FPTA Spring Conference, Orlando, FL March 28, 2015

Transcription

1 Walking rehabilitation for individuals who have sustained a stroke: evidence-based review of intervention strategies Chitra L. K. Balasubramanian, PT, PhD Walking status post stroke About 85% of stroke survivors are able to walk independently by 6 months However, only 7-10% of these individuals are reported to be independent in community ambulation Jorgensen et al. (2002) Lord et al. (2004) Lord et al. (2008) Consequences of limited walking ability post stroke are huge 73% incidence of falls 4-fold increase in falls risk at the same age Of those who fall, stroke survivors experience a 10-fold increase in hip fracture compared to non-stroke Limited mobility leads to social isolation and depression 1/3 rd of individuals with stroke experience depression Nyberg et al. (1995) Hackett ML et al. (2014) Chitra L.K. Balasubramanian PT, PhD 1

2 Walking training post stroke Improved walking ability is one of the most often stated goal for stroke rehabilitation. Bohannon et al. (1988) Much of the impetus for stroke rehabilitation rests in the desire to regain normal walking, a goal still identified as relevant months or years after the acute event. Harris & Eng (2004) ) Stroke Gait: Typical Deficits Spatiotemporal parameters: Slower walking speed compared to able-bodied individuals Spatiotemporal asymmetries: - Stance phase (paretic and non-paretic) > Swing - Non-paretic stance time > Paretic stance time - Longer gait cycle time in paretic pre-swing phase Highly variable stepping parameters Olney & Richards (1996) Balasubramanian et al. (2007) Balasubramanian et al. (2009) Balasubramanian et al. (2010) Stroke Gait: Typical Deficits Kinematic parameters (paretic side): Stance phase Limited ankle dorsiflexion at initial contact and during stance Knee hyperextension Excessive knee flexion Swing phase Decreased knee flexion Hip hiking or circumduction Olney & Richards (1996) Mulroy et al. (2003) Chitra L.K. Balasubramanian PT, PhD 2

3 Stroke Gait: Typical Deficits EMG and kinetic deviations: Co-activation of knee muscles during stance Large bursts of hip flexor activity at pull off on the paretic side, and increased hip flexor power Excessive energy costs per unity distance walked Large bursts of ankle plantar flexor activity on the nonparetic side of the body Olney & Richards (1996) Stroke Gait: Physiologic (Non-paretic) compensation Ground Reaction Forces in a healthy individual Non-paretic leg force compensation for paretic in an individual with stroke Bowden, Balasubramanian, Neptune, Kautz. Stroke Stroke Gait: Deficits in gait adaptability Individuals with stroke have difficulties in several domains of gait adaptability Obstacle negotiation Temporal demands Cognitive and motor dual-tasks Terrain demands Ambient demands Postural transitions Balasubramanian et al. (2014) Chitra L.K. Balasubramanian PT, PhD 3

4 Stroke gait rehabilitation Many different therapeutic interventions have been tested over the years Stroke gait rehabilitation Evidence-based Review of Gait Rehabilitation Post Stroke Chitra L.K. Balasubramanian PT, PhD 4

5 Evidence-based Review of Gait Rehabilitation Post Stroke Evidence Based Review of Stroke Rehabilitation (EBRSR) is intended to be an up-to-date review of the current evidence in all the different aspects of stroke rehab Updated Annually, Last updated in 2013 Individual RCTs assessed using the Physiotherapy Evidence Database (PEDro) tool Conclusive statements based on levels of evidence PEDro Scale Levels of Evidence used in EBRSR Level 1a (Strong): Findings were supported by the results from a metaanalysis, when available or from the results of 2+ RCTs of at least fair quality. Level 1b (Moderate): Findings were supported by a single RCT of at least fair quality. Level 2 (Limited): Findings supported by at least 1 controlled trial with a minimum of 10 subjects in each group. Level 3 (Consensus): In the absence of evidence, agreement by a group of experts on the appropriate treatment. Regarded as the lowest form of evidence. Level 4 (Conflicting): Disagreement between the findings of at least 2 RCTs. If 4+ RCTs exist and only one was conflicting, conclusions based on results of the majority, unless conflicting study was of higher evidence. Chitra L.K. Balasubramanian PT, PhD 5

