Locomotor Training Improves Daily Stepping Activity and Gait Efficiency in Individuals Poststroke Who Have Reached a “Plateau” in Recovery

BACKGROUND AND PURPOSE: Individuals with chronic stroke often demonstrate a "plateau," or deceleration of motor recovery, which may lead to discharge from physical therapy (PT). However, numerous studies report improvements in motor function when individuals are provided intensive practice of motor tasks. We suggest that reduced task-specific walking practice during clinical PT contributes to limited gains in ambulatory function in those with a perceived plateau poststroke, and suggest that further gains can be realized if intensive stepping, or locomotor training (LT) is provided after discharge. METHODS: Twenty subjects with chronic stroke completed a repeated baseline measures, randomized crossover trial in which walking performance was assessed during the last 4 weeks of clinical PT before discharge secondary to reaching a plateau, followed by 4 weeks of intensive LT and 4 weeks of no intervention. Outcome measures included clinical and physiological (metabolic) measures of walking overground and on a treadmill, and measures of daily stepping activity in the home and community, including during clinical PT and subsequent LT sessions. RESULTS: Stepping practice was more than 4-fold higher during LT versus clinical PT sessions, with significant improvements in daily stepping and gait efficiency only after LT. Changes in daily stepping after clinical PT and intensive LT were correlated (P<0.001) with the amount of stepping practice received during these interventions. CONCLUSIONS: Intensive LT results in improved daily stepping in individuals poststroke who have been discharged from PT because of a perceived plateau in motor function. These improvements may be related to the amount and intensity of stepping practice.