Gait Training in Stroke
Original Editor - Sheik Abdul Khadir
Introduction to Gait
Walking dysfunction occurs at a very high prevalence in stroke survivors. Human walking is a phenomenon often taken for granted, but it is mediated by complicated neural control mechanisms. The automatic process includes the brainstem descending pathways and the intraspinal locomotor network. Stroke leads to damage to motor cortices and their descending corticospinal tracts and subsequent muscle weakness. On the other hand, brainstem descending pathways and the intraspinal motor network are disinhibited and become hyperexcitable. The wide range and hierarchy of post-stroke hemiplegic gait impairments is a reflection of mechanical consequences of muscle weakness, spasticity, abnormal synergistic activation and their interactions. The below video gives an idea of how gait training with a stroke client may be undertaken and advanced.
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 .
The major requirements for successful walking  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. 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.
Typical Kinematic Deviations and Adaptations 
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°
- 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.
Spatiotemporal Adaptations 
- 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 
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
- Symmetrical Weight bearing training
- Weight shifting
- Stepping training (swinging / clearance )
- Heel strike
- Single leg standing
- Push off / Calf rise.
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. 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 
Strength training to improve walking ability Task-specific training to improve walking ability
Body weight supported treadmill training was one of the first translations of the task-specific repetitive treatment concept in gait rehabilitation after stroke. Through a systematic review of 6 RCTs of Body Weight Supported Treadmill Training (BWSTT) and 2 RCTs without BWSTT, Teasell et al. 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.
Turning-based treadmill training has recently been studied as a treatment for stroke gait training. This treadmill is similar to a regular treadmill except for its circular running motor belt (0.8-m radius), which forces patients to continually turn rather than walk straight. Participants walked on the perimeter of the circular belt as it rotated either clockwise or counterclockwise. The finding were interesting. Reporting that EEG-EEG connectivity and EEG-EMG connectivity during walking can be enhanced more by a turning-based treadmill instead of a regular treadmill. Moreover, the improvement in gait symmetry, but not the gait speed, correlated with the modulations in the EEG-EEG and EEG-EMG connectivity over frontal-central-parietal areas of the brain.
A 2018 systematic review designed to assess the effectiveness of two models of gait re-education in post-stroke patients, namely conventional physical therapy and treadmill training, made the concluding remarks that " if advanced gait re-education methods, requiring costly equipment, cannot be used for various reasons, a well-designed conventional gait training is an adequate, affordable and straightforward method to achieve the intended effects of rehabilitation after stroke." Conventional physical therapy referred to (general exercise program/regular physiotherapy) involved stretching, strengthening, endurance, balance, coordination, range of motion activities, and overground walking practice.
Robotic Assisted Training
Robotic devices provide safe, intensive and task oriented rehabilitation to people with mild to severe neurologic injury. It does
- precisely controllable assistance or resistance during movements
- good repeatability
- objective and quantifiable measures of subject performance,
- 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 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.
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