(Australian) Stroke Foundation guideline recommendations for improving walking after stroke

//(Australian) Stroke Foundation guideline recommendations for improving walking after stroke

(Australian) Stroke Foundation guideline recommendations for improving walking after stroke

By |2019-05-26T12:17:38+00:00June 23rd, 2019|Practice Tips|Comments Off on (Australian) Stroke Foundation guideline recommendations for improving walking after stroke

Article by Simone Dorsch

The Stroke Foundation’s clinical guidelines for rehabilitation contain a guideline for improving walking after stroke that is a STRONG recommendation:

Stroke survivors with difficulty walking should be given the opportunity to undertake tailored repetitive practice of walking (or components of walking) as much as possible. (French et al. 2016 [173])

This StrokeEd Blog will share our interpretation of this guideline recommendation. Three points will be discussed:

  • “Tailored” repetitive practice of walking
  • “Components” of walking
  • “As much as possible”

Repetitive practice of walking is evident – but what is meant by the term “tailored”?  We interpret this to mean practice of walking that is tailored to eac h stroke survivor’s specific problems. Some examples of common problems, and training strategies to address those problems, could include:

Problem = decreased stance time on affected leg

Training strategies=

  • Walking with auditory cueing of cadence (Nascimento et al 2015)
    • Note- see StrokeEd Blog on cueing of cadence
  • Visual cueing of cadence
    • Walking with visual cues for increased step length/symmetrical steps

Problem = decreased hip/knee/ankle flexion to clear the ground in swing

Training strategies =

  • Walking with an obstacle course
  • Walking on treadmill with increasing speeds and inclines

Problem = walking with knee hyperextension

Training strategies =

  • If stroke survivor can prevent knee hyperextension, walking with feedback device to indicate knee hyperextension
  • If stroke survivor cannot prevent knee hyperextension – strategies to reduce hyperextension (Note: I don’t know of any evidence for these) can include;
    • applying rigid tape to back of knee while the knee is flexed
    • applying a firm bandage in figure of 8 while knee is in 90 degrees flexion
What is meant by “components” of walking? We interpret this to mean practice of a component of walking that the stroke survivor cannot perform well. By implication, they need to do ‘part-practice’ of walking.  Using the examples of common problems described above, we have suggested

Problem = slow walking with decreased stance time on affected leg

Training strategies that target a component:

  • Stepping intact leg forward and back with visual cues for distance and base of support and for hip extension if necessary

  • Stepping intact leg on/off a block with cues to maintain extension of affected leg if necessary ie standing with back to wall

Problem = decreased hip/knee/ankle flexion to clear the ground in swing

Training strategies that target a component:

  • Stepping affected leg forward and backward with visual cues for distance
    • To encourage more ankle dorsiflexion
      • verbal cueing to achieve heel strike will focus attention on ankle dorsiflexion
    • To decrease hip circumduction
      • place block to side of affected leg, stroke survivor needs to try to avoid the block
    • Stepping affected leg on and off a block
      • To encourage more ankle dorsiflexion
        • place the block immediately in front of affected foot as foot will catch edge of block if no dorsiflexion
      • To encourage more hip/knee flexion
        • place a higher block in front of affected leg

Problem = walking with knee hyperextension

Training strategies that target a component:

  • Stepping intact leg forward and back with visual cues for distance
    • To encourage shank to move forward over foot (this will reduce knee hyperextension)
      • use verbal instruction “bring knee forward over your foot”
      • use tactile cue, knee needs to move forward to touch cue

While we do not know the dosages of practice needed to change a person’s performance, there is a dose-response relationship (ie more practice = better outcomes). To provide opportunities for people to do as much practice as possible, the following strategies can be used:

  • Semi-supervised practice (ie circuit classes, workstations set-up in gym environment for safe practice)
  • Independent practice