Can a patient with a hemorrhagic stroke walk properly?

Can Hemorrhagic Stroke Patients Walk Properly?

Most hemorrhagic stroke patients will not walk properly initially, but approximately 54% will regain some walking ability with intensive rehabilitation, though many will retain permanent gait abnormalities requiring assistive devices or supervision. 1

Initial Walking Impairment

• 46% of all first-ever stroke patients (including hemorrhagic) are completely unable to walk at hospital admission, with 44% presenting lower extremity motor impairment 1
• Hemorrhagic stroke patients demonstrate the same baseline functional deficits and recovery trajectories as ischemic stroke patients when receiving rehabilitation 2
• The severity of initial neurological deficit (NIHSS score) is the strongest predictor: scores >16 indicate high likelihood of severe disability, while scores <6 predict good recovery including walking 3

Recovery Potential and Timeline

• Patients with any walking ability at admission (even with therapist assistance) have 9.48 times greater odds of being discharged home compared to those completely unable to walk 1
• Significant recovery continues during the first 6 months post-stroke, with the most dramatic improvements occurring in this window 3
• Walking function has greater recovery potential than hand function because leg motor control is less dependent on the lateral corticospinal tract 4
• Even patients with chronic stroke (>6 months) can benefit from additional rehabilitation therapy 3

Rehabilitation Requirements for Walking Recovery

Stroke survivors with walking difficulty must undertake tailored repetitive practice of walking using circuit class therapy with overground walking practice and/or treadmill training. 5

Specific Training Parameters:

• Exercise frequency: minimum 3 times weekly for at least 8 weeks, progressing to 20+ minutes per session 5
• Treadmill training improves both cardiovascular fitness (17% improvement) and ambulatory performance (30% improvement in 6-minute walks) compared to conventional stretching programs 6
• For patients unable to walk independently, body-weight support treadmill training enables repetitive practice and improves overground walking speed 5
• Multiple short bouts (three 10-15 minute sessions) throughout the day may be better tolerated than single long sessions 5

Progressive Resistance Training:

• Lower extremity strengthening is essential, particularly targeting knee extensors which are the most important muscle group predicting gait speed 7
• Perform 10-15 repetitions at 40-60% of one-repetition maximum, 2-3 days per week 7
• Resistance training increases gait speed and muscular strength without increasing spasticity 5
• Focus on leg extensions, leg curls, and leg press exercises 7

Functional Electrical Stimulation and Adjuncts

• FES should be considered for patients with gait disturbance to reduce motor impairment and improve function 5
• Rhythmic auditory stimulation can improve gait velocity, cadence, stride length, and symmetry 5
• Force platform biofeedback should be used for patients with standing difficulty 5

Long-Term Walking Outcomes

• Energy expenditure during hemiplegic gait is elevated up to 2 times that of able-bodied persons, with mechanical efficiency reduced up to 50% 8
• Between 25-50% of stroke survivors require at least some assistance with activities of daily living long-term 8
• More than 30% of survivors report persistent participation restrictions 4 years after stroke 3
• Continued exercise is required indefinitely as benefits are not sustained if exercise stops 7

Critical Prognostic Factors

• A STREAM score above 38 at admission predicts independent gait by discharge (AUC 0.897), while a score above 29 predicts walking independence at one-month follow-up 9
• Presence of active leg movements on admission is an important prognostic factor 3
• Balance and coordination disorders increase fall risk and slow recovery 3
• Cognitive impairment and visual neglect negatively affect rehabilitation potential 3

Common Pitfalls to Avoid

• Do not assume hemorrhagic stroke patients have worse outcomes than ischemic stroke patients—recovery is equivalent with proper rehabilitation 2
• Do not discontinue therapy at discharge; extend rehabilitation to home or outpatient settings for sustained benefits 5
• Do not neglect cardiovascular fitness training; treadmill training at 2-3 mph with progressive grade increases provides both task-specific practice and aerobic conditioning 5
• Do not use neurodevelopmental techniques as they are not superior to other therapy types 5