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Use of Three Gait-Training Strategies in an Individual with Multiple, Chronic Strokes

Vidoni, Eric D. PT, PhD; Tull, Annette DPT; Kluding, Patricia PT, PhD

Journal of Neurologic Physical Therapy: June 2008 - Volume 32 - Issue 2 - p 88-96
doi: 10.1097/NPT.0b013e31817613b0
Case Report
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Background and Purpose: There is little information available regarding gait-training interventions for people with chronic, multiple strokes who are nonambulatory. The purpose of this case report is to describe the feasibility and outcome of three different task-oriented gait-training techniques in an individual with chronic, multiple strokes who was not able to ambulate independently.

Case: The participant was a 61-year-old man with chronic quadriparesis resulting from five brainstem strokes sustained over five years previously. He maintained home and community mobility with a power wheelchair but sought to ambulate home and short community distances without assistance. Three six-week gait-training interventions were implemented sequentially twice per week: (1) overground gait training with manual assistance, (2) body weight–supported treadmill training (BWSTT), and (3) overground gait training with variable task practice.

Outcome: Independent home and short community ambulation was not achieved by this individual after these interventions. However, he improved gait speed and endurance as well as balance over the 18-week intervention period.

Discussion: There appeared to be no advantage to BWSTT over traditional gait training for this individual, as improvement was noted during all three interventions at a comparable rate. Although these gait-training interventions facilitated gains in gait and balance measures during the treatment, no change in functional ambulation status was achieved. Given the time, financial, and labor demands involved with BWSTT and the lack of apparent benefit, traditional overground therapeutic intervention was reasonable and appropriate for this participant with a history of chronic, multiple strokes.

Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, Kansas.

Supplemental information (videos) for this article can be found at www.jnptextra.org

Address correspondence to: Eric D. Vidoni, E-mail: evidoni@kumc.edu

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INTRODUCTION

Between one fourth and one half of individuals with a diagnosis of stroke have impairments in gait.1,2 Gait deficits include both decreased walking velocity3,4 and decreased walking endurance5 and may be severe enough to completely limit functional gait activities. In a group of community-dwelling stroke survivors, 14.6% reported that they were not able to ambulate outside the home.6 Several researchers have found correlations between measures of muscle strength, balance, daily ambulatory activity, aerobic fitness, spasticity, and lower extremity motor control with short distance (seven to 10 meters) walking velocity in stroke survivors.7–10 Impairments in these various body structures may lead to difficulty with gait because of the inability to use the hemiparetic leg for support, the inability to advance the hemiparetic leg, or poor trunk control.

Multiple strokes can significantly complicate the clinical presentation of an individual, with increased risk of severe disability. There is very little rehabilitative literature regarding gait deficits or gait training for those who have had multiple strokes, as one-time stroke events are often an inclusion criterion for studies.11,12 However, the risk of recurrent stroke is approximately 40% over 10 years after a first stroke,13 necessitating a more comprehensive research focus on this population. In one study of 313 patients admitted to a stroke rehabilitation unit, 110 had recurrent stroke.14 Greater levels of handicap have been found in two-year stroke survivors who experience a recurrent stroke,15 and chronic stroke survivors will have increased risk of cardiovascular, integumentary, musculoskeletal, and psychological complications of immobility. Although formal rehabilitation commonly ends after the first few months after a stroke in our current healthcare system, recent research has indicated that functional recovery in upper extremity function16,17 and walking status18–20 is possible. Possibly this progress results from preserved neuroplastic capacity or peripheral improvements in those who had a stroke years before.21

Traditional physical therapy for people who are nonambulatory after stroke has focused on the use of adaptive equipment, preambulation strengthening programs, and standing exercises.22,23 Although these approaches are widely accepted and used in the clinic, they may fail to address new evidence suggesting that task-specific training is critical to brain reorganization.24–26 Task-specific gait training is focused on repetition of the complete gait cycle with some degree of weight-bearing. For people who are unable to independently ambulate, task-oriented training is perhaps a more appropriate concept.20 Practice that simulates natural walking can be done with manual assistance during overground walking with assistive devices or in the parallel bars or with the use of body weight–supported treadmill training (BWSTT). Positive findings have been reported with the use of BWSTT in people with stroke,20,27–35 possibly because of the large amount of repetition experienced with this practice strategy.19 Further, unloading of body weight and increased postural support by the harness may embolden the client to move in a way that he or she might otherwise deem unsafe.34,36 However, other studies have found BWSTT to be no more effective than more traditional gait rehabilitation strategies in early rehabilitation,11,37 and this conclusion was echoed in a recent Cochrane review.38

