Posts Tagged gait training

[Abstract] Lessons learned from robotic gait training during rehabilitation: Therapeutic and medical severity considerations over 3 years


BACKGROUND: Robotic exoskeletons are increasingly available to inpatient rehabilitation facilities though programmatic implementation evidence is limited.

OBJECTIVE: To describe therapists’ clinical practice experiences with robotic gait training (RGT) over 3 years during inpatient rehabilitation. 

METHODS: Therapists participated in a survey and semi-structured focus group to discuss their RGT experiences. Interviews were recorded, transcribed, and analyzed using a theoretical analysis-driven thematic approach.

RESULTS: Therapists averaged 7.6 years of neurologic rehabilitation experience and 1.85 years with RGT. Eight of 10 therapists had completed ⩾ 50 RGT sessions, with frequency of 1–5 sessions/week, including on-label (spinal cord injury, stroke) and off-label (e.g., traumatic brain injury) experiences. Three adverse events occurred over 716 RGT sessions with 186 patients. Qualitative analysis identified three major themes and corresponding subthemes: 1-Comparison with traditional gait training approaches (6 sub-themes), 2-Clinical decision-making considerations (3), and 3-On-label and off-label utilization (4). Stated RGT benefits included decreased therapists’ physical burden and increased patient motivation. Clinical concerns with RGT included tonicity, continence, and patient communication (e.g., aphasia). Off-label RGT was used to overcome barriers in traditional gait therapy and achieve early mobility.

CONCLUSIONS: Therapists’ level of training and clinical knowledge furthered RGT implementation and allowed for safe utilization with on-label and off-label patients.


, , , , , ,

Leave a comment

[WEB SITE] Gait Training & Ceiling Mounted Physical Therapy System – Gorbel Rehabilitation


Gorbel Rehabilitation

“We Improve People’s Lives” is the cornerstone in Gorbel’s Mission. Improving the safety, efficiency and quality of gait training and balance therapy is our fundamental purpose with each device we design, develop and manufacture. Our best opportunity to meet this objective has always been by working directly with the people we aim to serve; rehabilitation therapists. Whether it is a body weight support system, a rehabilitation harness, or a fall protection mobility trainer, the contributions of therapists are evident in every product in the SafeGait Solutions for rehabilitation.

Dynamic Gait and Mobility Products









For more visit site —–>

, , , ,

Leave a comment

[Abstract] State-of-the-art robotic gait rehabilitation orthoses: Design and control aspects


Background: Robot assisted gait training is a rapidly evolving rehabilitation practice. Various robotic orthoses have been developed during the past two decades for the gait training of patients suffering from neurologic injuries. These robotic orthoses can provide systematic gait training and reduce the work load of physical therapists. Biomechanical gait parameters can also be recorded and analysed more precisely as compared to manual physical therapy.
Objectives: A review of robotic orthoses developed for providing gait training of neurologically impaired patients is provided in this paper. Methods: Recent developments in the mechanism design and actuation methods of these robotic gait training orthoses are presented. Control strategies developed for these robotic gait training orthoses in the recent years are also discussed in detail. These control strategies have the capability to provide customised gait training according to the disability level and stage of rehabilitation of neurologically impaired subjects.
Results: A detailed discussion regarding the mechanism design, actuation and control strategies with potential developments and improvements is provided at the end of the paper.
Conclusions: A number of robotic orthoses and novel control strategies have been developed to provide gait training according to the disability level of patients and have shown encouraging results. There is a need to develop improved robotic mechanisms, actuation methods and control strategies that can provide naturalistic gait patterns, safe human-robot interaction and customized gait training, respectively. Extensive clinical trials need to be carried out to ascertain the efficacy of these robotic rehabilitation orthoses.


via State-of-the-art robotic gait rehabilitation orthoses: Design and control aspects | Request PDF

, ,

Leave a comment

[Abstract] A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors



Stroke is a leading cause of death and disability in the Western world, and leads to impaired balance and mobility.


To investigate the feasibility of using a Virtual Reality-based dual task of an upper extremity while treadmill walking, to improve gait and functional balance performance of chronic poststroke survivors.


Twenty-two individuals chronic poststroke participated in the study, and were divided into 2 groups (each group performing an 8-session exercise program): 11 participated in dual-task walking (DTW), and the other 11 participated in single-task treadmill walking (TMW). The study was a randomized controlled trial, with assessors blinded to the participants’ allocated group. Measurements were conducted at pretest, post-test, and follow-up. Outcome measures included: the 10-m walking test (10 mW), Timed Up and Go (TUG), the Functional Reach Test (FRT), the Lateral Reach Test Left/Right (LRT-L/R); the Activities-specific Balance Confidence (ABC) scale, and the Berg Balance Scale(BBS).


Improvements were observed in balance variables: BBS, FRT, LRT-L/R, (P < .01) favoring the DTW group; in gait variables: 10 mW time, also favoring the DTW group (P < .05); and the ABC scale (P < .01). No changes for interaction were observed in the TUG.


