Article: Sharon - Will I Be Able To Walk?

Sharon - SSTattler

One of the first things therapists are often asked on admission is, “Will I be able to walk?” Predicting walking outcomes post-stroke is a  challenge for health professionals.

In a very recent study (Scrivener, Sherrington, & Schurr, 2012), the authors looked at records of 191 stroke survivors admitted to a comprehensive stroke unit to determine what predicted walking recovery.  The best predictor was receiving more than the average amount of exercise repetitions (703) in the first week.  So amount or intensity of exercise in the first week is critical.

While this is a single study and the findings are likely important because it is published in a reputable peer reviewed journal and it also fits with other studies that find early and intensive rehabilitation critical to superior recovery both early and long term physical functional (walking and arm movement).


Elizabeth Preston’s group (2011) completed a systematic review of many walking studies to find the answer to just that question asked by many people who are not walking ask immediately after their stroke --  “What is the probability of patients who are nonambulatory after stroke regaining independent walking? “  Seventeen studies comprising 2856 participants were entered into their meta-analyses.  This was the first systematic review to pool data from prospective, consecutive studies of patients who were nonambulatory in the first month after stroke to determine the probability of regaining independent walking.

So what were the results?  A substantially greater proportion of patients managed in a rehabilitation unit regained independent walking at three months compared with those managed in an acute unit.

Rehabilitation Units: At 3 months -- 60% of initially nonambulatory stroke patients regained independent walking and this increased to 65% by six-months after stroke.

Acute Care Units: A three-months only 39% of initially nonambulatory stroke patients regained independent walking. However, at six-months after stroke, a similar proportion of patients managed in an acute unit (69%) regained independent walking to those managed in a rehabilitation unit.

The authors provide several explanations for the difference between the two units in 3 month walking outcomes:

1. Survivors admitted to a rehabilitation unit have generally been selected as being likely to benefit from a prolonged period of rehabilitation, thus increasing the probability of this population regaining independent walking, compared with an unselected population of patients managed in an acute unit after stroke. 
2. People admitted to an acute unit after stroke can include those with severe stroke, including those with significant physical and cognitive impairment. The severity of impairments in these patients would also contribute to a reduced probability of regaining independent walking for patients managed in an acute unit. 
3. The outcome of stroke is associated with intensity of therapy and rehabilitation units are designed and resourced to provide a greater intensity of therapy than acute units, thus increasing the probability of improved walking outcomes in these patients.

Holland and colleagues (2011) take this one step further. They wanted to know what helped stroke survivors to resume functional walking — being able to walk according to whatever the environment demands. Functional walking means that rehabilitation must restore a coordinated gait pattern which may be defined as, ‘‘an ability to maintain a context-dependent and phase-dependent cyclical relationship between different body segments or joints in both spatial and temporal domains.’’

Environmental demands are very important of functional walking.  Some stroke survivors might be able to walk confidently inside the house or a shopping mall, but are very unsure of their balance outside where there might be more environmental challenges like uneven sidewalk, holes in the pavement, or hills to climb.  Holland identified four main interventions that directly targeted functional walking:

1. task specific locomotor training (over ground and treadmill training with or without body weight support),
2. ankle foot orthotics (AFO) and functional electrical stimulation (FES), 
3. auditory cueing,  and 
4. exercise. 

Treadmill training provides repetitive practice of a more normal walking pattern, while auditory cueing provides stroke survivors with feedback.  AFOs prevent foot-drop and promote heel contact, while exercise improves coordination and fitness.

When considered individually, each type of intervention improved gait function, but for co-ordination, the only intervention to show a significant benefit was auditory cueing. In other words, someone to cue survivors to improve their walking pattern seemed to be the most helpful at restoring normal walking patterns.

References:

• Hollands, K. L., Pelton, T. A., Tyson, S. F., Hollands, M. A., & van Vliet, P. M. (2012). Interventions for coordination of walking following stroke: Systematic review. Gait & Posture, 35(3), 349-359. doi: 10.1016/j.gaitpost.2011.10.355 
• Preston, E., Ada, L., Dean, C. M., Stanton, R., & Waddington, G. (2011). What is the probability of patients who are nonambulatory after stroke regaining independent walking? A systematic review. International Journal of Stroke, 6(6), 531-540. doi: 10.1111/j.1747-4949.2011.00668.x 
• Scrivener, K., Sherrington, C., &  Schurr, K. (2012).  Amount of Exercise in the First Week After Stroke Predicts Walking Speed and Unassisted Walking .  Neurorehabilitation and Neural Repair, 26 (8); 932-938   DOI: 10.1177/1545968312439628 (if you want more information about this article, please email us to SSTattler).