6 Chapter 9: Mobility and Lower Extremity Evidence Summary Statements Restorative (Bobath) approach is associated with similar gains in function, but longer lengths of hospital stay, compared with other therapeutic approaches. Augmented PT may improve gait post-stroke, although results are not maintained over time. Task-specific gait training improves gait post-stroke. Virtual reality devices may enhance gait performance. Balance training, using specific devices or exercise, post-stroke is beneficial. Rhythmic sensory auditory stimulation improves gait post-stroke. Robotic devices may not offer additional benefit compared with conventional therapy. It is uncertain whether partial body weight support and treadmill training results in improved gait training. Strength training is beneficial for hemiparetic stroke patients. Cardiovascular training improves physical fitness post-stroke. Encourage self-propelling a wheelchair by hemiplegic stroke patients does not have an impact on functional outcomes. The use of canes is associated with improved mobility post-stroke. Chapter 9: Mobility and Lower Extremity Evidence Summary Statements Electrical stimulation combined with gait training improves hemiplegic gait. EMG/Biofeedback treatment improves gait training. Ankle foot orthoses appear to improve gait, particularly in association with tibial nerve deinnervation. A variety of drugs may help to improve functional outcome following stroke including levadopa, Selegiline, L-threo-3,4-dihydroxyphenylserine (L-DOPS), Almitrine + Raubasine, Citicoline and Citalopram. It is unclear whether amphetamines improve motor recover and/or functional outcomes. A tilt table or night splint can prevent ankle contracture early post-stroke. Electrical stimulation and therapeutic ultrasound can reduce ankle plantarflexion spasticity. Treatment with Botulinum toxin reduces lower-limb spasticity, but has not convincingly been shown to improve function. Oral pharacological agents can be effectively used in the mangement of spasticity, although some are associated with significant side effects. Intrathecal Baclofen can reduce spasticity in chronic stroke. Focus of this presentation Discuss evidence from EBRSR resource specifically related to gait rehabilitation Intensity of gait training Task-specific gait training Treadmill training without body-weight support Cardiovascular conditioning Virtual-reality gait training Feedback methods during gait training Functional electrical stimulation Partial body-weight support and treadmill training Robotic devices in gait training Strength training Chitra L.K. Balasubramanian PT, PhD 6

7 Evidence from EBRSR guidline not discussed in this presentation Balance training** Assistive and Orthotic Devices Electrical stimulation (TENS) and therapeutic ultrasound Pharmacologic interventions **Interventions not discussed since the evidence statements refer to several aspects of lower extremity function and mobility and not exclusively walking. Discussion of evidence is organized based on level of evidence recommended by EBRSR Level 1a: Strong Evidence Intensity of gait training Task-specific gait training Treadmill training without body-weight support Cardiovascular conditioning and Aerobic exercises Virtual-reality gait training Feedback methods during gait training Functional electrical stimulation Level 4: Conflicting Evidence Combination of partial body weight support and treadmill training Robotic devices Strength training EBRSR statement: Intensity of gait training Augmented physical therapy may improve gait post-stroke, although the results are not maintained over time Chitra L.K. Balasubramanian PT, PhD 7

8 Intensity of gait training= There is strong (Level 1a) evidence that augmented physical therapy is associated with improvements in gait. However, there is also strong (Level 1a) evidence that the beneficial effect is not maintained once therapy has ceased. EBRSR use Augmented PT to refer to Intensity Intensity/Treatment Dosage is not clearly defined in stroke rehab EBRSR statement based on 14 studies (12 RCTs) **Average number of steps taken during a typical Outpatient PT session is 357 compared to 5117 steps/day in a healthy individual (Lang et al., 2009) Intensity of gait training: Sample studies Retrospective analysis of 993 stroke patients in a SNF, reported that patients receiving < 1 hour therapy/day (combined OT/PT/ SLP) had longer lengths of stay compared those receiving hour/day (Jette et al. 2005) Treatment time 3 hours associated with greatest functional improvements (Wang et al. 2013) Patient s described this intensive task-specific mobility training intervention (3 hrs/day for 10 consecutive days) as difficult, but doable (Merlo et al. 2013) EBRSR statement: Task-specific gait training Task-specific gait training improves gait poststroke Chitra L.K. Balasubramanian PT, PhD 8

