Chapter 4A - Lower Extremity Post Stroke

Stroke Rehabilitation Clinician Handbook 2016
4. Motor Rehabilitation
4A. Lower Extremity and Mobility
Robert Teasell MD, Norhayati Hussein MD
4.1 Motor Recovery of the Lower Extremity Post Stroke

Factors that Predict Motor Recovery
Motor deficits post-stroke are the most obvious impairment (Langhorne et al. 2012) and have a disabling
impact on valued activities and independence. Motor deficits are defined as “a loss or limitation of
function in muscle control or movement or a limitation of movement” (Langhorne et al. 2012; Wade 1992).
Given its importance, a large proportion of stroke rehabilitation efforts are directed towards the recovery
of movement disorders. Langhorne et al. (2012) notes that motor recovery after stroke is complex with
many treatments designed to promote recovery of motor impairment and function.
The two most important factors which predict motor recovery are:
1. Stroke Severity: The most important predictive factor which reduces the capacity for brain
reorganization.
2. Age: Younger patients demonstrate greater neurological and functional recovery and hence have
a better prognosis compared to older stroke patients (Adunsky et al. 1992; Hindfelt & Nilsson
1977; Marini et al. 2001; Nedeltchev et al. 2005).
Changes in walking ability and gait pattern often persist long-term and include increased tone, gait
asymmetry, changes in muscle activation and reduced functional abilities (Wooley 2001; Robbins et al.
2006; Pizzi et al. 2007, Pereira et al. 2012). Ambulation post stroke is often less efficient and associated
with increased energy expenditure (Pereira et al. 2012). Hemiplegic individuals have been reported to
utilize 50-67% more metabolic energy that normal individuals when walking at the same velocity (Wooley
et al. 2001).
For mobility outcome, trunk balance is an additional predictor of recovery (Veerbeek et al. 2011). Non-
ambulant patients who regained sitting balance and some voluntary movement of the hip, knee and/or
ankle within the first 72 hours post stroke predicted 98% chance of regaining independent gait within 6
months. In contrast, those who were unable to sit independently for 30 seconds and could not contract
the paretic lower limb within the first 72 hours post stroke had a 27% probability of achieving independent
gait.
4.2 Assessments of Mobility

Some commonly used assessments of motor function post stroke include:
• The Berg Balance Score
Stroke Rehabilitation Clinician Handbook pg. 1 of 27

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• Chedoke-McMaster Stages of Motor Impairment

• Timed Up and Go (TUG)
• 2 or 6-Minute Walking Test
Berg Balance Score

Questions Answer
What does it Quantitative assessment of balance in older adults (Berg et al. 1989).
measure?
What is the scale? 14 items requiring subjects to maintain positions or complete movement tasks of
varying levels of difficulty. Items receive a score of 0-4 based on ability to meet the
specific time and distance requirements of the test.
0 = inability to complete the item; 4 = ability to complete the test independently.
What are the key Maximum score = 56. A score of less than 45 is indicative of balance impairment or risk
scores? of falling.
What are its Measures a number of different aspects of balance, both static and dynamic.
strengths? Requires little equipment or space and no specialized training.
High levels of reliability even when test is administered by an untrained assessor.
Particularly well suited to acute stroke rehabilitation, as the majority of patients do not
obtain maximum scores on admission to rehabilitation.
Often correlates well with functional mobility gains on rehabilitation.
What are its Takes somewhat longer to administer than other balance measures and may not be
limitations? suitable for the evaluation of active, elderly persons, as the item included are not
sufficiently challenging for this group.
As no common standards for interpretation of BBS scores exist, their relationship to
mobility status and the requirement for mobility aides is not known.
Decreased sensitivity in early stage post-stroke among severely affected patients as
scale includes only one item relating to balance in the sitting position.
Chedoke-McMaster Stroke Assessment Scale

Questions Answer
What does it The Chedoke-McMaster Stroke Assessment Scale (CMSA) is a 2-part assessment consisting of
measure? a physical impairment inventory and a disability inventory. The impairment inventory is
intended to classify patients according to stage of motor recovery while the disability
inventory assesses change in physical function.
What is the scale? The scale’s impairment inventory has 6 dimensions; shoulder pain, postural control, arm
movements, hand movements, leg movements, and foot movements. Each dimension (with
the exception of ‘shoulder pain’) is rated on a 7- point scale corresponding to Brunnstrom’s 7
stages of motor recovery. The disability inventory consists of a gross motor index (10 items)
and a walking index (5 items). With the exception of a 2-minute walking test (which is scored
as either 0 or 2), items are scored according to the same 7-point scale where 1 represents
total assistance and 7 represents total independence.
What are the key The impairment inventory yields a total score out of 42 while the disability inventory yields a
scores? total score out of 100 (with 70 points from the gross motor index and 30 points from the
walking index).
What are its The use of Brunnstrom staging and FIM scoring increases the interpretability of the CMSA
strengths? and may facilitate comparisons across groups of stoke patients.
The CMSA is relatively comprehensive and has been well studied for reliability and validity.
What are its Taking approximately 1 hour to complete, the length and complexity of the CMSA may make
limitations? the scale less useful in clinical practice.

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As primarily a measure of motor impairment, the CMSA should really be accompanied by a

measure of functional disability such as the BI or the FIM.
7 Brunnstrom Stages of Motor Recovery

1. Flaccid paralysis. No reflexes.
2. Some spastic tone. No voluntary movement. Synergies elicited through facilitation.
3. Spasticity is marked. Synergistic movements may be elicited voluntarily.
4. Spasticity decreases. Synergistic movements predominate.
5. Spasticity wanes. Can move out of synergies although synergies still present.
6. Coordination and movement patterns near normal. Trouble with more rapid complex
movements.
7. Normal
Stages of Motor Recovery of the Chedoke McMaster Stroke Impairment Inventory (Gowland et al.
1993)
Stages Characteristics
Flaccid paralysis is present. Phasic stretch reflexes are absent or hypoactive. Active movement cannot
1
be elicited reflexively with a facilitatory stimulus or volitionally.
Spasticity is present and is felt as a resistance to passive movement. No voluntary movement is
2 present but a facilitatory stimulus will elicit the limb synergies reflexively. These limb synergies consist
of stereotypical flexor and extensor movements.
3 Spasticity is marked. The synergistic movements can be elicited voluntarily but are not obligatory.
Spasticity decreases. Synergy patterns can be reversed if movement takes place in the weaker synergy
4 first. Movement combining antagonistic synergies can be performed when the prime movers are the
strong components of the synergy.
Spasticity wanes, but is evident with rapid movement and at the extremes of range. Synergy patterns
5 can be revised even if the movement takes place in the strongest synergy first. Movements that utilize
the weak components of both synergies acting as prime movers can be performed.
Coordination and patterns of movement can be near normal. Spasticity as demonstrated by resistance
6 to passive movement is no longer present. Abnormal patterns of movement with faulty timing emerge
when rapid or complex actions are requested.
Normal. A “normal” variety of rapid, age appropriate complex movement patterns are possible with
7 normal timing, coordination, strength and endurance. There is no evidence of functional impairment
compared with the normal side. There is a “normal” sensory-perceptual motor system.
Timed Up and Go (TUG)

