Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence
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Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence

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  • 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.
  • 6 MWT for health adults is 400m
  • Daily step counts 5000- 6000 steps per day
  • Useful for patients that are more fragile neurologically and physiologically
  • Must utilize the most tools available to benefit the patient.

Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence Presentation Transcript

  • 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.
    View slide
  • 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.
    View slide
  • 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