Changes in gait parameters using two types of step training in a patient following hemiplegic stroke

Abstract

[Purpose] We report a case of stroke hemiplegia in which two types of step training affected gait parameters. [Participant and Methods] A 50-year-old man presented with right-sided hemiplegia caused by a left putaminal hemorrhage. Four months after the onset of asymmetric gait, he practiced stepping in the anterior–posterior directions on a 20-cm platform. Step training was conducted over three 5-day periods. Gait parameters were evaluated on the day following the completion of each training period. Data on the maximum walking speed, single- and double-leg support phases, and step length were collected. Furthermore, the symmetry ratio and trailing limb angle were calculated. [Results] Post-training improvements were noted in gait symmetry, and the trailing limb angle on the affected side improved after anterior–posterior step training. [Conclusion] Anterior–posterior step training may improve gait parameters following a hemiplegic stroke.

INTRODUCTION

Restoring gait in patients with hemiplegic stroke is a critical goal¹⁾ and significant challenge. Gait impairments in these patients lead to slower walking speed^{2, 3)}, higher risk of falls⁴⁾, reduced activity levels⁵⁾, and diminished quality of life⁶⁾. In addition, patients with hemiplegic stroke often exhibit an asymmetric gait compared with healthy individuals⁷⁾. This asymmetry can result in poorer balance⁸⁾, higher energy expenditure⁹⁾, and compromised walking independence due to increased fall risk¹⁰⁾. Therefore, the gait symmetry should be enhanced. However, achieving a symmetrical gait in clinical practice can be particularly difficult for patients with larger body size and severe hemiplegia.

The step training method promotes gait symmetry¹¹⁾. It can be tailored to help patients normalize a more typical gait pattern. Previous studies have shown that step training improves step length and step-time symmetry¹¹⁾, with step training on the paretic side specifically enhancing step length symmetry¹²⁾. In clinical settings, step training using these steps is sometimes implemented to improve lower limb support on the affected side. However, most studies have focused on patients with chronic stroke, with limited research on step training during the recovery phase of hemiplegic stroke. In addition, the impact of the front-to-back and platform step exercises on gait parameters has not been thoroughly explored.

In this case report, we applied two types of step training in conjunction with standard gait training for a patient recovering from hemiplegic stroke and examined the resulting changes in gait parameters.

PARTICIPANT AND METHODS

A 50-year-old man was presented with right-sided hemiplegia caused by left putaminal hemorrhage. The patient was 174 cm tall, weighed 84 kg, and had a BMI of 27.7. Before the stroke, he was independent in all activities of daily living (ADL). The patient was admitted to the rehabilitation ward on the 12th day after the onset of his condition.

Upon admission, he was fully conscious. His motor function scored 8 on the Fugl–Meyer assessment for lower extremity (FMA-LE), and he scored 0 on the trunk control test (TCT). Muscle tone, measured using the modified Ashworth scale (MAS), was 0. His Berg Balance Scale (BBS) score was 4. The patient required assistive devices and multiple caregivers for basic tasks, including sitting, standing, and transferring. His Barthel index (BI) was 0, and his functional independence measure (FIM) was 21. He could not walk, and the functional ambulation category (FAC) score was 0 (Table 1). A knee–ankle–foot orthosis (KAFO) was made, and gait training was initiated. The intervention involved five trials of 20 m, adjusted according to the patient’s condition. However, despite sufficient training, the KAFO experienced difficulty in relearning knee joint control during the stance phase on the affected side.

Table 1. Progress during hospitalization.

	12th day after onset	143rd day after onset	169th day after onset
FMA-LE	8	20	22
TCT	0	100	100
MAS	0	1	1
BBS	4	33	46
BI	0	65	80
FIM-motor	13	51	70
FIM-cognitive	8	24	24
FIM-total	21	75	94
FAC	0	2	4

FMA-LE: Fugl-Meyer Assessment for Lower Extremity; TCT: Trunk Control Test; MAS: Modified Ashworth Scale; BBS: Berg Balance Scale; BI: Barthel Index; FIM: Functional Independence Measure; FAC: Functional Ambulation Category.

By the 143rd day, the patient’s FMA-LE score had improved to 20, and the TCT score increased to 100 points. MAS was one in the right hamstring and right triceps surae muscles. Sensory evaluation revealed slight dulling of the superficial and positional sensations. His balance score on the BBS improved to 33 points, and he could perform basic activities with minimal support, supervision, or light assistance. The patient scored 65 on the BI and 75 on FIM for ADL (Table 1). He could walk with light assistance using a T-cane and ankle–foot orthosis (AFO), with an FAC of 2. During the stance phase on the affected side, a buckling knee pattern (BKP)¹³⁾ was observed early in the stance, causing excessive knee flexion and instability. In the late stance phase, hip extension was limited because of the anterior trunk tilt. During the swing phase, trunk extension compensated for leg movement, and there were occasional instances of foot catching, resulting in an asymmetrical gait. We hypothesized that gait training alone might worsen gait symmetry and that repetitive practice of specific gait cycle components was necessary. Therefore, step training was initiated on the 144th day after the onset.

Step training was conducted over three periods of 5 days each. In addition to standard physical therapy, anterior–posterior step training was performed during the first and third periods, while step training on a 20-cm platform was performed in the second period. Because of trunk instability and fatigue after repeated exercises, the patient could not perform many repetitions. As a result, each trial was limited to 10 repetitions (with 5 trials per day, totaling 50 repetitions) with adequate rest between sessions. In each period, the starting position was the early stance on the paretic side, and the ending position was the late stance on the paretic side with the nonparetic leg in an upright position (Fig. 1). Because BKP was observed after the early stance phase, the patient was instructed to minimize knee flexion on the paretic side during single-leg support. During training, the paretic hip was maintained in a neutral rotational position, and foot placement remained consistent with minimal assistance. Step positions were marked, and the patient performed steps with a uniform length. To prevent falls, the patient was lightly held onto the parallel bars.