The results of this study demonstrate the potential of VR-based DTW to improve walking and balance in people after stroke; thus, it is suggested to combine training sessions that require the performance of multiple tasks at the same time.


via A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors. – PubMed – NCBI

, , , , , , , , , , ,

Leave a comment

[WEB PAGE] Gait Training: Keep it Challenging

Published on 

At Kessler Institute for Rehabilitation an individual utilizes a body-weight-support system over ground with addition of manual facilitation, as needed, to minimize errors or compensatory strategies.

At Kessler Institute for Rehabilitation an individual utilizes a body-weight-support system over ground with addition of manual facilitation, as needed, to minimize errors or compensatory strategies.

By Katherine De Tata, PT, DPT, and Justine Mamone-Lucciola, PT, DPT

Individuals who have survived a cerebrovascular accident (CVA) or an acquired brain injury (ABI) commonly present to an inpatient rehabilitation facility (IRF) with impairments that result in poor walking abilities. These impairments are addressed by a physical therapist who utilizes a variety of interventions to train proper walking mechanics and incrementally increase the timed intervals or measured distances of walking each therapy session. For those who are “not ready” to walk, the emphasis is traditionally placed on improving hemodynamic stability and upright tolerance first. Safe walking abilities, however, play a significant role in the determination of whether an individual discharges to home versus a skilled nursing facility.1 Upon admission to a facility such as Kessler Institute for Rehabilitation (KIR), headquartered in West Orange, NJ, there is often a limited length of stay that an individual is afforded to improve his/her walking ability and prepare for a return to home. Based on the severity of the injury, the typical length of stay across the country in an IRF is 9 days to 22 days.2 Hornby and colleagues indicated that substantial recovery in lower limb motor function, which is directly related to improved walking capacity, often occurs in the first 3 months following a stroke.1 With that being said, early and intense inpatient rehabilitation with a strong emphasis on walking is crucial within the time allotted.

Challenge of Gait Training

The overarching goal while in an IRF is for safe discharge to home with as little burden of care as possible and clinically, the most commonly reported goal of an individual receiving inpatient rehabilitation is to return to walking. Conventional therapeutic interventions used in an IRF are designed to address the vast number of impairments and functional limitations that may be present, yet with only 34% of time devoted to gait training.1,3 The remainder of the time spent within a therapy session is dedicated to lower extremity exercise (27%), balance (15%), and transfers (11%) with smaller percentages devoted to other areas, such as stair negotiation and upper extremity exercise.1 At KIR, physical therapists use conventional rehabilitation approaches including balance re-training, sensory integration, pre-gait activities, transfer training, gait and elevation training, and functional electrical stimulation as well as advanced technology that are incorporated into a plan of care. As for gait training, a variety of methods are used over ground as well as with the use of a treadmill.

One of the methods commonly used in gait training is incorporating a body weight support (BWS) system with the addition of manual facilitation, as needed, to minimize errors or compensatory strategies. Walking conditions are also varied by incorporating uneven surfaces, multi-directional stepping, obstacle negotiation, providing resistance, and dual tasking for a greater challenge. Often, the specificity, amount, and intensity of these interventions are inconsistent among clinicians during conventional plans of care. As the practice of physical therapy continues to evolve, there is more and more evidence becoming available that highlights the importance of incorporating high aerobic intensities into more consistent practice. Activities that provide an aerobic intensity ranging from 70%-85% of predicted maximum heart rate (HR) or heart rate reserve (HRR), as suggested by Hornby et al, is the target range to achieve during this type of intervention.1,4 It is, however, uncommon for individuals to achieve high aerobic intensities during conventional physical therapy sessions despite what their level of function may be.

KIR 2011 107 ret(low-res)

Task Specificity and Intensity

High-intensity stepping training is defined as walking faster speeds or by increasing task demands with variability in practice.4 Adding greater intensity to conventional interventions by increasing repetitions of stepping practice and targeting high aerobic intensities will, in turn, increase neuromuscular and cardiovascular demands. Large amounts of task-specific practice are considered to be a critical variable to enhance plastic changes in the nervous system; thus, emphasizing the importance of incorporating this type of practice into rehabilitation for return to independent ambulation.1 Task specificity, in this case, would be specific to locomotor training (LT) since walking is the primary goal. Moore et al investigated changes in walking performance related to stepping dosage and demonstrated that the amount of practice performed during training may have contributed to the observed improvements in community ambulation.1,5 It has also been indicated that variability of task-specific practice rather than practice of variable tasks has been shown to modulate motor learning and ultimately contribute to improvements seen or desired.3

A variety of strategies are used to increase demand and task difficulty, including the addition of resistance bands, removing or reducing upper extremity support, adding additional weight to a limb or trunk via a cuff weight or weighted vest, increasing speed, stepping over obstacles, etc. The principle utilized by Moore and colleagues, specifically the FITT principle, is a training paradigm to help clinicians determine how to elicit increased stepping activity. FITT is defined as the frequency, intensity, time, and type of interventions. Creating FITT guidelines specific to each facility and therapeutic model assists in providing structure to the implementation of these interventions.1,5 The frequency and time are consistent with the treatment model used at KIR, as well as other IRFs across the country, making these interventions easy and effective to apply into practice.

