Design, implementation, and evaluation of a community-based physiotherapy gait retraining program for stroke survivors

Thesis Abstract

Stroke survivors frequently experience abnormal gait patterns and reduced mobility, which contribute to dependence, lower quality of life, and increased risk of secondary complications; community-based physiotherapy gait retraining has the potential to enhance functional outcomes beyond traditional clinic-based programs, yet robust evidence on its effectiveness, scalability, and cost-benefit in real-world settings remains limited. The aim of this study is to design, implement, and evaluate a community-based gait retraining program for stroke survivors that leverages task-specific training, feedback modalities, and home-integrated practice to improve walking speed, symmetry, and independence in mobility. The specific objectives are to (1) develop a theory-informed, transdisciplinary gait retraining protocol aligned with behavioral change theories, (2) assess feasibility and acceptability among participants and community physiotherapists, (3) evaluate effects on primary outcomes of comfortable walking speed, gait symmetry (asymmetry index), and Timed Up and Go performance over a 12-week intervention and 6-month follow-up, (4) examine secondary outcomes including endurance (6-minute walk test), balance (Berg Balance Scale), and quality of life (Stroke Quality of Life Scale), (5) identify barriers and facilitators to implementation at the community level, (6) conduct a cost-effectiveness analysis from the healthcare payer perspective, and (7) develop evidence-based guidelines for scaling up in diverse community settings. A mixed-methods design guides the study, integrating a quasi-experimental, non-randomized controlled cohort (n = 120 stroke survivors) with equally sized intervention and control groups, complemented by qualitative interviews and focus groups (n ? 40 participants and 12 therapists) to enrich interpretation. The population includes community-dased adults aged 40–80 years, 3–24 months post-stroke, able to ambulate at least 10 meters with or without an assistive device. The intervention combines (a) individualized gait retraining sessions incorporating task-specific practice, cueing strategies, treadmill or overground training, and real-time feedback, (b) a mobile-health companion app delivering daily home practice plans, reminders, and progress tracking, (c) monthly group exercise sessions to reinforce social support, and (d) remote supervision by licensed physiotherapists to ensure fidelity. Data collection instruments include standardized performance measures (10-m walk test with velocity, GAITRite-based gait symmetry, Timed Up and Go, 6-minute walk test, Berg Balance Scale, Stroke Quality of Life Scale), objective activity monitoring (accelerometry), and economic data (cost diaries and health resource utilization). Validity and reliability will be established through pilot testing, assessor blinding for outcome measures where feasible, and cross-validation of gait metrics with embedded technology. Data analysis will employ a hierarchical linear model to assess longitudinal changes in primary outcomes, controlling for baseline covariates (age, time post-stroke, comorbidity). Secondary analyses will use repeated-measures ANOVA for functional measures and generalized estimating equations for binary outcomes (independence in mobility). The qualitative component will utilize thematic analysis of interview and focus group transcripts, guided by the Theory of Planned Behavior and social cognitive theory, to elucidate determinants of adherence, engagement, and perceived barriers. A cost-effectiveness analysis will calculate incremental cost per quality-adjusted life year gained, with sensitivity analyses exploring variations in program delivery costs and adherence rates. Expected findings include statistically and clinically meaningful improvements in walking speed (increase ?0.15 m/s), improved gait symmetry (reduction in asymmetry index by ?0.10), and better Timed Up and Go performance (reduction ?2 seconds) in the intervention group relative to controls, with sustained gains at 6-month follow-up. Qualitative data are anticipated to reveal key facilitators such as perceived self-efficacy, social support, and convenient access to community-based services, alongside barriers including transportation and technology literacy. The study contributes to knowledge by bridging a gap between laboratory-based gait rehabilitation evidence and scalable, community-embedded practice, integrating behavioral theories with pragmatic implementation science to optimize uptake and sustainability. It informs policy and practice by providing a detailed blueprint for scalable gait retraining programs, including training curricula for therapists, technology-enabled home programs, fidelity monitoring, and cost-effectiveness benchmarks. The main conclusion is that a structured, theory-informed, community-based gait retraining program can produce durable improvements in gait and mobility for stroke survivors while remaining feasible and cost-effective in diverse real-world settings. Recommendations include adopting integrated care pathways that combine clinician-led sessions with digital home practice, investing in therapist training and community partnerships, and conducting multicenter trials to confirm generalizability and long-term impact.