A few investigators have studied the impact of BWSTT either in individuals with chronic stroke18–20,33,39 or in those who are nonambulatory after stroke.28,40 The benefit of BWSTT compared to other gait interventions in nonambulatory individuals with chronic stroke has not been addressed in the literature. The purpose of this case report is to describe the feasibility and outcome of three different task-oriented gait-training techniques in an individual with chronic, multiple strokes. Although the project was conducted in the manner of a single case design to assess feasibility for a larger project, we have chosen to report in the style of a case report to facilitate clinically relevant interpretation of the results. The individual was identified as an appropriate subject for this project as he was (1) at least six months post-stroke, (2) able to transfer from a sitting to a standing position with minimal assistance, (3) unable to walk independently, (4) without language or cognitive deficits that would impair his ability to give informed consent, and (5) without a medical condition that would prevent him from safely participating in an exercise program. Institutionally approved informed consent and approval from his primary physician to participate in gait-training activities were obtained.

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CASE DESCRIPTION

History and Diagnosis

The participant was a 61-year-old white male with chronic quadriparesis resulting from five brainstem ischemic strokes. The strokes were bilateral and resulted in greater involvement of the right side of the body. Before his strokes, the participant was fully independent and worked full time as a carpenter superintendent. All five strokes occurred over an eight-week period five or more years before enrollment and were found to be due to a previously undiagnosed hereditary blood coagulation disorder (factor 5 Leiden). The first stroke was mild, followed by a much more severe stroke that was life-threatening, and then three additional strokes. Immediately after his strokes, he participated in eight weeks of inpatient and 16 weeks of outpatient rehabilitation. He reported that during his outpatient rehabilitation, he was able to ambulate several hundred yards with a quad cane and assistance of one person.

In the years after his stroke, he participated in exercise using a total-body recumbent stepper and received only occasional gait-training practice, primarily during patient lab practice experiences for physical therapy students. During these sessions, he either walked in parallel bars with moderate assistance of one person or walked overground with a quad cane and minimal to moderate assistance of two people. At no time after the strokes did he achieve independent ambulation. The participant was active in his community using a powered wheelchair for home and community mobility. He volunteered in an office two days each week and stayed home alone three days each week. He was independent in most daily activities, using his left hand exclusively to perform activities of daily living (ADLs) and instrumental ADLs (IADLs), including computer use. He lived with his wife in a ranch-style house with a ramp to the entrance and home modifications such as wider doors and grab bars in the bathrooms. His wife provided assistance with dressing and showering as needed.

At the time of enrollment, his medical history included chronic low back pain with three herniated intervertebral disks (L2-4), which were diagnosed a few months before the stroke, type 2 diabetes (diagnosed 22 years previously), hypertension, and hypercholesterolemia. His medications included Avandia (rosiglitizone maleate), Glocotrol XL (glipizide), Metformin (glucophage) for diabetes; anticlotting agents Lovenox (enoxoparin) and Coumadin (warfarin); antihypertensive agents Vasotec (enalapril maleate) and Cardura (doxazosin), Lasix (furosemide) as a diuretic; lipid-lowering agents Zocor (simvastatin) and Zetia (ezetimibe); and antidepressants Zoloft (sertraline) and Norpramin (desipramine).

The individual expressed an interest in participating in ambulation practice to aid his personal goal of supervised, short-distance ambulation in the home and community. A specific goal was to walk with assistance down the aisle of an airplane by the time of his vacation, which was 20 weeks after enrollment. Additionally, he was interested in trying BWSTT since he had not experienced it previously.

