Gait training strategies utilized in poststroke rehabilitation: are we really making a difference?

Stroke is the leading cause of disability in the United States. Restoration of walking continues to be a major goal of rehabilitation for persons with stroke. The concept of a minimal change in performance to be considered important or significant has recently been addressed in the field of stroke rehabilitation. We examine some of the changes in locomotor function in poststroke individuals. None of the neurofacilitation approaches have shown significant improvement in walking performance after stroke. Functional electrical stimulation (FES) can be performed by stimulating over the muscle, intra-muscularly, or over the peripheral nerve that innervates a muscle providing insufficient force for gait. To date, no form of artificial stimulation can match natural activation for precision or fatigue resistance. Body weight-supported treadmill training (BWSTT) is thought to contribute substantially to the reorganization of neural circuitry and has been shown to restore gait of nonambulatory individuals. Despite the promising recovery suggested by BWSTT, the time and physical demands on therapists have prevented it from wide clinical acceptance. Thus various robotic devices have been developed to provide such "mechanical" stepping assistance. The magnitude of changes induced with robotic devices does not appear to be any greater than that achieved with more traditional approaches or as compared to task-specific BWSTT.