High Intensity Gait Training for Patient With Apraxia Following Ischemic and Hemorrhagic Stroke

Research Objectives: High intensity gait training (HIGT) has strong research evidence for improved gait outcomes post-stroke; however, few studies address motor planning deficits within this framework. The purpose of this case study is to describe the application and outcomes of HIGT in a patient with apraxia undergoing inpatient rehabilitation after stroke.

Design: Case report

Setting: Inpatient Rehabilitation Hospital

Participants: An 81-year-old female with ischemic left middle cerebral artery stroke and hemorrhagic conversion with mild motor deficits but moderate motor planning and cognitive impairments impacting gait function.

Interventions: Interventions consisted of at least five, hour-long HIGT physical therapy sessions per week, tailored to remediate her motor planning impairments and promote independence with ambulation. To address her apraxia, the cognitive demands during HIGT were initially minimized then progressively challenged, achieved through careful selection of cues, feedback, assistive devices, and training environments. Dynamic stability and limb swing biomechanical subcomponents were progressively challenged as physical assistance/tactile cues were weaned.

Main Outcome Measures: Functional outcomes assessed with the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), 6-minute walk test, 10-meter walk test, and the Berg Balance Scale (BBS).

Results: Following a 30-day inpatient rehabilitation hospital stay, the patient demonstrated clinically meaningful improvements exceeding the minimal detectable change in functional outcomes as evidenced by the IRF-PAI (31-point gain, 124% improvement), the 6-minute walk test (0 ft at admission, 405 ft at discharge), 10-meter walk test (0.56 m/s at discharge), and the BBS (3/56 at admission, 26/56 at discharge). The patient was discharged home and achieved household ambulation with four-wheeled walker and supervision.

Conclusions: Implementation of HIGT customized to address this patient’s apraxia and gait impairments resulted in global improvements in her functional skills and level of independence with walking skills. This case study provides a reflection on clinical strategies to remediate apraxia and motor learning deficits using a HIGT paradigm applied in a patient following acute stroke.

Author(s) Disclosures: Dr. Evans received a salary as a Physical Therapy Neurologic Resident at Mary Free Bed Rehabilitation Hospital.