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Section 5.6.3

Lower-Limb Gait Training Following Stroke

4th Edition 2012-2013 UPDATE
July 10, 2013
 
  1. Task and goal-oriented training that is progressively adapted, meaningful, salient, and involves active participation should be used to improve performance of selected lower-extremity tasks [Evidence Level: Early-Level B; Late-Level B].
  2. Treadmill-based gait training (without body support) can be used to enhance walking speed, endurance, and distance walked when over-ground training is not available or appropriate. When used, it is suggested that therapy should be provided for 30 minutes a day, five days a week, for two weeks [Evidence Level: Early-Level C; Late-Level B].
  3. Body weight supported treadmill training, (BWSTT) is one method that can be used for patients with low ambulatory function when other strategies for walking practice are unsuccessful or unsafe [Evidence Level: Early-Level A; Late-Level A].
  4. Following medical clearance, patients should participate regularly in an aerobic exercise program that accommodates the patient’s co-morbidities and functional limitations to improve gait speed, endurance, stroke risk factor profile, mood, and cognition [Evidence Level: Early-Level A; Late-Level A].  Refer to the AEROBICS Best Practice Recommendations. 
Rationale

Stroke frequently affects balance and the use of the legs. Walking is a valued function by patients to facilitate every day interaction. The ability to walk also requires sufficient balance to avoid falls. For walking to be a feasible alternative to wheelchair mobility, critical elements would include having a reasonable walk speed and endurance.

System Implications

To achieve timely and appropriate assessment and management of lower limb function and gait the organization requires:

  • Organized stroke care, including stroke rehabilitation units with a critical mass of trained staff and an interprofessional team during the rehabilitation period following stroke.
  • Initial and ongoing standardized assessment performed by clinicians experienced in stroke rehabilitation.
  • Timely access to specialized, interprofessional stroke rehabilitation services.
  • Timely access to appropriate intensity of rehabilitation for stroke survivors.
  • Access to appropriate equipment.
  • Access to ECG monitored exercise stress testing and experienced physician to develop appropriate intensity of aerobic exercise.
Performance Measures
  1. Extent of change (improvement) in functional status on the 6-Minute Walk Test from admission to an inpatient rehabilitation program to discharge. Change (improvement) in functional status scores (FIM® Instrument sub score locomotion) from admission to an inpatient rehabilitation program to discharge.
  2. Extent of change (improvement) in functional status score (CMSA lower limb sub scale) from admission to an inpatient rehabilitation program to discharge.
  3. Average hours per day (minimum of three) of direct task-specific therapy provided by the interprofessional stroke team.
  4. Average days per week (minimum of five) of direct task specific therapy provided by the interprofessional stroke team.

Measurement Notes:

  • Therapy time may be extracted from rehabilitation professional workload measurement systems where available.
Summary of the Evidence

Task oriented training (also called task-specific training) involves practicing real-life tasks, with the intention of acquiring or reacquiring a skill. The tasks should be challenging and progressively adapted and should involve active participation. Evidence suggests that this type of therapy helps to improve gait speed and endurance. A Cochrane review (English & Hillier 2010) included the results from 6 RCTs that examined repetitive practice of functional tasks arranged in a circuit with the aim of improving mobility.  Compared with the control condition, there were significant improvements in performance on the 6-Metre Walk test (6MWT) (MD=76.6 m, 95% CI 38.4 to 114.7, p<0.0001) and gait speed (MD=0.12, 95% CI 0.0 to 0.24, p=0.043), but not on measures of balance or on the Timed Up and Go (TUG test) associated with treatment. Van de Port et al. (2012) recruited 250 patients who had completed their inpatient rehabilitation following stroke, who were able to walk 10 m without physical assistance and were to be discharged home, with the intention of participating in an outpatient rehabilitation program. Patients were randomized to receive a graded task specific circuit training program or usual outpatient physiotherapy. At the end of follow-up (24 weeks), patients in the task-specific therapy group had significantly higher scores on the mobility sub scale of the Stroke Impact Scale and increased distance walked on the 6MWT, compared with patients in the control group. Salbach et al. (2004, 2005) randomized 91 community-dwelling subjects with a residual walking deficit within one year of stroke to an intervention group which comprised 10 functional tasks designed to strengthen the lower extremities and enhance walking balance, speed and distance or to a control intervention focusing on upper extremity activities. Patients in the active intervention group walked a further distance on the 6MWT and increased their comfortable and maximal walking speed to a greater degree compared with patients in the control group.

In terms of superiority of any one particular therapy approach, A Cochrane review authored by Pollock et al. (2007) examined the efficacy of various treatment approaches for lower limb rehabilitation. The results from 21 RCTS were included; eight trials compared a neurophysiological approach with another approach, eight compared a motor learning approach with another approach, and eight compared a mixed approach with another approach.  A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardized mean difference= 0.94, 95% CI 0.08 – 1.80).  Nevertheless, the authors concluded that there was insufficient evidence that any single approach had a better outcome than any other single approach or no treatment control.

