PDF Format

Stroke can impair many essential functions, from speech to cognitive ability to self-care tasks. But the biggest rehabilitation need after a stroke is walking. More than half of patients say they're most concerned with regaining movement and mobility after a stroke, according to a recent survey by the National Stroke Association.

Sustaining a stroke can take away the strength, flexibility and proprioception necessary for smooth, fluid gait. Spasticity can cause muscles to involuntarily contract, resulting in stiff and tight extremities. Atrophy can lead to weakened muscles. Sensory disturbances can hinder the ability to recognize the position of an extremity in space, and joints can lose their ability to move through their full range.

Also, a repetitive cycle of learned non-use can arise, in which patients neglect to practice and move affected limbs. If patients don't repeat essential tasks and movements, the ability to accomplish those movements can be lost forever.

An important element in relearning skills after stroke is repetitive practice. Over time, intensive practice (massed practice) may teach the brain to perform previous tasks. And current research holds that more is better-more resistance, repetitions, speed and duration return the highest functional outcomes.

Recent studies have found that treadmill exercise can actually improve walking ability by rewiring damaged areas of the brain. Patients should complete treadmill training with the smallest level of assistance necessary, which allows them to work on balance and self-correction. Here are the most common forms of gait rehab after stroke.

Bodyweight-supported treadmill training (BWS-TT). BWS-TT allows patients to practice walking while suspended in a harness over a treadmill. Assisted walking builds muscle mass and cardiovascular endurance, and forges new neuronal pathways. This intervention is frequently reimbursed under CPT codes for gait training or neuromuscular education.

Split-belt treadmill training. Researchers at the University of Delaware in Newark are experimenting with a specially designed split-belt treadmill, in which the belts can move together or at independent speeds. Researchers postulate that when the legs move at different speeds, the brain receives an error signal. The brain and nervous system use feedback to adjust. The cerebellum recalls this message after the treadmill stops, and for a few minutes, stroke patients can walk easier, according to researchers.

Robotic technology. Robot-aided therapy takes many forms. Robotic attachments can help place a subject's feet on the treadmill during walking to provide an adjustable level of assistance without a therapist being required to perform this labor-intensive task. However, a study in Stroke has suggested that human-assisted walking may be more potent than robotic-assisted training, perhaps because robotic attachments make therapy more passive, and don't allow a patient to self-correct after small errors or imbalances.

Functional electrical stimulation (FES). Electrodes apply low-level stimulation to specific muscles in weak or paralyzed limbs to facilitate walking. FES systems may also minimize sensory disturbances by stimulating receptors in the skin, muscles and joints. Because the stimulation causes muscles to contract, FES may also help increase strength, increase range of motion, and improve local blood circulation. FES can also help lift the foot during the gait phase and limit the effects of foot drop.

Before initiating a course of FES, perform a tho-rough evaluation. While there are few contraindications, some anecdotal reports raise concerns in cases of circulatory problems, skin conditions, cancer, epilepsy or pregnancy.

Rehab after stroke is always hard work, and you should prepare patients for this intensive process if you're going to achieve maximum outcomes.

No matter which intervention you choose, the key is high repetitions that relate to the patient's own rehab goals.

Information adapted from the International Functional Electrical Stimulation Society; Science Daily; the American Stroke Association; Stroke; the Journal of Rehabilitation Research and Development; and Stronger After Stroke (Demos Publishing) by Peter Levine.