Outpatient and community-based stroke rehab: the dosage cliff

1. Case. A 62-year-old man, four months post-left-MCA stroke. Comfortable gait speed 0.62 m/s, 6MWT 220 m, single-point cane. Goal: return to coaching his daughter's soccer team — standing, walking sidelines, intermittent jogging.

2. CPG section. AHA/ASA 2016 endorses continued outpatient rehabilitation when functional goals remain (Class I, Level A). The Locomotor CPG (Hornby 2020) issues a strong recommendation for moderate-to-high intensity walking training (60–80% heart rate reserve or 70–85% HRmax) to improve walking speed and timed distance in individuals greater than 6 months post-CNS injury. Although the patient is at 4 months, the same dose-response principles apply with appropriate monitoring.

3. Reasoning walkthrough. His comfortable gait speed places him in the limited community ambulator range (Perry J et al. *Stroke*. 1995;26:982–989: <0.4 household, 0.4–0.8 limited community, ≥0.8 community). His 6MWT of 220 m sits below the 288 m threshold associated with independent community ambulation (Fulk GD, He Y, Boyne P, Dunning K. *Stroke*. 2017;48:406–411). Push gait speed past 0.8 m/s and 6MWT past ~300 m. Build sessions around high-intensity stepping practice — overground, treadmill, stairs, varied terrain — with heart rate or RPE monitoring. Target ≥40% of session time in the 70–85% HRmax zone, consistent with Locomotor CPG implementation work (Holleran CL et al., *Phys Ther*. 2021).

4. Outcome measure. 10MWT comfortable and fast. Stroke MCID 0.06 m/s small meaningful and 0.13–0.16 m/s substantial meaningful in subacute stroke (Tilson JK et al., *Phys Ther*. 2010;90:196–208; Perera S et al., *J Am Geriatr Soc*. 2006;54:743–749). MDC for comfortable speed in the 0.4–0.8 m/s stratum ≈ 0.11 m/s (Hayashi S et al., *Front Neurol*. 2023).