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Examination

The participant had minimal volitional control of his right upper and lower extremities, with only slight movements in the flexor synergy noted in the upper extremity and only active knee extension observed in the lower extremity. He had full active movement of the left upper and lower extremities, with slight incoordination and weakness. Strength in the lower extremities was tested with a hand-held dynamometer (MicroFET; Hoggan Health Industries, West Jordan, UT). The baseline strength values and a description of the testing procedures are provided in Table 1 along with age-appropriate norms for hand-held dynamometer testing.41 The interclass correlation coefficient (ICC = 3,1) was calculated using these procedures in 26 people with stroke and was found to range from 0.851 to 0.984 for the muscle groups tested (Kluding, unpublished data).

TABLE 1

TABLE 1

Hypertonicity in the right elbow, wrist, and finger flexors and in the right hip and knee flexors was generally graded 2/4 on the Modified Ashworth Scale (MAS).42,43 No hypertonicity was noted in the left upper and lower extremity (0/4 on the MAS). Passive range of motion was full with the exception of right ankle dorsiflexion, which was limited to approximately 0 degrees, and right shoulder flexion, which was limited to approximately 90 degrees.

He scored 26 on the Berg Balance Scale44 and was independent with transfers while supporting himself primarily with the left arm and leg. He was able to stand unsupported for two minutes with supervision and slight sway and was able to stand with left upper extremity support on a hemicane for a much longer period.

The participant was at a level 1 on the Functional Ambulation Category scale, defined as “the patient needs continuous support from one person who helps to carry the patient’s weight and helps with balance.”28 During a six-minute walk test,5 he was able to walk 11.58 meters (38 ft) with multiple rest periods and used a hemicane in his left hand with minimal assistance to advance the right lower extremity. Because he could not ambulate independently outside the parallel bars, a timed parallel bar walk (TPBW) was performed as a modification of the Timed Up and Go test.45 On the “go” command, the patient stood up from his wheelchair, walked the three-meter length of the parallel bars, turned, walked back to his chair, and sat down. Timing started when he lifted his buttocks from the chair and stopped when he sat. He took 84 seconds to complete this task, using his left hand for support and leaning heavily on the bars to the left in order to advance the right lower extremity. During all gait activities, he wore an ankle-foot orthosis (AFO) on the right lower extremity (double upright, dorsiflexion spring assist with a plantar-flexion stop), with a surgical shoe cover over the right shoe to reduce friction.

In addition to the objective measures of gait function, a detailed task analysis of his function during walking tasks may help to identify where the problems occur.46 Analysis of his walking ability in an environment that would be expected to maximize his performance (a quiet area with minimal distractions, adequate lighting, a smooth surface with the shoe cover to further reduce friction, and maximal support with assistive devices and an AFO) revealed that he was unable to ambulate without assistance, as noted above. Consideration of the temporal sequence of movements during this task46 revealed that in attempting to advance his right lower extremity, he had several problems: (1) initial posture was such that he did not fully unweight the right limb before attempting to advance it, (2) the timing of this movement attempt was delayed, and (3) the amplitude of movement execution was impaired.

The participant had no difficulty with expressive or receptive communication. He weighed 106.59 kg (235 pounds) and was 1.75 m (five feet, nine inches) tall, with a body mass index (BMI) of 34.7 at the time of enrollment. Aerobic fitness, sensation, and cognitive status were not formally assessed.

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Evaluation, Diagnosis, and Prognosis

It was determined that this participant fit into Practice Pattern 5D: impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system acquired in adolescence or adulthood.47 The primary patient-identified problem (PIP) was inability to walk independently, and this was the focus of our examination. Specifically, we identified inability to advance his right lower extremity as the primary problem limiting his ability to ambulate. We determined that several impairments may have contributed to his ambulation difficulty, including severe right lower extremity weakness, moderate left lower extremity weakness and coordination deficits, right lower extremity hypertonicity and plantar flexion contracture, and low back pain. There may have been other contributing factors, such as deficits in trunk control, sensation, and aerobic fitness, although these impairments were not assessed.

There is very little information in the literature to guide prognosis for gait training in individuals with multiple, bilateral, chronic strokes. However, we believed that this individual’s difficulties with advancing the right lower extremity (ie, unweighting the limb, timing, and movement amplitude) might be modifiable. He was able to generate force with his right hip abductors and knee extensors as determined on the manual muscle testing (MMT), he had not had regular gait-training practice in more than five years, and had never experienced BWSTT. He was highly motivated to participate, and we believed that providing gait practice opportunities to him might improve his gait posture and right lower extremity timing and strength, which could influence his ambulation status. Specifically, we believed that he could achieve short distance, in-home ambulation (eg, bathroom door to toilet) with assistance of a railing.

