Stroke survivors have to figure out how to walk safely in the community. Walking in PT gyms and on deserted sidewalks did not prepare me for walking in community settings. I had to teach myself how to maneuver around carts and people in a grocery store, squeeze past closely placed chairs and tables in a restaurant, and deal with children in a shopping mall who do not look where they are going. PTs do not know that walking requires divided attention because they walk clients in wide empty spaces that provide no cognitive challenges. Equally unfortunate, OTs who are trained to assess and treat cognitive issues do not assess community ambulation because walking is PTs domain. So community ambulation falls through the cracks.
A recent study simulated the unpredictability of walking in the community. Inness learned what stroke survivors did when they experienced an unexpected balance challenge (1). Subjects were asked to stand with their feet on two force plates. At an unexpected time the force plates were tipped forward and subjects had to recover their balance by stepping forward onto a third force plate. Traditional clinical tests like the Berg Balance Test did not have a significant correlation with the unexpected stepping test. The Berg Test does not measure real world balance because it allows clients to concentrate fiercely on their own body and decide when they want to initiate movement.
Bottom Line: Being afraid to walk in crowded environments is a major barrier to participating in valued community activities. Limiting gait training to walking in the home contributes to social isolation and depression.
1. Inness E, Mansfield A, Lakhani B, Bayley M, McIlroy W. Impaired reactive stepping among
patients ready for discharge from inpatient stroke rehabilitation.