A Review of the Physical Demands of Stair Negotiation in Healthy Aging and Following Stroke

Special Article - Stroke Rehabilitation

Phys Med Rehabil Int. 2015; 2(7): 1057.

A Review of the Physical Demands of Stair Negotiation in Healthy Aging and Following Stroke

Ridgway HM, Bisson EJ and Brouwer B*

Motor Performance Laboratory, School of Rehabilitation Therapy, Queen’s University, Ontario, Canada

*Corresponding author: Brouwer B, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada

Received: July 31, 2015; Accepted: September 02,2015; Published: September 04, 2015


Stair negotiation is an important determinant of community ambulation and functional independence. Compared to level ground walking, the ability to manage stairs requires greater joint range of motion, muscle strength and cardiovascular fitness which can pose challenges for older adults secondary to age-related decline in physical capacity. For older adults who have experienced a stroke, the superimposition of the resultant physical impairments can further compromise mobility and may limit the capacity for community ambulation risking social isolation. This paper summarizes the research describing the lower limb joint mobility, the muscle moment requirements, and the oxygen demands of stair negotiation relative to level walking to characterize the physical ‘costs’ of mobility essential for community ambulation. Specifically, alterations in movement patterns due to age-related changes in physical capacity are discussed in the context of better understanding the impact of stroke-related impairments on the ability to compensate in order to negotiate stairs. This information is relevant to physical rehabilitation specialists to assist in determining individuals’ capacity for community ambulation and to provide guidance in developing targeted strategies to enhance mobility in people aging with stroke.

Keywords: Aging; Biomechanics; Function; Gait; Mobility; Rehabilitation


ROM: Range Of Motion; COM: Centre Of Mass; SOS: Step-Over- Step; SBS: Step-By-Step


Stroke is the leading cause of adult neurological disability, disproportionately affecting the aging population. In 2005, it was estimated that 16 million people worldwide suffered from a first-ever stroke, and 62 million live with the effects of stroke [1]. In terms of disability, this translates into an annual loss of 43.7 million disabilityadjusted life-years reflecting the extraordinary disease burden [1]. Nearly all survivors of mild stroke, and 85% of survivors of moderate to severe stroke return to living in the community [2], although a much smaller percentage are functionally independent [3].

The extent of physical deficits including muscle weakness, spasticity, sensory loss, and gait or balance impairments generally relates to the location and the severity of the stroke [4-6]. The impact is often significant in terms of mobility restriction, loss of independence, social isolation, and reduced community participation [3,7-11] and may be exacerbated by comorbidities and aging.

Seventy-five percent of individuals discharged post-stroke prioritize being active in the community; however, one third of community ambulators pre-stroke were unable to walk unsupervised in their communities when discharged following stroke [12]. Mobility limitations, lower levels of physical activity post-stroke, and an inability to negotiate stairs can restrict independence outside the home [7,9]. Indeed many stroke survivors (60-70%) are able to walk by the time of discharge from hospital [12-14], though this is tempered by accounts that only 7-22% can walk independently outside of their homes [15]. Among long term stroke survivors (4 years post-stroke), 71% report incomplete recovery and 49% require assistance with daily activities [16]. While 76% are able to walk independently indoors, a much lower percentage (63%) can do so outdoors [16]. It stands to reason that the primary focus of rehabilitation is the restoration of independent ambulation; walking being the principle goal [17,18].

Arguably, independent living requires physical mobility beyond walking. Stair negotiation is an important determinant of discharge destination and independence, surpassing walking speed as the single best predictor of community ambulation [2,19]. Despite this, little is known about the physical demands of stair negotiation in rehabilitation populations such as stroke and studies involving healthy adults are few. In contrast, the movement patterns, strength requirements and energy demands of walking have been studied extensively in stroke [20-25]. A similar depth of understanding of the physical ‘cost’ of stair negotiation and the cost relative to walking is essential to gauge mobility function, establish physical rehabilitation goals, re-train safe stair ambulation and appreciate the merit of alternate movement strategies adopted by those with mobility limitation in order to manage stairs.

This review examines the physical demands associated with mobility, particularly stair negotiation in healthy older adults and in older adults with hemiparesis due to stroke. The specific objectives are: a) to describe the lower limb joint mobility, the active force output required from the major lower limb muscle groups and the energy demands of stair negotiation, b) to discuss age-related alterations in movement patterns as a means of compensating for changes in physical capacity, and c) to explore the impact of chronic stroke on the biomechanical and energy demands of stair negotiation. Information pertaining to level walking is presented to provide contextual reference serving to highlight the elevated demands of stair negotiation.


The authors searched the literature (PubMed and Google Scholar) for studies involving human subjects using the following key words: stair ascent, stair climbing, stair descent, and stair negotiation as well as outcome descriptors including kinematics, kinetics, metabolic demand, aerobic demand and oxygen uptake. Journal articles published from 1990 to 2014 that provided primary data (observational and experimental) or reviews of research studies relevant to the objectives were reviewed. In addition, we drew on findings from our laboratory to supplement available information.

Physical demands of stair negotiation

Stair negotiation requires both concentric and eccentric muscle activation to lift (or lower) the body vertically and translate it horizontally. Stair ascent primarily involves positive (concentric) work as the stance limb accepts body weight, then pulls the body up to provide full support on the next step, and finally maintains progression while the swing limb clears the intermediate step to make contact with the next step (forward continuance). During stair descent, the stance limb accepts body weight and controls the lowering of the body’s centre of mass (eccentric muscle work) as the swing limb is pulled forward to contact the lower step. A combination of adequate joint mobility, strength and aerobic capacity to meet the energy demand is required to accomplish the tasks of ascent and descent which involve physical requirements that typically exceed those associated with level walking.

Joint mobility

Compared to natural speed walking, stair negotiation requires greater sagittal plane range of motion (ROM) at all lower limb joints [26-29], see Table 1. The magnitude of the differences depends on the particular joint in question and the direction of movement (i.e. ascent or descent). The ankle ROM is greatest during descent, whereas mobility at the knee and hip, primarily in flexion, is greatest during ascent. At the hip joint, the ROM is about 40% greater than that observed during level walking or stair descent [27,30]. The greater hip flexion ensures step clearance and avoidance of tripping. At the knee, the angular displacement is comparable for ascent and descent reflecting an increase in ROM of more than 50% (or ~30o) over level walking in order to scale the rise of the step.