Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence<br />Steve Chmiele...
Purpose	<br />To analyze novel and emerging gait training strategies and propose research directed treatments to enable op...
Stroke Characteristics<br />Increasing in incidents in older adult population <br />Increasing in stroke pts due to an inc...
Major Stroke Impairments<br />Muscle weakness<br />Pain<br />Spasticity<br />Poor balance<br />Reduced activity tolerance-...
Walking Implications<br />Average Adults<br />Ability/time to ambulate 400m<br />Predictor of mortality, CVD, Disability<b...
Common Regression<br />Selected Walking Speed and the 6 Minute Walk Test are excellent predictors of a patient’s VO2 max, ...
Major Determinants of Ambulation in Stroke patients<br />Muscle Strength<br />Paretic Limb- PFs, Hip Flexors, Knee Extenso...
Minor Determinants of Ambulation in Stroke patients<br />Cardiovascular Fitness <br />Plays a greater role in ambulation t...
Useful  Outcome Measures <br />Self Selected Walking Speed<br />10m distance required<br /><0.4m/s – household ambulation<...
Useful  Outcome Measures <br />Timed Up and Go<br />10ft, a chair w/ armrests<br />Dynamic balance activity<br />Timed Up/...
6MWT-                          +/- 18.6m
Timed Up Stairs-           +/- 0.67s
Timed Down Stairs-      +/- 0.90s
TUG                               +/- 1.14s</li></li></ul><li>Contextual Factors prior to Training<br />Personal <br />Mot...
Training Strategies to improve walking ability<br />Neurodevelopmental Techniques (7)<br />Muscle Strengthening (5)<br />T...
Neurodevelopmental<br />Focus<br /><ul><li>Inhibit excessive tone
Stimulate muscle activity
Facilitate normal movement patterns</li></li></ul><li>Muscle Strengthening<br />Focus<br /><ul><li>Improve muscle unit con...
Recruit more motor units
Enhance Synchronization of motor unit firing</li></li></ul><li>Task-Specific Training<br />Focus<br />Repetitive tasks may...
Intense Mobility Training<br />Focus<br />- Provide the most challenging functional task training by increasing the intens...
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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

    1. 1. Gait training Strategies to Optimize Walking Ability in People with Stroke: A Synthesis of the Evidence<br />Steve Chmielewski, SPT<br />
    2. 2. Purpose <br />To analyze novel and emerging gait training strategies and propose research directed treatments to enable optimal recovery and maintenance of walking in stroke patients.<br />
    3. 3. Stroke Characteristics<br />Increasing in incidents in older adult population <br />Increasing in stroke pts due to an increase in older populations and an increase in acute phase survival rate<br />75-85% of stroke pts are discharged home and 90% claim mobility to be their primary impairment.<br />Gains in functional recovery tend to plateau around a year post-stroke.<br />
    4. 4. Major Stroke Impairments<br />Muscle weakness<br />Pain<br />Spasticity<br />Poor balance<br />Reduced activity tolerance- most difficult to address<br />* 65-85% of stroke patient learn to walk independently by 6 months post stroke, but gait abnormalities still persist.<br />
    5. 5. Walking Implications<br />Average Adults<br />Ability/time to ambulate 400m<br />Predictor of mortality, CVD, Disability<br />Slow walking speeds, Inability to ambulate 1mile (1609m), Inability to walk a flight of stairs<br />Predictor of Frailty and Disability<br />Health of Stroke Patients<br />Inability to walk independently<br />Predictor of being discharged to a nursing home and correlated with an increase chance of mortality<br />6 Minute walk test correlates to community reintegration<br />Ambulation may prevent or postpone secondary complications such as osteoporosis and heart disease<br />
    6. 6. Common Regression<br />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.<br />
    7. 7. Major Determinants of Ambulation in Stroke patients<br />Muscle Strength<br />Paretic Limb- PFs, Hip Flexors, Knee Extensors, Knee Flexors<br />Dorsi Flexors?<br />Non-Paretic Limb- Knee Flexors, PFs<br />Motor Control<br />Balance<br />Postural control while performing functional activities<br />Ex. Walking around/over objects<br />Standing postural exercises were lowly correlated as determinants of walking<br />
