Changes in Post-Stroke Gait Biomechanics Induced by One Session of Gait Training

Special Article – Gait Rehabilitation

Phys Med Rehabil Int. 2015; 2(10): 1072.

Changes in Post-Stroke Gait Biomechanics Induced by One Session of Gait Training

Kesar TM¹*, Reisman DS², Higginson JS³, Awad LN4 and Binder-Macleod SA5

¹Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia.USA

²Department of Physical Therapy, University of Delaware, Newark, Delaware, USA

²Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA

4Harvard John A Paulson School of Engineering and Applied Sciences and Wyss Institute For Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA

5Department of Physical Therapy, University of Delaware, Newark, Delaware, USA

*Corresponding author: Kesar Trisha M, Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University, 1441 Clifton Rd NE, Atlanta, Georgia, USA

Received: November 28, 2015; Accepted: December 23, 2015; Published: December 28, 2015


The objective of this study was to determine whether one session of targeted locomotor training can induce measurable improvements in the post-stroke gait impairments. Thirteen individuals with chronic post-stroke hemiparesis participated in one locomotor training session combining fast treadmill training and functional electrical stimulation (FES) of ankle dorsi- and plantar-flexor muscles. Three dimensional gait analysis was performed to assess withinsession changes (after versus before training) in gait biomechanics at the subject’s self-selected speed without FES. Our results showed that one session of locomotor training resulted in significant improvements in peak anterior ground reaction force (AGRF) and AGRF integral for the paretic leg. Additionally, individual subject data showed that a majority of study participants demonstrated improvements in the primary outcome variables following the training session. This study demonstrates, for the first time, that a single session of intense, targeted post-stroke locomotor retraining can induce significant improvements in post-stroke gait biomechanics. We posit that the within-session changes induced by a single exposure to gait training can be used to predict whether an individual is responsive to a particular gait intervention, and aid with the development of individualized gait retraining strategies. Future studies are needed to determine whether these single-session improvements in biomechanics are accompanied by short-term changes in corticospinal excitability, and whether single-session responses can serve as predictors for the longer-term effects of the intervention with other targeted gait interventions.

Keywords: Gait rehabilitation; Stroke; Biomechanics; Propulsion; Functional electrical stimulation


FES: Functional Electrical Stimulation; AGRF: Anterior Ground Reaction Force; SS Speed: Self-Selected Speed


Common impairments in post-stroke gait kinematics include reduced hip, knee, and ankle flexion during swing phase. To alleviate reduced dorsiflexion during swing phase or ‘foot drop’, functional electrical stimulation (FES) delivered to ankle dorsi-flexor muscles is commonly used as an intervention [1-3]. Previous studies from our laboratory have shown that in contrast to the traditional FES approach of stimulating the ankle dorsiflexors during swing phase, delivering FES to both dorsi- and plantar-flexor muscles provides greater biomechanical advantages and may address both swing phase and stance phase gait deficits post-stroke [4,5]. Decreased push-off force generation by the paretic limb during terminal stance is a poststroke impairment that has recently received attention in the literature due to its relationships with hemiparetic severity and walking speed [6,7]. ‘FastFES’, a novel gait rehabilitation intervention involving the combination of fast treadmill training with functional electrical stimulation of ankle plantar-and dorsi-flexor muscles, is a novel and effective post-stroke locomotor training intervention [5,8-10]. The FastFES intervention targets slowed walking speed, decreased paretic push-off and decreased knee and ankle flexion during swing. Twelve weeks (36 sessions) of FastFES gait training have been shown to produce significant improvements in walking function, activity, and participation post-stroke [8,9,10,11].

While improvements in post-stroke gait are commonly observed after several weeks of training with FastFES and other gait retraining interventions, when and how these improvements in gait first evolve is unclear. Experiments employing a single session of exposure to unique, challenging, and well-controlled locomotor paradigm, such as walking with a weight added to one leg [12], stepping on a rotating disc [13], and split-belt treadmill walking [14] demonstrate that human locomotion adapts rapidly in the short-term. However, longlasting therapeutic effects of these locomotor adaptation paradigms have not been well studied. In contrast, FastFES has been shown to produce marked long-term therapeutic benefits on post-stroke gait, but it is not known whether it can induce measurable improvements in post-stroke gait impairments within a single session.

The changes induced in gait following each session of gait training may be important because they form the ‘building blocks’ that accumulate to produce the long-term therapeutic effects of an intervention. We posit that within-session changes in gait performance, if present, may provide a valuable ‘probe’ or evaluation tool to assess an individual’s short-term responsiveness to an intervention and aid with future development of customized gait retraining strategies. For example, if a single session of training is found to induce changes in gait biomechanics, before implementing a long-term gait rehabilitation program comprising 18 to 24 sessions over the course of 6 to 12 weeks, perhaps biomechanical data obtained during a single session of training can be utilized to determine whether the individual shows any measurable improvements in gait biomechanics following a single session of training. Furthermore, establishing that within-session changes in gait biomechanics are induced by clinical training protocols such as FastFES would lay foundations for future studies investigating the neurophysiological and biomechanical mechanisms underlying the effects of gait rehabilitation. The objective of this study, therefore, was to determine whether one FastFES gait training session (comprising 30-minutes of stepping practice with and without FES) can induce improvements in post-stroke gait biomechanics, as demonstrated by carry-over of improvements in gait during walking without FES.

Materials and Methods


Thirteen individuals with chronic post-stroke hemiparesis (age 42-75 years, 2 females, and time post-stroke 5-90 months) were recruited for the study (Table 1). Study inclusion criteria included >6 months post-stroke and the ability to walk for 4-minutes without an orthosis. Individuals were excluded if they had neurological diseases other than stroke, neglect, hemianopia, orthopedic problems affecting walking, or inability to communicate with investigators. Participants provided informed consent and study procedures were approved by the institutional review board.