A number of treatment interventions are effective in enhancing lower limb function and gait post-stroke. A Cochrane review (Mehrholz et al. 2007) examined the effectiveness of electromechnical and robot-assisted gait training s for improving walking after stroke. Seventeen RCTs were included that examined subjects who were ambulators, non-ambulators, or both ambulators and non-ambulators. The treatment contrasts included comparison of electromechnical and robot-assisted gait training devices (with or without electrical stimulation), designed to assist stepping cycles by supporting body weight and automating the walking therapy process with the addition of physiotherapy compared with physiotherapy or routine care only. Treatment was not associated with increases in gait speed or endurance;however, the odds of becoming an independent ambulator were significantly increased for patients who had experienced their stroke < 3 months previously (OR=2.56, 95% CI 1.67 to 3.94, p<0.0001). Morone et al. (2011, 2012) included 48 participants, an average of 20 days post stroke, stratified by motor impairment (high vs. low).  All patients underwent standardized rehabilitation for 3 months. After one week of therapy, subjects in the robotic group underwent additional robotic-assisted gait training instead of a second therapy session (20 sessions in total). Subjects in the control group participated in a second therapy session. At the end of treatment subjects in the low impairment robot group had improved significantly more than subjects in the low impairment control group on the Functional Ambulation Category (FAC)(p < .001), the Rivermead Mobility Index (p = .001) and the 6-Minute Walk test (p = .029). Although subjects in the high impairment groups also improved over time, there were no significant between-group differences on any of the outcomes. At 2 year follow-up, patients in the low impairment robot group continued to demonstrate significantly improved scores, while there were no significant differences between groups for highly-impairment patients. Treadmill training can also be used to increase walking speed, endurance and distance late post stroke. Macko et al. (2005) reported that 61 chronic stroke patients with hemiparetic gait patients who received 6 months of progressive treadmill aerobic exercise program had significantly greater improvement in ambulatory performance and mobility function compared with patients in a control group who received a program of stretching plus low-intensity walking. Langhammer & Stanghelle (2010) reported that patients in the treadmill group had better walking speed, endurance, and walking distance following an intervention consisting of 2.5 weeks/5 days week for 30 min of treadmill training versus a control intervention consisting of outdoor walking.

Treadmill training with body weight support (BWS) may also be effective for patients with initial poor ambulatory status, although the evidence is less clear. Duncan et al. (2011) randomized 408 community-dwelling patients with stroke onset of 2 months, who were able to walk 3 meters with maximum of one person assist, to receive a 3-4 month course of early or delayed treadmill training with partial body-weight support or to a home-based exercise program. At one-year, 52% of all patients had improved functional walking ability. There was no difference in the proportion of improvement found among the 3 groups. In the MOBILISE trial, (Ada et al. 2010, Dean et al. 2010) 126 patients within 28 days of stroke were randomized to an experimental or a control group and received treatment until they achieved independent walking or for as long as they remained in hospital. Subjects in both groups received 30 minutes of walking practice 5 days/week. Additional lower-limb therapy was provided for an additional 30 minutes/day. Subjects in the experimental group undertook up to 30 minutes per day of treadmill walking with sufficient body weight support such that initially, the knee was within 15 degrees of extension in mid stance. Subjects the control group received up to 30 minutes of overground walking training, with the use of aides, if required. Although there were no differences in the proportion of independent ambulators between groups at one, two or 6 months, subjects in the experimental group achieved independence in ambulation a median of 14 days sooner.

Aerobic exercise can be used to improve measures of gait performance. A Cochrane review (Brazzelli et al. 2011), included the results from 32 trials of patients in both the acute and chronic stages of stroke. Interventions were classified as 1) Cardiorespiratory training vs. usual care, 2) Resistance training vs. usual care and 3) Mixed training interventions, which included combinations of cardiorespiratory and resistance training methods. At the end of follow-up, cardiorespiratory training was not associated with reductions in disability (measured by FIM), but maximal and preferred walking speed and walking capacity were significantly improved. Increased gait speed and improved walking capacity were also associated with mixed training interventions. Pang et al. (2006) also conducted a systematic review of aerobic exercise following stroke, which included the results from 7 RCTs, evaluating patients in all stages of stroke recovery. Exercise intensity in the included studies ranged from 50% to 80% of heart rate reserve, while duration varied from 20-40 min for 3-5 days a week for 3-19 weeks. Regardless of the stage of stroke recovery, there was a significant benefit of therapy. Improvements were noted in the parameters of peak VO2, peak workload, walking speed and endurance. Jin et al (2012) and Globas et al (2012) reported significant improvements in measures of cardiovascular fitness, walking ability and performance in patients >6 months post stroke who had received a progressive graded, high-intensity aerobic treadmill exercise or aerobic cycling exercise, with lower extremity weights. MacKay-Lyons et al. (2013) reported that a 12-week aerobic conditioning program using body-weight supported treadmill training was associated with improvements in cardiovascular fitness and walking ability that were sustained for one year. 

Evidence Table 5.6.3 and Reference List

For further information and references, please consult the Evidence Based Review of Stroke Rehabilitation; and StrokEngine.