    8. 8. Minor Determinants of Ambulation in Stroke patients<br />Cardiovascular Fitness <br />Plays a greater role in ambulation the more acute the stroke.<br />Sensory of Paretic Limb<br />Rhythmic Central Pattern Generator may play a greater role<br />
    9. 9. Useful Outcome Measures <br />Self Selected Walking Speed<br />10m distance required<br /><0.4m/s – household ambulation<br />0.4-0.8m/s- limited community ambulator<br />Ambulation of curb independently- independent community ambulator<br />6 Minute Walk Test<br />Endurance<br />Ave for Mild- Mod. Stroke Patients- 200-300m<br />
    10. 10. Useful Outcome Measures <br />Timed Up and Go<br />10ft, a chair w/ armrests<br />Dynamic balance activity<br />Timed Up/Down Stairs <br />12 Stairs<br />Community Ambulation<br />Daily Count Steps<br />2800-3000 steps/day for community ambulating<br /><ul><li>Stroke patients</li></li></ul><li>Significant Changes in Outcome Measures<br />Did your make a significant change in the patient’s gait performance?<br />Standard Errors of Measurements<br /><ul><li>Self-paced gait speed- +/- 0.07m/sec
    11. 11. 6MWT- +/- 18.6m
    12. 12. Timed Up Stairs- +/- 0.67s
    13. 13. Timed Down Stairs- +/- 0.90s
    14. 14. TUG +/- 1.14s</li></li></ul><li>Contextual Factors prior to Training<br />Personal <br />Motivation<br />Ready to Change? Will they adhere to an intervention program<br />Self Efficiency<br />Confidence to perform unsupervised vs. supervised activities<br />HEP <br />Functional Activities upon discharge<br />Environmental<br />Accessibility to training intervention, weather, transportation, community services, home safety, intervention setting, Ect.<br />
    15. 15. Training Strategies to improve walking ability<br />Neurodevelopmental Techniques (7)<br />Muscle Strengthening (5)<br />Task specific Training (17)<br />Body Weight Supported Treadmill Training<br />Intense Mobility Training (10)<br />
    16. 16. Neurodevelopmental<br />Focus<br /><ul><li>Inhibit excessive tone
    17. 17. Stimulate muscle activity
    18. 18. Facilitate normal movement patterns</li></li></ul><li>Muscle Strengthening<br />Focus<br /><ul><li>Improve muscle unit contraction and efficiency
    19. 19. Recruit more motor units
    20. 20. Enhance Synchronization of motor unit firing</li></li></ul><li>Task-Specific Training<br />Focus<br />Repetitive tasks may facilitate the development of new motor programs or the refinement of current motor programs to accommodate the patient’s deficits<br />Types<br />1- Treadmill Training (BWSTT) <br />Evidence has displayed that fast or maximal walking speeds are more effective than slower speeds and conventional therapy<br />Increases Self Efficacy<br />2- A Variety of Functional Mobility Training<br />
    21. 21. Intense Mobility Training<br />Focus<br />- Provide the most challenging functional task training by increasing the intensity and difficulty of the activity. <br />Inclusion Criteria<br /><ul><li>Ambulate 10m w/ or w/out assisted device
    22. 22. Ambulate Independently or w/ supervision</li></ul>3 Components <br /><ul><li>Graded Strengthening using functional activities
    23. 23. An aerobic component
    24. 24. Challenging walking activities w/ substancial postural demands</li></li></ul><li> Major Limitation<br />This study did not include patient populations utilizing assisted devices, AFO, prosthesis, or modalities to improve their gait. <br />
    25. 25. Conclusion<br />Improved walking ability is one of the highest priorities of patient’s suffering from a stroke<br />Muscle weakness, incoordination, poor endurance, pain, spasticity, and poor balance lead to difficulties in walking for stroke patients.<br />Gait training interventions have the potential to improve the body’s function/structure, activities, and participation pertaining to walking abilities<br />.<br />
    26. 26. Conclusion<br />Gait retraining through different types of exercise are the most common approaches to improving gait abilities.<br />Graded muscle strengthening is not functional and does not transfer over to improved walking ability, but did improve patient’s muscle strength.<br />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.<br />
    27. 27. Conclusion<br />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.<br />Neurodevelopmental approaches were equivalent or inferior to other approaches to improve walking ability<br />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<br />

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