Basic rules

As in the case of regaining arm and hand movements, the following five basic rules apply to regain walking after a stroke.

This post looks at the evidence about how caregivers should apply the above rules to regain walking ability.

Assess severity

The journey begins with a severity assessment. A specially trained physiotherapist should assess and start physiotherapy according to the NICE guidelines¹.

Start early

Starting to move as early as possible, between 24 – 48 hours², after stroke yields better recovery of walking ability as in the case of all other recovery efforts. Strong evidence exists that early movements followed by intense training sessions improve gait and leg function³. The National Guidelines for stroke² recommend the following for those with difficulty in moving but are medically stable;

• Frequent, daily movements – sitting-out-of-bed, standing, walking – assisted by trained staff
• Movments should begin within 24 hours after the stroke incident only by those with no/little assistance.

Choose meaningful activities and exercises

The new neurons, who take over the tasks previously done by their dead neighbours need training. The NICE Guidelines¹ recommend the following task-specific activities;

Sit-to-stand

Sit-to-stand is essential for walking. In 2014, a Cochrane systematic review by Pollock et al.⁴ found that sit-to-stand exercise improved the time taken to stand and the weight held by the affected leg. This review included only those who were able to stand or walk independently.

The 2021 Australian Guidelines⁵ strongly recommend the following for those who have difficulty standing;

• Practising functional tasks while standing
• Activities that challenge balance such as overground walking, obstacle courses
• Provide visual/auditory feedback

The 2016 French et al. Cochrane review of 20 RCTs found that overground walking improves leg function and walking distance, but not balance³. This is a strong evidence.

Walking

The 2021 Australian Guidelines⁵ strongly recommend that those with difficulty walking need support for “tailored repetitive practice of walking as much as possible”. It recommends circuit class therapy and a treadmill with or without body weight support.

Those who can walk independently need treadmill training with or without body weight support. And, those who need support to walk need mechanical-assisted gait training including body weight support.

This training should be of adequate intensity, progressive, task-specific and challenging to improve outcomes.

Exercise bike

According to The 2020 Stroke Rehabilitation Clinicians Handbook³, cycling on an exercise bike may be beneficial to improve balance, activities of daily living, and leg function, but not gait, muscle strength, and spasticity.

Trunk training

• Those who have impaired sitting balance require trunk training exercises¹.
• Those with significant impairment in balance and walking ability require progressive balance training¹.
• Those with moderate to severe walking ability should be assessed for walking aids¹.

Walking aids

Those with moderate to severe walking impairment in walking ability need walking aids¹. We can find several varieties of walking aids or devices. You can find useful information about walking sticks (canes) for stroke patients.

Ankle-foot orthosis

Those with significant impairment in balance and walking ability may need ankle-foot orthosis¹.

Aerobic and muscle-strengthening exercises

The Stroke Rehabilitation Clinicians Handbook³ recommends aerobic and muscle-strengthening exercises for all,

• Those who can walk with or without assistance
• Those who use wheelchairs
• Trunk training for balance

Repeat the chosen activities progressively

Strong evidence exists that early intense training improves gait and leg function².

The word intensity refers to the number of repetitions within an hour or any time duration.

Further reading

• Basic rules to recover movements after a stroke
• Best practices to recover arm and hand movements after stroke

References

1. National Institute for Health and Care Excellence (NICE): NICE Pathways. Managing movement difficulties after stroke. Accessed on June 4, 2021.
2. Royal College of Physicians (2016): National Clinical Guidelines for Stroke, Fifth Edition, 2016, NICE accredited. accessed May 26, 2021.
3. Stroke Rehabilitation Clinicians Handbook (2020): ebrsr, http://www.ebrsr.com/sites/default/files/Chapter%203_Lower%20Extremity_2020_ML.pdf
4. Pollock  A, Gray  C, Culham  E, Durward  BR, Langhorne  P. Interventions for improving sit‐to‐stand ability following stroke. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD007232. DOI: 10.1002/14651858.CD007232.pub4. Accessed 05 June 2021.
5. Australian Clinical Guidelines for Stroke Management (2021): Chapter 5: Rehabilitation. Accessed on June 6, 2021