The specific gait-training strategies used with this individual were selected with the intent to provide multiple practice opportunities focused solely on gait. Alternative options for gait training may have been appropriate, but we thought that including these three distinct strategies in the treatment plan for this individual would maximize his opportunities to improve.

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Gait Training

Three different gait-training strategies (A, B, C) were selected a priori to be implemented sequentially, with six weeks in each phase. Outcome measures were assessed weekly during the training periods. Strategies A and C consisted of overground gait training, and strategy B consisted of BWSTT. Because the participant had not had gait-training opportunities for so long, we thought that overground practice with physical assistance (strategy A) would allow him to gradually build his strength and cardiovascular endurance. BWSTT was implemented in strategy B to provide intense gait practice opportunities at higher speeds than were possible with overground walking. After these two periods of training, we hoped to build on any improvements by returning to overground training in strategy C, with an emphasis on task-oriented practice in varied natural environments. We hypothesized that the increased repetition and body-weight support afforded by BWSTT would result in an increased rate of improvement in walking ability during that period compared to overground training.

All sessions lasted one hour and were scheduled twice each week. A typical session began with 30 minutes of lower extremity stretching and testing of blood pressure, heart rate, and outcome measures. This was followed by 30 minutes of gait training. A student physical therapist provided assistance during all but one overground gait-training session of strategies of A and C, with a physical therapist present to help direct the sessions. All researchers (ie, authors) provided assistance as necessary during BWSTT (strategy B). During all training epochs, the participant self-selected rest periods, which were included in the 30-minute training time limit. All strategies used a task-oriented approach to gait training, with assistance provided to simulate multiple executions of the complete gait cycle without stopping. Reduction of therapist assistance to advance the right lower extremity and increased walking distance were identified as goals throughout the training. The participant wore his AFO during all sessions.

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Strategy A

Strategy A, training weeks 1–6, was the most conventional and conservative of the intervention phases. It consisted of overground ambulation training activities using parallel bars or assistive devices with manual cueing and physical assistance of one person. Manual cues in the parallel bars emphasized minimizing the forward and leftward lean of the trunk during attempts at advancing the right leg, with minimal and moderate assistance provided to the right lower extremity. Verbal encouragement and physical facilitation techniques were provided to activate right hip and knee flexors in swing phase. The participant also walked down a long, low-pile carpeted hallway with a hemicane and minimal assistance of one physical therapy student to the right leg for abduction to be able to advance the lower extremity. He independently chose to have his AFO plantar flexion stop adjusted to an increased dorsiflexion position in week 5 because he thought it would help with right toe clearance. We were informed of this change after it occurred, and we were not asked for advice on this matter. Because the participant had a significant ankle plantar flexion contracture, we believe that there was little to gain from adjusting the AFO. However, we did not want to interfere with his choice and asked him to keep us informed of any further changes. Back pain was reported by the participant during three training sessions in this period and required the participant to stop and take rests.

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Strategy B

Strategy B, consisting of training weeks 7–12, lasted six weeks but was interrupted for one week due to overnight hospitalization for a respiratory infection between training weeks 10 and 11. Weight support was achieved using a LiteGate (Mobility Research, Tempe, AZ) harness system positioned over a variable-speed treadmill. The harness allowed for monitoring of weight support and was adjusted to relieve 30% of the participant’s body weight (measured each day) in quiet standing on the treadmill. Thirty percent body-weight support was chosen to approximate previous protocols.27 Body-weight support was maintained at this level except for nine minutes during a session in week 10 when support was increased to 50%. This increase was performed in an attempt to assist the participant with right lower extremity swing through. He expressed discomfort with this amount of harness support, and it was discontinued.

