Stroke Recovery: Regaining Mobility And Walking Again

A stroke can cause a person to lose the ability to walk, but it is possible to regain this ability through rehabilitation. The likelihood of this depends on several factors, such as the type of stroke, its severity, the person's age, and the intensity of rehabilitation.

Rehabilitation should begin as soon as the patient is stable, and typically involves physical therapy to improve movement, coordination, and strength. This can include passive stretches, active exercises, and therapeutic modalities such as massage or electrical stimulation. Gait training is also beneficial, as it focuses on improving walking patterns and can involve walking on different surfaces to improve safety and independence.

Most people who have had a stroke regain the ability to walk within six months, but for some, it may take a few years, and some may never walk independently again. The majority of improvements occur within the first six months, and early rehabilitation is associated with better outcomes.

Gait rehabilitation

• Conventional gait training (over-ground gait training)
• Strength training
• Neuromuscular re-education (NMR)
• Body weight supported treadmill training
• Functional electrical stimulation (FES)
• Robotic-assisted training
• Setting goals according to specific rehabilitation aims of an individual might improve the outcomes.
• Good rehabilitation outcome seems to be strongly associated with a high degree of motivation, and engagement of the patient and their family.
• Cognition is strongly related to successful rehabilitation. Attention is a key factor for rehabilitation in persons with stroke as poorer attention performances are associated with a more negative impact of stroke disability on daily functioning.

Passive and active exercises

Passive exercises are those in which the patient's body is moved by an external force, such as a therapist or trained caregiver. They are often used when the patient has little to no active movement in their legs. Passive exercises can be used to improve flexibility, prevent contractures, increase blood flow, and stimulate the brain. Passive exercises often focus on ankle, knee, and hip movement, and can be combined with mental practice, such as visualising oneself performing targeted movements, to enhance results. As movement improves, patients may be able to move on to active exercises.

Active exercises, on the other hand, involve using one's own strength to perform a specific movement. Both leg and core exercises are essential for regaining the ability to walk. Weights and resistance bands may also be added as needed. Some examples of active exercises include:

• Seated marches: raising one leg at a time towards the chest as if marching, then relaxing the leg back down.
• Toe taps: raising the toes off the floor and then lowering them back down.
• Sit-to-stands: beginning in a seated position and pushing up to standing, using support if needed, before returning to sitting.

Gait training is a specialised method for relearning to walk after a stroke. It focuses on improving walking patterns and is especially beneficial for individuals who have sufficient movement and strength to walk but have not yet achieved their normal gait pattern. Gait training can include leg, core, and even arm exercises, as well as walking practice with real-time feedback from a physical therapist. It may also involve walking on different surfaces or navigating sidewalks and curbs to improve safety and independence.

Gait training

• Passive exercises: These involve gentle stretches, often performed by a therapist or trained caregiver. They may be used to improve flexibility, prevent contractures, increase blood flow, and stimulate the brain.
• Active exercises: These involve using one's own strength to perform a specific movement. Both leg and core exercises are essential for regaining the ability to walk. Weights and resistance bands may also be added as needed.
• Gait training: This is the most specialized method for relearning to walk after a stroke. It focuses on improving walking patterns and is especially beneficial for individuals who have sufficient movement and strength to walk but have yet to achieve their normal gait pattern.
• Aquatic therapy: Warm pool water can relax muscles and aid in pain relief. Moving against water resistance can help improve muscle strength, and the buoyancy of water allows individuals to practice moving with less weight on their joints and can reduce the fear of falling.
• Treatment modalities: Physical therapists may also utilize treatment modalities like massage or electrical stimulation (e-stim) to improve walking after a stroke.
• Conventional gait training: This involves breaking down parts of the gait cycle, training and improving the abnormal parts, and then reintegrating them into ambulation to return to a more normal gait cycle.
• Strength training: All rehabilitation programs will involve strength training, which can be performed as a formal exercise program or through functional activities.
• Neuromuscular re-education (NMR): This involves neurofacilitation techniques to inhibit excessive tone, stimulate muscle activity, and facilitate normal movement patterns through hands-on techniques.
• Bodyweight-supported treadmill training (BWSTT): This involves the use of a suspension system with a harness over a treadmill for gait training. The person with a stroke is secured in the harness for fall prevention and can be unweighted by the suspension system, reducing the amount of weight bearing through their lower limbs.
• Functional electrical stimulation (FES): FES is a useful modality for rehabilitation after a stroke and can supplement NMR and strengthening interventions. It is used to elicit action potentials in the peripheral nerves of axonal branches and generate muscle contractions via surface electrodes placed over a muscle group.
• Robotic-assisted training: Robotic devices provide safe, intensive, and task-oriented rehabilitation to people with mild to severe neurological injury. They provide precisely controllable assistance or resistance during movements, good repeatability, objective and quantifiable measures of subject performance, and increased training motivation through the use of interactive biofeedback.

