After an individual experiences a stroke, it can be a long and tedious journey to restore function not only for the stroke survivor but also for the physical therapist. Stroke patients often start their rehab requiring assistance from their PT for essential tasks like bed mobility and transfers, but once these basic skills are recovered, the focus shifts to higher-level goals such as regaining the ability walk safely. A patient's potential to restore gait may be determined by the location and severity of his stroke, and by his motivation to work hard at recovery. If the stroke survivor is motivated, it is essential that therapy begins early in a structured program with an experienced interdisciplinary team.

Facilitating locomotion and all the components that go into it must be carefully directed by the therapist. Determining whether sensory and proprioceptive inputs are intact or impaired is essential for the development of pre-gait and gait treatment plans. Physical therapists already possess the skills to analyze and evaluate gait without instrumentation, and there are many standardized low-cost and convenient functional assessment measures available.

In addition, the therapist now is also equipped with several new technology gait tools that may be able to both analyze and train patients to walk earlier in a safer recovery environment. These tools come at a higher rehabilitation cost, but the greatest return on investment may in fact be demonstrated in giving stroke survivors a competitive advantage to reach their goal of improved walking ability. It is important to mention that even with a potential technology boost, the required effort and repetitions must still be performed in adequate volume by the patient to drive neuroplastic change.

Many of the fantastic gait technologies now available like computerized gait analysis (CGA) can generate important pre-intervention data that may be missed by mere observation, and potentially are an important part of the gait treatment planning process, especially with complex gait patterns. Post-intervention, having available CGA data may provide an objective means of quantifying outcomes and documenting functional improvements.

Several other new stroke recovery technologies in gait training can reduce the burden of the often heavy lifting required by the therapist that is necessary with task-specific rehabilitation. Patient access to some of these new state-of-the-art technologies for gait training may be currently limited to larger stroke rehab centers and hospitals while others are making their way into outpatient therapy settings as well as directly to patient's homes.

There have been several contributing factors driving the development of these new technologies for stroke rehabilitation. One factor has been gait research that focuses on activity-based training or task-specific training to restore optimal gait function versus using compensatory training strategies to allow adaptive movement patterns to develop in order to walk. The other real factor has been driven by health care economics and reducing disability costs, all while shortening rehabilitation stays. Stroke is the leading cause of adult disability in America, with some recent figures reporting 4 million survivors unable to return to their previous lifestyles and levels of independence.¹ The devastating financial impact of stroke on survivors and their families has further intensified research to improve medical treatment and rehabilitation techniques to achieve a more rapid and complete recovery.

Bodyweight-supported treadmill training (BWSTT) is an example of using task-specific training as a therapy tool in the early stages of stroke recovery to foster "forced-use" of a lower extremity as well as allowing for safely adjusting gait variables throughout the continuum of care. Using a partial-weight-bearing (PWB) gait suspension system device provides for proper upright posture as well as improved balance and safety support either over ground or during treadmill walking.

As the patient regains strength and dynamic coordination, device assistance can be decreased as the patient tolerates increased bodyweight. Treadmill speed can also be increased, so that the variables now start to match real-world walking conditions. Because the patient is in a supported environment, the therapist is better able to observe and manually manipulate foot placement, weight shift and trunk rotation as well as proper extension and timing, which are all keys to the development of a symmetric gait pattern.

In a stroke recovery study that examined functional outcomes following bodyweight support combined with treadmill training, "retraining gait in severely impaired stroke subjects with a percentage of their bodyweight supported resulted in better walking and postural abilities than did gait training in patients bearing their full weight."^2,3

In addition to innovative products, other companies are offering unweighting systems for gait training. Engineers have also created more advanced robotic systems to enable early gait training. One is a robotic assisted locomotor training device, or gait orthosis that attaches to the lower extremities. This device is capable of supporting a patient who is not yet able to support his own body weight but can provide early intervention and cortical stimulus to move his leg in a consistent, repetitive pattern. This technology uses biofeedback by enabling the therapist to see a graphic display of the patient's effort.