9 Task-specific gait training There is strong (Level 1a) evidence that task-specific gait training techniques can be used to improve gait post stroke. EBRSR statement based on 21 studies (19 RCTs, PEDro Score 3 9) Task-specific training is a broad term and not well clarified in the literature. EBRSR included: circuit training, reaching in sitting, sit to stand, weight-shifting, backward walking, agility, ball exercises, dual-tasking, etc. Studies spanning all stages of recovery but majority tested in chronic stroke. Examples of Semi-supervised Lower Limb Circuit classes Carr & Shephard, 2003 Task-specific gait training: Circuit Training (chronic) Salbach et al. (2004). A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial. PEDro Score = 8 91 community-dwelling individuals within one year of first or recurrent stroke were randomized into intervention group comprising of 10 functional tasks or to control group focusing on UE activities 3x/wk for 6 wks Outcomes: 6-Min. Walk Test (6MWT), 5-m walk (comfortable and max pace), Berg Balance Scale and Timed Up & Go Intervention group achieved greater improvements 6MWT, comfortable and max walking speed, and TUG Chitra L.K. Balasubramanian PT, PhD 9

10 Task-specific gait training: Salbach et al. (2004) Task-specific gait training: Salbach et al. (2004) Task-specific gait training: Circuit Training (acute) Rose et al. (2011). Feasibility and effectiveness of circuit training in acute stroke rehabilitation. Individuals with an acute onset of stroke participated in either a circuit training (n = 72) or standard physical therapy (n = 108), 5 days/wk for the duration of their hospital stay Both Circuit training and standard PT dosage - total of 1.5 h/d of physical therapy (1 60-min. and 1 30-min. session), 5 d/wk, 1:1 therapist to patient ratio. Outcomes: Gait speed, Fugl-Meyer Assessment, and FIM Intervention group increased gait speed significantly more when assessed after treatment Chitra L.K. Balasubramanian PT, PhD 10

11 Task-specific gait training: Rose et al. (2011) Task-specific gait training: Dual task gait training An et al. (2014). The effect of various dual task methods with gait on the balance and gait of patients with chronic stroke. 36 chronic stroke individuals randomized to motor dual task gait training, cognitive dual task gait training, motor + cognitive dual task gait training, 30 mins/day, 3x/wk, 8 wks. Outcomes were stability test index, the weight distribution index, the functional reach test, the timed up and go test, the four square step test,10 m walk test and a 6 min walk test. Greatest improvements were seen in all tests, except for the timed up and go test, following the motor + cognitive dual task gait training. Task-specific gait training: An et al. (2014) Chitra L.K. Balasubramanian PT, PhD 11

12 EBRSR statement: Treadmill training (without Body Weight Support, BWS) Treadmill training is beneficial in the chronic stage of stroke Treadmill Training (without BWS) There is strong (Level 1a) evidence that treadmill training (without body weight support) can improve gait velocity in ambulatory patients in the chronic stage of stroke. EBRSR statement based on 17 studies (11 RCTs, PEDro Score 5 8) Treadmill training has been used as a form of task-specific training Provides a permissive environment for repetitive practice of gait Studies spanning all stages of recovery but majority tested in chronic stroke Treadmill Training (without BWS): Chronic stroke Langhammer & Stanghelle. (2010). Exercise on a treadmill or walking outdoors? A randomized control trial comparing effectiveness of two walking exercise programmes late after stroke. PEDro score = 8 39 individuals with chronic stroke who were ambulatory and admitted into a rehab hospital received treadmill training or went for an outdoor walk for 30 mins, 5x/wk, 8 sessions Outcomes: 6-min. walk test, 10-m walk test, pulse rates at rest and during activity Intervention group demonstrated significant improvements in 6-min. walk test distance and speed, bilateral step length and step width Chitra L.K. Balasubramanian PT, PhD 12

