Training for walking after stroke

Repetitive training that simulates everyday leg function can help people walk more easily after stroke, according to a new review of studies.

Practicing everyday tasks resulted in modest gains in walking speed, walking distance and patients' ability to stand up, the review found.

The analysis appears in the latest issue of The Cochrane Library , a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

“People who had repetitive task training were able to go 50 meters farther in six minutes compared to people who hadn't,” said lead review author Beverley French. She is a senior research fellow at the University of Central Lancashire in England.

In the real world that distance equates to being able to cross an intersection while the walk sign remains lit or to go from a parking lot into a grocery store, she said.

The review gathers evidence from 14 trials with more than 650 study participants.

In the studies, patients repeatedly practiced everyday tasks or the movements associated with the tasks, like buttoning clothes, walking up steps, reaching for items on shelves or standing up from sitting.

“The idea of repeatedly practicing tasks is based on the thought that you can re-pattern the damaged brain,” French said.

The analysis found that repetitive task training is effective — and does result in health gains for stroke patients — but did not determine whether the approach is better than other rehabilitation interventions.

French said that repetitive task training is not a method of therapy; rather, many therapies can incorporate the technique as “an underpinning for everything a therapist does with a patient.”

The therapy typically lasted for one-hour sessions, three to five times a week for six to eight weeks. Researchers tested both arm and leg mobility in the studies, but the review only found significant improvements for lower limb function. Moreover, it is not clear if the gains in leg mobility were permanent.

“The measurement of lasting effects wasn't good enough to be conclusive,” French said.

The analyzed studies included a mix of patients, people who had had a stroke recently and those who suffered a stroke years in the past. Both groups of patients experienced similar health gains.

“There's this idea that people with chronic stroke can't improve; our evidence didn't support that,” French said.

One other review in the current issue of The Cochrane Library also explores gait training —assisting people with walking ability — after stroke.

That review found that physical therapy after stroke that incorporated electromechanical devices for gait training was better than usual care.

The programmed robotic devices support and steady a patient's body weight while footplates guide the legs through repeated walking movements. People who rely on a wheelchair and are unable to stand or walk alone are the most common users of the devices.

All of the electromechanical devices analyzed in the review performed about equally.

“Gait training with electromechanical devices is better than without such devices if ambulation is the main goal of people who have had a stroke,” said lead review author Jan Mehrholz.

He is a researcher in the Department of Public Health, Technical University of Dresden and physical therapist in the Department of Early Rehabilitation at The Klinik Bavaria in Kreischa, Germany.

Mehrholz said the devices increased the chance that patients regained the ability to walk without help.

“Walking dependency is a major problem after stroke for patients and their relatives,” Mehrholz said. “To be able to walk without any assistance is therefore a major goal for many people.”

“If electromechanical devices are used in gait rehab, one of four people with stroke would now be able to walk alone again,” he said. Three of four people with stroke remain dependent in walking or need assistance even if they use the devices in rehabilitation.

The Cochrane analysis compiles evidence from eight studies, including both published and unpublished data, on more than 400 participants.

The health gains documented in the review might allow a patient to move around at home, in the bath or kitchen.

However, rehabilitation researcher Clare Bassile says health professionals are also looking for evidence of therapies that get stroke patients moving outside of the home.

“This review doesn't really address the patient's community ambulation abilities. It makes it look like they are doing great, but we can't know if they can get out and manage in the community,” said Bassile, assistant professor of clinical physical therapy in Columbia University's Program in Physical Therapy.

Therapists use electromechanical gait-training devices infrequently in the United States.

“I haven't come across any in New York City. We are reading about them and we are hearing about them, but mostly they are being used in laboratory settings for research. They are quite expensive and it's mostly just big research centers that have them on loan from the manufacturer,” Bassile said.

French B. et al. Repetitive task training for improving functional ability after stroke (Review). Cochrane Database of Systematic Reviews 2007, Issue 4.

Mehrholz J. et al. Electromechanical-assisted training for walking after stroke (Review). Cochrane Database of Systematic Reviews 2007, Issue 4.

The Cochrane Collaboration is an international non-profit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.