Vol. 13 Issue 7
Stroke & Gait
Follow these guidelines to achieve maximum post-stroke gait training
Stroke, or cerebrovascular accident (CVA), is the leading cause of serious, long-term disability in the United States. Each year, more than 500,000 people suffer new strokes and 100,000 people suffer recurrent strokes.1
Rehabilitation is an important component of post-stroke services for the more than 450,000 patients with stroke annually. Acute-care therapy services after stroke focus on stabilizing the patient and preparing him to move to the next level of care. Rehabilitation begins during acute hospitalization, but only a minority of patients regain enough independence to return home. Most patients require further rehabilitation services at an inpatient rehab unit/hospital or a skilled nursing facility, where gait training becomes a key function in regaining independence.
Much of the focus in post-stroke rehab is on maximizing function as quickly as possible. The average length of stay in an inpatient rehab unit is only 20 days. Function–or accomodating loss of function–is an important issue for the 75 percent of these patients returning home.2
To help patients succeed at functional activities, therapists must first build a proper foundation, especially during gait training. Therapists do patients a disservice when they rush into activities that patients don't have the basic skills to perform.
Dragging patients through the parallel bars and calling it "gait training" is bad for both patients and therapists. Patients may gain false hopes of walking independently or learn substitution patterns that may cause abnormal, unstable gait patterns they can't later correct. Therapists may become frustrated by a patient's lack of functional progress, and sustain considerable wear and tear on their bodies as they "carry" patients through the parallel bars.
In the long run, if a patient can't gain an independent gait with or without an assistive device, functional outcomes are not maximized.
A useful treatment planning tool is the APTA's Guide to Physical Therapist Practice, which includes interventional goals of improved motor and postural control for patients post-stroke.
The guide also lists specific direct interventions such as developmental activities training; motor function training or retraining; neuromuscular education or reeducation; perceptual training; posture awareness training; sensory training or retraining; and gait, locomotion and balance training.
Treatment plans should be as inclusive as time and patient tolerance allows to provide mat activities, transfer activities and pre-gait or gait activities.3
Build a foundation. The first step to any gait training plan is to build proximal stability. Remember that patients must have proximal stability to gain distal mobility. The following developmental sequence helps by developing trunk stability: Progress the patient from rolling to resting prone on elbows, to hands and knees, to kneeling, to tall kneeling and to standing. In each position, help the patient improve joint position sense, co-contraction of muscles around the involved joints and gain proximal stability.
Add weight-shifting activities and volitional movement of uninvolved and involved extremities to further challenge the patient's abilities and strengthen the foundation for later higher-level activities.
Introduce pre-gait activities. As patients demonstrate appropriate abilities within the developmental sequence, initiate pre-gait activities such as assisted standing in the parallel bars, weight shifting side-to-side, diagonals and forward and back.
When standing, patients can work on lower extremity muscle control and joint position sense in activities such as small squats, marching or unilateral steps forward and back. With a well-built foundation, patients can improve motor function and control, and more successfully progress to forward gait.
Exercise. An ongoing component of the post-stroke treatment plan is therapeutic exercise that increases muscle tone and strength and decreases abnormal tone in the primary muscles used during stance and gait, including hip extensors, hip abductors, knee extensors and ankle dorsiflexors.
Use neuromuscular strategies such as PNF4 or Bobath5 in the therapeutic exercise program to facilitate normal motor activity.
Strengthen and improve motor control in the proximal muscle groups with activities that facilitate hip extension with knee flexion, such as bridging or kneeling to tall kneeling. It's also important to improve knee control to avoid or limit hyperextension during gait with activities such as standing small squats.
Although you should address ankle dorsiflexion strengthening, this is a lower priority since the ankle is the most amenable lower extremity joint to assist or control through bracing.
A treatment plan that builds a strong foundation and helps patients progress to higher-level functional activities will maximize post-stroke abilities in any activity that requires proximal stability with distal mobility. In the long run, everyone will be more satisfied with what they accomplished.
1. American Stroke Association. Impact of stroke. Retrieved March 26, 2002 from the World Wide Web: http://www.strokeassociation.org/presenter.jhtml?identifier=1033
2. Uniform Data System for Medical Rehabilitation. (2001) Second quarter statistics. Buffalo, NY: Author.
3. American Physical Therapy Association. (1999). Guide to physical therapist practice. Alexandria, VA: Author.
4. Voss, D.E., & Ionta, M.K. (1980). Proprioceptive neuromuscular function: Patterns and techniques. (3rd ed.). Lippincott-Raven.
5. Bobath, B. (1990). Adult hemiplegia: Evaluation and treatment. .(3rd ed.). Woburn, MA: Butterworth D. Heinemann.
Jean Kestner is manager of marketing and public relations for SSM Rehab in St. Louis. She has more than 20 years of clinical experience in a variety of health care settings.