13 Treadmill Training (without BWS): Speed paradigm Lau & Mak. (2011). Speed-dependent treadmill training is effective to improve gait and balance performance in patients with subacute stroke. PEDro score = 6 30 individuals with sub-acute stroke who were able to walk on level ground without assistance underwent short interval walking trials with stepwise increases in speed or treadmill training at a steady speed for 10 sessions, 30 mins. Individuals in both groups received an additional 90 mins of rehab. Outcomes: Gait speed, stride length, cadence, BBS The intervention group increased its mean walking speed and step length significantly more than the control. Both groups improved cadence and BBS score but there was no significant difference between groups. EBRSR statements: Cardiovascular conditioning Cardiovascular training improves physical fitness after stroke Cardiovascular Conditioning There is strong (Level 1a) evidence that while cardiovascular training post stroke improves level of physical fitness and gait performance; it does not result in additional improvement in ADL performance. EBRSR statement based on 26 studies (20 RCTs, PEDro Score 3 8) Persons with stroke are profoundly deconditioned (Reisman et al., 2009) Intervention modes: treadmill, walking, stair climbing, recumbent and arm bikes Studies spanning all stages of recovery but majority tested in chronic stroke Chitra L.K. Balasubramanian PT, PhD 13

14 Cardiovascular conditioning: Aerobic Treadmill Training Pang et al. (2006). The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a metaanalysis. Meta-analyses included 480 patients with stroke (nine studies, 7 RCTs) The exercise intensity ranged from 50% to 80% heart rate reserve. Exercise duration was min for 3-5 days/wk. All studies reported positive effects on aerobic capacity (Peak V O2 ), regardless of stage of recovery Favorable improvements reported in walking speed and walking endurance Concluded that intensity of treadmill training is the key for beneficial effects Cardiovascular conditioning: Elliptical (feasibility study) Jackson et al. (2010). Use of an elliptical machine for improving functional walking capacity in individuals with chronic stroke: a case series. 3 individuals with chronic stroke who were able to walk on level ground without an assistive device trained 2-3x/wk, 8 wks using an elliptical machine. Outcomes: Gait speed, TUG, 6-min. walk, BBS Elliptical training was safe and feasible. No improvements in gait speed but variable improvements in endurance, balance and functional mobility. Cardiovascular conditioning: Home PT program Duncan et al. (2003). Randomized clinical trial of therapeutic exercise in subacute stroke. 100 individuals with stroke received usual care or a therapist supervised exercise program at home that was structured, progressive and physiologically based for 36 sessions of 90-min each, 12 wks. Outcomes: Strength, Fugl-Meyer, balance (BBS), peak aerobic capacity and exercise duration, UE function (Wolf Motor Function Test) and mobility (10-m and 6-min walk distance) Intervention group demonstrated greater gains in balance, endurance, peak aerobic capacity and mobility. Chitra L.K. Balasubramanian PT, PhD 14

15 Cardiovascular conditioning: Duncan et al. (2003) EBRSR statement: Virtual Reality Virtual reality devices may enhance gait performance Virtual reality (VR) devices There is strong (Level 1a) evidence that virtual reality training can be used to enhance gait recovery following stroke. EBRSR statement based on 10 studies (9 RCTs, PEDro Score 4-8) VR devices can be immersive or nonimmersive. Commercial gaming consoles are also included Examples of VR interventions: customized VR environments (level walking on treadmill with interactive VR scenes, treadmill training with optic flow, etc.), Ninetendo Wii, Playstation 2 Studies spanning sub-acute and chronic stroke Immersive VR Chitra L.K. Balasubramanian PT, PhD 15

16 Virtual reality gait training: Virtual scenes (chronic) Yang et al. (2008). Virtual reality-based training improves community ambulation in individuals with stroke: a randomized controlled trial. PEDro Score = 7 20 individuals at least 6-mos post stroke underwent treadmill training or virtual reality-based training for a 3- wk period Outcomes: Walking speed, community walking time, walking ability questionnaire (WAQ), and activitiesspecific balance confidence (ABC) scale Intervention group improved more significantly in walking speed and community walking time, maintained at 1- month follow up Virtual reality gait training: Yang et al. (2008) Virtual reality: Real-world video recording Cho et al. (2013). Virtual walking training program using a realworld video recording for patients with chronic stroke: a pilot study. PEDro Score = 7 16 individuals with chronic stroke received treadmill training program with or without real-world video recording 3x/wk for 6 wks. Both groups participated in standard rehabilitation program (exercise, OT, and FES) Outcomes: Berg Balace Scale, Timed Up & Go, gait speed, cadence, step length, stride length, and single-limb support for the paretic limb using the GAITrite Intervention group demonstrated significantly greater improvements in walking balance (BBS and TUG), gait speed and cadence measures. Chitra L.K. Balasubramanian PT, PhD 16

