Gait rehabilitation

after stroke
S. Hesse

Klinik Berlin, Dept. Neurological

Rehabilitation, Free University Berlin
www.reha-hesse.de
 Agenda
• Principles of locomotor therapy after stroke
• The non-ambulatory patient
• The ambulatory patient
• Future
• Conclusion
Patients wish to walk
Tone inhibiting and gait preparatory
maneuvers were dominating
Task specific repetitive approach
 Treadmill
training with
partial body
weight support
(BWS)
Theoretical background:
activation of spinal and supraspinal
locomotor pattern generators
• Recovery of full-weight-bearing
stepping in the adult spinal cat
• In primates however: spinal step
generators depend more on supraspinal
inputs
Avoid swinging in the harness

major peripheral drives

of the locomotor
centers:

- hip extension and

- loading/deloading
 Treadmill training in chronic patients

A1 B A2
TM PT TM

S
t
a
n
d

Meßzeitpunkte

TM: 3 weeks treadmill training, Hesse et al, 1995

PT: 3 weeks physiotherapy
 Miyai et al 2003:
after locomotion therapy shift
towards the affected
hemisphere
 Gait trainer GT I:
less effort - more intense

Treadmill training is strenuous

 Two systems

Lokomat

Gait Trainer GT I
Functional Electrical Stimulation on
the Gait Trainer
 DEGAS
DEutsche GAngtrainer Studie

• Multicentre RCT – single blind

• 155 subacute first time stroke patients, non-
ambulatory
• Primary variables: Functional Ambulation
Category (FAC, 0-5), Barthel Index (BI, 0-
66)
• Secondary variables: gait velocity,
endurance, Rivermead Mobility Index and
Gross Function
 Intervention

Group A Group B
Every workday for weeks, i.e.
20 sessions

20 min Gait
Trainer

+ Content of PT:

25 min - stance 45 min

Physiotherapy - gait Physiotherapy
Functional Ambulation Category

Functional Ambulation Category (FAC, 0-5)

5 FAC [0-5]

Gruppe A

3 Gruppe B

0 [t]
Studienbeginn nach 2 Wochen nach 4 Wochen nach 6 Monaten
FAC (0-5) FAC (0-5)
after 4 weeks after 6 months

Responder
= FAC 4,5

Non-
Responder
= FAC 0-3
Barthel Index
Barthel Index (0-100)

100 BI [0-100]

90

80

70 Gruppe A

Gruppe B
60

50

40

30

20

10

0 [t]
Studienbeginn nach 2 Wochen nach 4 Wochen nach 6 Monaten
Barthel Index (0-100) Barthel Index (0-100)
after 4 weeks after 6 months

Responder
= BI ≥ 75

Non-
Responder
= BI < 75
 Future:
KineAssist
Future: „String-Man“ and virtual reality
Very near future: HapticWalker,
a robotic gait trainer
The ambulatory patient

• Gait Quality
• Speed
• Aerobic Fitness
in: Stroke 2002;33:553-57
Mean Walking Energy Cost of
Hemiparetic Subjects on the Belt
16 [J/kg/m]
14
12
10
8
6
4
2
0
v-slow v-self-adopted v-fast

THE FASTER YOU WALK, THE LESS ENERGY YOU NEED

 Mean Heart Rate
160 [beats/min]

150
140
130
120
110
100
90
80
v-slow v-self-adopted v-fast

Mean Lactate ---- = aerobic threshold

5 [mmol/l]
4
3
2
1
0
v-slow v-self-adopted v-fast
THR = (HRmax – HRrest)*0.6 + HRrest
 1,2

Maximum walking speed [m/s]

0,8

Group A
0,6 Group B

0,4

0,2

0 Time [wk]
week 0 week 6 week 18

350

300

250
Maximum walking capacity [m]

200
Group A
Group B
150

100

50

0 Time [wk]
week 0 week 6 week 18
 Conclusion
Who wants to regain walking, has
to walk!

• Non-ambulatory stroke patients: automated gait

training
• Ambulatory stroke patients: treadmill training to
increase speed and fitness