Gait Training in Stroke


Introduction to Gait 

The ability to walk independently is a prerequisite for most daily activities. The capacity to walk in a community setting requires the ability to walk at speeds that enable an individual to cross the street in the time allotted by pedestrian lights, to step on and off a moving walkway, in and out of automatic doors, walk around furniture, under and over objects and negotiate kerbs. A walking velocity of 1.1-1.5 m/s is considered to be fast enough to function as a pedestrian in different environmental and social contexts. It has been reported that only 7% of patients discharged from rehabilitation met the criteria for community walking, which included the ability to walk 500 m continuously at a speed that would enable them to cross a road safely [1].

The major requirements for successful walking [2] are:

  • Support of body mass by lower limbs
  • Propulsion of the body in the intended direction
  • The production of a basic locomotor rhythm
  • Dynamic balance control of the moving body
  • Flexibility, i.e. the ability to adapt the movement to changing
    environmental demands and goals.

Gait in Stroke 

Poststroke hemiplegic gait is a mixture of deviations and compensatory motion dictated by residual functions, and thus each patient must be examined and his/her unique gait pattern identified and documented.[3] Walking dysfunction is common in neurologically impaired individuals, arising not only from the impairments associated with the lesion but also from secondary cardiovascular and musculoskeletal consequences of disuse and physical inactivity. Muscle weakness and paralysis, poor motor control and soft tissue contracture are major contributors to walking dysfunction after stroke.

ICF STROKE.jpg

Typical Kinematic Deviations and Adaptations [4]

Initial Stance (Heel/Foot Contact and Loading)

  • Limited ankle dorsiflexion - decreased activation of anterior tibial muscles ; contracture and/or stiffness of calf muscles with premature activation.
  •  Lack of knee flexion (knee hyperextension) - contracture of soleus ; limited control of quadriceps 0-15°


Mid-Stance

  • Lack of Knee Extension (knee remains flexed 10-150 with excessive ankle dorsiflexion) - decreased activation of calf muscles to control movement of shank forward at ankle (ankle dorsiflexion) ; limited synergic activation of lower limb extensor muscles.
  • Stiffening of Knee (Hyperextension). This interferes with preparation for push-off -  contracture of soleus ; an adaptation to fear of limb collapse due to weakness of muscles controlling the knee.
  • Limited hip extension and ankle dorsiflexion with failure to progress body mass forward over the foot - contracture of soleus.
  • Excessive Lateral Pelvic Shift  -  decreased ability to activate stance hip abductors and control hip and knee extensors.


Late Stance (Pre-Swing)

  • Lack of Knee Flexion and Ankle Plantarflexion, prerequisites for push-off and preparation for swing - weakness of calf muscles.


Early and Mid-Swing

  • Limited Knee Flexion normally 35-40° increasing to 60° for swing  and toe clearance - increased stiffness in or unopposed activity of two-joint rectus femoris ; decreased activation of hamstrings.


Late Swing (Preparation for Heel Contact and Loading)

  • Limited Knee Extension and Ankle Dorsiflexion jeopardizing heel contact and weight-acceptance - contracted or stiff calf muscles ; decreased dorsiflexor activity.


[5]

Spatiotemporal Adaptations [4]

These include: 

  • decreased walking speed
  • short and/or uneven step and stride lengths
  • increased stride width
  • increased double support phase
  • dependence on support through the hands.

Gait Training [4]

Intervention aims to optimize walking performance by:

  • preventing adaptive changes in lower limb soft tissues
  • eliciting voluntary activation in key muscle groups in lower limbs
  • increasing muscle strength and coordination
  • increasing walking velocity and endurance
  • maximizing skill, i.e., increasing flexibility
  • increasing cardiovasular fitness.


The major emphasis in walking training is on:

  • support of the body mass over the lower limbs
  • propulsion of the body mass
  • balance of the body mass as it progresses over one or both lower limbs
  • controlling knee and toe paths for toe clearance and foot placement
  • optimizing rhythm and coordination.


Conventional Gait Training 

Conventional gait training has focused on part-practice of components of gait in preparation for walking. It includes 

  • Symetrical Weight bearing training
  • Weight shifting
  • Stepping training (swinging / clearance )
  • Heel strike
  • Single leg standing
  • Push off / Calf rise.