17 Virtual reality gait training: Cho et al. (2013) Virtual reality gait training: Ninento Wii Kim et al. (2012). Clinical feasibility of interactive commercial Nintendo gaming for chronic stroke rehabilitation. PEDro scale = 4 17 chronic stroke individuals received general exercise for 30 min + e-stim of affected tibialis anterior for 15 min, 3x/week for 3 weeks. The intervention group exercised additionally using the Nintendo Wii (15 min tennis game/15 min boxing game). Outcomes: Postural Assessment scale (PASS), Modified Motor Assessment Scale (MMAS), and FIM Significant improvements in PASS and MMAS for the intervention group but what about gait improvements? Virtual reality gait training: Ninento Wii & PlayStation 2 Fritz et al. (2013). Active video-gaming effects on balance and mobility in individuals with chronic stroke: a randomized controlled trial. PEDro scale = 8 15 individuals with chronic stroke were randomized into a gaming group or control group. The gaming group was divided into a Nintendo Wii or Playstation 2 group. Gaming groups performed the game mins, 4 days/wk for 5 wks. Outcomes: Berg Balance Scale, Dynamic Gait Index, 6-Min. Walk Test, 3-Meter Walk Test, Stroke Impact Scale, Timed Up & Go There were no significant differences found between the two gaming groups so they collapsed into one intervention group which had no significant differences from the control group for any of the outcome measures. Chitra L.K. Balasubramanian PT, PhD 17

18 EBRSR statements: Feedback methods Both auditory and verbal feedback may improve gait performance post stroke EMG/biofeedback treatment improves gait retraining Feedback methods There is strong (Level 1a) evidence that a variety of feedback methods, employing visual or auditory feedback, can improve measures of gait and balance. EBRSR statement based on 23 studies (19 RCTs, PEDro Score 5-6) 12 studies with gait outcomes (10 RCTs) Feedback types: sensory, auditory, visual (action observation), rhythmic auditory stimulation Examples of interventions included: biofeedback training using a miniature muscle trainer, electrogoniometer, positional feedback, rhythmic auditory stimulation, etc. Studies spanning all stages of recovery Verbal feedback Dobkin et al. (2010). International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improves outcomes. PEDro scale = individuals with stroke in inpatient rehabilitation received feedback about self-selected fast walking speed immediately after a single 10-m walk or received no reinforcement of speed Outcomes: Gait speed for a 15.2 m (10 ft) timed walk at discharge, walking distance in 3 minutes, LOS, Functional Ambulation Classification (FAC) Intervention group demonstrated faster walking speed at discharge. No difference was found between groups for LOS; however, LOS was shorter for individuals with walking speed >0.4 m/s at entry for both groups. Chitra L.K. Balasubramanian PT, PhD 18

19 Verbal Feedback: Dobkin et al. (2010) Auditory feedback: Rhythmic Auditory Stimulation (RAS) Thaut et al. (1997). Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation 20 individuals received twice-daily gait training with rhythmic auditory stimulation (RAS) or to receive twice-daily gait training for 30 mins, 5x/wk for 6 wks Outcomes: Barthel Index, Fugl-Meyer, Berg Balance Scale, walking patterns Intervention group demonstrated significant improvements in velocity, stride length, reduction in EMG amplitude of gastrocnemius. Additionally, swing asymmetry greatly improved with RAS. Visual feedback: Action observation Kim & Kim. (2012). Clinical feasibility of action observation based on mirror neuron system on walking performance in post stroke patients. PEDro scale = 4 30 individuals received 30 mins of PT in addition to watching 10 mins of video on proper walking performance or 10 mins of video featuring a stretching program Outcomes: Spatiotemporal gait parameters via the GAITRite Intervention group significantly improved on all spatiotemporal gait parameters in comparison to the control group Chitra L.K. Balasubramanian PT, PhD 19