Assistance of one to three people was required for all BWSTT activities.[Video_1 BWSTT] Right dorsiflexion and knee flexion assistance was provided at all times to clear the right toe. Verbal and manual prompts to initiate hip flexion and advance the right leg were provided before assistance was given on each step. Assistance was also provided at the hips to help weight shift to encourage right lower extremity advancement. This assistance was phased out over the 6 weeks of BWSTT as the participant became able to shift his own weight to assist swing through of both legs.

Rather than following a previously established protocol for treadmill speed, this was maintained between 0.18 and 0.27 m/min, based on the participant and therapist comfort. An increase to 0.45 m/min was attempted for short bouts; although this resulted in a more fluid-appearing gait cadence, it required markedly increased therapist assistance and was therefore discontinued. The training lasted for 30 minutes with self-selected rest periods, as with the other gait strategy sessions. The participant preferred to grip handles mounted to the support device when walking. When necessary, the right hand was held in position on the handle with an elastic wrap. He again had his AFO plantarflexion stop adjusted into more dorsiflexion in week 9 in an attempt to improve toe clearance.

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Strategy C

For strategy C, training weeks 13–18, overground training was resumed with assistance of one person. In addition to activities described in strategy A, strategy C also included motor learning concepts associated with improved retention and transfer of skills,48 with regular changes in task demands or environment. The training tasks included walking over variable floor surfaces, walking through a curved or variable path, and step-over obstacle training. A wide-base quad cane was used for these gait activities, and minimal right leg abduction assistance was provided to help advance the right lower extremity.[Video_2 Overground Walking] A cast shoe was used on the left foot to elevate the body and provide a biomechanical advantage for right toe clearance during gait. Additionally, parallel bars and chairs were positioned to mimic an airplane seating arrangement. Session activities were selected at random and switched regularly to encourage retention and transfer of skills. Progression was primarily distance based, although the simulated airplane situation was evaluated more qualitatively for effectiveness. At the start of strategy C training, the participant began wearing an off-the-shelf neoprene back wrap, which appeared to ameliorate his back pain. He also began attending a local gym during strategy C, with strengthening exercises and cycling assisted by his wife.

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Outcomes

Functional changes were assessed with weekly testing of six-minute walk (6-MW), Berg Balance Scale (BBS), TPBW, and lower extremity MMT. To reduce fatigue before gait training, BBS and MMT were completed on the first session of the week, TPBW and 6-MW on the second session. The same tester provided assistance during all gait testing, except week 10. The same tester performed all dynamometer measurements, except week 9. A two-measurement mean was recorded for bilateral hip flexion, hip abduction, and knee flexion, extension, and dorsiflexion. Testing was completed in the same room at the same time of day, and there were no other patients or activities in that room during testing.

The participant was able to complete 18 weeks of twice-weekly gait training. He did not achieve his personal goals of supervised short distance home walking or walking to his seat on the airplane with assistance. He was able to participate in a local stroke support group fundraising walk, which was held outside over an uneven surface, by walking approximately 30 meters with assistance of one person and a quad cane after the gait training.

Walking distance covered during training was tracked during the overground training periods and on the treadmill display during BWSTT. As can be seen in Figure 1, the total distance walked during strategy B was much greater than in either A or C. There was a gradual increase in distance walked during the 6-MW test over the course of the gait training, as illustrated in Figure 2, from the baseline value of 11.58 m (38 ft) to a peak of 37.19 m (122 ft) during strategy C. There appears to be a plateauing in strategy C, but no other difference between strategies is observed. The mean 6-MW values for each period are presented in Table 2. A gradual improvement in TPBW performance was noted throughout the gait training (Fig. 3 and Table 2), from 84 seconds at baseline to a low of 57 seconds during strategy C. BBS scores also improved generally over the course of the gait training (Fig. 4 and Table 2), with greater variability during periods B and C. An increase from baseline BBS of 24 to a peak of 31 during the final session was noted. No consistent improvement was noted in strength measures during the different gait-training strategies (Table 2).

FIGURE 1.

FIGURE 1.

FIGURE 2.

FIGURE 2.

TABLE 2

TABLE 2

FIGURE 3.

FIGURE 3.

FIGURE 4.

FIGURE 4.