Followed by 

Circuit training (reaching in sitting and standing, sit-to-stand, step-ups, heel lifts, isokinetic strengthening, walking over obstacles, up and down slopes).

Traditional approaches to stroke recovery have a focus on neurofacilitation or neurodevelopmental techniques (NDT) to inhibit excessive tone, stimulate muscle activity if hypotonia is present and to facilitate normal movement patterns through hands-on techniques.[6] Practice based on the framework advocated by Berta Bobath remains the predominant physical therapy approach to stroke patients in the UK  and is also common in many other parts of the world, including Canada, United States, Europe, Australia, Hong Kong and Taiwan. The Bobath framework has evolved from its original foundations, however, therapists surveyed on the core Bobath elements still emphasize normal tone and the necessity of normal movement patterns to perform functional tasks [7]


Strength training to improve walking ability Task-specific training to improve walking ability


Treadmill Training 

Body weight supported treadmill training was one of the first translations of the task-specific repetitive treatment concept in gait rehabilitation after stroke.[8]  Through a systematic review of 6 RCTs of Body Weight Supported Treadmill Training (BWSTT) and 2 RCTs without BWSTT, Teasell et al. [9]concluded that there was conflicting evidence that treadmill training with or without BWSTT resulted in improvements in gait performance over standard treatments. Although the evidence supporting treadmill training appears to be conflicting, two recent clinical practice guidelines  recommended that BWSTT be included as an intervention for stroke.[6]


Robotic Assisted Training

Robotic devices provide safe,intensive and task oriented rehabilitation to people with mild to severe neurologic injury. It does

  1. precisely controllable assistance or resistance during movements
  2. good repeatability
  3. objective and quantifiable measures of subject performance,
  4. increased training motivation through the use of interactive (bio)feedback.

In addition, this approach reduces the amount of physical assistance required to walk reducing health care costs [88,91] and provides kinematic and kinetic data in order to control and quantify the intensity of practice, measure changes and assess motor impairments with better sensitivity and reliability than standard clinical scales.[10]

[11]

Recent Related Research (from Pubmed)

References

  1. Hill K, Ellis P, Bernhardt Jet al. (1997) Balance and mobility outcomes for stroke patients: a comprehensive audit. Aust J Physiother, 43, 173-180.
  2. Forssberg H (1982) Spinal locomotion functions and descending control. In Brain Stem Control of Spinal Mechanisms (eds B Sjolund, A Bjorklund), Elsevier Biomedical Press,New York.
  3. Balaban, Birol et al.:Gait Disturbances in Patients With Stroke : PM&R , Volume 6 , Issue 7 , 635 - 642
  4. 4.0 4.1 4.2 Janet H Carr EdD FACP , Roberta B Shepherd EdD FACP; Stroke Rehabilitation- Guidelil1es for Exercise and Training to Optimize Motor Skill ; First edition; 2003
  5. 閆傳心. Gait analysis of stroke. Available from https://www.youtube.com/watch?v=Y0ezuXY7m4U [last accessed 12/09/16]
  6. 6.0 6.1 Janice J Eng, PhD, PT/OT, Professor and Pei Fang Tang, PhD, PT ;Gait training strategies to optimize walking ability in people with stroke: A synthesis of the evidence; Expert Rev Neurother. Oct 2007; 7(10): 1417–1436.
  7. Lennon S, Baxter D, Ashburn A. Physiotherapy based on the Bobath concept in stroke rehabilitation: a survey within the UK. Disabil Rehabil. 2001;23(6):254–262.
  8. Stefan Hesse ; Treadmill training with partial body weight support after stroke: A review ; NeuroRehabilitation 22 (2007) 1–11
  9. Teasell RW, Bhogal SK, Foley NC, Speechley MR. Gait retraining post stroke. Top Stroke Rehabil. 2003;10(2):34–65.
  10. Juan-Manuel Belda-Lois et al; Rehabilitation of gait after stroke: a review towards a top-down approach ;Journal of NeuroEngineering and Rehabilitation 2011, 8:66
  11. Walkbot. Walkbot - Walking Available from:https://www.youtube.com/watch?v=rbPfnDIBOvI [last accessed 18/09/2016]