Stroke patients who had intensive home-based physical therapy improved their walking ability just as well as those who
underwent a more "high tech" program where they walked on treadmills with their body weight supported by a harness,
according to the results of the largest stroke rehabilitation study ever conducted in the US.
Funded primarily by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH), with assistance from the National Center for Medical Rehabilitation Research, the study also found that patients continued to improve up to 12 months after suffering a stroke, defying the widely held view that recovery happens early and peaks at six months.
In fact, this study showed that even patients who started intensive rehab six months after stroke improved their walking.
Dr Pamela W. Duncan, principal investigator of the Locomotor Experience Applied Post-stroke (LEAPS) trial , and professor at Duke University School of Medicine in Durham, North Carolina, and colleagues, presented their findings on 11 February at the American Stroke Association's International Stroke Conference 2011 in Los Angeles, and on 12 February at the American Physical Therapy Association's (APTA) 2011 Combined Sections Meeting in New Orleans.
Duncan told the press that:
"We were pleased to see that stroke patients who had a home physical therapy exercise program improved just as well as those who did the locomotor training."
"The home physical therapy program is more convenient and pragmatic. Usual care should incorporate more intensive exercise programs that are easily accessible to patients to improve walking, function and quality of life," she added.
NINDS deputy director Dr Walter Koroshetz said that more than 4 million stroke survivors in the US experience difficulty walking, so it is important to conduct rigorous comparisons of available physical therapy treatments to determine which is best:
"The results of this study show that the more expensive, high tech therapy was not superior to intensive home strength and balance training, but both were better than lower intensity physical therapy," said Koroshetz.
Locomotor training, which is becoming very popular in the US, is where patients go to a rehab center and walk on a treadmill in a harness that partially supports their body weight. When they have completed this part of the program they practise walking.
Previous studies have suggested that this "high tech" training, using commercial lifts or robot-assisted treadmills, is very effective at helping patients walk again after a stroke.
But none has tested them on a large scale and looked at them in terms of the best time to have the therapy.
So Duncan and colleagues set out to compare the effectiveness of locomotor training started at two months after stroke and six months after stroke, and compare both against a home-based program supervised by a physical therapist.
For the study they recruited 408 patients of average age 62 who recently suffered a stroke and were being treated at 6 stroke rehabilitation centers in the US between April 2006 and June 2009.
The participants were 45% female, 58% Caucasian, 22% African American, and 13% Asian.
They were assigned to have 36 sessions lasting 75 to 90 minutes for 12 to 16 weeks, either comprising the locomotor training (starting at two or six months after stroke) or the home-based training (starting at two months after stroke). In all three groups the program was structured and progressive and the patients had to achieve specific goals and tasks.
The home-based program, which started at two months after stroke, aimed to improve patients' strength and balance, flexibility and range of motion, as a way to improve walking.
The main measure the researchers were interested in was how much each of the three groups' walking had improved one year after stroke. However, they also looked at what it was like at 6 months after stroke.
To measure improvement in a patient population where there were different ranges of walking ability post-stroke, the researchers based their assessment on how well patients were able to walk independently by the end of the 12 month study period.
For example, a severely impaired stroke patient who by the end of the study was able to walk around inside the home without help was considered improved, as was a patient who was already mobile inside the home but who by the end of the study had progressed to walking independently in the community.
All participants started the study with the usual care, where they underwent a number of physical therapy sessions lasting about an hour each, before being assigned to one of the three study groups.
The researchers' assumption at the start of the study was that by the end of the 12 month study period, the patients on the more "high tech" locomotor programs would show better improvements than the ones on the home-based exercise program, especially the ones that started their locomotor training two months after stroke.
But what they found was:
- After 12 months, all groups made similar gains in walking speed, movement or motor recovery, balance, social participation and quality of life.
- 52% of all participants had made significant improvements in their walking ability.
- The timing of the locomotor training did not make a difference: after 12 months, there were no differences between the early and late locomotor training groups in terms of the proportion of patients who improved their walking ability.
- And stroke severity did not affect their ability make progress by the 12-month mark.
"In all groups, the biggest improvements in outcomes were made after the first 12 sessions of therapy, but 13% of the subjects continued to make functional gains in walking recovery by 24 sessions and another 7% improved by 30 to 36 sessions," she added.
There were some differences between the locomotor and home-based groups in that patients in the locomotor groups were more likely to feel dizzy and faint during their exercise, and those in the early locomotor group had more falls. 57% of all participants fell once, 34% fell more than once, and 6% had a fall that resulted in injury.
Falls are common among stroke survivors, and Duncan and colleagues said their study strengthens the case for more research on how to prevent falls among stroke survivors.
Another interesting finding was that patients who had only received the usual care up to the 6 month mark did show some improvement in walking speed, but only about half the improvement shown in patients who had been assigned to receive either the locomotor or the home-based program at the 2-month mark.
Duncan said this was further evidence that either the locomotor or the home-based program, both intensive, were more effective than the usual care, the current standard of practice, in getting patients back on their feet and walking.
In the US, two thirds of stroke survivors have limited walking ability 3 months after their stroke.
"The bottom line is that patients recover faster and sustain recovery when the intervention is given early," said Duncan.
Sources: NIH News, American Physical Therapy Association (press releases, 11 Feb 2011).
Written by: Catharine Paddock, PhD