in Stroke patients

Cardiovascular Fitness

• Plays a greater role in ambulation the more acute the stroke.

Sensory of Paretic Limb

• Rhythmic Central Pattern Generator may play a greater role

Useful Outcome Measures

Self Selected Walking Speed

• 10m distance required

• <0.4m/s – household ambulation

• 0.4-0.8m/s- limited community ambulator

• Ambulation of curb independently- independent community ambulator

6 Minute Walk Test

• Endurance

• Ave for Mild- Mod. Stroke Patients- 200-300m

Useful Outcome Measures

Timed Up and Go

• 10ft, a chair w/ armrests

• Dynamic balance activity

Timed Up/Down Stairs

• 12 Stairs

• Community Ambulation

Daily Count Steps

• 2800-3000 steps/day for community ambulating- Stroke patients

Significant Changes in Outcome Measures

• Did your make a significant change in the patient’s gait performance?

Standard Errors of Measurements

- Self-paced gait speed- +/- 0.07m/sec

- 6MWT- +/- 18.6m

- Timed Up Stairs- +/- 0.67s

- Timed Down Stairs- +/- 0.90s

- TUG +/- 1.14s

Contextual Factors prior to Training

• Personal • Motivation

• Ready to Change? Will they adhere to an intervention program

• Self Efficiency• Confidence to perform unsupervised vs. supervised

activities• HEP

• Functional Activities upon discharge

• Environmental• Accessibility to training intervention, weather,

transportation, community services, home safety, intervention setting, Ect.

Training Strategies to improve walking ability

• Neurodevelopmental Techniques (7)

• Muscle Strengthening (5)

• Task specific Training (17)• Body Weight Supported Treadmill Training

• Intense Mobility Training (10)

Neurodevelopmental

Focus

- Inhibit excessive tone

- Stimulate muscle activity

- Facilitate normal movement patterns

Muscle Strengthening

Focus

- Improve muscle unit contraction and efficiency

- Recruit more motor units

- Enhance Synchronization of motor unit firing

Task-Specific Training

Focus

Repetitive tasks may facilitate the development of new motor programs or the refinement of current motor programs to accommodate the patient’s deficits

Types

1- Treadmill Training (BWSTT) • Evidence has displayed that fast or maximal walking

speeds are more effective than slower speeds and conventional therapy

• Increases Self Efficacy

2- A Variety of Functional Mobility Training

Intense Mobility Training

Focus

- Provide the most challenging functional task training by increasing the intensity and difficulty of the activity.

Inclusion Criteria

- Ambulate 10m w/ or w/out assisted device

- Ambulate Independently or w/ supervision

3 Components

- Graded Strengthening using functional activities

- An aerobic component

- Challenging walking activities w/ substancial postural demands

Major Limitation

This study did not include patient populations utilizing assisted devices, AFO, prosthesis, or modalities to improve their gait.

Conclusion

• Improved walking ability is one of the highest priorities of patient’s suffering from a stroke

• Muscle weakness, incoordination, poor endurance, pain, spasticity, and poor balance lead to difficulties in walking for stroke patients.

• Gait training interventions have the potential to improve the body’s function/structure, activities, and participation pertaining to walking abilities

.

Conclusion

• Gait retraining through different types of exercise are the most common approaches to improving gait abilities.

• Graded muscle strengthening is not functional and does not transfer over to improved walking ability, but did improve patient’s muscle strength.

• Treadmill training has been found to have equivalent effects to overground gait training in subacute rehabilitation, but beneficial effects compared w/ low-intensity control groups in chronic stroke. A combination of treadmill with task-specific practice may be optimal.

Conclusion

• Intensive mobility training, incorporating functional strengthening, balance, and aerobic exercises, and practiced on a variety of walking tasks, improves gait ability both in sub-acute and chronic stroke.

• Neurodevelopmental approaches were equivalent or inferior to other approaches to improve walking ability

• Intensive mobility training, which incorporates functional strengthening, balance, and aerobic exercises, and practice on a variety of walking tasks, improves gait ability both in sub-acute and chronic stroke