Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation

Abstract

Background and Purpose: We investigated the effect of higher therapeutic exercise doses on walking during inpatient rehabilitation, typically commencing 1 to 4 weeks poststroke. Methods: This phase II, blinded-assessor, randomized controlled trial recruited from 6 Canadian inpatient rehabilitation units, between 2014 and 2018. Subjects (n=75; 25/group) were randomized into: control (usual care) physical therapy: typically, 1 hour, 5 days/week; Determining Optimal Post-Stroke Exercise (DOSE1): 1 hour, 5 days/week, more than double the intensity of Control (based on aerobic minutes and walking steps); and DOSE2: 2 hours, 5 days/week, more than quadruple the intensity of Control, each for 4 weeks duration. The primary outcome, walking endurance at completion of the 4-week intervention (post-evaluation), was compared across these groups using linear regression. Secondary outcomes at post-evaluation, and longitudinal outcomes at 6 and 12-month evaluations, were also analyzed. Results: Both DOSE1 (mean change 61 m [95% CI, 9–113], P =0.02) and DOSE2 (mean change 58 m, 6–110, P =0.03) demonstrated greater walking endurance compared with Control at the post-evaluation. Significant improvements were also observed with DOSE2 in gait speed (5-m walk), and both DOSE groups in quality of life (EQ-5D-5 L) compared with Control. Longitudinal analyses revealed that improvements in walking endurance from the DOSE intervention were retained during the 1-year follow-up period over usual care. Conclusions: This study provides the first preliminary evidence that patients with stroke can improve their walking recovery and quality of life with higher doses of aerobic and stepping activity within a critical time period for neurological recovery. Furthermore, walking endurance benefits achieved from a 4-week intervention are retained over the first-year poststroke. REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01915368.

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

“…Though the mean step count per physical therapy session in the Exoskeleton group was nearly double that of the Usual Care group, 592 steps is low relative to other walking intervention studies. Klassen et al conducted a randomized controlled trial comparing one or two daily high-dose walking-focused physical therapy sessions to standard physical therapy care during subacute stroke rehabilitation; participants receiving either higher-dose therapy regimens achieved greater 6MWT distances at follow-up than participants receiving standard care [ 56 ]. In that study, participants in standard physical therapy took an average of 580 steps per session, whereas the higher dose groups achieved 2169 and 4747 steps per session [ 56 ].…”

“…Klassen et al conducted a randomized controlled trial comparing one or two daily high-dose walking-focused physical therapy sessions to standard physical therapy care during subacute stroke rehabilitation; participants receiving either higher-dose therapy regimens achieved greater 6MWT distances at follow-up than participants receiving standard care [ 56 ]. In that study, participants in standard physical therapy took an average of 580 steps per session, whereas the higher dose groups achieved 2169 and 4747 steps per session [ 56 ]. Participants in a trial conducted by Hornby et al took 2358 steps per intervention session, and demonstrated greater gait speed and 6MWT improvements than participants in the control group [ 57 ].…”

“…Recent guidelines for stroke rehabilitation have called for more intensive therapy, suggesting that interventions for walking recovery should encompass moderate to high-intensity aerobic exercise [ 8 , 22 ]. The walking interventions in the aforementioned studies by Klassen et al and Hornby et al were purposefully delivered at moderate to high cardiovascular intensities, which may have been a key factor in driving positive outcomes [ 56 , 57 ]. Research has shown that patients participating in robotic-assisted gait training achieve only low-intensity aerobic thresholds, relative to overground walking practice [ 58 , 59 ]; thus, participants in our study most likely did not achieve the moderate- to high-intensity guideline suggested for locomotor training.…”

Association of Daily Number of Steps with Walking Ability in Hospitalized Patients with Sub-acute Stroke

“…On the other hand, the number of steps in the walking non-independence group was 1970 steps/day (IQR, 1334.8-3105.3 steps/day) for FAC 2 and 2646 steps/day (IQR, 1669-3521 steps/day) for FAC 3. Klassen et al reported that the number of steps during a physical therapy session was 580 (SD, 440) for usual care physical therapy, 2169 (SD, 1106) for more than double the intensity of the control, and 4747 (SD, 2083) for more than quadruple the intensity of the control, and walking recovery was improved in the higher dose group [29]. Patients with FAC 2.3 in our study did not reach the values of the previous study; however there is still a possibility of improvement.…”

Step Number and Aerobic Minute Exercise Prescription and Progression in Stroke: A Roadmap

“…In the absence of specific exercise prescription guidelines, rehabilitation therapists provide low exercise doses, despite evidence that higher intensity exercise improves neural and functional recovery. 1,3 When general targets are given to research therapists, our recent study shows more than double the steps and aerobic minutes can be achieved vs usual care and translates to improved long-term walking outcomes. 1 Yet, safety concerns keep some therapists from delivering higher exercise intensity 4 since the subacute stroke period is a time of higher risk for cardiac complications.…”