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• W3085863669 abstract "HomeStrokeVol. 51, No. 10Gait Rehabilitation After Stroke Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBGait Rehabilitation After StrokeShould We Re-Evaluate Our Practice? Carmen M. CirsteaMD, PhD Carmen M. CirsteaCarmen M. Cirstea Correspondence to: Carmen M. Cirstea, MD, PhD, Department of Physical Medicine and Rehabilitation, University of Missouri, One Hospital Dr, DC046.00, Columbia, MO 65212. Email E-mail Address: [email protected] https://orcid.org/0000-0002-4059-9893 Department of Physical Medicine and Rehabilitation, University of Missouri, Columbia. Search for more papers by this author Originally published11 Sep 2020https://doi.org/10.1161/STROKEAHA.120.032041Stroke. 2020;51:2892–2894This article is a commentary on the followingStepwise Regression and Latent Profile Analyses of Locomotor Outcomes PoststrokeThe path up and down is one and the same.—HeraclitusStroke is a leading cause of long-term disability. Of the individuals who survive, more than 80% have gait impairment1 that recovers with some extent in the first 2 months after stroke.2 Yet, community ambulation often remains compromised in most survivors.3 Gait ability has major implications for health; it is an essential predictor for functional independence4,5 and long-term survival5,6 after stroke. Unsurprisingly, regaining gait ability is one of the most common goals of stroke survivors.7 Although most treatment sessions during stroke rehabilitation are directed at gait training and mobility practice, current options are unfortunately of limited effectiveness.8 As the result of increased life expectation in our country, paired with an improved acute stroke phase survival rate, the number of stroke survivors with such impairment will increase in the next decade (3.9% of the US population older than 18 years of age is projected to have had a stroke by 20309), and the resulting growth in related expenses will place a future pressure on our healthcare system (an increase by 129% of total annual costs of stroke9). To proactively address this concern, maximizing gait recovery is of high priority.See related article, p 3074High-intensity practice is critical for producing long-lasting changes in motor system networks and motor learning.10,11 Since these changes underpin gait recovery from stroke, a recent focus has been placed on increasing the intensity of rehabilitation practice. In this context, high-intensity practice has been explored in 2 ways: increasing the number of repetitions included during a therapeutic intervention or increasing the total time of the therapeutic intervention. Despite a range of robust evidence12–18 in support of high-intensity training in gait recovery, the reality is that most patients in stroke rehabilitation wards still spend as little as 20% of their time in physical therapy19 doing activities related to gait recovery. For instance, the daily dose of lower limb exercise after stroke is ≈300 repetitions (mean 288; SD, 240).20 This number is insufficient in terms of repetitions to drive neuroplastic changes and accelerate recovery.12–15 Indeed, a daily increase of only 100 repetitions results in improved walking speed.20 Likewise, increasing the therapy time by an additional 16 hours (during the weekend for example) improves activities of daily living.21 So why is there so much controversy? Why has high-intensity training not been widely clinically implemented? Simply put, there is a lack of translation of research findings into clinical practice. To date, there are no evidence-based guidelines to inform rehabilitation practice relative to exercise intensity, timing, and duration for this population.22For instance, exercise intensity is the most critical parameter to maximize gain after stroke but is also the most challenging parameter to establish in clinical settings. Standard guidance related to exercise intensity would benefit functional gait outcomes in stroke survivors. The article by Hornby et al23 in this journal sheds light on this issue in a large sample of 144 stroke survivors evaluated at >1 month after the acute event. Pooling data from different walking training paradigms (high-intensity stepping performing variable, difficult tasks; high-intensity stepping performing forward walking; low-intensity stepping of variable tasks; conventional walking exercises), Hornby and colleagues used validated assessment techniques and advanced analysis