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DISCUSSION

This case report describes the use of three different gait-training strategies in an individual with multiple, bilateral, chronic strokes who was not a functional ambulator. Both overground training and BWSTT paradigms were feasible for this person with several chronic strokes, suggesting further research would be helpful for evaluating ambulation training strategies for those with chronic, multiple strokes. Although his gait speed, endurance, and balance improved, he did not achieve his goal of independent home and short-distance community ambulation. No differences in functional change, as measured by 6-MW, TPBW, and BBS, were seen between training strategies. These ambulation and balance outcomes are discussed first in the context of previous research. Second, the clinical relevance of these data is discussed.

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Measured Functional Outcomes

Previous studies have reported moderate gains in overground walking velocity with BWSTT.19,20,28,31 The present results suggest little difference between intervention strategies in the rate of improvement for TPBW, 6-MW, and BBS measures. BWSTT did not appear to afford this participant with a history of chronic, multiple strokes a greater intervention benefit than traditional, task-specific gait training despite an increase in total distance ambulated during training in strategy B. The present gains in 6-MW and TPBW likely reflect a gain in both average velocity and endurance. However, these improvements remained far from what would be considered typical for community ambulators with a disability: 20-s Timed Up and Go test49 and 250–300 m on a 6-MW.50 Further, comparison of these outcome measures to existing literature should be done carefully as the present data reflect performance on modified tests.

Although BBS scores generally improved over the course of the project in an intervention-indiscriminate manner, the individual never achieved a score of 40. Below 40 is the threshold for those who are high risk of falls.51 We also noted a decrease in BBS scores occurs during strategy B (before the hospitalization). Previous research has found larger gains (14–20/56) in BBS scores after a period of BWSTT.20,31 In the present study, BBS scores appear to have varied with the balance demands of the specific intervention. Perhaps body weight support reduced the dynamic balance practice inherent in overground walking. This would support the notion of task-specific training. The weight-support and weight-shift assistance provided early on in strategy B allowed the participant to practice weight transfer in an environment that did not mimic the testing situation and decreased the participants need to practice this component of ambulation.

As suggested by balance scores, one possible explanation for the lack of difference between strategies is the commonality of skill-oriented training in overground walking and BWSTT. All three strategies used with this individual emphasized task-oriented training, with assistance provided to simulate repetitive, forward locomotion through the complete gait cycle. Task-specific practice has been found to be more effective than conventional interventions for gait training for people with acute stroke,52 and it has been suggested that high-intensity task-specific practice may be the most effective strategy for evoking neuroplastic change after stroke.19 Although this case report did not assess neuroplastic difference, our findings appear not to support the hypothesis of practice intensity. Rather, despite a large increase in distance walked per 30-minute training session during strategy B, no differences were seen in rates of 6-MW improvement. This is likely a result of both the participant’s level of impairment and the reduced ecological validity of BWSTT, ie, decrease balance and weight-bearing requirements compared to overground walking. Comparisons of randomized trials and case reports should be performed cautiously, however, and more research is necessary on the value of task intensity and mode of task-specific or task-oriented training.

Another possible explanation for the lack of difference between strategies is that the hospitalization event during strategy B may have masked true differences in functional improvement. However, we believe visual analysis of the first four 6-MW measures of strategy B suggests that BWSTT did not result in an altered rate of improvement compared to time strategy A. Further, no apparent effect of hospitalization was seen on TBWP or BBS measures. Finally, training parameters for BWSTT were derived from previous literature, speed and body-weight support were not highly varied during BWSTT, and no specific schedule of weight-support reduction or treadmill speed increase was used. This may have limited the potential benefit of this strategy.

There are several confounding factors in this case report. The participant was not asked to refrain from changing his daily routine and in fact began a program of assisted cardiovascular exercise and strength training on his own three nights a week during strategy C. He also had his AFO adjusted for greater plantarflexion stop twice during the intervention: once in time strategy A (week 4) and once again in strategy B (week 9). Several changes were made during period C to assist ambulation: he began wearing a neoprene lumbar wrap to alleviate back pain that he felt limited his walking, and a cast shoe was introduced on the left foot to help with clearance of the right foot during swing phase. He reported that both measures made walking easier. Some confounds were beyond our control including a missed week of therapy due to hospitalization.

