Strength Training in Neurological Rehabilitation

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Jess Bell, Kim Jackson, Tony Lowe, Lucinda hampton, Admin and Tarina van der Stockt

Introduction

Muscle weakness (paresis) is a key physical impairment in neurological conditions and a major contributor to mobility limitations. Across a range of neurological conditions, resistance training has been shown to improve muscle strength. There is growing evidence that strength gains can translate into improved walking outcomes, although the extent of this transfer appears to depend on how the training is prescribed, including the muscle groups targeted, training intensity and movement speed. For example, a 2025 systematic review by Noguchi et al. found that strength training improved walking capacity and functional mobility after stroke, and that more frequent training and power-focused intensities positively impacted outcomes. This page explores how an understanding of gait biomechanics and the distinction between strength and power can guide more effective exercise prescription for walking.

Biomechanics of Gait

Strength refers to the maximum amount of force a muscle can produce. Power is the rate of force production — not how much force, but how quickly it can be generated. This distinction is important for understanding how muscles function during walking.

Muscle recruitment and speed influence walking mechanics across the hip, knee and ankle joints. The three key power generation events in the gait cycle are:

• hip extensor power generation at initial contact
• ankle plantar flexion power generation at push-off (terminal stance)
• hip flexor power generation at toe-off to accelerate the leg through the swing phase

Of the three power generation events, the ankle plantarflexors make the largest contribution to forward propulsion during the stance phase of gait, with much of this power coming from energy storage and release in the Achilles tendon. Importantly, this power is generated over a very brief period during push-off, which has implications for how we prescribe strengthening exercises.

At the knee joint, muscles primarily contribute to power absorption rather than generation:

• the knee extensors absorb power at terminal stance
• the knee flexors absorb power at terminal swing to decelerate the leg

Yet when Williams et al. investigated the task specificity of strength training for walking across neurological conditions, they found that quadriceps and hamstrings exercises were prioritised, despite their relatively minor role in forward propulsion during gait. While quadriceps strength is vital for tasks such as sit-to-stand and stair climbing, it is not a key driver of walking performance. The muscle groups most important for walking — the ankle plantarflexors, hip extensors and hip flexors — were often undertargeted or omitted from training programmes.

From Strength to Power Training

Progressive resistance training uses heavy loads and is the best method for improving maximum force production and muscle hypertrophy, but it does not significantly change the rate of force production. Ballistic or plyometric training, by contrast, uses lighter loads performed at high speed, utilising the stretch-shortening cycle. Although peak strength gains are smaller, force is developed more quickly — meaning more force is available in the brief time windows that matter for walking.

This distinction is particularly relevant at the ankle. Push-off occurs over approximately 0.15 seconds during terminal stance, and muscle function for walking occurs at high angular velocities. This means that the ability to produce force quickly may be more important than the ability to produce maximum force, hence the interest in ballistic strength training to improve walking.

A number of studies have explored this approach in neurological populations. A 2017 study found that functional high-velocity resistance training improved muscle strength and walking capacity in children with cerebral palsy. Gjesdal et al. found that ballistic strength training was feasible in adults with cerebral palsy. Williams et al. found that applying ballistic principles to conventional leg strengthening exercises resulted in increased peak velocity and peak height compared with conventional techniques in individuals with neurological injuries. Williams and Ada found that home-based ballistic exercises were safe (88% of the time), although accuracy was lower (49%). In an RCT of 144 people with traumatic brain injury, Williams et al. found that ballistic resistance training was at least as effective as non-ballistic exercise rehabilitation for improving mobility.

Clinical Applications and Exercise Examples

Williams proposes that exercise prescription for walking should be guided by task specificity principles, ensuring that the muscle groups targeted, type of contraction, joint alignment, load and — critically — speed of movement match the demands of walking. He argues that speed of movement has been the key element missing from lower limb strength training programmes in neurological rehabilitation to date.

For example, a quick 'calf drop' — raising up onto the toes then quickly dropping down and pushing up again — is more appropriate for walking than a slow, controlled calf raise. A mini-trampette can be used for bouncing between alternate heel raises, as demonstrated in the video below.

A leg sled or Pilates reformer can also be used for ballistic exercises such as single-leg or double-leg jumps. The incline can be adjusted to modify the load. If the patient is unable to produce power at the ankle, the load should be reduced until they can perform the exercise quickly, and then loaded up later. If the patient is unable to isolate the target muscle, other modifications should be applied to allow for appropriate performance.

Summary

If the goal is to improve walking following a neurological injury, clinicians should consider the biomechanics of gait when prescribing strengthening exercises. The ankle plantarflexors, hip extensors and hip flexors are the key muscle groups for forward propulsion, and exercises targeting these muscles should prioritise speed of movement over heavy load.