Questions Answer
What does it measure? The TUG is an objective measure of basic mobility and balance maneuvers that
assesses an individual’s ability to perform sequential motor tasks relative to walking
and turning.
What is the scale? The TUG requires subjects to stand up from a chair, walk a distance of 3 meters, turn
around, walk back to the chair and seat themselves. The subject is permitted to use a
walking aid if one is normally required and is allowed to walk through the test once
before the timed session is undertaken.
What are the key The TUG score consists of the time taken to complete the test activity, in seconds.
scores?
What are its strengths? The TUG is quick and easy to administer, requiring no specialized equipment or
training.

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Timed scores are objective, straightforward, and more sensitive to change over time
than ordinal measures (Whitney et al. 1998).
What are its The TUG may not be suitable for use with cognitively impaired subjects; although
limitations? verbal cueing during the test may eliminate this concern (Nordin et al. 2006; Rockwood
et al. 2000).
Because normative data is not available for the TUG, its primary use has been
assessment of change within the individual (Thompson & Medley 1995).
Overall, the TUG is a limited measure that addresses relatively few aspects of balance
and yields a narrower assessment than more comprehensive balance measures, such
as the Berg Balance Scale (Whitney et al. 1998).
6 Minute Walking Test (6MWT)

Questions Answer
What does it measure? The 6MWT is a functional walking which measures the distance that a patient can walk
on a flat, hard surface in a period of 6 minutes. It is used to determine functional
capacity in individuals with compromised ability.
What is the scale? The 6MWT requires the patient to walk at the fastest speed over a period of 6 minutes.
Walking is performed along a 30 m walking course.
The subject is permitted to use a walking aid if required, with the use of the aid is kept
consistent from test to test. Patient is allowed to rest during the course of walking.
What are the key The 6 MWT consists of the distance taken to walk within 6 minutes, in meters. Number
scores? of rest should also be recorded.
What are its strengths? The 6MWT is quick and easy to administer, requiring no specialized equipment or
training. As it usually reflects the submaximal aerobic capacity, thus it's more reflective
in performance of ADLs compared to other functional walk test.
What are its The 6 MWT is not suitable for use with those unable to ambulate.
limitations? Stroke specific impairment, i.e. hemiparesis, spasticity, etc. may influence the distance
walked.

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4.3 Intervention for Mobility Impairment Post Stroke
Interventions for Mobility Impairment

Post Stroke
Task Specific Therapeutic

Orthosis
Training Exercise
Strength/ Conventional FES-based

Circuit Class Treadmill Resistance Neural
Training Training Orthosis
Training Orthosis
Without Body With Body
Balance
Weight Weight
Support Training
Support
Cardiovascular/
Electromechanical/
Manual Aerobic training
Robotic Assisted
Canadian Best Practice Guidelines: Update 2015 (Hebert et al. 2016) state that, “Patients should engage
in training that is meaningful, engaging, progressively adaptive, intensive, task-specific and goal-oriented
in an effort to improve transfer skills and mobility (Evidence Level A)”.
4.3.1 Therapy Intensity
Kwakkel et al. (2004) conducted a further meta-analysis, evaluating the benefit of augmented physical
therapy, including 20 studies which had assessed many interventions: occupational (upper extremity),
physiotherapy (lower extremity), leisure therapy, home care and sensorimotor training. After adjusting
for differences in treatment intensity contrasts, augmented therapy was associated with statistically
significant treatment effects for the outcomes of ADL and walking speed. Augmented therapy was found
to be more effective when initiated within six months of the stroke.
The term, “intensity”, most frequently refers to the frequency of repetitions within a given period of time,
although more correctly, is defined as the amount of mechanical output of physical activity. However,
such measurement is not usually possible within a clinical setting. Therefore, establishing a dose-response
relationship is problematic in stroke rehabilitation. Many factors preclude the routine recommendation
of standard amounts of therapy time an individual patient should receive, with many guideline
recommendations regarding intensity and duration of therapy to reflect consensus by clinicians rather
than research evidence (Foley et al. 2012). Therefore, it is extremely difficult to know how early therapy
should be initiated post stroke or how much additional therapy would confer benefit. In a prospective
cohort study, a relationship between lower limb exercise dose (mean daily number of exercise repetitions)
and improved walking speed was found (Scrivener et al. 2012).

