Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence
- 1. Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the EvidenceSteve Chmielewski, SPT
- 2. 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.
- 3. Stroke CharacteristicsIncreasing in incidents in older adult population Increasing in stroke pts due to an increase in older populations and an increase in acute phase survival rate75-85% 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.
- 4. Major Stroke ImpairmentsMuscle weaknessPainSpasticityPoor balanceReduced 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.
- 5. Walking ImplicationsAverage AdultsAbility/time to ambulate 400mPredictor of mortality, CVD, DisabilitySlow walking speeds, Inability to ambulate 1mile (1609m), Inability to walk a flight of stairsPredictor of Frailty and DisabilityHealth of Stroke PatientsInability to walk independentlyPredictor of being discharged to a nursing home and correlated with an increase chance of mortality6 Minute walk test correlates to community reintegrationAmbulation may prevent or postpone secondary complications such as osteoporosis and heart disease
- 6. Common RegressionSelected 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.
- 7. Major Determinants of Ambulation in Stroke patientsMuscle StrengthParetic Limb- PFs, Hip Flexors, Knee Extensors, Knee FlexorsDorsi Flexors?Non-Paretic Limb- Knee Flexors, PFsMotor ControlBalancePostural control while performing functional activitiesEx. Walking around/over objectsStanding postural exercises were lowly correlated as determinants of walking
- 8. Minor Determinants of Ambulation in Stroke patientsCardiovascular Fitness Plays a greater role in ambulation the more acute the stroke.Sensory of Paretic LimbRhythmic Central Pattern Generator may play a greater role
- 9. Useful Outcome Measures Self Selected Walking Speed10m distance required<0.4m/s – household ambulation0.4-0.8m/s- limited community ambulatorAmbulation of curb independently- independent community ambulator6 Minute Walk TestEnduranceAve for Mild- Mod. Stroke Patients- 200-300m
- 10. Useful Outcome Measures Timed Up and Go10ft, a chair w/ armrestsDynamic balance activityTimed Up/Down Stairs 12 StairsCommunity AmbulationDaily Count Steps2800-3000 steps/day for community ambulatingStroke patientsSignificant Changes in Outcome MeasuresDid your make a significant change in the patient’s gait performance?Standard Errors of MeasurementsSelf-paced gait speed- +/- 0.07m/sec
- 11. 6MWT- +/- 18.6m
- 12. Timed Up Stairs- +/- 0.67s
- 13. Timed Down Stairs- +/- 0.90s
- 14. TUG +/- 1.14sContextual Factors prior to TrainingPersonal MotivationReady to Change? Will they adhere to an intervention programSelf EfficiencyConfidence to perform unsupervised vs. supervised activitiesHEP Functional Activities upon dischargeEnvironmentalAccessibility to training intervention, weather, transportation, community services, home safety, intervention setting, Ect.
- 15. Training Strategies to improve walking abilityNeurodevelopmental Techniques (7)Muscle Strengthening (5)Task specific Training (17)Body Weight Supported Treadmill TrainingIntense Mobility Training (10)
- 18. Facilitate normal movement patternsMuscle StrengtheningFocusImprove muscle unit contraction and efficiency
- 19. Recruit more motor units
- 20. Enhance Synchronization of motor unit firingTask-Specific TrainingFocusRepetitive tasks may facilitate the development of new motor programs or the refinement of current motor programs to accommodate the patient’s deficitsTypes1- Treadmill Training (BWSTT) Evidence has displayed that fast or maximal walking speeds are more effective than slower speeds and conventional therapyIncreases Self Efficacy2- A Variety of Functional Mobility Training
- 21. Intense Mobility TrainingFocus- Provide the most challenging functional task training by increasing the intensity and difficulty of the activity. Inclusion CriteriaAmbulate 10m w/ or w/out assisted device
- 22. Ambulate Independently or w/ supervision3 Components Graded Strengthening using functional activities
- 24. Challenging walking activities w/ substancial postural demands Major LimitationThis study did not include patient populations utilizing assisted devices, AFO, prosthesis, or modalities to improve their gait.
- 25. ConclusionImproved walking ability is one of the highest priorities of patient’s suffering from a strokeMuscle 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.
- 26. ConclusionGait 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.
- 27. ConclusionIntensive 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 abilityIntensive 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
Editor's Notes
- #8: outcome testsMuscle strength - self pace walking, Stair climbing speedMotor Control- Fugal Meyer Assessment, Chedoke McMaster Stroke AssessmentBalance-Berg BalanceStanding Postural Act. may be more beneficial in static balance act.
- #10: 6 MWT for health adults is 400m
- #12: Daily step counts 5000- 6000 steps per day
- #15: Useful for patients that are more fragile neurologically and physiologically
- #19: Must utilize the most tools available to benefit the patient.