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Archived Comments for: Rehabilitation of gait after stroke: a review towards a top-down approach

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  1. Comment on Belda-Lois et al.

    william rymer, Northwestern University

    23 January 2012

    This review focuses on assessing the impact of a wide range of rehabilitation therapies promoting gait recovery after hemispheric stroke. The review emphasizes the role of reorganizing the central nervous system in promoting gait recovery, by contrasting this approach with classical therapies targeting peripheral neuromuscular interventions. The review is detailed, broad and comprehensive.

    The authors affirm the position taken recently by an number of United States Agencies including the Veterans Administration, the Department of Defense (1) and the American Heart Association (2), that gait retraining with either body weight supported treadmill training techniques, or with robotic devices has not been shown to be demonstrably superior to traditional therapy methods.

    It is interesting to speculate as to why so many therapies appear to be promising in preliminary studies, yet fail to reach satisfactory outcomes in larger multicenter clinical trials. There are several possibilities:

    1. Difficulties in standardizing therapy in Multicenter trials
    In many recent clinical trials, studies were performed in multiple sites, and relied on multiple therapists for patient selection and care delivery. It is rather hard to be certain that in such multicenter trials, different sites adopt consistent study entry criteria and that they administer therapy in a consistent manner.

    2. Outcome Assessments
    Our outcome assessments for gait retraining are relatively imprecise. Most investigators rely on a 10-meter walk, which is a measure of speed, and a 6 min. walk, which is a measure of endurance. There is rarely an opportunity for assessment of gait kinematics or even gait asymmetry.

    3. Timing of therapy
    Many researchers believe that there may be a window of opportunity arising relatively early after a stroke, conceivably beginning within a few days of the acute lesion. This time frame is not usually regarded as either safe or appropriate for energetic early gait retraining, but this interval may be our best chance to modify cortical structure and function.

    For all these reasons, we may be missing promising therapeutic responses, and treating potentially rational therapies as ineffectual.

    Finally, the authors of this review assert that combination therapies appear to be the most effective. While this claim may well be correct, a rational experimental analysis of combination therapies is very difficult because of the need to use many different dose combinations in order to precisely chracterize combinatorial effects.

    For the future, this reviewer would prefer to see a more rigorous experimental analysis of individual therapies before launching into studies requiring that multiple therapies be delivered.

    Key References:

    1. Management of Stroke Rehabilitation Working Group. Management of stroke rehabilitation. VA/DOD Clinical Practice Guideline. VA/DOD Evidence Based Practice. Version 2.0, 2010. Washington, DC: Veterans Health Administration, Department of Defense; 2010. Available at:

    2. Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient : A Scientific Statement From the American Heart Association Elaine L. Miller, Laura Murray, Lorie Richards, Richard D. Zorowitz, Tamilyn Bakas, Patricia Clark and Sandra A. Billinger Stroke 2010, 41:2402-2448: originally published online September 2, 2010

    Competing interests

    None declared