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Kwakkel (2006) has demonstrated an association between effect size and additional treatment time, and
Foley et al. (2012) have found that the total amount of occupational therapy (OT) time is a significant
predictor of gains in functional independence measure (FIM) scores. Furthermore, researchers have
reported that intensive practice of function-focused physiotherapy predicts greater than expected gains
in mobility (Bode et al., 2004), with a treatment time of 3 hours or longer being associated with greatest
functional improvements (Wang et al. 2013).
Overall, there is strong evidence that early intensive therapy may improve gait and general motor
function; there is conflicting high quality evidence regarding the effect of augmented physical therapy on
gait at follow-up.
4.3.2 Task-Specific Training
As discussed under Organized Stroke Care, stroke rehabilitation should be task-specific wherever possible
and practical. Functional reorganization of cortex is greater for tasks that are meaningful to the animal;
repetitive activity is not enough. Task-specific training has been shown to have longer-lasting cortical
reorganization. Rehabilitation must be task specific, focusing on tasks which are important and
meaningful to the patient. In stroke rehabilitation, task-specific training principle is practiced in mobility
training and has been shown to improve gait speed and endurance. Task-specific training is performed
via actual over-the ground walking, and can be incorporated in circuit class therapy.
HIGHLIGHTED STUDY
English C, Hillier SL. Circuit class therapy (CCT) for improving mobility after stroke. Cochrane Database of
Systematic Reviews2010, Issue 7. Art. No.: CD007513. DOI: 10.1002/14651858. CD007513.pub2
Methods: Examined 6 RCTs which included repetitive practice of functional tasks arranged in a circuit with the aim
of improving mobility. Trials were performed on 292 participant whom were long-term stroke survivors living in
the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance.
Results: Four studies measured walking capacity and three measured gait speed, demonstrating that CCT was
superior to the comparison intervention: 1) Six Minute Walk Test: mean difference (MD), fixed 76.57 metres, 95%
confidence interval (CI) 38.44 to 114.70, P < 0.0001; 2) Gait speed: MD, fixed 0.12 m/s, 95% CI 0.00 to 0.24, P=
004); Two studies measured balance, showing a superior effect in favour of CCT; 3) Step Test: MD, fixed 3.00 steps,
95% CI 0.08 to 5.91, P = 0.04; 4) Activities-specific balance and confidence: MD, fixed 7.76, 95% CI 0.66 to 14.87, P
= 0.03.
HIGHLIGHTED STUDY
Van de Port IGL, Wevers LEG, Lindeman E, Kwakkel G/ Effects of circuit training as alternative to usual
physiotherapy after stroke: A randomised controlled trial. BMJ 2012; 344,e2072.
Methods: Included 250 patients who completed inpatient stroke rehabilitation, able to walk 10 m without
physical assistance. Randomized to receive graded task-specific circuit program vs usual outpatient physiotherapy.
Results: At the end of follow-up (24 weeks), patients in the task-specific therapy group had significantly higher
scores on the mobility sub scale of the Stroke Impact Scale and increased distance walked on the 6MWT,
compared with patients in the control group.

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HIGHLIGHTED STUDY
Salbach NM, Mayo NE, Wood-Daphinee S, Hanley JA, Richard CL. A task-oriented intervention enhances walking
distance and speed in the first year post stroke. A randomized controlled trial. Clinical Rehabilitation 2004; 18:
509-519.
Methods: 91 community-dwelling stroke survivors with residual walking deficit within 1 year of stroke randomized
to intervention of 10 functional tasks designed to strengthen L/E and enhance walking balance, speed and distance
vs. control intervention focusing on U/E activities, 3x/week x 6 weeks.
Results: Intervention group improved more in 6minWT (40meters vs. 5meters); comfortable walking speed (0.14
vs. 0.03 meters/second); maximum walking speed (0.20 vs. -0.01 meters/second); TUG (-1.2 vs. 1.7 second).
Performance on measures of Performance measures for the Six-

Walking Speeds minute Walking Test
Change in Speed Over 6 weeks of
Mobility Training UE Training Mobility Training UE Training

0.25 260
0.2 250
Training (m/s)
Distance (m)
0.15 240
0.1 230
0.05 220
0 210
-0.05
200
Comfortable Maximum Walking Pre Post
Walking Speed Speed 6 week Training Period
There is strong evidence that task-specific gait training improves gait post-stroke. Canadian Best Practice
Guidelines: Update 2015 (Hebert et al. 2016) noted that, “task and goal-oriented training that is repetitive
and progressively adapted should be used to improve performance of selected lower extremity tasks such
as walking distance and peed and sit to stand (Evidence Level A)”.
4.3.3 Treadmill Training in the Absence of Partial Body Weight Support
Treadmill training without body weight support can be used when standard over-ground gait training is
not available or appropriate. The evidence however, does not support treadmill training as necessarily
more effective than standard gait training.
HIGHLIGHTED STUDY
Pohl M, Mehrholz J, Ritschel C, Ruckriem S. Speed-dependent treadmill training in ambulatory hemiparetic
stroke patients. A randomized controlled trial. Stroke 2002; 33:553-558.
Methods: 60 ambulatory patients suffering from hemiparesis, were randomized into 1 of 3 groups: structured
speed-dependent treadmill training (STT), limited progressive treadmill training (LTT), and conventional gait
therapy (CGT).

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Results: After 4 weeks training period, the STT group scored significantly higher than the LTT and CGT for all
outcome measures.
HIGHLIGHTED STUDY
Macko RF, Ivey FM, Forrester LW, Hanley D, Sorkin JD, Katzel LI et al. Treadmill exercise rehabilitation improves
ambulatory function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial.
Stroke 2005; 36(10):2206-2211.
Methods: 61 chronic stroke patients with hemiparetic gait patients were randomized to receive 6 months of
progressive treadmill aerobic exercise program or stretching plus low intensity walking.
Results: Significant greater improvement in ambulatory performance and mobility function in the treadmill
training group compared with patients who received a program of stretching plus low-intensity walking.
HIGHLIGHTED STUDY
Langhammer B, Stanghelle JK. Can physiotherapy after stroke based on the Bobath concept result in improved
quality of movement compared to the motor relearning programme. Physiother Res Int
2011; 16(2):69-80.
Methods: Intervention consisting of 2.5 weeks/5 days week for 30 minutes of treadmill training versus a control
intervention consisting of outdoor walking.
Results: Patients in the treadmill group had better walking speed, endurance, and walking distance compared to
controls who were involved in outdoor walking.
LOS for Physiotherapy using the Motor Relearning Programme

(MRP) vs. Bobath
Bobath 34
MRP 21 p=.008
0 5 10 15 20 25 30 35
Length of Stay (days)
There is strong evidence that treadmill training either in combination with conventional therapy or
delivered alone, may improve gait velocity, stride length and lower limb functional mobility; however, it
may not improve balance.
4.3.4 Partial Body Weight Support and Treadmill Training (PBWSTT)
“Those who want to walk learn by walking” (Hesse et al. 2003). Based on animal models whereby various
motor activities, such as stepping, may be induced by brainstem and spinal cord with little cortical

