Stroke recovery often requires specialized, coordinated care. Guidelines from the American Heart Association and American Stroke Association continue to recommend treatment in an inpatient rehabilitation hospital rather than a skilled nursing facility for many stroke survivors. An inpatient rehabilitation hospital provides a multidisciplinary approach that includes physical therapy, occupational therapy and speech-language pathology, all working together to support recovery.
As movement specialists, physical therapists and physical therapy assistants play a critical role in helping patients regain mobility. To effectively do that, clinicians must rely on interventions that are most effective at restoring function in stroke survivors. One approach with growing support is high-intensity gait training.
How high-intensity gait training supports post-stroke recovery
When we ask our patients recovering from stroke about their therapy goals, most share the same answer — they want to walk again.
Because walking is so important to independence and quality of life, therapists must use evidence-based interventions to support gait recovery. There is increasing evidence that high-intensity gait training (HIGT) leads to higher discharge home rates from inpatient rehabilitation by improving mobility.
High-intensity gait training involves repeated walking practice performed at a high enough intensity to elevate the heart rate into a target range. The intensity should range from 70 to 85 percent of your patients' maximum heart rate.
High-intensity gait training is not limited to those who can already walk. Even patients with low mobility can make big improvements. In one study, patients who scored at least a 6/56 on the Berg Balance Scale during their first week of inpatient rehabilitation were likely to walk with supervision or better at discharge.
A focus on HIGT in therapy can also help therapists use limited therapy time more efficiently. When high-intensity gait training is prioritized, patients show improvement in both ambulation and non-practice tasks. These activities include sitting-to-stands and transfers. An added benefit of HIGT is improved cardiovascular fitness and endurance, which may decrease their risk of future stroke.
High-intensity gait training and neuroplasticity
After a stroke, the brain has undergone cell death, which is what causes the functional decline we see in a patient's mobility. Neuroplasticity is the brain’s ability to adapt and create new pathways to compensate for the areas lost from the stroke. The principles of neuroplasticity include:
- Use it or lose it
- Use it and improve it
- Specificity
- Repetition matters
- Intensity matters
- Time matters
- Salience matters
- Age matters
- Transference
- Interference
High-intensity gait training aligns closely with the principles of neuroplasticity. It emphasizes task specificity, intensity, repetition and salience, all while focusing on the goal that matters deeply to patients — walking again.
Specificity
To facilitate neuroplasticity using the principle of specificity, the intervention must be specific to the task and should mimic the activity as closely as possible. In other words, to activate the neural pathways that control walking, the patient has to be walking.
Clinical practice guidelines show that patients who work on walking tasks at 70 to 85 percent of their maximum heart rate show better results when compared with conventional therapy. If the rate of perceived exertion (RPE) scale is used instead of heart rate to monitor intensity, it is recommended that patients maintain an RPE greater than or equal to 14/20 or 7/10.
Repetition
Additionally, the more repetitions of the task the patient performs at these higher intensities, the better the outcomes. Conventional therapy produces about 250 steps per session, on average, with the target heart rate achieved less than 5 percent of the time. In contrast, high-intensity gait training in inpatient rehabilitation settings produces about 1,500 steps per day on average in an inpatient rehabilitation unit and achieves higher intensities 40 percent of the time.
What does HIGT look like?
To keep patients within the target heart rate zone, walking may take place on a treadmill or on the ground. The therapist can increase the challenges in different ways, such as:
- Wearing ankle weights or a weighted vest
- Increasing gait speed
- Adding stairs or ramps
- Changing directions
- Introducing resistance
- Reducing upper extremity support while encouraging weight bearing through the lower extremities
- Adding obstacles
While these strategies increase challenge, they do not ensure your patients are exercising at the proper intensity. Monitoring heart rate or perceived exertion is essential.
Maximum heart rate can be estimated by using the formula:
HRmax=208 − (0.7 x age)
The target heart rate range is 70 to 85 percent of that value. Note that the target heart rate is 10 bpm lower if the patient is on a beta blocker.
When the heart rate drops below the target zone, it is time to get the patient moving again. When the heart rate rises above the target zone, brief rest periods are appropriate but make sure they are resting and not waiting.
It is also important to note that optimized kinematics is not the primary goal. Your aim is to have patients complete as many steps as possible. In fact, making sure your patients have a normal gait may prevent them from achieving the intensity that is required, slowing progress. Instead, interventions that maximize the amount and intensity of stepping practice in challenging environments, with limited attention toward gait kinematics, show significant gains in locomotor function.
What stands in your way?
Despite strong evidence supporting high-intensity gait training, many still aren't using it.
Common barriers include:
- Inconsistent monitoring of heart rate or perceived exertion
- Uncertainty about appropriate intensity targets
- Time spent on low-intensity activities such as seated exercises
- Comfort with familiar treatment approaches
As clinicians, we may look at our treatments and past patients and think to ourselves, "Why change? My patients still show progress." However, progress alone is not enough. We should aspire to treat our patients using interventions that are supported by the best available evidence. High-intensity gait training challenges traditional habits, but it offers a powerful opportunity to help patients recover walking ability and regain independence.
By embracing evidence-based approaches and measuring intensity intentionally, therapists can deliver care that aligns with patient goals and supports meaningful recovery.
References
Ardestani M. (2019). Compensation or recovery? Altered kinetics and neuromuscular synergies following high-intensity stepping training post stroke. Neurorehabilitation and Neural Repair. 47-58.
Feigin, V. (2022). World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. International Journal of Stroke : Official Journal of the International Stroke Society. 18-29.
Henderson, C. (2022). Predicting discharge walking function with high-intensity stepping training during inpatient rehabilitation in nonambulatory patients post stroke. Archives of Physical Medicine and Rehabilitation. S189-S196.
Hornby T. (2015). Feasibility of focused stepping practice during inpatient rehabilitation post stroke and potential contributions to mobility outcomes. Neurorehabilitation and Neural Repair. 923-932.
Hornby, T. (2011). Importance of specificity, amount, and intensity of locomotor training to improve ambulatory function in patients post stroke." Topics in Stroke Rehabilitation. 293-307.
Moore, J. (2020). Implementation of high-intensity stepping training during inpatient stroke rehabilitation improves functional outcomes. Stroke. 563-570.
Scrivener, K. (2012). Exercise dose and mobility outcome in a comprehensive stroke unit: description and prediction from a prospective cohort study. Journal of Rehabilitation Medicine. 824-9.
Straube, D. (2014). Effects of dynamic stepping training on nonlocomotor tasks in individuals post stroke. Physical Therapy. 921-33.
NOTE: The opinions in this article are the author's own and do not necessarily reflect the views of Encompass Health.