methods to determine the relative contributions of demographic, clinical, and training variables to outcomes. The authors revealed that the number of steps per session and number of sessions are the strongest predictors of primary gait outcomes, defined here as improvement in both speed and quality of ambulation. They also showed that higher functional and younger patients are likely to achieve greater amount and intensities of stepping practice. Overall, these data provide approximate amounts and intensity of stepping practice (mean 2460 [SD 1057] steps/session, 30 [SD 7] sessions) that can be achieved in this population and also explicitly show that specific patients may demonstrate larger gains with such training. The authors were also very explicit regarding key components of the intervention and what can be adapted to ensure implementation of such training, that is, greater amounts of practice at higher cardiovascular intensities, into regular clinical rehabilitation protocols.Importantly, particular consideration should be paid to the lack of serious adverse events during the training. This suggests that stroke survivors, at least in the late subacute and chronic phases of stroke, can perform higher intensity walking exercises and more difficult tasks than previously thought possible. This finding corroborates well with preliminary results from an on-going clinical trial (URL: https://www.clinicaltrials.gov. Unique identifier: NCT01915368) showing that subacute stroke survivors can tolerate doses that are more than 2 to 7 times the amount of conventional therapy. Given the comorbidities usually present in this population, Hornby et al rigorously monitored the vitals to ensure safe participation to such training. Since all eligible participants were studied, ambulatory and nonambulatory, ischemic and hemorrhagic stroke, cortical and subcortical stroke, right and left paresis, the sample is likely to be representative of people with stroke. In sum, these findings highlight that high-intensity gait training may be feasible clinically with appropriate safety considerations. Future work should also extend the promising results of Hornby and collegues’ study into those under 1-month post-stroke, when immobility peaks24 and in which larger gains could be obtained with rehabilitation.25,26The past 20+ years of neuroscience research has resulted in the consensus that rehabilitation that does not challenge the central nervous system is insufficient to make a clinically significant difference in a patient’s recovery trajectory after stroke. Ideal rehabilitation involves repetitive and intensive practice, which is continually incremented in difficulty according to the tolerance of the patient. To improve mobility even in the community settings, it is time to move beyond traditional low-intensity/low-demanding rehabilitation. Obviously, this is not a stress-free process. System-level changes (eg, access to resources and staff), changes in therapists’ knowledge/beliefs, along with innovative methods are required to make these high-intensity trainings accessible, cost-effective, and feasible to implement in clinical practice. These challenges are well worth considering. However, the immediate and far-reaching implications for the development of evidence-based guidance for such training vastly outweigh these potential barriers. For the million Americans expected to suffer stroke in the next decade,9 these changes are imperative.Sources of FundingNone.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 2893.Correspondence to: Carmen M. Cirstea, MD, PhD, Department of Physical Medicine and Rehabilitation, University of Missouri, One Hospital Dr, DC046.00, Columbia, MO 65212. Email [email protected]missouri.eduReferences1. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical practice guideline.Stroke. 2005; 36:e100–e143. doi: 10.1161/01.STR.0000180861.54180.FFLinkGoogle Scholar2. Wade DT, Wood VA, Heller A, Maggs J, Langton Hewer R. Walking after stroke. Measurement and recovery over the first 3 months.Scand J Rehabil Med. 1987; 19:25–30.MedlineGoogle Scholar3. Combs SA, Van Puymbroeck M, Altenburger PA, Miller KK, Dierks TA, Schmid AA. Is walking faster or walking farther more important to persons with chronic stroke?Disabil Rehabil. 2013; 35:860–867. doi: 10.3109/09638288.2012.717575Google Scholar4. Portelli R, Lowe D, Irwin P, Pearson M, Rudd AG; Intercollegiate Stroke Working Party. Institutionalization after stroke.Clin Rehabil. 