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stimulus. The evidence of PBWS and treadmill training is mixed but the weight of the evidence is moving
towards supporting PBWS. This is supported by the general trend towards task-specific therapies. It does
require some equipment and can be therapist intensive.
HIGHLIGHTED STUDY
Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through
body weight support and treadmill stimulation. Stroke 1998; 29:1122-1128.
Methods: 100 stroke patients (onset > 6 months) randomized to walk training on treadmill with 40% of BW
supported by overhead harness or treadmill with no BWS.
Results: Significant effect in favour of BWS at end of treatment and 3 months follow-up for motor recovery and
overground walking speed.
Walking Endurance
Walking
Speed
Motor Recovery
0 0.1 0.2 0.3 0.4
Balance
no BWS BWS
0 50 100 150 200
no BWS BWS
HIGHLIGHTED STUDY
Ada L, Dean CM, Morris ME, Simpson JM, Katrak P. Randomized Trial of Treadmill Walking With Body Weight
Support to Establish Walking in Subacute Stroke. The MOBILISE Trial. Stroke 2010; 41:1237-1242.
Methods: 126 acute (<28 days post stroke), non-ambulatory stroke patients randomly allocated to 30
minutes/day treadmill training with BWS via overhead harness or control group with 30 minutes/day overground
walking. Primary outcomes was proportion of participants achieving independent walking within 6 months
Results: 37% of PWBTT and 26% of control patients achieved independent walking at 1 month; 66% vs. 55% at 2
months, 71% vs. 60% at 6 months (p=0.13). The PWBTT groups walked 2 weeks earlier, with median time to
independent walking 5 weeks compared to 7 weeks for control group. Secondary outcomes reported: walking
quality and capacity, walking perception, community participation and falls.
Among independent walkers at 6 months, there was no difference between the groups in speed (0.10
meters/second) or stride (6 cm). Independent walkers in PWBTT group walked 57m further in 6 min walk test vs.

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control group. PBWTT group (walkers and non-walkers) rated their walking 1 point out of 10 higher than the
control group. No differences noted between groups in community participation or number of falls.
HIGHLIGHTED STUDY
LEAPS (Locomotor Experience Applied Post-Stroke) trial - Duncan PW et al. Body-weight-supported treadmill
rehabilitation after stroke. NEJM. 2011; 364:2026-36.
This is a Phase 3, single blinded, multicentred RCT.

Objective: To compare the efficacy of three protocols for improving walking ability post stroke
1. Body weight supported treadmill training (BWSTT) initiated 2 months post stroke (AKA early locomotor
training (LT)).
2. BWSTT initiated 6 months post stroke (AKA late LT).
3. Home exercise program initiated 2 months post stroke (AKA HE group).
Methods:
1. Early or late LT group: 90 minute sessions 3x/week, duration of 12-16 weeks (minimum 30-36 sessions),
BWSTT with manual assistance as needed for 20-30 minutes followed by walking over ground for 15 minutes.
2. Home exercise group: Physical therapist guided program in the home, focused on flexibility, ROM, strength of
arms and legs, static and dynamic balance, coordination. Designed as active control (not task-specific walking).
All patients also received “usual care”.
Results: 408 subjects stratified by severity and study site then randomized to one of three groups. Outcomes
measured at baseline, 6 months and 12 months. There was no significant difference in primary outcome (higher
functional walking level). Overall 52% of participants transitioned to higher functional walking level. Early LT
compared to HE: OR 0.83 (CI 0.5-1.39); Late LT compared to HE: OR 1.19 (CI 0.72-1.99). Secondary outcomes
showed at one year, no difference between groups for walking speed, number of steps in a day, ADLs, motor
recovery, social participation, balance. Late LT group was significantly slower at 6 months, less steps in a day at 6
months.
Conclusions: BWSTT was not found to be superior to a home-based physiotherapist provided multi-modal
exercise program for improving functional walking. At 1 year, all groups showed significant improvements. At 6
months, late LT results lagged behind (had only had “usual care” up until then). Study showed BWSTT may be
associated with higher of multiple non-injurious falls. Home based therapy program was more pragmatic based on
cost and outcomes.
PBWS and Treadmill Training – Summary of Studies
Author PEDro Score N Outcome

Eich et al. 2004 8 50 +
Nilsson et al. 2001 7 73 -
Werner et al. 2002 7 30 +
Visintin et al. 1998 6 100 +

Suputtiada et al. 2004 6 48 -
Yagura et al. 2006 6 49 -
Duncan et al. 2011 8 480 -

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There is strong evidence that partial body weight support treadmill training may not improve gait or
balance outcomes compared to conventional or other gait training interventions based on the most
definitive trial, the LEAPs trial (Duncan et al. 2011). Treatment does require equipment and is labour
intensive. PBWSTT can be considered for patients with low ambulatory function especially when other
mobility strategies are inappropriate or unsafe.
4.3.5 Cardiovascular/Aerobic Training
Cardiovascular conditioning is increasingly being advocated for stroke patients. American Heart
Association (2004) published exercise recommendations which included aerobic exercises as a means to
improve sensorimotor function and help with secondary prevention of stroke. Patients with stroke should
participate in an aerobic program following medical clearance.
HIGHLIGHTED STUDY
Duncan P, Studenski S, Richards L, et al. Randomized clinical trial of therapeutic exercise in subacute stroke.
Stroke 2003; 34:2173-2180.
Methods: 100 stroke patients randomly assigned to structured, progressive exercise program (36x90 minute
sessions over 12 weeks) or usual care in single-blinded study.
Results: Improvements seen in balance, endurance, peak aerobic capacity and mobility.
Change in 10-m Gait Velocity for a

Usual Care Group vs. an Intervention
Group
Usual Care
p<.05
Intervention
0 0.05 0.1 0.15 0.2

Change in 10-m Gait Velocity from baseline to 3
months (m/s)
HIGHLIGHTED STUDY
Pang MYC, Eng JJ, Dawson AS, Glyfadóttir S. The use of aerobic exercise training in improving aerobic capacity in
individuals with stroke: a meta-analysis. Clin Rehabil 2006; 20:97-111.
Methods: Conducted systematic review of aerobic exercise post-stroke which included 7 RCTs.
Results: Exercise intensity ranged from 50-80% heart rate reserve, while duration varied from 20-40 minutes x 3-5
days/week. Regardless of stage of stroke recovery, there was a significant benefit of therapy in parameters of VO2
peak workload, walking speed and endurance.

