Improving Gait Post-Stroke: Strategies For Rehabilitation And Recovery

Stroke patients often experience gait disorders, which can affect their quality of life and put them at a greater risk of falls and injuries. Gait training and balance training are key components of post-stroke rehabilitation to help patients relearn how to walk, improve their balance and coordination, and increase the strength of their ankles, knees, and hips to support their body when they move.

Some gait deviations observed in patients post-stroke include:

- Decreased stride length

- Decreased stance time on the weakened leg

- Decreased standing balance and stability, especially while weight shifting

- Decreased steps per minute

- Decreased ankle dorsiflexion, limiting foot clearance

These challenges can cause instability while walking, limiting the ability to bear weight through the weaker side of the body.

Some key muscle groups that can benefit from strength training to improve gait quality after a stroke include:

- Hip flexors

- Glutes

- Quadriceps

- Tibialis anterior

Improve hip flexor strength to increase foot clearance and step length

Gait training is a key component of post-stroke rehabilitation. Gait refers to the specific pattern of walking, which requires the coordination of multiple muscle groups and body functions. Gait training exercises aim to improve strength and balance, and target the legs, feet, trunk, and even arms.

Hip flexor strength is crucial for improving foot clearance and step length. Here are some exercises to improve hip flexor strength:

• Step-ups: Stand in front of a step and place one foot on it, followed by the other. Then, step down and repeat several times, alternating between sides. This exercise can be made more challenging by increasing the step height or by not relying on arm support to maintain balance.
• Standing hip flexor march: Stand next to a table, chair, or wall for support. Slowly lift one leg up, hold for two seconds, and then lower. Repeat with the other leg. To increase the difficulty, add ankle weights.
• Seated hip flexor march: Begin seated with one leg lifted, hold for two seconds, and then lower. Repeat with the other leg. To increase the difficulty, add ankle weights.
• Lunges: Take a generous step forward with one foot, keeping your trunk upright. Bend the extended knee and transfer your weight onto the front leg, lowering yourself slowly into the lunge. Step back into the standing position and repeat with the other leg in front.
• Side-stepping: Step to the side with one leg and then follow with the other. Repeat several times and then change directions. This exercise increases glute activation and dynamic stability, especially during lateral weight shifting.
• Forward-to-backward weight shifting: Stand next to a stable object for support. Take a step forward with one foot, and then lift that leg up and move it back behind your body. Repeat several times and then switch sides. This exercise improves foot clearance, pelvis stability, and standing balance.

These exercises can be supplemented with strength training and balance and core exercises to improve gait and overall mobility.

Improve glute strength to increase force generation, step length and gait speed

Improving glute strength can help stroke patients increase force generation, step length, and gait speed. The glute muscle group is responsible for our ability to walk upright without falling over and is central to how we move. When these muscles are weak, it can lead to a ripple effect of issues, including poor mobility, instability, and pain in the pelvic area, hips, knees, and ankles.

To improve glute strength, patients can perform exercises such as:

• Squats: Squats are one of the most effective exercises for strengthening the glutes as they target all three glute muscles. Squats can be performed with body weight or with added resistance such as a barbell or dumbbells.
• Lunges: Lunges are another excellent exercise for targeting the glutes and can also be performed with body weight or added resistance.
• Step-ups: Step-ups target the glutes and hamstrings and can be performed with body weight or added resistance.
• Glute bridges: Glute bridges help target the glutes and core. To perform a glute bridge, lie on your back with your knees bent and feet flat on the floor, then lift your hips as high as possible, squeezing your glutes.
• Clamshell: Clamshells are an excellent exercise for targeting the glutes and hip abductors. To perform a clamshell, lie on your side with your knees bent and feet together, then lift your top knee as high as you can, squeezing your glutes.

In addition to these exercises, patients can also incorporate side lunges, single-leg squats, and side skates into their routine to further strengthen their glutes and improve their gait.

Improve quadriceps and glute strength for improved leg strength and stability

Improving quadriceps and glute strength is key to improving leg strength and stability, which in turn helps stroke patients to walk independently. Here are some exercises to help with this:

• Sit in a chair, lean forward, and use your legs to stand up. Then, slowly lower yourself back into the chair with control, without "plopping". Try not to use your arms to help push you up from the chair. To make this exercise more challenging, add a resistance band around your knees to increase glute activation by abducting, or pushing your legs out, against the band. Alternatively, lower the seat surface to make the movement more challenging.
• Stand with your feet hip-distance apart and, with control, reach your hips back and bend your knees as if you are beginning to sit down. Stop halfway and return to standing, focusing on squeezing your glutes as you do so.
• Lie on your back with your knees bent and feet flat. Draw your stomach in and squeeze your glutes to lift your hips up without arching your lower back, then lower them back down. To increase the difficulty of this exercise, add a resistance band around your knees to increase glute activation by abducting, or pushing your legs out, against the band.
• Stand in front of a wall or counter to hold for support if needed. Step to the side with one leg, then follow with the other. Repeat several times, then change directions and repeat. To increase the challenge, add a resistance band around your knees to increase glute activation when side-stepping. Challenge yourself further by not relying on arm support to maintain your balance.

Improve ankle dorsiflexion strength to improve foot clearance

Improving ankle dorsiflexion strength is an important aspect of gait training for stroke patients. This is because the ankle joint and its surrounding muscles and tendons play a vital role in facilitating everyday movements such as walking, getting up from a chair, or climbing stairs.

For athletes, ankle mobility is crucial for performance, enabling movements such as deceleration, sidestepping, cutting, jumping, and landing.

• Half-Kneeling Ankle Mobility Exercise: This exercise involves getting into a half-kneeling position and placing a stick over the fifth toe. The knee is then brought over the fifth toe outside the stick, driving the calcaneus into inversion and locking out the midfoot and subtalar joint. This targets the posterior ligaments and helps to increase dorsiflexion.
• Pivoting: Ask your patient to plant one foot and rotate or pivot, planting the opposite foot. Ensure they are putting load through the ball of the big toe of the planted foot, creating inversion eversion opposition. This will target the medial deltoid and help improve ankle range of motion.
• Slouch Exercise: Place a towel on the floor and ask your patient to place their forefoot on the towel. They should then slouch, keeping their chin down, and leading with the fingers to the floor. Ask them to push through the pad of the big toe to target the flexor hallucis longus.
• Foam Rolling: Use a foam roller to roll the length of the calf, hitting all aspects of the muscle. This will help to improve ankle dorsiflexion by releasing tension in the calf muscles.
• Wall Lean Stretch: Place your foot up on a wall or step and lean your body in to stretch the calf. This will help to improve ankle dorsiflexion and stretch the Achilles tendon and plantar fascia.

Improve single-leg strength and stability when standing and weight shifting

Improving single-leg strength and stability when standing and weight shifting is a key component of gait training and can help stroke patients regain the ability to walk independently. Here are some exercises to help with this:

• Side-stepping with a resistance band around your knees to increase glute activation and dynamic stability and balance with lateral weight shifting.
• Forward-to-backward weight shifting to improve foot clearance, pelvis stability, and standing balance with weight shifting.
• Step-ups to increase hip flexor strength to improve foot clearance, and increase single-leg strength and stability when standing and weight shifting.
• Chair stands to increase quadriceps and glute strength for improved leg strength and stability.
• Standing or sitting leg lifts to increase hip flexor strength for improved foot clearance, and increase single-leg strength and stability when standing and weight shifting.

Frequently asked questions