Mobility aids

• Front-wheeled walkers
• Four-wheeled walkers
• Canes
• Wheelchairs

As stroke survivors improve their strength, balance, and coordination, they may transition to less stable walking devices or walk unaided. However, for optimal outcomes, survivors should use any walking device recommended by their therapist and consistently practice their rehabilitation exercises.

In addition to these standard mobility aids, there are also exercise devices that can aid in stroke recovery:

• Anti-gravity treadmills: These treadmills can support a user's body weight, allowing individuals to practice walking even if they lack the strength or endurance to walk independently.
• Recumbent cross-trainers: These devices allow individuals to sit while moving their arms and legs in a gliding motion, activating muscles used during walking.
• Stationary bikes: These are particularly useful for individuals with hemiplegia or severe hemiparesis, as the non-affected leg can assist the affected leg.
• Home rehabilitation devices: These can provide personalized exercises and encourage high repetition, which is key to neuroplasticity and rewiring the brain.

Home exercises

Regaining the ability to walk after a stroke is a significant goal in post-stroke rehabilitation. Gait training and balance training are crucial components of this process, helping individuals improve their balance and coordination, strengthen their lower body, and regain the ability to walk independently.

Ankle Dorsiflexion

• Loop a resistance band around your foot, pulling your foot downwards.
• Activate your tibialis anterior by drawing your foot up towards your body.
• Increase resistance by using a stronger resistance band.

Hip Flexor Strengthening

• Sitting: Lift one leg, hold for 2 seconds, then lower. Repeat with the other leg.
• Standing: Stand next to a stable object for support. Weight shift onto one leg and slowly lift the other leg. Hold for 2 seconds, then lower. Repeat on the other side.
• Progression: Add ankle weights to increase difficulty.

Glute Strengthening

• Lie on your back with knees bent and feet flat. Draw your stomach in and squeeze your glutes to lift your hips, then lower.
• Progression: Add a resistance band around your knees to increase glute activation.

Quadriceps and Glute Strengthening

• Sit in a chair, lean forward, and use your legs to stand up.
• Slowly lower yourself back into the chair without "plopping". Try not to use your arms for support.
• Progression: Add a resistance band around your knees to increase difficulty.

Side Stepping

• Step to the side with one leg, then the other. Repeat several times, then change directions.
• Progression: Add resistance bands around your knees to increase glute activation.

Forward-Backward Weight Shifting

• Stand next to a stable object for support.
• Step forward with one foot, then lift that leg and move it behind your body. Repeat several times, then switch sides.
• Progression: Add ankle weights to increase difficulty.

Step-ups

• Stand in front of a step. Step up with one foot, then the other, then step down. Repeat several times, then switch sides.
• Progression: Increase step height for added difficulty.

These exercises can help improve strength and balance, which are crucial components of post-stroke rehabilitation. It is important to note that a high degree of motivation, engagement, and participation is required from the patient for optimal outcomes.

Frequently asked questions