20 EMG/Biofeedback Biofeedback training improved gait and standing post-stroke in the majority of fair to good quality RCTs, consitituting strong (Level 1a) evidence of a positive benefit in gait training. EBRSR statement based on 10 studies (8 RCTs, PEDro Score 3 7) Examples of interventions: biofeedback training using a miniature muscle trainer, electrogoniometer, positional feedback, etc. Studies spanning all stages of recovery EMG / Biofeedback Jonsdottir et al. (2010). Task-oriented biofeedback to improve gait in individuals with chronic stroke: motor learning approach. PEDro scale = 7 20 individuals with chronic stroke received conventional therapy that included task-specific training or EMG biofeedback for 20 sessions 3x/week for 45 mins Outcomes: Quantitative gait analysis Intervention group achieved significant increases in peak ankle power at push off and stride length that remained significant at 6-week follow up EBRSR statement: Functional Electrical Stimulation (FES) FES combined with gait training improves hemiplegic gait Chitra L.K. Balasubramanian PT, PhD 20

21 FES There is strong (Level 1a) evidence that FES and gait retraining results in improvements in hemiplegic gait. EBSRB statement based on 37 studies (26 RCTs, PEDro Score 4 8) Direct stimulation of the muscle or motor nerve (typically common peroneal nerve to stimulate ankle dorsiflexion) Types of FES: implantable and surface electrodes Studies spanning all stages of recovery FES: Intramuscular FES Daly et al. (2011). Recovery of coordinated gait: randomized controlled stroke trial of functional electrical stimulation (FES) versus no FES, with weight-supported treadmill and overground training. PEDro scale = 7 53 individuals with chronic stroke received strengthening exercises, overground gait training and BWSTT with or without FES for 1.5 hrs, 4x/wk for 12 wks. Outcomes: Gait Assessment and Intervention Tool (GAIT) Intervention group achieved significantly greater improvements in GAIT following treatment that were maintained at 6 months. 50% of those in the intervention group improved by at least 10 points on the GAIT compared with only 21% in the control group. FES: Combined Fast Treadmill Training and FES Kesar et al. (2011). Combined effects of fast treadmill walking and functional stimulation on post-stroke gait. Individuals walked on a treadmill at their self-selected speed without FES (SS), at the SS speed with FES (SS-FES), at their fastest speed (FAST), and at the FAST speed with FES (FAST-FES) FES was delivered to paretic ankle PF s (terminal stance) and DF s (swing) Outcomes: peak anterior ground reaction force (AGRF), trailing limb angle, swing phase knee flexion FAST-FES versus SS-FES resulted in greater peak AGRF, trailing limb angle, and swing phase knee flexion. FAST-FES versus FAST resulted in further increases in AGRF. Chitra L.K. Balasubramanian PT, PhD 21

22 FES: FES during walking adaptations Swigchem et al. (2012). Deficits in motor response to avoid sudden obstacles during gait in functional walkers poststroke. 24 individuals with chronic stroke who regularly use an AFO were fitted with a transcutaneous FES device. While wearing either the AFO or FES participants attempted to avoid 30 obstacles dropped in front of them while walking on a treadmill. Outcomes: Obstacle avoidance success rates The intervention group demonstrated higher success rates, effects were greater at 8 weeks versus 2 weeks. Additionally, those with a lower Motricity Index score were more likely to benefit from FES. EBRSR statement: Partial Body Weight Support (P-BWS) Treadmill Training It is uncertain whether partial body weight support and treadmill training results in improved gait training. P-BWS Treadmill Training There is conflicting (Level 4) evidence that the combination of partial body weight support and treadmill training results in improved gait performance compared with other physiotherapy interventions. EBRSR statement based on 25 studies (23 RCTs, PEDro score 3 8) Includes step training on a treadmill with BWS and therapist assistance Studies spanning all stages of recovery. Chitra L.K. Balasubramanian PT, PhD 22

