Lower Limb Gait following Stroke

Stroke frequently affects balance and the use of the legs. Walking is critical to regaining normal roles in society. The ability to walk also requires sufficient balance to avoid falls. One critical element is walking endurance and speed for walking to be a feasible alternative to wheelchair mobility.

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

• Organized stroke care available, including stroke units with critical mass of trained staff and interprofessional team during the rehabilitation period following stroke.
• Initial 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.

1. Change (improvement) in functional status scores (FIM® Instrument sub score locomotion) from admission to an inpatient rehabilitation program to discharge.
2. 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.

• Functional Independence Measure (FIM ® Instrument)
• Chedoke-McMaster Stroke Assessment
• 6 minute walk test

A number of treatment interventions are effective in enhancing lower limb function and gait post-stroke.

Aerobic exercise has been shown to be effective but often features a "cocktail" of different types of treatment (e.g. strength training, flexibility training as well as a strong aerobic training component, bicycling, water aerobics) so conflicting research findings may be due, in part, to the combination of different treatments. Overall the findings suggest that studies that include only cycling training do not find benefits greater than control intervention. In the sub-acute phase (>1 month) there is strong evidence from two high quality studies that aerobic exercise is effective in improving endurance^450,451 and balance ⁴⁵⁰ while the evidence on walking distance is conflicting, with Duncan finding effectiveness and Katz-Leurer  finding no benefit versus conventional treatment. Of note, the intervention by Duncan and colleagues was for a longer period (12-14 weeks and included endurance, strength, balance, and upper extremity exercise) versus Katz-Leurer’s progressive cycling program for eight weeks.

For aerobic exercise late after stroke the evidence is weaker with limited evidence that aerobic activity improves endurance and conflicting evidence regarding walking distance.^{452, 453} Pang and colleagues found a significant effect of the 19 week FAME program that included 19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises compared to the control group who received a 19-week seated upper extremity exercise program, ⁴⁵⁴ but Lee’s group found no greater improvement after 10 to 12 weeks of aerobic cycling.⁴⁵⁵ Similarly, Chu and colleagues found a significant difference in walking speed following eight weeks of water-aerobics versus a control treatment of hand and arm exercise offered in sitting⁴⁵⁶ while Lee found no effect after aerobic cycling.⁴⁵⁵ The use of lower limb strengthening alone does not have a positive effect on gait speed or walking distance.⁴⁵⁷

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.³⁸⁸ The few studies on patients in the acute stage (^458-460 It should be noted that the Richards and colleagues’ study may not have been adequately powered to find significant results but showed a trend in favor of the task oriented training group.⁴⁶⁰ In the subacute stage (>one month) there is moderate evidence from one high quality RCT that task-specific training may improve walking endurance and functional mobility.⁴⁶¹ Late post stroke (>six months) task-specific training improves gait endurance and speed but not functional mobility as measured by timed up and go compared to various control interventions.^{443, 462, 463}

Treadmill training should be considered for increasing walking speed, endurance and distance late post stroke. ^{464, 465} In a high quality RCT, 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.⁴⁶⁵ Macko and colleagues (2005) also found significantly greater improvement in ambulatory performance and mobility function in the group receiving 6 months of treadmill training versus conventional rehabilitation.⁴⁶⁴

Treadmill training with body weight support (BWS) has been found to be effective for patients with initial poor ambulatory status. ^466-469 Walking speed was significantly faster at post-treatment and at three-month follow-up for patients with sub-acute stroke who received BWS treadmill training as compared to treadmill training without BWS but only in patients with low ambulatory status.^{467, 466} Kosak and colleagues (2000) also found significant improvements in walking speed in sub-acute patients with low ambulatory status (but not high ambulatory status)treated with BWS compared to aggressive bracing-assisted walking over ground. ⁴⁶⁸ Similarly, in a high quality RCT studied patients with acute stroke who were non-ambulatory initially.⁴⁶⁹ The group that received treadmill training for up to 30 minutes per day walked independently significantly earlier (on average two weeks earlier at five weeks compared to at seven weeks) versus a control group that received 30 minutes of over ground walking. Franceschini and coworkers (2009) compared 60 minutes five days a week for four weeks of treadmill training with BWS to over ground gait training in patients with sub-acute stroke and found no differences before the groups on measures of functional walking measures or walking speed. ⁴⁷⁰

For additional information and more extensive reviews of the literature, please refer to:

StrokEnginewww.strokengine.ca/

Evidence Based Review of Stroke Rehabilitation www.ebrsr.ca