Rising to the challenge of adding a 10# ankle weight to the more affected lower extremity while ambulating over a treadmill at increasing speed and enjoying every minute!

Rising to the challenge of adding a 10# ankle weight to the more affected lower extremity while ambulating over a treadmill at increasing speed and enjoying every minute!

Frequency and Focus

The frequency and time described by Moore et al was outlined to be two to five sessions per week for 4 weeks with a total treatment time of 45 minutes per session. The type of intervention utilized was LT over a treadmill with minimal body weight support and with varying degrees of physical assistance and/or facilitation. Walking speeds were varied to sustain intensity between 75% and 85% of predicted maximum HR. Many aspects of the FITT principle are currently utilized in conventional therapy except for consistently measuring HR, as well as a smaller emphasis on variability of stepping activities designed to specifically increase intensity. During the implementation of high-intensity stepping training, the focus switches from training normal gait kinematics to increasing training intensity and cardiovascular demands. Of note, when challenging locomotor tasks at high intensities and with a large amount of variability, errors in movement patterns may be present.1,5,6

Learning from Errors

Many conventional physical therapy models discourage errors, and therapists will traditionally intervene or correct errors during training in order to minimize compensation or poor mechanics. During high intensity LT the goal is for the individual to adjust his/her locomotor strategies or augment these errors in order to improve his/her performance without compensatory strategies. Holleran et al demonstrated that there are long-term improvements in walking performance with the implementation of error augmenting perturbations for specific gait deficits.6 In addition, there is a “reverse transfer effect” that shows early walking at higher intensities improves non-walking tasks. Often in conventional physical therapy, approximately 70% of a treatment session is spent practicing other therapeutic interventions including balance re-training, transfer training, and strengthening activities, and ultimately leaving little time for stepping practice.1 Knowledge of the “reverse transfer effect” allows the physical therapist to place the emphasis of treatment sessions on LT while their therapy counterparts can address other areas such as transfers.

Large amounts of task-specific practice are considered a critical variable to enhance plastic changes in the nervous system; thus, emphasizing the importance of incorporating this type of practice into rehabilitation for return to independent ambulation.

Large amounts of task-specific practice are considered a critical variable to enhance plastic changes in the nervous system; thus, emphasizing the importance of incorporating this type of practice into rehabilitation for return to independent ambulation.

Measuring Change

As a physical therapist, it is largely important to be able to measure functional changes and express how these improvements relate to the patient’s social and employment roles for, not only reimbursement purposes, but also for patient buy-in. Outcome measures such as the 10 Meter Walk Test (MWT) and 2- or 6- Minute Walk Test are utilized to objectively measure walking speeds and distances, respectively.4,6 These outcome measures can provide insight into an individual’s ability to meet community demands, such as crossing a street or obstacle negotiation in the community. The 10 MWT and 2- or 6- Minute Walk Test in addition to other measures such as the Berg Balance Scale and the Five Times Sit-to-Stand Test have been used to identify and accurately track changes anticipated to occur.4 Research has shown that high-intensity stepping training has demonstrated improvements in the measures listed above, as well as improvements in lower extremity strength, power output via EMG, and transfer mechanics and levels of assist.1 Despite the outcomes that have shown improvements across multiple areas of recovery, like with many advanced interventions and technologies, there are still several barriers to implementation of high-intensity stepping interventions within practice.

The barriers to implementing high-intensity stepping training involve both the patient and the therapist. Gait training being the most-performed activity in an IRF, yet performed at much lower intensities with fears of potentially increasing spastic motor activity and/or abnormal movement patterns.3 For an individual functioning at a lower level, there are concerns regarding postural instability and safety with early stepping practice. Therefore, the focus defaults to static stability prior to initiating early stepping training. As previously mentioned, there is the potential of errors during high intensity LT that may pose concerns regarding safety, and with a lack of available resources, clinicians may not have the level of comfort required to independently implement these interventions. Despite the potential for errors or compensatory strategies with the various perturbations added during LT, upon removal of the perturbations, there should be immediate improvements in mobility.

2015 - BWST 138(low-res)

In Pursuit of Continued Improvement

The goal continues to be to minimize compensatory strategies and to promote recovery and independence.4 If compensatory strategies are to arise over time, then these strategies are utilized to optimize independence outside of what the individual can achieve with his/her neural recovery capability. In this case, despite the presence of compensation, these individuals should still be pushed at higher intensities for the potential of continued improvements in overall mobility. The ongoing research that suggests the use of large amounts of high-intensity, task-specific locomotor training to improve walking performance and the suggested frequency, time, and type of intervention fits into the current treatment models utilized at KIR and other IRFs. However, for patients to receive the benefits of this type of practice, there needs to be a paradigm shift in the intensity of physical therapy interventions. In order to do this, continued training and education is required to provide clinicians with the knowledge of how to greater challenge their patients based on the parameters provided in the current literature. RM

Katherine De Tata, PT, DPT, is a Board-Certified Clinical Specialist in Neurologic Physical Therapy, Inpatient Brain Injury Unit, Kessler Institute for Rehabilitation, West Orange, NJ.

