LEARNING TO WALK AFTER A STROKE

If you or someone you know is recovering from a stroke, the road to recovery can be challenging, but there are many different therapies, treatments, and equipment that can help improve the return to an active life. 

According to the CDC, almost 800,000 people a year have a stroke; of these, 75% are new or first-time strokes. Stroke is the leading cause of long-term disability and affects the mobility of more than half of those who are over the age of 65. 

After having a stroke, the focus on rehab to regain walking skills becomes paramount. Often, patients are admitted to a rehab facility, but in less severe cases, the person may work with a physical therapist on an outpatient basis and be given a progressive menu of exercises.  

Walking ability after a stroke is strongly determined by how severe the stroke was and which areas of the brain were deprived of blood flow and oxygen. In most cases, a  stroke on one side of the brain (hemisphere) usually impairs the other side of the body. What that means is a left-sided brain injury can affect part or all of the right side of the body. However, different deficits may result from other types of strokes.  

Cognitive changes can also result from a stroke. A person may be unable to accurately judge where to put their foot or have sensory alterations that impair their ability to sense the ground underneath. Visual changes can compound this problem and can cause dizziness. Communication deficits may interfere with understanding instructions or expressing oneself. 

Hemiparesis and hemiplegia are two common problems that can determine how much difficulty a person will have with learning to walk after a stroke. Hemiparesis is weakness, whereas hemiplegia is paralysis, each being of one half (hemi) side or part of one side of the body.  Evidence suggests that as many as 65% of patients may have hemiparesis after a stroke.  While the bulk of function can return in the first three months, improvement can continue over a longer period due to changes in the neuroplasticity of the brain.

Normal walking involves the smooth transfer of weight from one leg and foot to the other. If a stroke also affects the person’s arm, then abnormal arm swing adds to the difficulty of achieving a balanced gait. Many feel more stable using a cane or walker or the assistance of a caregiver. 

Immobility after a stroke often leads to overall weakness and loss of muscle mass. Plus, the work of rehabilitation and exercise takes a lot more energy. 

Hemiparesis and hemiplegia can also lead to foot drop because the person has lost the ability to flex their ankle or raise up on their toes. Toe strength is commonly the last place to regain function due to being the farthest point away on an extremity. A person may naturally try to compensate for the foot drop by using a “steppage gait” or other changes similar to those seen in Parkinson’s disease.

One of the ways people can try to work around foot drop is to wear shoes such as the Cadense style, which helps keep the dragging toe from restricting the swing of that leg and foot, reducing the chance of tripping. 

Nerve impulses from the brain that tell muscles to contract can become erratic. Many people develop spasticity or contractures after a stroke, which causes muscle tightness and stiffness. Impaired depth perception can also lead to missteps and increased fear of falling. Making sure obstacles are cleared from walkways and that grab rails are installed in shower and toilet areas can help prevent falls. 

Walking slower after a stroke is common, as a result of the difficulty of generating the smooth concert of motions needed to get through gait. Fear of falling can also slow people down. Learning to walk after a stroke can also cause fatigue, resulting in a slower pace.

Claw toe is flexion or bending of the four lesser toe’s middle joints, and it affects the ability of the foot to push off effectively during gait.  The “knuckles” of the toes can develop calluses and blisters from rubbing against the ends of socks or shoes.

Working with a PT may help stretch and flatten the toes so they can regain natural positioning and normal movement. 

A hammer toe typically occurs in the 2nd or other lesser toes and differs from a claw toe in that only a single toe develops this bent contracture, due to a shortening of ligaments and muscles. A hammer toe can be flexible or rigid. Those that are flexible can be gently stretched out, while a rigid hammer toe may require surgery.

Rehabilitation is a crucial step in learning to walk after a stroke. A physical therapist can create an individualized list of exercises that will get a person on the path of regaining walking skills and building core muscles to assist with balance. 

Here are examples of the most common ones, with links to videos demonstrating the techniques. 

Sit on a firm, stable chair. Slide your body forward in the chair so you are sitting near the front edge. Clasp your hands together, lean forward, and push yourself to a standing position. Try to keep your weight equally on both legs and as you lean your body forward, keep your nose over your toes. After fully standing up, pause, then slowly sit back down. Repeat this exercise 15 to 20 times.    

Stand at one end of a long hallway free of obstacles.  Keep your eyes open and look forward. Sidestep at a comfortable pace for six big steps.  Then, sidestep back six big steps. Make sure your feet are pointed forward. Repeat this exercise several times.   

You will need a stair step and double handrail for support while doing this exercise. Step up one step, keeping your hip, knee, and ankle aligned. Don’t let your hip or knee shift from this position. Then, step back down. Repeat this exercise 10-15 times on each side.

Lay on your back and bend your knees while keeping your feet planted on the ground. Push your bottom and hips up into a bridge position. Try to keep your hips level. Place your hands on the ground on either side of your hips for balance. Slowly shift your weight to your affected side and then back to your unaffected side. Make sure your hips stay level. Then relax and bring your bottom and hips down. Repeat this exercise until you feel too tired to continue.

Adequate foot care becomes a needed mainstay for walking progress after a stroke. Foot care starts with basic washing and drying of the feet daily and looking for any possible injuries, such as corns, calluses, or blisters. This is especially important if a person has developed neuropathy in their feet and can’t feel those changes. 

Sometimes, orthotics are worn to stabilize the foot to improve walking.  Orthotics may be the type that are inserted inside the shoe or an ankle-foot orthotic (AFO) that also extends up the ankle to help brace the lower leg.  AFOs are often prescribed for people with foot drop to maintain a 90-degree angle to keep their toes up in gait.

Post-stroke shoes should be comfortable, with good arch support, and should have a wide toe box. Shoes that tighten using laces have the best and most supportive fit, but tightening those laces can be cumbersome. Velcro straps work well but may not provide a customized fit.

Shoes like Cadense combine the best of both worlds. They are laced up but have a single closure flap, which makes putting them on and off much easier. The additional feature Cadence shoes have is their sliding puck mechanism under the front of the shoe, which can assist people who have foot drop in sliding the front of their foot as they glide forward. The center puck provides slip resistance, so the shoe stays stable.