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HIGHLIGHTED STUDY
Brazzelli M, Saunders DH, Greig CA, Mead GE. Physical fitness training for stroke patients. Cochrane Database of
Systematic Reviews 2011, Issue 11. Art. No.: CD003316. DOI:10.1002/ 14651858. CD003316.pub4.
Methods: 32 trials were included, patients were recruited in both the acute and chronic stages of stroke.
Intervention were classified into 3 major groups: cardiorespiratory training vs usual care; resistance training vs
usual care ; mixed training inclusive of both cardiorespiratory and resistance training method.
Results: In the cardiorespiratory training group, the walking speed (maximal speed and preferred speed) and
walking capacity were significantly improved. However, cardiorespiratory training was not associated with
reductions in disability as reflected by FIM.
There was strong evidence cardiovascular training post-stroke improves level of physical fitness and gait
performance; however, it did not result in additional improvement in ADL performance.
4.3.6 Strength Training to Improve Mobility
HIGHLIGHTED STUDY
Moreland JD, Goldsmith CH, Huijbregts MP, Anderson RE, Prentice DM, Brunton KB, O’Brien A, Torresin WD.
Progressive resistance strengthening exercises after stroke: a single-blind randomized controlled trial. Arch Phys
Med Rehabil 2003; 84:1433-40.
Methods: A case controlled study of 133 stroke patients were randomized to the experimental group, receiving 9
lower-extremity progressive resistance exercises or to the control group who performed the same exercises
without resistance.
Results: No significant difference on the rate of change on the Disability Inventory or the 2-minute walking test
was found between the groups.
HIGHLIGHTED STUDY
Mead GE, Greig CA, Cunningham I et al. Stroke: a randomized trial of exercise or relaxation. J Am Geriatr Soc
2007; 55:892-899
Methods: 66 ambulatory stroke patients who completed inpatient rehab randomized to receive a 12 week
outpatient program of strength and resistant treatment or relaxation with treatments provided 1.5 hours, 3 x per
week.
Results: At 3 months, the role-physical component of the SF-36, timed up and go, and walking economy were
significantly better among patients in the exercise group compared to the relaxation group. By 7 months, the only
difference that remained between groups was the role physical component of the SF-36.
There is mixed evidence that strength training improves outcomes post stroke. Some of the studies were
positive while others were not. For instance, there is strong evidence that functional strength training
may improve gait speed but may not improve knee extension and flexion strength. There is also strong
evidence that progressive resistance training may improve strength and knee extension but not gait.
Canadian Best Practice Guidelines: Update 2015 (Hebert et al. 2016) has noted that, “Strength training
should be considered for persons with mild to moderately lower extremity function in both subacute (Level
Evidence C) and chronic phases (Evidence Level B) of recovery. Strength training does not affect tone or
pain (Evidence Level A)”.

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4.3.6 Balance Training and Falls Prevention Post Stroke
Improvement in balance has been identified as the strongest predictor of distance walked. There have
been a large number of RCTs examining balance which have employed a number of therapy approaches.
Trunk-specific balance training and balance-focused exercise programs have been shown to improve
balance post stroke. Whole body and local vibration, thermal stimulation, and interventions involving
feedback may not improve balance outcomes. It is unclear whether task-specific balance training
programs and virtual reality training improve balance, gait and functional recovery post stroke.
Patients experience a stroke are at a higher risk of falling with 25-39% of patients falling while on the
stroke rehabilitation unit and 73% falling within 6 months of discharge form hospital. Several RCTs have
exhausted the effectiveness of exercise programs in reducing falls while one study (see highlighted study
below) actually studies a falls prevention study.
HIGHLIGHTED STUDY
Batchelor et al. Effects of a multifactorial falls prevention program for people with stroke returning home after
rehabilitation: A randomized controlled trial. Arch Phys Med Rehabil 2012; 93(9):1548-1655.
Methods: 156 participants with stroke at risk of recurrent falls being discharged home from rehab were
randomized to a tailored multifactorial falls prevention program and usual care (n=71) or to control usual care
(N=85).
Results: There was no significant difference in the fall rate or the proportion of fallers between the two groups.
There was also no significant difference in injury fall rate.
There is strong evidence that exercise-based falls prevention programs may not reduce the rate of falls
post stroke.
4.3.7 Electromechanical and Robotic Assisted Mobility Training
Electro-mechanical and robotic-assisted therapy have gained much recent interest in stroke motor
rehabilitation. Theoretically, robot-assisted therapies are able to provide alternative to labour-intensive
therapist-assisted interventions, thus fulfil the stroke rehabilitation principles of high intensity and task
specificity. However the potential benefits have not yet been fully apparent in research and clinical
practice; with studies showing mixed outcome results.

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HIGHLIGHTED STUDY
Pohl M, Werner C, Holzgraefe M, Kroczek G, Mehrholz J, Wingendorf J et al. Repetitive locomotor training and
physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized
multicentre trial (DeutscheGAngtrainerStudie, DEGAS). Clin Rehabil. 2007; 21(1):17-27.
Methods: 155 stroke patients admitted to rehab unit randomized to receive either 20 minutes of repetitive
practice on a gait trainer, followed by 25 minutes of individual PT every day for 25 minutes x 4 weeks (group A) or
45 minutes of individual PT (group B). Total treatment time was identical between groups.
Results: At end of treatment a significantly greater proportion of patients in group A were able to walk
independently (53% vs. 22%, p<0.0001). Significantly more patients in group A attained a BI score of >75 (57% vs.
27%, p<0.0001). By 6 months, significantly more patients could walk independently (70% vs. 36%, p<0.0001)
although there were no longer differences in the proportion of patients with BI > 75 (58% vs. 46%, p=0.025). There
were no differences in proportion of patient living at home (68% vs. 68%).
HIGHLIGHTED STUDY
Schwartz I, Sajin A, Fisher I, Neeb M, Shochina M, Katz-Leurer M, Meiner Z. The effectiveness of locomotor
therapy using robotic-assisted gait training in subacute stroke patients: a randomized controlled trial. PMR
2009; 1:516-523.
Methods: 67 patients admitted to rehab < 3 months post stroke randomized to 2 groups. Both groups received PT
for 30 minutes/day x 5 days/week x 6 weeks. Experimental group received additional therapy (20 minutes x
3x/week x 6 weeks) using the Lokomat training device.
Results: Control group received an equal amount of PTA after 6 weeks, a greater proportion of subjects in
experimental group could walk independently (20/37 vs. 8/28, p<0.03). Subjects in experimental group had better
NIHSS scores at the end of treatment (6.6 vs. 8.0, p<0.01).
HIGHLIGHTED STUDY
Mehrholz J, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke. Cochrane
Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006185. DOI: 10.1002/ 14651858.CD006185.pub2.
Methods: 17 trials with 837 participants comprising of ambulators, non-ambulators and combination of both.
Interventions include electromechanical and robotic -assisted devices (with or without electrical stimulation) with
the addition of physiotherapy compared with physiotherapy or routine care only.
Results: Electro-mechanical assisted gait training in combination with physiotherapy increased the odds of
becoming independent in walking (OR 2.21, 95% CI: 1.52 to 3.22). However, there is no significant increment in
walking velocity or walking capacity.
HIGHLIGHTED STUDY
Morone G, Bragoni M, Iosa M, De Angelis D, Venturiero V, Coiro P, Pratesi L, Paolucci S. Who may benefit from
robotic-assisted gait training? A randomized clinical trial in patients with subacute stroke. Neurorehabil Neural
Repair 2011; 25:636–644.
Morone G, Iosa M, Bragoni M, De Angelis D, Venturiero V, Coiro P, Riso R, Pratesi L, Paolucci S. Who may have
durable benefit from robotic gait training: a 2-year follow-up randomized controlled trial in patients with
subacute stroke? Stroke 2012; 43(4):1140-1142.