Justine Mamone-Lucciola, PT, DPT, is a Board-Certified Clinical Specialist in Neurologic Physical Therapy Inpatient Clinical Specialist Physical Therapist at Kessler Institute for Rehabilitation, Saddle Brook Campus. For more information, contact


1. Horby TG, Straube DS, Kinnaird CR, et al. Importance of specificity, amount, and intensity of locomotor training to improve ambulatory function in patients poststroke. Top Stroke Rehabil. 2011;18(4):293-307.

2. Camicia M, Wang H, DiVita M, Mix J, Niewczyk P. Length of stay at inpatient rehabilitation facility and stroke patient outcomes. Rehabil Nurs. 2016; 41(2):78-90.

3. Horby TG, Moore JL, Lovell L, Roth EJ. Influence of skill and exercise training parameters on locomotor recovery during stroke rehabilitation. Trauma Rehabil. 2016;29(6):677-683.

4. Hornby TG, Holleran CL, Hennessy PW, et al. Variable intensive early walking Ppststroke (VIEWS): a randomized controlled trial. Neurorehabil Neural Repair. 2016;30(5):440-450.

5. Moore JL, Roth EJ, Killian C, Hornby TG. Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a “plateau” in recovery. Stroke. 2010;41:129-135.

6. Holleran CL, Straube DD, Kinnaird CR, Leddy AL, Hornby G. Feasibility and potential efficacy of high-intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabil Neural Repair. 2014;28(7):643-651.

via Gait Training: Keep it Challenging – Rehab Managment

, , ,

Leave a comment

[NEWS] Walk This Way to Post-Stroke Recovery

Published on 



by Kate Drolet, PT, DPT, NCS, CLT-LANA, and Kristine Buchler, PT, DPT

In the heart of Chicago’s bustling Streeterville neighborhood lies Shirley Ryan AbilityLab, formerly the Rehabilitation Institute of Chicago. In March 2017, the organization opened a $550 million, 1.2-million-square-foot facility as a “translational” research hospital in which clinicians, scientists, innovators, and technologists work together in the same space, surrounding patients, discovering new approaches, and applying (or “translating”) research in real time.

Within the 27-floor rehabilitation hospital, this translational model plays out in the five ability labs—applied research and therapeutic spaces—each focused on specific functional outcomes. Together, therapists and researchers offer evidence-based interventions for a minimum of 3 hours each day. The goal: better, faster outcomes for patients.

For instance, the Legs + Walking Lab is a dynamic, two-story space designed for inpatients to focus specifically on gait training, stairs, balance and strengthening related to lower-body impairments due to brain injury, stroke, spinal cord injury, or diseases of the nerves, muscles, or bones.

While this list is not all-encompassing, one of the most prevalent diagnoses treated in the Legs + Walking Lab is stroke—and one of the most common therapies offered for post-stroke patients is gait training.

At the heart of Shirley Ryan AbilityLab’s efforts to lead patients toward an optimum outcome are more than 200 active clinical trials and research studies aimed at improving recovery post-stroke. Interdisciplinary teams consisting of physical therapists, occupational therapists, speech-language pathologists, doctors, nurses, researchers, psychologists, and social workers work together with patients to identify specific goals and then outline a treatment program aimed at maximizing functional independence.

Patients also are referred to therapists based within the various ability labs who specialize in areas such as gait training, vestibular therapy, task-specific upper extremity training, aphasia, dysphagia, cognition, and pain. These therapists work closely with the primary therapists to identify the proper dosage, intensity and duration of sessions needed to facilitate neural reorganization for their specific interventions.



Gait Training Out of the Gate

In the Shirley Ryan AbilityLab Legs + Walking Lab, gait therapists focus on promoting locomotor recovery for patients post-stroke. The primary physical therapists refer patients to gait therapy if walking goals are indicated, usually soon after completion of the initial evaluation.

Why is it so important to commence gait therapy soon after evaluation? Research indicates that earlier and more intensive rehabilitation post-stroke yields a quicker return to independent ambulation and improved functional mobility.1As a result, getting patients up and moving as quickly as possible is the expectation once vitals are stable. If gait training is indicated but is not yet safe due to unstable vitals or orthostatic hypotension, patients still often will be referred to gait therapists to assist with tolerance to upright training using the tilt table or stander before progressing to ambulation.

The literature has shown that repetition, intensity, and task-specificity are important principles of neuroplasticity to consider for gait recovery post-stroke.2 Gait therapists work with the primary physical therapists to promote large amounts of high-intensity, task-specific gait training with each patient to facilitate plasticity of both neuromuscular and cardiopulmonary systems. Walking practice is prioritized during most physical therapy sessions to achieve sufficient dosage and repetition.

Although conventional practice often involves spending time on multiple different interventions, research has indicated that high-intensity gait training also can translate to improvements in non-walking tasks such as balance and transfers, despite not focusing on those tasks.2-4

Using the Latest Specialized Equipment

At Shirley Ryan AbilityLab, therapists are fortunate to have a great deal of specialized equipment readily available to assist with implementing gait interventions with stroke survivors.