23 P-BWS treadmill training: Chronic Stroke Sullivan et al. (2007). Step training with body weight support: effect of treadmill speed and practice paradigms on poststroke locomotor recovery. PEDro score = 5 24 individuals with chronic stroke were stratified by locomotor severity and received BWSTT at slow, fast, or variable speeds for 20 mins for 12 sessions over 4 wks. Outcomes: Self-selected over ground walking speed (SSV) Speed significantly increased in all groups. Significant improvements in speed were found with fast training speeds versus slow and variable groups. P-BWS treadmill training: Acute Stroke Ada et al. (2010). Randomized trial of treadmill walking with body weight support to establish walking in subacute stroke: the MOBILISE trial. PEDro score = acute (<28 days of stroke onset), nonambulatory individuals with stroke received up to 30 mins/day of BWSTT or up to 30 mins/day of overground walking. Outcomes: Proportion of participants achieving independent walking within 6 months The proportion of experimental participants who achieved independent walking were 37% compared to 26% at 1 month, 66% compared to 55% at 2 months, and 71% compared to 60% at 6 months. Additionally, the experimental group walked 2 weeks earlier, with a median time to independent walking of 5 weeks compared to 7 weeks for the control group. P-BWS treadmill training: LEAPS trial Duncan et al. (2011). Body weight supported treadmill rehabilitation after stroke. 408 participants with a sub-acute stroke were randomly assigned to one of three training groups P-BWS treadmill training 2 mos. poststroke (Early), P-BWS treadmill training 6 mos. post-stroke (Late) and the a HEP 2 months post-stroke Each intervention included 36 sessions of 90 mins each for 12 to 16 wks. Outcomes: proportion of participants in each group who had an improvement in functional walking ability 1 year after the stroke All groups had similar improvements in walking speed, motor recovery, balance, functional status, and quality of life Adverse events were slightly higher in the Early and Late groups compared to the HEP group Chitra L.K. Balasubramanian PT, PhD 23

24 EBRSR statement: Electromechanical-assisted Training Devices Robotic devices may not offer additional benefit compared with conventional therapy. Robotic devices There is conflicting (Level 4) evidence that robotic devices are superior to conventional gait training in the improvement of functional walking performance. EBRSR statement based on 22 studies (20 RCTs, PEDro score 4 8) Types of robotics: End Effector Device or Exoskeleton Device Studies spanning all stages of recovery Robotic Devices: Cochrane Review Mehrholz et al. (2013). Electromechanical-assisted training for walking after stroke. Cochrane review included 23 trials, n = 999 Reported that robotic devices in combination with PT increases the chances of persons becoming independent ambulators but did not significantly increase walking velocity or walking capacity Suggested caution in interpretation because of the variations with respect to devices used, duration, treatment frequency, etc. Sub-group analyses suggested that people in the acute phase may benefit but not those in the chronic phase Chitra L.K. Balasubramanian PT, PhD 24

25 EBRSR statement: Strength Training Strength training may be beneficial for hemiparetic stroke patients Strength Training There is conflicting (Level 4) evidence that strength training results in improvements in ADL performance, distance walked or gait speed. EBRSR statement based on 25 studies (17 RCTs, PEDro Score 4 8) Weakness is an important concern in individuals poststroke (Miller et al. 1998) Types of strength training included: progressive resistance training, functional strength training, therapeutic exercise, and isokinetic training Studies spanning all stages of recovery **Strength has a non-linear relationship with functional performance (Ng et al., 2003) Strength training: Progressive Resistance Training (PRT) Flansbjer et al. (2012). Progressive resistance training after stroke: effects on muscle strength, muscle tone, gait performance and perceived participation. PEDro score = 6 24 individuals with chronic stroke participated in usual daily activities or in a supervised progressive resistance training of the knee muscles (80% of maximum) 2x/wk for 10 wks. Outcomes: Muscle strength assessed dynamically and isokinetically, muscle tone (Modified Ashworth), Timed Up & Go (TUG), fast gait speed, 6-Minute Walk Test, and perceived participation (Stroke Impact Scale) The intervention group demonstrated greater improvements in knee strength. At the 4 year follow up, the intervention group maintained muscle strength, improvements in TUG, 6MWT distance, and fast gait speed while the control group had deterioration in fast gait speed and 6MWT distance. Chitra L.K. Balasubramanian PT, PhD 25