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Methods: 48 nonambulatory participants after subacute stroke were stratified by Motricity Index into high (<29)
and low (≥29) motor impairment groups. Each arm was randomized to a robotic (robotic -assisted and
conventional gait training or control group (conventional gait training only) at a mean of 20 days after stroke. The
primary outcome was Functional Ambulation Category, and secondary measures were the Rivermead Mobility
Index and Barthel Index scores. The scales were administered before and after the inpatient stay and 2 years after
discharge.
Results: Low motor-impairment group: Participants in the low impairment robot group had improved significantly
more than subjects in the control group – Functional ambulation category (4.7±0.5 versus 3.1±1.5, P=0.002),
Barthel Index (76.9±11.5 versus 64.7±14.0, P=0.024), and Rivermead Mobility Index (11.8±3.5 versus 7.0±3.6,
P=0.010). High motor- impairment group: Highly impaired participants improved over time, but there were no
significant between-group differences on any of the outcomes. Conventional and robotic therapies were equally
effective in the high impairment groups.
There is strong evidence that Lokomat may not improve gait and balance in the acute phase of stroke
recovery. Evidence is less clear regarding its use in the subacute and chronic phase of stroke. Canadian
Best Practice Guidelines: Update 2015(Hebert et al. 2016) have noted that, “Electromechanical (robotic)
assisted gait training devices could be considered for patient who would not otherwise practice walking.
They should not be used in place of conventional gait training (Evidence Level A for Early and Late Rehab)”.
4.3.9 Functional Electrical Stimulation FES-Based Neural Orthosis for Gait Cycle
Use of the Ness L300® decreases spasticity, improves dynamic instability and creates a more normal gait
pattern with chronic hemiparesis.

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FES of the common peroneal nerve has been used to enhance ankle dorsiflexion during the swing phase
of gait. Although weak ankle dorsiflexion with plantar flexion hypertonicity is typically corrected by an
ankle foot orthosis, FES may be a suitable alternative for highly motivated patients who are able to walk
independently or with minimal assistance. Although not widely used or available, there is growing
evidence that FES combined with gait training improves hemiplegic gait. Systematic reviews (Kottink et
al. 2004; Robbins et al. 2006) both showed a benefit for walking speeds. There is strong evidence FES and
gait retraining results in improvements in hemiplegic gait. Canadian Best Practice Guidelines: Update
2015 notes that, “FES should be used to improve strength and function (gait) in selected patients, but the
effects may not be sustained (Evidence Level: Early – Level A; Late – Level A).”
HIGHLIGHTED STUDY
Daly JJ, Zimbelman J, Roenigk KL, McCabe JP, Rogers JM, Butler K et al. Recovery of Coordinated Gait:
Randomized Controlled Stroke Trial of Functional Electrical Stimulation (FES) Versus No FES, With Weight-
Supported Treadmill and Over-Ground Training. Neurorehabil Neural Repair 2011; 25(7):588-596.
Methods: 53 patients with stroke onset > 6 months received 12 week treatment program (1.5 hours, 4X per week)
consisting of strengthening exercises, overground gait training and BWSTT. Patients randomized to intramuscular
FES (implanted into 8 muscles). Primary outcome measure was Gait Assessment and Intervention Tool (GAIT)
assessed at baseline, post-treatment and at 6 months.
Results: Patients in both groups improved over treatment period. Patients in IM FES group achieved significantly
greater improvements in GAIT (p=0.045) following treatment that were maintained at 6 months. 50% of IM FES
group improved by at least 10 points on GAIT compared to 21% of control group.
4.3.10 Feedback
Feedback-based training has been used to help improve balance and mobility. Feedback can come in the
form of auditory, visual and touch sensation sensory inputs and these additional sensory cues can improve
motor performance. The type of feedback can be quite variable but tends to fall under one of these
categories: auditory stimulation, action observation and biofeedback methods. Feedback to patients as
to how they perform motor tasks during gait rehabilitation has been shown to improve performance and
learning (Johnson et al. 2013). Stanton et al. (2011) in a systematic review reported that taking into

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consideration all types of sensory feedback, in aggregate it was associated with significant show short and
long-term outcomes.
HIGHLIGHTED STUDY
Dorsch et al. SIRRACT: An international randomized clinical trial of activity feedback during inpatient stroke
rehabilitation enabled by wireless sensing. Neurorehabil Neural Repair 2015; 29(5):407-415.
Methods: 151 participants were randomized to receive either speed-only feedback or augmented feedback by a
computer.
Results: No significant differences were found between the two feedback groups in daily walking time or 15 –
meter walking speed. 30% of participants decreased their total daily walking time over their rehabilitation stay.
HIGHLIGHTED STUDY
Dobkin et al. International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of
walking sped (SIRROWS) improves outcomes. Neurorehabili Neural Repair 2010; 24(3):235-242.
Methods: 179 inpatients were randomized to either feedback about self-selected fast walking speed (daily
reinforcement of speed) immediately after a single day, daily 10-metre walk, or to no reinforcement of speed.
Results: Participants receiving reinforcement of speed performed better on the walking speed; however, no
difference between groups was found on the length of stay, as both groups showed a decrease. The reinforcement
group did not have a higher proportion of the functional ambulation category of independent walkers and did not
walk longer distances.
Moreland et al. (1994, 1998) concluded that EMG-biofeedback was an effective adjunct to lower limb
physiotherapy. Cochrane review evaluating EMG-biofeedback vs. either sham or no treatment found no
benefit to treatment on pooled results (Woodford and Price 2007). Most of the studies are small RCTs.
Biofeedback training improved gait and standing post-stroke in a majority of “fair” to “good” quality RCTs.
However, there is enough negative trials that evidence regarding the effect of EMG Biofeedback on lower
limb function post stroke was regarded as conflicting and “not ready”. There is strong and moderate
evidence that auditory feedback may improve gait activity. There is limited and conflicting evidence
regarding visual feedback on gait.
4.3.11 Repetitive Transcranial Magnetic Stimulation