Therapists often are helping patients get up for the first time after their strokes. This may require a great deal of assistance. Because the safety of both patients and therapists is always a priority, the Legs + Walking Lab is outfitted with body-weight supported treadmills and overhead gait tracks for mobilizing lower-level patients.

Even for patients who may not require body weight support, harness systems are still used for safety and fall prevention when performing treadmill training or when challenging patients during higher-level balance activities overground. There is also a suspension system over the staircase in the Legs + Walking Lab, which provides a safe method for patients to relearn stair climbing.

In terms of modality of walking practice, the evidence is unclear as to whether treadmill or overground training is more effective in facilitating locomotor recovery. Therefore, therapists must consider how best to achieve the principles of neuroplasticity when choosing the modality for gait training. For lower-level patients who require more assistance, this generally means an increased, early focus on body weight-supported treadmill training early on to maximize repetition and intensity. Then, as patients progress, therapists can integrate overground gait training more frequently to promote increased task specificity. For patients who require less assistance, treatment sessions are generally more evenly divided between treadmill and overground gait training.

Although the Legs + Walking Lab has a robotic treadmill device, it is not commonly used during stroke rehabilitation. Evidence indicates that robotic-assisted gait training is less effective than therapist-assisted gait training in improving walking ability post-stroke.5,6 However, there are certain circumstances in which robotic-assisted gait training may be indicated to reduce the physical burden placed on therapists when gait training with stroke survivors who do not have much motor return and require a significant amount of assistance to advance both legs.

In addition, therapists have access to various exoskeletons for patients in the Legs + Walking Lab that are used in conjunction with treadmill and overground gait training due to limited research using exoskeletons in the post-stroke population.

The Shirley Ryan AbilityLab’s Legs + Walking Lab is designed for patients and research participants with diagnoses affecting lower-body function due to brain or spinal cord injury and diseases of the nerves, muscles, and bones. Researchers and clinicians focus on  advancing trunk, pelvic, and leg function, movement, and balance in this dynamic, applied research and therapeutic space.

The Shirley Ryan AbilityLab’s Legs + Walking Lab is designed for patients and research participants with diagnoses affecting lower-body function due to brain or spinal cord injury and diseases of the nerves, muscles, and bones. Researchers and clinicians focus on advancing trunk, pelvic, and leg function, movement, and balance in this dynamic, applied research and therapeutic space.

When to Challenge, When to Modify

When progressing gait interventions for patients post-stroke, the initial focus is on decreasing the amount of body weight support or level of assistance as able. Once patients begin to require less assistance and are able to perform stepping without assistance, therapists can begin to progress the challenge of the task. Evidence suggests that variability and error play an important role in motor learning and can contribute to improvements in locomotor function in stroke survivors.3,5-8 Therefore, these principles are crucial to integrate into gait interventions. This is done by allowing kinematic variability and providing variation to the task and environment, incorporating activities such as multi-directional stepping, obstacle negotiation, uneven surfaces, or changes in gait speed. Therapists can then adjust the level of challenge depending on patient response. If a patient does not make any errors, it generally means that the task is not challenging enough and should be progressed. Conversely, if a patient demonstrates several consecutive errors and is unable to correct without assistance, that generally indicates that the task is too challenging and should be modified.

Throughout the progression of gait training, the physical therapists monitor intensity and exercise tolerance based on heart rate and blood pressure response to activity, rating of perceived exertion (RPE), and verbal and nonverbal signs and symptoms if a patient has cognitive and/or communication deficits. It is also important to evaluate progress in order to guide clinical decision-making and determine whether the interventions are effective. This is done using various outcome measures, such as the Functional Independence Measure, 6 Minute Walk Test, 10 Meter Walk Test, Berg Balance Scale and Functional Gait Assessment, in addition to clinical judgment and observation. At times, primary physical therapists or lab therapists who specialize in gait training may need to decrease the frequency of gait training sessions if a patient is not responding well, if progress is limited, or if the goals of a patient’s stay shift to family education in preparation for discharge.

The Next Chapter: Therapy After Discharge

After patients discharge from the hospital, they will likely continue at a Shirley Ryan AbilityLab DayRehab or Shirley Ryan AbilityLab outpatient location. There, they will receive additional therapy, similar to the inpatient setting, while commuting to and from their homes. Therapists at DayRehab and outpatient locations continue to promote high-intensity gait training with an emphasis on home exercise programs, community reintegration, and return to work, when appropriate.

Some patients travel long distances for the intensive inpatient therapy program, so outpatient therapy at a local clinic or hospital may be the only option close to home after discharge. For these patients, inpatient therapists at the Shirley Ryan AbilityLab train families and personal caregivers to implement the principles of neuroplasticity and advocate for high-intensity gait training after discharge.

Regardless of a patient’s particular journey, the message for post-stroke recovery is clear: the more walking, the better. RM

Kate Drolet, PT, DPT, NCS, CLT-LANA, earned a bachelor’s degree in exercise physiology and a doctorate in physical therapy from Marquette University in Milwaukee. She is a Board Certified Clinical Specialist in Neurological Physical Therapy and a Certified Lymphedema Therapist through the Lymphology Association of North America. She practices at the Shirley Ryan AbilityLab (formerly Rehabilitation Institute of Chicago) and specializes in gait training for patients with neurologic conditions in the inpatient setting.