26 Strength training: Functional Strength Training Bale et al. (2008). Does functional strength training of the leg in subacute stroke improve physical performance? A pilot randomized controlled trial. PEDro score = 6 18 individuals in the subacute phase of stroke rehabilitation received training-as-usual or functional strength training of the lower extremity for 50 mins, 5x/wk for 4 wks. Outcomes: Maximum weight-bearing in standing, isometric muscle strength, gait speed, and items of Motor Assessment Scale (MAS) Intervention group demonstrated clinically significant differences in 7/9 outcomes compared to 3/9 for the control group. Maximum weight bearing on the affected LE improved more in the intervention group but was not significant. Strength training: Bale et al. (2008) Strength training: Training the unaffected side Dragert & Zehr. (2013). High-intensity unilateral dorsiflexor resistance training results in bilateral neuromuscular plasticity after stroke. 19 individuals with chronic stroke received high-intensity, isometric dorsiflexion resistance training to their less affected limb for 25 mins, 3x/wk for 6 wks. Outcomes: Dorsiflexor and plantarflexor maximal voluntary isometric contraction (MVCI), EMG, and nerve stimulation/maximal motor waves on less affected (LA) and more affected (MA) extremities Overall, significant gains in voluntary strength and muscle activation found in the untrained limb, supporting the cross-trainer effect. Dorsiflexor MVCI increased significantly in both limbs with no significant differences in the amount of increase between sides. Plantarflexor MVCI remained unchanged. EMG max increased in the LA TA and MA TA (20% and 59%, respectively), with no difference seen in SOL. Chitra L.K. Balasubramanian PT, PhD 26

27 Emerging promising interventions not included in the EBRSR Transcranial Magnetic Stimulation (rtms) Split-belt paradigm Transcranial Direct Current Stimulation (tdcs) CONCLUSIONS There are many different types of rehabilitative strategies available to improve walking function post-stroke EBRSR is ONE source to appraise the overall evidencebase in post-stroke gait rehab **Conflicting results regarding level of evidence exists for several rehabilitative interventions DePaul et al. (2014). Varied overground walking training versus body weight supported treadmill training in adults within 1 year of stroke: a randomized controlled trial. Chitra L.K. Balasubramanian PT, PhD 27

28 DePaul et al., 2011, 2014 Variations in treatment dosage, control groups, outcomes selected make it difficult to arrive at definitive conclusions regarding most effective interventions Laver et al., 2011, 2012 published 2 Cochrane reviews (19 RCTs, n=565) on Virtual Reality in post-stroke rehab and found insufficient evidence to suggest a beneficial effect on gait speed. Saunders et al., 2004 in their Cochrane review (12 RCTs, n=289) on Cardiovascular training in post-stroke rehab reported that definitive conclusions cannot be reached regarding efficacy due to the heterogeneous treatments. Dickstein. (2008). Rehabilitation of gait speed after stroke: a critical review of intervention approaches. Chitra L.K. Balasubramanian PT, PhD 28

29 So how should we use the evidence in post-stroke gait rehabilitation?? Need to use a pragmatic approach for post-stroke gait rehabilitation Know your tool-box of interventions, consider availability of equipment, consider feasibility of intervention Case-based customized approach tailored to fit the motor control deficits of our patient Consider applying principles of contemporary task practice Motor learning principles Activity-based neuroplasticity So where are we headed?? Combination of therapies?? Multidimensional Approach to Gait Rehab + Balasubramanian et al. (2014) Bowden et al. (2011) Chitra L.K. Balasubramanian PT, PhD 29

30 So where are we headed??....need to study response mechanisms Little evidence on what is the mechanism of therapeutic response? Who will benefit most from what and how best to deliver this treatment? UNF Research: Post-Stroke Gait Rehab UNF Research: Post-Stroke Gait Rehab Chitra L.K. Balasubramanian PT, PhD 30

31 UNF Research: Post-Stroke Gait Rehabilitation We believe that the C-mill treadmill system provides a safe and controlled environment to practice intense and task-specific walking function study some individual mechanisms of walking rehabilitation deliver combination of evidence-based rehabilitative strategies treadmill intense gait training, cardiovascular training virtual projections on the treadmill surface belt that necessitate walking adaptations task-specific, virtual reality, feedback methods auditory cueing feedback methods UNF Research: Post-Stroke Gait Rehabilitation Research studies using the innovative C-mill system are currently underway at UNF. For further information, research collaborations and if you are interested in referring your patient, please contact; Chitra Balasubramanian, PT, PhD, c.k-balasubramanian@unf.edu Dawn Saracino PT, DPT, MHS, NCS dsararin@unf.edu Jessica Howarth PT, DPT jessicanhowarth@gmail.com Chitra L.K. Balasubramanian PT, PhD 31

32 THANK YOU! Acknowledgements: Dawn M. Saracino PT, DPT, MHS, NCS Jessica Howarth PT, DPT UNF Physical Therapy Program Chitra L.K. Balasubramanian PT, PhD 32