Lower Extremity Recovery After Stroke: Nothing New Under The Sun

Research into post-stroke rehabilitation has tipped some sacred cows. Traditional neurofacilitation techniques have generally wilted under the intense glare of clinical research. ¹ Partial weight supported walking had mixed results in the LEAPS trial. Robotic devices seem to provide no benefit beyond that of conventional therapy. But all this bad news is actually good news for a number of reasons.

First, we need to know what doesn't work and what is equivocal. Clinical research is not about coddling the status quo, it's about getting us closer to the truth. And in this regard it is brutal. Once a particular treatment option is tested the researchers are left with the basic question: what does the data say? At that point the data becomes impersonal. It says what it says. The data may tear a hole right through a cherished intervention. But this is a good thing. We need to know what does not work. But there is nuance as well... we may find out that something isn’t AS effective as we thought it was. Or we may find out its effective, but not as effective as other things. Or we may find out that we don't know its level of efficacy. That’s a core irony of research: sometimes research reveals that we just don’t know. I think this is what often makes clinicians in rehab distrustful of research. What research reveals is often muddled, difficult to interpret and delineates few definitive positions. But that's what science does. Physicists argue about the origin of the universe, anthropologists argue about the origin of species, geologists disagree about where the oil is etc. etc. But in healthcare there seems to be this perspective that you're not allowed to be indecisive. You're the clinician; you have to know the answers because the patient is right there in front of you and needs treatment. But maybe it's not indecisiveness. Maybe its thoughtfulness.

Research takes time and it is often difficult to interpret, true. But it also provides the best general guidelines for clinical practice. And it’s not all “bad” news; research does give us clues as to what does work. And what research is revealing about what works for the lower extremity after stroke, well… let’s just say there's not very much new under the sun. What got me thinking about the power of the basics of rehab was a simple statement in a recent systematic review. This was the statement...

Task-specific gait training improves gait post-stroke.

Wow. That's not very research-y. It pretty much says that walking helps retrain walking. Clinicians in rehabilitation have been doing gait training since before Mary McMillan. Then again, nothing should be assumed. I've seen clinical research that questions many of the foundational assumptions from both PT and OT.

So gait training works. That's good to know. What else works to rehabilitate the lower extremities after stroke? Balance training seems to work, although some techniques work better than others. For instance repetitive sit to stand protocols, tai chi, and cycling training seem to work, whereas body vibration, biofeedback in standing practice don't.

Strength training helps lower extremity function. Some clinicians in rehab are concerned that strength training will exacerbate spasticity. Intuitively that makes sense; if you increase the strength of muscles used during walking you will also increase the strength of some overwhelmingly strong spastic muscles, thereby increasing spasticity. But as counterintuitive as it may seem, increasing muscular strength does not increase spasticity. In fact, muscles that are spastic are actually weaker than their counterpart of the contralateral side. Bottom line: muscle strengthening does not decrease motor control and, in some patients at least, increases distance walked and gait speed.

Cardiovascular training seems to be helpful in improving gait post-stroke. In some studies cardio training has been observed to decrease need for assistance during ambulation, and increase walking speed and distance.³  Strength training and cardio training, cornerstones of rehabilitation since its inception may simply work because movement after a stroke is so fatiguing. In fact, fatigue is the leading complaint among stroke survivors. When age matched against folks who don’t exercise but are otherwise healthy, stroke survivors have half as much cardio strength and half as much affected-side strength. And you can add to that the fact that everything a survivor does (usually measured against walking) takes twice as much energy. And energy is essential to implementing most leading edge concepts in lower extremity stroke rehabilitation. For instance, we know that intensity works rehabilitate the lower extremity after stroke. Robust repetitive practice protocols rewire the brain after stroke to provide for better motor outcomes. But patients may not be able to benefit from these protocols because they are simply too pooped to practice. “Banking” energy, through strengthening of the cardiovascular and muscular systems can give survivors a fighting chance on their road to recovery.

So, there it is. What we always thought worked, works.

1. Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence? Stroke 2009;40:e89-e97.
2. Saunders DH, Greig CA, Mead GE, Young A. Physical fitness training for stroke patients. Cochrane Database Syst Rev 2009.