Kristine Buchler, PT, DPT, earned a bachelor’s degree in kinesiology at the University of Illinois at Urbana-Champaign and a doctor of physical therapy degree at Northwestern University. She currently practices as a physical therapist at the Shirley Ryan AbilityLab and specializes in gait training for patients with neurologic conditions in the inpatient setting. For more information, contact

This article appears in the January/February 2019 print issue of Rehab Management with the title, “Walk This Way.”


1. Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking. Stroke. 2011;42(1):153-158.

2. Hornby TG, Straube DS, Kinnaird CR, et al. Importance of specificity, amount, and intensity of locomotor training to improve ambulatory function in patients poststroke. Top Stroke Rehabil. 2011;18(4):293-307.

3. Hornby TG, Holleran CL, Hennessy PW, et al. Variable intensive early walking poststroke (VIEWS). Neurorehabil Neural Repair. 2015;30(5):440-450.

4. Straube DD, Holleran CL, Kinnaird CR, Leddy AL, Hennessy PW, Hornby TG. Effects of dynamic stepping training on nonlocomotor tasks in individuals poststroke. Phys Ther. 2014;94(7):921-933.

5. Hornby TG, Campbell DD, Kahn JH, Demott T, Moore JL, Roth HR. Enhanced gait-related improvements after therapist- versus robotic-assisted locomotor training in subjects with chronic stroke. Stroke. 2008;39(6):1786-1792.

6. Hidler J, Nichols D, Pelliccio M, et al. Multicenter randomized clinical trial evaluating the effectiveness of the Lokomat in subacute stroke. Neurorehabil Neural Repair. 2009;23(1):5-13.

7. Holleran CL, Straube DD, Kinnaird CR, Leddy AL, Hornby TG. Feasibility and potential efficacy of high-intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabil Neural Repair. 2014;28(7):643-651.

8. Reisman DS, McLean H, Keller J, Danks KA, Bastian AJ. Repeated split-belt treadmill training improves poststroke step length asymmetry. Neurorehabil Neural Repair. 2013;27(5):460-468.


via Walk This Way to Post-Stroke Recovery – Rehab Managment

, , , , ,


[ARTICLE] Randomized controlled trial of robot-assisted gait training with dorsiflexion assistance on chronic stroke patients wearing ankle-foot-orthosis – Full Text



Robot-assisted ankle-foot-orthosis (AFO) can provide immediate powered ankle assistance in post-stroke gait training. Our research team has developed a novel lightweight portable robot-assisted AFO which is capable of detecting walking intentions using sensor feedback of wearer’s gait pattern. This study aims to investigate the therapeutic effects of robot-assisted gait training with ankle dorsiflexion assistance.


This was a double-blinded randomized controlled trial. Nineteen chronic stroke patients with motor impairment at ankle participated in 20-session robot-assisted gait training for about five weeks, with 30-min over-ground walking and stair ambulation practices. Robot-assisted AFO either provided active powered ankle assistance during swing phase in Robotic Group (n = 9), or torque impedance at ankle joint as passive AFO in Sham Group (n = 10). Functional assessments were performed before and after the 20-session gait training with 3-month Follow-up. Primary outcome measure was gait independency assessed by Functional Ambulatory Category (FAC). Secondary outcome measures were clinical scores including Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Berg Balance Scale (BBS), Timed 10-Meter Walk Test (10MWT), Six-minute Walk Test (SMWT), supplemented by gait analysis. All outcome measures were performed in unassisted gait after patients had taken off the robot-assisted AFO. Repeated-measures analysis of covariance was conducted to test the group differences referenced to clinical scores before training.


After 20-session robot-assisted gait training with ankle dorsiflexion assistance, the active ankle assistance in Robotic Group induced changes in gait pattern with improved gait independency (all patients FAC ≥ 5 post-training and 3-month follow-up), motor recovery, walking speed, and greater confidence in affected side loading response (vertical ground reaction force + 1.49 N/kg, peak braking force + 0.24 N/kg) with heel strike instead of flat foot touch-down at initial contact (foot tilting + 1.91°). Sham Group reported reduction in affected leg range of motion (ankle dorsiflexion − 2.36° and knee flexion − 8.48°) during swing.


Robot-assisted gait training with ankle dorsiflexion assistance could improve gait independency and help stroke patients developing confidence in weight acceptance, but future development of robot-assisted AFO should consider more lightweight and custom-fit design.


Stroke is caused by intracranial haemorrhage or thrombosis, which cuts off arterial supply to brain tissue and usually damages the motor pathway of the central nervous system affecting one side of the body. About half of the stroke survivors cannot walk at stroke onset, but they have 60% chance to regain independent walking after rehabilitation [1]. Reduced descending neural drive to the paretic ankle joint causes muscle weakness and spasticity, often accompanied with drop foot which is characterized by the foot pointing downward and dragging on the ground during walking [23]. To maintain sufficient foot clearance in swing phase, people with dropped foot have to compensate either by hip hiking with exaggerated flexion in hip and knee joints, or circumduction gait with the body leaning on the unaffected side and the leg swinging outward through an arc away from the midline [456]. These inefficient asymmetric gait patterns hinder the walking ability and contribute to slower walking speed [78], increasing risk of falling [910], and greater energy expenditure [11]. Poor mobility results in sedentary lifestyle and limited physical exercise [12], which further deteriorates lower-limb functionality.