Fig. 1.

Start and end positions for step training.

(A) Start position for step training. (B) End position for step training.

(C) Start position for step training on steps. (D) End position for step training on steps.

The gait parameters were evaluated the day after each step of the training period was completed. The measurement instruments used were a Walkway MW-1000 (ANIMA, Co., Ltd., Tokyo, Japan) and a digital video camera (SONY, Co., Ltd., Tokyo, Japan) with a sampling frequency of 100 Hz. The walking path was 8.4 m long, including a 3-m acceleration and deceleration section before and after the 2.4-m measurement area. The patient walked at their maximum speed. A physiotherapist was positioned near the patient to prevent falls during the measurement. Data on maximum walking speed, single-leg support phase, double-leg support phase, and step length were collected. The average of three trials was used as the representative value. The symmetry ratio was calculated by dividing the higher value of either the paretic or nonparetic side by the lower value, with a ratio closer to 1 indicating a more symmetrical gait⁷⁾. The gait during the test was also recorded from the sagittal plane using a digital video camera. ImageJ for Microscopy (National Institutes of Health, Bethesda, MD, USA) was used to calculate the trailing limb angle (TLA) on the paretic side. The TLA was defined as the angle between the line connecting the fifth metatarsal head and the greater trochanter and a vertical line through the hip axis¹⁴⁾. Two experienced physiotherapists measured the TLA multiple times using ImageJ to ensure accurate positioning, and the average of the measurements was taken as the representative value. As an ethical consideration, the purpose and content of this report were fully explained to the participants and his written consent was obtained.

RESULTS

Gait evaluation conducted the day after each step training period showed improvements in the step length symmetry during the first and third training periods, with an increase in the TLA on the paretic side in the third period. In contrast, during the second period, which involved step training on a 20-cm platform, there was a reduction in walking speed, single-leg support on the paretic side, step length, and TLA (Table 2).

Table 2. Gait assessment progress.

	Initial measurement	First period	Second period	Third period
Gait speed (m/s)	0.66	0.66	0.58	0.68
Paretic single leg support (%)	25.0	26.2	24.0	28.0
Nonparetic single leg support (%)	44.7	39.4	34.0	39.0
Paretic double leg support (%)	21	31.4	28.5	22.5
Nonparetic double leg support (%)	9.8	9.0	8.9	9.8
Paretic step length (m)	0.58	0.59	0.56	0.55
Non paretic step length (m)	0.41	0.42	0.36	0.41
TLA (°)	11.5	9.83	6.80	11.0
Double leg support symmetry	2.14	3.49	3.20	2.30
Single leg support symmetry	1.79	1.50	1.42	1.39
Step length symmetry	1.41	1.40	1.56	1.34

Double-leg support symmetry, single-leg support symmetry, and step length symmetry are calculated by high/low value.TLA: Trailing Limb Angle.

By discharge, motor function had improved, with an FMA-LE score of 22 and BBS score of 46, indicating enhanced standing balance. The patient was independent in basic activities, with BI and FIM scores of 80 and 94, respectively, reflecting better performance in ADL. Gait improvements included reduced BKP during the early stance phase on the affected side and increased hip extension in the late stance phase, resulting in a smoother swing phase. The patient could walk for >45 m despite occasional foot catch on the paretic side. On the 169th day after onset, the patient was discharged to a facility for the disabled at the request of the patient and family for further rehabilitation, with an FAC of 4, using a T-cane and AFO (Table 1).

DISCUSSION

This report describes changes in gait parameters in a stroke patient with hemiplegia during recovery following two types of step training. We determined that the patient required intervention to improve asymmetric gait and to further enhance gait ability. Alongside standard physiotherapy, two interventions were implemented: step training on a 20-cm platform and anterior–posterior step training focusing on the repetition of parts of the gait cycle. The results indicated that anterior–posterior step training improved step length symmetry and increased the TLA on the paretic side. However, during step training on the platform, there was a decrease in the single-leg support on the paretic side, as well as in the step length, TLA, and gait speed on the paretic side. These findings are discussed below.

First, step training improved the step length symmetry and increased the TLA on the paretic side. The step length of the nonparetic side and step length symmetry are related to the propulsive force of the paretic limb¹⁵⁾. This improvement likely resulted from repetitive stepping with the nonparetic limb at a consistent speed^{11, 12)}. The step training involved maintaining a constant step position and ending each step with hip extension on the paretic side. Therefore, repetitive stepping with a fixed step length may enhance the propulsive force on the paretic side, thereby improving the step length symmetry.

Second, step training on a platform resulted in reduced gait speed, decreased single-leg support on the paretic side, shorter step length, and lower TLA on the paretic side. In this training, the nonparetic leg was positioned on the step, resulting in hip flexion on the nonparetic side and hip extension on the paretic side. When the lower limb contracted with the ground during step climbing, a backward ground reaction force was generated¹⁶⁾, which could impede forward movement. Repeated training with this force may have hindered the forward propulsion. In addition, the nonparetic limb’s placement on the step was rapid, which might have made it challenging to provide adequate support to the paretic side. These findings suggest that step training on a platform has a minimal impact on improving gait parameters.

In summary, we reported changes in gait parameters in a poststroke hemiplegic patient during the recovery phase following two types of step training in addition to standard physiotherapy. Forward and backward step training improved the step length symmetry and increased the TLA of the paretic side, indicating that step training enhanced walking independence.

Funding and Conflict of interest

None.