2005; 19:97–108. doi: 10.1191/0269215505cr822oaCrossrefMedlineGoogle Scholar5. 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Ovbiagele B, Goldstein LB, Higashida RT, Howard VJ, Johnston SC, Khavjou OA, Lackland DT, Lichtman JH, Mohl S, Sacco RL, et al.; American Heart Association Advocacy Coordinating Committee and Stroke Council. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association.Stroke. 2013; 44:2361–2375. doi: 10.1161/STR.0b013e31829734f2LinkGoogle Scholar10. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage.J Speech Lang Hear Res. 2008; 51:S225–S239. doi: 10.1044/1092-4388(2008/018)CrossrefMedlineGoogle Scholar11. Nudo RJ. Adaptive plasticity in motor cortex: implications for rehabilitation after brain injury.J Rehabil Med. 2003:7–10. doi: 10.1080/16501960310010070Google Scholar12. Hornby TG, Holleran CL, Leddy AL, Hennessy P, Leech KA, Connolly M, Moore JL, Straube D, Lovell L, Roth E. Feasibility of focused stepping practice during inpatient rehabilitation poststroke and potential contributions to mobility outcomes.Neurorehabil Neural Repair. 2015; 29:923–932. doi: 10.1177/1545968315572390Google Scholar13. Moore JL, Nordvik JE, Erichsen A, Rosseland I, Bø E, Hornby TG; FIRST-Oslo Team. Implementation of high-intensity stepping training during inpatient stroke rehabilitation improves functional outcomes.Stroke. 2020; 51:563–570. doi: 10.1161/STROKEAHA.119.027450LinkGoogle Scholar14. Lohse KR, Lang CE, Boyd LA. Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation.Stroke. 2014; 45:2053–2058. doi: 10.1161/STROKEAHA.114.004695LinkGoogle Scholar15. Rose DK, Nadeau SE, Wu SS, Tilson JK, Dobkin BH, Pei Q, Duncan PW. Locomotor training and strength and balance exercises for walking recovery after stroke: response to number of training sessions.Phys Ther. 2017; 97:1066–1074. doi: 10.1093/ptj/pzx079Google Scholar16. Cooke EV, Mares K, Clark A, Tallis RC, Pomeroy VM. The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis.BMC Med. 2010; 8:60. doi: 10.1186/1741-7015-8-60CrossrefMedlineGoogle Scholar17. Kuys SS, Brauer SG, Ada L. Higher-intensity treadmill walking during rehabilitation after stroke in feasible and not detrimental to walking pattern or quality: a pilot randomized trial.Clin Rehabil. 2011; 25:316–326. doi: 10.1177/0269215510382928CrossrefMedlineGoogle Scholar18. Caruana EL, Kuys SS, Clarke J, Bauer SG. A pragmatic implementation of a 6-day physiotherapy service in a mixed inpatient rehabilitation unit.Disabil Rehabil. 2017; 39:1738–1743. doi: 10.1080/09638288.2016.1211181Google Scholar19. Kuys SS, Ada L, Paratz J, Brauer SG. Steps, duration and intensity of usual walking practice during subacute rehabilitation after stroke: an observational study.Braz J Phys Ther. 2019; 23:56–61. doi: 10.1016/j.bjpt.2018.06.001Google Scholar20. Scrivener K, Sherrington C, Schurr K. Exercise dose and mobility outcome in a comprehensive stroke unit: description and prediction from a prospective cohort study.J Rehabil Med. 2012; 44:824–829. doi: 10.2340/16501977-1028Google Scholar21. Kwakkel G, van Peppen R, Wagenaar RC, Wood Dauphinee S, Richards C, Ashburn A, Miller K, Lincoln N, Partridge C, Wellwood I, et al.. Effects of augmented exercise therapy time after stroke: a meta-analysis.Stroke. 2004; 35:2529–2539. doi: 10.1161/01.STR.0000143153.76460.7dLinkGoogle Scholar22. 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Bernhardt J, Hayward KS, Kwakkel G, Ward NS, Wolf SL, Borschmann K, Krakauer JW, Boyd LA, Carmichael ST, Corbett D, et al.. Agreed definitions and a shared vision for new standards in stroke recovery research: the stroke recovery and rehabilitation roundtable taskforce.Neurorehabil Neural Repair. 2017; 31:793–799. doi: 10.1177/1545968317732668Google Scholar26. Duncan PW, Lai SM, Keighley J. Defining post-stroke recovery: implications for design and interpretation of drug trials.Neuropharmacology. 2000; 39:835–841. doi: 10.1016/s0028-3908(00)00003-4CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesStepwise Regression and Latent Profile Analyses of Locomotor Outcomes PoststrokeT. George Hornby, et al. Stroke. 2020;51:3074-3082 October 2020Vol 51, Issue 10Article InformationMetrics Download: 4,532 © 2020 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.120.032041PMID: 32912098 Originally publishedSeptember 11, 2020 Keywordssurvival rategoalsurvivorsEditorialsgaitPDF download SubjectsCerebrovascular Disease/StrokeRehabilitation" @default.
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