Repetitive Transcranial Magnetic Stimulation (rTMS) has not been
widely researched as a rehab treatment of lower extremity motor
recovery. In a single study (Beaulieu et al. 2015) has
demonstrated moderate evidence that rTMS may improve muscle
strength and ankle
ROM.
4.3.12 Virtual Reality
This technology allows individuals to experience and interact with 3-dimensional environments. Virtual
reality is classified as immersive (person is within a virtual environment through a worn piece of
equipment, such as a head-mounted display) or non-immersive (2-dimensional environments using
computer monitors or projection screens). Corbetta et al. (2015) in a systematic review, analyzing the

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results form 15 trials found that when VR therapy replaced standard rehab, walking speed, balance and
mobility were significantly improved (Corbetta et al. 2015). Conversely, when VR therapy was delivered
in addition to standard therapy, only mobility was found to be improved.
In summary, VR may improve gait and balance when combined with treadmill training. When delivered
alone, it may only improve balance.
4.3.13 Motor Imagery/Mental Practice
The use of motor imagery to improve gait/lower extremity performance has been adapted from the field
of sports psychology. Motor imagery involves rehearsing a specific task or series of tasks mentally. Mental
practice can be used to supplement conventional therapy and can be used at any stage of recovery. There
is strong evidence that mental practice/mental imagery may improve gait and balance problems when
used as an adjunct to other treatments.
4.3.14 Ankle Foot Orthoses
Upper motor neuron injury in gait deviation,

including hip and knee extension and ankle plantar
flexion during the stance phase. To facilitate swing
phase of gait an AFO may be used to compensate
for excessive ankle plantar flexion and lack of knee
flexion.
One of the advantages of hemiplegic hypertonicity

is it maintains the hip and knee in extension during
stance phase (see diagram to right).
Patients who are unsure of their stance phase will

sometimes overextend their knee to push up
against the posterior ligaments; however, this places an enormous amount of
stress on the knee ligaments during weight bearing and should be discouraged
(see diagram to left).
An AFO set in 5 degrees of dorsiflexion will not only help to clear the foot but
will make it more difficult for patient to hyperextend the knee (see diagram on
right).
There is limited evidence that an AFO when combined with posterior tibial
nerve denervation, improves gait outcomes in hemiplegic patients. There is
limited evidence AFOs improves various parameters of gait.
4.4 Spasticity Post Stroke

4.4.1 Defining Spasticity Post Stroke

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Spasticity is usually seen days to weeks post-ischemic stroke. Spasticity is velocity-dependent resistance
to passive movement of affected muscles at rest. Spastic equinovarus is the most common presentation.
It is most frequently encountered during the terminal swing and stance phase.
4.4.2 Clinical Features of Spastic Equinovarus and Associated Problems.
Decreased weight bearing Functional leg-length

Pain on loading
in the heel discrepancy
•Pain on weight bearing •Ankle instability •Interference with
on the hemiplegic limb, •Abnormal base of transfers
thus affecting transfers support •Interference smooth
•Increased loading phase, •Genu varum and forward progression of
shortened stance phase recurvatum the center of gravity
•Unstable gait , impaired •Shortened contralateral
balance step length
•Increased energy
consumption
4.4.3 Potential Treatments for Spasticity in Lower Extremity Post-Stroke
Non-pharmacological Pharmacological management Surgical Procedure

management
Focal Generalized

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Stretching Botulinum Toxin A Oral Medications: Tendon, muscle:

Cold/hot therapy Phenol baclofen, dantrolene Release
Hydrotherapy sodium, tizanidine Lengthening
Orthotics Intrathecal : Baclofen Transfer
Serial Casting
Indications for Treatment of Spasticity of Lower Extremity

Lower limb spasticity may aid hemiplegic patient to weight-bear on affected leg during stance phase.
Primary goals of treatment are improvement in gait velocity and quality, reduced pain and improved
posture. Spasticity in the hemiplegic lower extremity is generally not treated, unless it impacts function
and results in significant pain. Main indication for treatment of lower extremity spasticity is equinovarus,
caused by spasticity of the gastrocnemius and tibialis posterior muscles.
Common indications for use of botulinum toxin in the spastic lower extremity, muscles commonly
involved and functional impact of these spastic muscles
• Hip adductors (adductor longus/brevis/magnus) to reduce scissoring thighs and improve hygiene.
• Flexed knee (hamstrings/gastrocnemius) to improve swing step length.
• Extended knee (gluteus medius/quadriceps) to improve knee flexion in the early swing phase of gait.
• Equinovarus foot (gastrocsoleus/tibialis posterior) to improve dorsiflexion and eversion.
• Extended big toe (extensor hallucis longus) to reduce hyperextension and improve ability to wear
shoes.
4.4.4 Botulinum Toxin
Botulinum toxin works by weakening spastic muscles by blocking the neuromuscular junction and
preventing release of acetylcholine. There are 2 main serotypes: A, B. Mode of action of BTX-A :
Botulinum toxin-A is taken up at the presynaptic cholinergic nerve terminals via endocytosis --> cleaves
the SNAP-25 (synaptosome associated protein 25) --> prevent assembly of fusion complex --> prevent
release of ACH --> relaxation of the muscle. Effect is reversible due to axonal sprouting proximal to the
nerve terminals and formation of new neuromuscular junctions. Clinical therapeutic effects may last for
up to 6 months.

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HIGHLIGHTED STUDY
Pittock SJ et al. A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type
A (Dysport®) in the treatment of spastic equinovarus deformity after stroke. Cerebrovasc Dis 2003; 15:289-30.
Methods: A case controlled study of 234 patients with hemiparesis with spastic equinovarus deformity of the
ankle after stroke. One of 4 treatment groups: 500 units of Dysport; 1000 units of Dysport; 1500 units of Dysport
and placebo.
Results: Distance covered during 2-minute walking test significantly increased in each group, but there were no
differences between groups.