In addition, several limitations should be considered. The choice of a measure similar to Timed Up and Go (TPBW), the BBS, and the 6-MW may be questioned for an individual who is not a functional ambulator. These measures were chosen for their widespread use and value in assessing functional performance and endurance.53–55 We believed that they would provide a general index of training outcome in terms of ambulation speed and endurance that could be compared to other functional measures in the literature. However, modifications made to TPBW and 6-MW do limit the ability to compare them to other reported values. Additionally, a consistent baseline data set before introduction of the intervention would have allowed for statistical analysis appropriate for single-subject designs, such as C-statistic and celeration line analysis.56 Finally, formal assessment of cardiovascular health and sensorimotor status would assist in the interpretation of these data.

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Clinical Relevance

Community mobility is an oft-cited goal of stroke survivors and a skill that affects quality of life.57 We believe that this participant’s specific goal of walking down an airplane aisle was ambitious, considering his previous mobility status. Despite this, we honored his personal goal and attempted to design activities in strategy C that would allow him to practice this. Overall, this subject proved to be highly motivated, and during each session he challenged himself to walk further distances than in the previous session. Although he did demonstrate improvement in walking speed, endurance, and balance with the interventions, he was never able to advance his right lower extremity without physical assistance. This may reflect that fact that no meaningful strength improvements were noted. Lack of a strengthening effect with BWSTT for some individuals has been reported previously.28 Anecdotally, the participant reported a perception of change in endurance, muscle tone, motor control, and feelings of confidence, which may have contributed to changes in 6-MW, TBPW, and BBS scores. However, we did not formally assess changes in these factors during the intervention, and aerobic fitness, coordination, sensation, perception, cognitive status, and self-efficacy were never formally assessed.

Intervention in this study was limited by the research protocol. This individual’s ambulation ability may have benefited from additional attention to his low back pain, with stretching or a core-strengthening program, and cardiovascular health. Some task-specific training paradigms, such as those for the arm, require an initial level of ability.58 It may be that BWSTT would have been more beneficial for this person had we first addressed strength and endurance59,60 or spasticity to foster less dependence on assistance during ambulation. The bilateral nature of his strokes also may have limited his ability to improve with a challenging, reciprocal task such as walking. Nevertheless, ambulation is an essential component of stroke recovery, and both the individual and the research team believed that gait training was warranted.

In a retrospective interview after training, the subject reported a slight preference for overground walking because he believed that it made him “do more” himself. He was pleased with his participation and achievements after the study, although he would have liked to have increased his short distance ambulation at home. He noted that after the interventions, he was able to complete his ADLs with greater ease and more “fluidly.” There was a consensus among the research team that BWSTT was more physically taxing for us. The physical demands of BWSTT on therapists have been previously noted.29,61 While this should not preclude use of the intervention, it is a necessary component in the consideration of intervention feasibility. The cost of body-weight support systems can also be prohibitive. In populations with cohorts who may realize little superior benefit of BWSTT, conventional physical therapy that incorporates walking practice may be considered appropriate, as it was for this individual. Facilities interested in acquiring a BWSTT system should examine the literature regarding efficacy in their target population.

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CONCLUSION

We conclude that BWSTT was no better than customary task-oriented gait training for a chronic, multiple-stroke survivor who was not a functional ambulator. While some improvement was seen in TPBW, 6-MW, and BBS scores, the rate of change between epochs did not appear to differ markedly. Furthermore, while changes in measured ambulation capacity and balance were substantial and motivating for the subject, the interventions did not result in greater home or community mobility.

Despite the lack of intervention differences, we believe that this report can guide future studies in three important ways. First, a chronic, multiple-stroke survivor who depended on a powered wheelchair for mobility was able to complete an 18-week gait intervention project. Second, there was a capacity for change in ambulation measures even five or more years later in a person with a history of multiple strokes. Finally, the subject reported an increase in feelings of confidence, overall endurance, and desire to engage in further exercise. These benefits should be studied in further detail. In addition, the overall health benefits of increased activity in chronic stroke survivors, regardless of final ambulation status, should not be dismissed. Other benefits of partial weight-bearing activity, such as those to cardiovascular health, should be researched further in a population with multiple, chronic strokes.

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Keywords:

stroke; hemiplegia; walking; ambulation; training; paresis

© 2008 Neurology Section, APTA