Foot drop can be managed using ankle-foot-orthosis (AFO), which is rigid or articulated ankle brace that controls ankle range of motion (ROM). Meta-analysis shows walking in conventional AFO has immediate or short-term beneficial effects on gait pattern and mobility of stroke patients, including an overall increase in ankle dorsiflexion throughout gait cycle, improvements in Functional Ambulatory Category (FAC), walking speed, and stairs-climbing speed [131415]. Recent development in robot-assisted AFO demonstrates power assistance at ankle joint can facilitate walking of patients presenting with foot drop, by actively assisting ankle dorsiflexion for foot clearance in swing phase and minimizing occurrence of foot slap at initial contact [161718]. Previous studies only evaluated the immediate effects of stroke patients walking in passive AFO [1415] or robot-assisted AFO [1920], but they were not sure whether any assistive effects could be carried over to unassisted gait after the patients had taken off the devices, i.e. the therapeutic effects.

Neuroscience studies suggest the brain is capable of altering its functions and structures for adapting to internal and external environment; an ability known as neuroplasticity [22122]. Researches show intensive repetitive skill training can enhance neuroplasticity and promote motor relearning of stroke patients [2324], which is achievable utilizing robot-assistance in clinical setting. The Anklebot that was developed in MIT can provide power assistance to stroke patients performing repetitive voluntary ankle sagittal movements in seated position, and a single-arm pilot study reports stroke patients (n = 8) had improved volitional ankle control and spatial-temporal gait parameters after 6-week 18-session training using the Anklebot [25]; 30-min seated skill training at ankle joint can induce plastic changes in cortical excitability in area controlling dorsiflexor [26]. Thus robot-assisted AFO with dorsiflexion assistance can potentially stimulate motor recovery of stroke patients with foot drop problem. Neuroscience studies further show the functional outcome of neuroplasticity is task-specific and dependent on the training nature [2212227]. It implies that in order to improve independent walking ability, stroke patients are expected to practise real over-ground walking instead of seated training. Incorporation of stair ambulation into gait training could facilitate generalization towards activity of daily-living, which requires stroke patients to perform skilled ankle dorsiflexion and plantarflexion when they are negotiating steps. Another characteristics of neuroplasticity is the importance of salient experiences for motor relearning from error correction [22122]. During gait training, powered ankle assistance from a robot-assisted AFO could serve as a source of salient proprioceptive feedback synchronized to gait pattern [28]. The robot can strengthen the experience-driven neuroplasticity by producing this proprioceptive feedback at each successfully triggered ankle power assistance [28]. In summary, researches on experience-driven neuroplasticity suggest stroke patients presenting with foot drop problem can potentially restore some level of independent walking ability through robot-assisted gait training with ankle dorsiflexion assistance on over-ground walking and stair ambulation.

To our knowledge, up to now no randomized controlled trial (RCT) has been carried out to validate the rehabilitation approach of robot-assisted AFO [2930]. The current study aims to evaluate whether gait training with robot-assisted AFO with dorsiflexion assistance can bring greater improvement in independent walking ability than training with passive AFO. In each session, stroke patients were trained in 20-min over-ground walking and 10-min stair ambulation. Assessments on the participating stroke patients focused on functional changes in unassisted gait after they had discontinued to wear the devices, i.e. the therapeutic effects. A meta-analysis study recommends FAC to be the primary outcome measure for clinical trials involving electromechanical gait training [30]. FAC is a reliable measurement of independent walking ability on level ground walking and stair ambulation, which is a good prediction of independent community walking post-stroke [31]. The demonstration of safety and effectiveness of the robot-assisted gait training can have positive impact on post-stroke rehabilitation and can potentially establish a new treatment method for stroke patients presenting with foot drop.[…]


Continue —>  Randomized controlled trial of robot-assisted gait training with dorsiflexion assistance on chronic stroke patients wearing ankle-foot-orthosis | Journal of NeuroEngineering and Rehabilitation | Full Text

Figure 1

Fig. 1a Robot-assisted AFO, and b Stroke patients walking on stairs wearing the robot-assisted AFO

, , , , ,

Leave a comment

[Abstract] Improving real-world walking habits after stroke requires behavioural change techniques, not just exercise and gait training [synopsis]


Summary of: Stretton CM, Mudge S, Kayes NM, McPherson KM. Interventions to improve real-world walking after stroke: a systematic review and meta-analysis. Clin Rehabil. 2017;31:310-318.

Objective: To examine whether interventions that target walking in the real world are more effective than usual care or no intervention for improving actual walking behaviour in real-world settings in people with stroke.

Data sources: EBSCO Megafile, AMED, Scopus, Cochrane Database of Systemic Reviews, PEDro, OTseeker, and PsycBITE were searched from inception to November 2015. The database search was supplemented by hand searching.