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Figure 2. A double-blind randomised placebo-controlled evaluation of three doses of botulinum
toxin type A (Dysport®) in the treatment of spastic equinovarus deformity after stroke. (Pittock et
al. 2003)
Stroke
234 stroke patients with hemiparesis Rehabilitation
and spastic Clinician
equinovarus deformity of theHandbook
ankle were randomized to 2016
one of 4 treatment groups: 500 units of Dysport; 1000 units of Dysport; 1500 units of Dysport and
placebo. Patients were assessed every 4 weeks over a 12-week period.
Walking Parameters at Baseline and 12 Weeks: Placebo vs. Different

Treatment Levels
80
70
Mean Outcome Value
60
50 No significant
40 differences were found
30 between groups
20
10
0
B aseline 12 Weeks B aseline 12 Weeks B aseline 12 Weeks
2-min Walking Test, m Difference in Step Length, cm Stepping Rate, steps/min
Placebo Dysport 500 units Dysport 1000 units Dysport 1500 units
Distance covered during the 2-minute walking test significantly increased in each group, but there were
no between-groups differences. Significant improvement in calf Spasticity and limb pain reduction in
HIGHLIGHTED STUDY
use of walking was noted in the Dysport groups relative to the control group.
Foley N, Murie-Fernandez M, Speechley M, Salter K, Sequeira K, Teasell R. Does the treatment of spastic
equinovarus deformity following stroke with botulinum toxin increase gait velocity? A systematic reviewand
meta-analysis. Eur J Neurol 2010; 17(12):1419-1427.
Methods: 8 trials, 5 RCTs, 3 uncontrolled (before/after) trials identified. BTX-A doses ranged from 190 to 400 U of
Botox ® and 500 to 2,000 U of Dysport ®.
Results: BTX-A was associated with a small, but significant treatment effect on gait velocity, (Hedges g = 0.193 ±
0.081; 95% CI: 0.033 to 0.353, p<0.018) representing an increase of 0.044 m/sec.
HIGHLIGHTED STUDY
Picelli et al. Efficacy of therapeutic ultrasound and transcutaneous electrical nerve stimulation compared with
botulinum toxin type A in the treatment of spastic equinus in adults with chronic stroke: a pilot randomized
controlled trial. Top Stroke Rehabili 2014; 21(S1):8-16.

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Methods: 30 participants were randomized to receive either therapeutic ultrasound to the affected leg calf
muscles, TENS, or 200 units of botulinum toxin in the treatment of focal spasticity in chronic stroke patients.
Results: Botulinum toxin improved the Ashworth Scale when compared to the therapeutic ultrasound and
improved ankle passive ROM when compared to TENS.
Botulinum toxin in the lower extremity has been shown to reduce spasticity but not necessarily function,
with the exception of gait velocity.
Part of the challenge in demonstrating improvements in ADLs or function with botulinum toxin injections
are:
- Weakness, part of UMN syndrome, more than spasticity, contributes to disability
- Studies have been inadequately powered to detect functional gain
- The outcome measures on function have been insufficiently sensitive
- May need to be used in combination with other treatments to maximize the impact of both

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Chapter 4A - Lower Extremity Post Stroke

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Chapter 4A - Lower Extremity Post Stroke

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Stroke Rehabilitation Clinician Handbook 2016

4.1 Motor Recovery of the Lower Extremity Post Stroke

4.2 Assessments of Mobility

Stroke Rehabilitation Clinician Handbook pg. 1 of 27

• Chedoke-McMaster Stages of Motor Impairment

Berg Balance Score

Chedoke-McMaster Stroke Assessment Scale

Stroke Rehabilitation Clinician Handbook pg. 2 of 27

As primarily a measure of motor impairment, the CMSA should really be accompanied by a

7 Brunnstrom Stages of Motor Recovery

Timed Up and Go (TUG)

Stroke Rehabilitation Clinician Handbook pg. 3 of 27

6 Minute Walking Test (6MWT)

Stroke Rehabilitation Clinician Handbook pg. 4 of 27

4.3 Intervention for Mobility Impairment Post Stroke

Interventions for Mobility Impairment

Task Specific Therapeutic

Strength/ Conventional FES-based

4.3.1 Therapy Intensity

Stroke Rehabilitation Clinician Handbook pg. 5 of 27

4.3.2 Task-Specific Training

Stroke Rehabilitation Clinician Handbook pg. 6 of 27

Performance on measures of Performance measures for the Six-

Mobility Training UE Training Mobility Training UE Training

4.3.3 Treadmill Training in the Absence of Partial Body Weight Support

Stroke Rehabilitation Clinician Handbook pg. 7 of 27

LOS for Physiotherapy using the Motor Relearning Programme

4.3.4 Partial Body Weight Support and Treadmill Training (PBWSTT)

Stroke Rehabilitation Clinician Handbook pg. 8 of 27

0 0.1 0.2 0.3 0.4

0 50 100 150 200

Stroke Rehabilitation Clinician Handbook pg. 9 of 27

This is a Phase 3, single blinded, multicentred RCT.

PBWS and Treadmill Training – Summary of Studies

Author PEDro Score N Outcome

Nilsson et al. 2001 7 73 -

Werner et al. 2002 7 30 +

Visintin et al. 1998 6 100 +

Yagura et al. 2006 6 49 -

Duncan et al. 2011 8 480 -

Stroke Rehabilitation Clinician Handbook pg. 10 of 27

4.3.5 Cardiovascular/Aerobic Training

Change in 10-m Gait Velocity for a

0 0.05 0.1 0.15 0.2

Stroke Rehabilitation Clinician Handbook pg. 11 of 27

4.3.6 Strength Training to Improve Mobility

Stroke Rehabilitation Clinician Handbook pg. 12 of 27

4.3.6 Balance Training and Falls Prevention Post Stroke

4.3.7 Electromechanical and Robotic Assisted Mobility Training

Stroke Rehabilitation Clinician Handbook pg. 13 of 27

Stroke Rehabilitation Clinician Handbook pg. 14 of 27

Stroke Rehabilitation Clinician Handbook pg. 15 of 27

Stroke Rehabilitation Clinician Handbook pg. 16 of 27

4.3.11 Repetitive Transcranial Magnetic Stimulation

4.3.12 Virtual Reality

Stroke Rehabilitation Clinician Handbook pg. 17 of 27

4.3.13 Motor Imagery/Mental Practice

4.3.14 Ankle Foot Orthoses

Upper motor neuron injury in gait deviation,

One of the advantages of hemiplegic hypertonicity

Patients who are unsure of their stance phase will

4.4 Spasticity Post Stroke

Stroke Rehabilitation Clinician Handbook pg. 18 of 27