Smart functional electrical stimulation (FES) systems are now available to improve gait and improve neuroplasticity. These units are an option to restore ankle mobility and improve gait pattern in patients with foot drop following stroke. These functional electrical stimulation (FES) systems send low-level electrical impulses to the common peroneal nerve in the leg, stimulating the muscles of the foot. These devices are considered a "neuroprosthesis," or a device that replaces or improves function that has been lost due to an impaired nervous system. They are able to sense in real time key gait variables such as walking position, varying gait speed and changing terrain.

Through research, these lightweight and portable FES devices have shown several important rehabilitation benefits including increased walking speed, increased muscle strength and force of voluntary muscle contraction, decreased energy cost of gait, as well as decreased spasticity.⁴

Sarah Rotondo, MSPT, said this technology can provide a more natural, efficient and safe walking pattern with or without special footwear. Rotondo pointed out not all stroke patients are appropriate candidates for this type of FES training tool and notes proper training and fitting are required by a credentialed and trained medical professional to evaluate whether an FES neuroprosthesis device is appropriate to enhance gait.

Health care reform and a tough economy are creating both the necessity for patients to continue much of their rehabilitation in their homes as well as opportunities for industry to develop new home-based tools to assist with patient recovery. Recent developments in equipment technology allow for users with physical and neurological limitations to develop strength and stamina in non-intimidating, transitional ways while still getting performance feedback and the needed stimulus or volume of work required for rewiring the brain. Seated machines available with adaptive lower- and upper-extremity attachments allow for accommodating resistance and can replicate the full articulating ankle ROM and reciprocal arm swing needed to allow for transition to optimal gait.

With isokinetic equipment, patients may practice transitional movement until they can tolerate full weight-bearing exercises. Other home rehabilitation technologies use teletherapy to maximize patient training and recovery both in a clinical setting and the home. New options include a combination of robotics, telemedicine and interactive gaming technology to improve patient compliance through immediate biofeedback during treatment and through consultation and monitoring with the therapist using a home teletherapy system via the phone or web. This promising technology offers a valuable educational component and access to vital repetitive task practice needed to restore lost function. The National Institutes of Health recently funded a trial of teletherapy service for rural patients and patients with limited access to therapy.⁵ 

Multiple factors most likely contribute to the best possible outcome after stroke. Many neurological recovery programs already use advanced rehabilitation tools and techniques effectively to complement the manual skills of the physical therapist, improve documentation of therapy benefits and alleviate the heavy lifting needed to help the patient restore function. These gait technologies were developed to further increase strength and mobility for optimized functional recovery following a stroke as well as to enhance training and effectiveness as part of the patient's clinical and home exercise routine. Bringing these tools to more local clinics to give patients access to the best possible treatment options is still an investment challenge.

As physical therapists, one of our most important goals is to motivate the patient, learn what the patient's true goals are for recovery, and find out what motivated them to action prior to stroke. In addition, therapists should educate at every stage of recovery and update the patient's home therapy program continuously to keep the stroke recovery plan interesting, challenging and purposeful. Speaking from personal experience during my own stroke recovery, the key to achieving the best possible outcome is teaching your patient along the way the value of hard work, and never giving up. Your investment in the best clinical tools to restore gait and aid in recovery is important, but it cannot be stressed enough that the patient must also invest in his own recovery. 

References are available online at www.advanceweb.com/pt

David Dansereau is a physical therapist and stroke survivor in private practice in the Providence, RI, area. He is an author and lecturer on overcoming obstacles and improving stroke awareness and screening. He is involved as a patient advocate for stroke awareness and fundraising through Tedy's Team, a division of the American Stroke Association. David is currently completing a new book for stroke recovery with emphasis on practical home-based stroke recovery strategies. He can be reached at my-physical-therapy-coach.com