Study selection: Randomised or quasi-randomised, controlled trials examining progressive task-oriented exercise interventions with or without behavioural change techniques. Studies had to have a usual care comparison group or a no-intervention/attention control group and measure the effects of the interventions on real-world walking (activity monitoring and/or self-report questionnaires).

Data extraction: Two reviewers extracted data. Methodological quality was assessed using the Cochrane Risk of Bias tool.

Data synthesis: Of the 4478 studies initially identified by the search, nine studies (10 treatment arms) with a total of 693 participants in the experimental group and 565 in the control group met the selection criteria and were included in the meta-analysis. Overall, the included studies were evaluated to have a low risk of bias. Based on the quantitative pooling of the available data from these trials, at post-intervention assessment there was a statistically significant difference in real-world walking in favour of the intervention group, by a standardised mean difference (SMD) of 0.29 (95% CI 0.17 to 0.41). Quantitative pooling of five studies with 3 to 6 month follow-up data found a SMD of 0.32 (95% CI 0.16 to 0.48) in favour of the intervention group. Pre-planned subgroup analysis found that interventions that incorporated at least one behaviour change technique were effective (SMD 0.27, 95% CI 0.12 to 0.43) whereas those without any behaviour change strategies were not effective (SMD –0.19, 95% CI –0.11 to 0.49).

Conclusion: Task-oriented exercise interventions alone appeared to be insufficient for improving real-world walking habits in people with stroke. Exercise and gait-oriented interventions that employed behaviour change techniques were more likely to be effective in changing real-world walking behaviour, but the estimated treatment effect was small.

Provenance: Invited. Not peer reviewed.

Source: Improving real-world walking habits after stroke requires behavioural change techniques, not just exercise and gait training [synopsis] – Journal of Physiotherapy

, , , ,

Leave a comment

[Abstract] Effects of treadmill training with load addition on non-paretic lower limb on gait parameters after stroke: a randomized controlled clinical trial


  • Load use as a restraint for the movement of non-paretic lower limb is proposed.
  • Currently, only immediate effects of this practice are available.
  • Stroke patients performed gait training with and without load addition, for two weeks.
  • Kinematic gait parameters were improved after training and maintained at follow-up.
  • Load addition did not provide additional benefits to gait training.


The addition of load on the non-paretic lower limb for the purpose of restraining this limb and stimulating the use of the paretic limb has been suggested to improve hemiparetic gait. However, the results are conflicting and only short-term effects have been observed.

This study aims to investigate the effects of adding load on non-paretic lower limb during treadmill gait training as a multisession intervention on kinematic gait parameters after stroke.

With this aim, 38 subacute stroke patients (mean time since stroke: 4.5 months) were randomly divided into two groups: treadmill training with load (equivalent to 5% of body weight) on the non-paretic ankle (experimental group) and treadmill training without load (control group). Both groups performed treadmill training during 30 minutes per day, for two consecutive weeks (nine sessions). Spatiotemporal and angular gait parameters were assessed by a motion system analysis at baseline, post-training (at the end of 9 days of interventions) and follow-up (40 days after the end of interventions).

Several post-training effects were demonstrated: patients walked faster and with longer paretic and non-paretic steps compared to baseline, and maintained these gains at follow-up. In addition, patients exhibited greater hip and knee joint excursion in both limbs at post-training, while maintaining most of these benefits at follow-up. All these improvements were observed in both groups.

Although the proposal gait training program has provided better gait parameters for these subacute stroke patients, our data indicate that load addition used as a restraint may not provide additional benefits to gait training.

Source: Effects of treadmill training with load addition on non-paretic lower limb on gait parameters after stroke: a randomized controlled clinical trial – Gait & Posture

, , , , , ,

Leave a comment

[ARTICLE] The Efficacy of State of the Art Overground Gait Rehabilitation Robotics: A Bird’s Eye View – Full Text


To date, rehabilitation robotics has come a long way effectively aiding the rehabilitation process of the patients suffering from paraplegia or hemiplegia due to spinal cord injury (SCI) or stroke respectively, through partial or even full functional recovery of the affected limb. The increased therapeutic outcome primarily results from a combination of increased patient independence and as well as reduced physical burden on the therapist. Especially for the case of gait rehabilitation following SCI or stroke, the rehab robots have the potential to significantly increase the independence of the patient during the rehabilitation process without the patient’s safety being compromised. An intensive gait-oriented rehabilitation therapy is often effective irrespective of the type of rehabilitation paradigm. However, eventually overground gait training, in comparison with body-weight supported treadmill training (BWSTT), has the potential of higher therapeutic outcome due its associated biomechanics being very close to that of the natural gait. Recognizing the apparent superiority of the overground gait training paradigms, a through literature survey on all the major overground robotic gait rehabilitation approaches was carried out and is presented in this paper. The survey includes an in-depth comparative study amongst these robotic approaches in terms of gait rehabilitation efficacy.

Download full text in PDF

Source: The Efficacy of State of the Art Overground Gait Rehabilitation Robotics: A Bird’s Eye View

, , , , , , , , , ,

Leave a comment

%d bloggers like this: