J.L. Moore1, J.E. Nordvik2, A.S. Erichsen3, I. Rosseland4, E. Bø3, T.G. Hornby5, F.-O. The FIRST-Oslo Study team: T. Barkenæs, H. Bratlie, M.Byhring, I. Grimstad, M. Hågå, J. Halvorsen, C. Henderson, M.Klokkerud, J.A. Mbalilaki, S.A. Rimehaug, K. Sæther, T. Tomren, K. Vergoossen1,2,3,4,5
1Sunnaas Rehabilitation Hospital, Regional Center of Knowledge Translation in Rehabilitation, Oslo/Nesodden, Norway, 2CatoSenteret Rehabilitation Hospital, Son, Norway, 3Oslo University Hospital, Medical departement, physiotherapy section, Oslo, Norway, 4Oslo Municipality Services, Reinforced Interdisciplinary Rehabilitation Aker, Oslo, Norway, 5Indiana University, Department of Physical Medicine and Rehabilitation, Indianapolis, United States
Background: The recovery of walking after having a stroke is a primary goal of patients and their families and a primary focus of rehabilitation. Research also suggests it is a primary determinant of daily function and community participation. Converging data over the past two decades on high-intensity gait training (HIGT) in stroke rehabilitation demonstrates a substantial impact on walking function, including improved gait speed, walking distance, balance, aerobic capacity, and stepping activity. A recently published clinical practice guideline for chronic central nervous system injury recommended that task-specific walking training be performed at higher intensities or with augmented feedback to improve walking function. However, evidence also suggests that these gait training strategies are not routinely used in rehabilitation clinics. This lack of translation into routine clinical practice indicates that patients may not benefit from the advances in research without innovative efforts to ensure implementation. Two rehabilitation institutions in Oslo were the first to implement a high-intensity stepping intervention to treat patients after stroke in 2018 (the FIRST-Oslo study). The intervention consists of high-intensity walking training in variable contexts (e.g., treadmill, overground, stairs, obstacles) and was delivered in inpatient rehabilitation.
Purpose: The purpose of this investigation was to determine the comparative effectiveness of providing HIGT on locomotor recovery early poststroke as compared with usual care.
Methods: A quasi-experimental design was used to compare stepping activity (StepWatch), walking, and balance outcomes during usual care versus HIGT intervention in inpatient stroke patients. Primary outcomes assessed weekly included self-selected and fastest gait speed, 6-minute walk test, and the Berg Balance Scale. Regression analyses identified relationships between demographics, baseline function, and training activities (steps per day; duration achieved, 70%– 85% maximum heart rates), and primary outcomes at discharge.
Results: Data were collected on 110 patients over two years (usual care, n=56; HIGT n=54). In this study, therapists successfully increased stepping activity and heart rates (HRs) in patients during physical therapy without an increased incidence of adverse events. Average steps/day with HIGT were 1800 more than during usual care. This increased dose resulted in greater increases in self-selected (0.39±0.28 vs 0.16±0.26 m/s) and fastest speed (0.47±0.41 vs 0.17±0.38 m/s, both p<0.001) than usual care. All differences in changes between HIGT and usual care were above thresholds considered clinically meaningful. Moderate to strong correlations were observed between primary discharge outcomes and impairments or functional deficits at admission. For training variables, only steps per day were consistently related to discharge outcomes.
Conclusion(s): The provision of HIGT applied during inpatient rehabilitation resulted in significantly greater walking and balance outcomes than usual care.
Implications: HIGT was successfully implemented and is now the standard care at both rehabilitation units. Further work is required to adequately assess the impact of HIGT on improving long-term outcomes of patients early poststroke.
Funding, acknowledgements: Norwegian Fund for Post-GraduateTraining in Physiotherapy, National Institute on Disability, Independent Living, and RehabilitationResearch, National Institutes of Health.
Keywords: stroke, implementation science, gait training
Topic: Neurology: stroke
Did this work require ethics approval? Yes
Institution: Oslo University Hospital and Oslo Municipality Services
Committee: Southeastern Norway Ethics Committee
Ethics number: 2016/873
All authors, affiliations and abstracts have been published as submitted.
