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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 Evidence Steve 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 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.
4. 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.
5. 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
6. 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.
7. 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
8. 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
9. 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
15. 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)
25. 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 .
26. 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.
27. 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
Editor's Notes
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.
