LOS ANGELES – An intensive poststroke home exercise program was as effective in improving walking speed as was a standard-care outpatient locomotor program in a randomized trial.
The learning platform did not matter nearly as much as the intervention’s timing, Pamela Duncan, Ph.D., reported at the International Stroke Conference. Patients who began to relearn walking 2 months after their stroke with the locomotor or home-based program progressed faster than did those randomized to the standard care of locomotor therapy beginning 6 months after their stroke.
"Patients recover faster and sustain recovery when the intervention is given early," she said.
Photo credit: Courtesy Dr. Pamela Duncan
A patient and physical therapist work on walking using the locomotor device (LTP)
Patients in the at-home exercise program also had significantly fewer falls than did those who underwent early outpatient locomotor training.
Dr. Duncan’s LEAPS (Locomotor Experience Applied Post Stroke) study randomized 408 patients to three groups: an early in-home program, an early outpatient locomotor program, and a wait-listed group that began outpatient locomotor training 6 months post stroke. Each training program lasted 12 weeks, and involved three 90-minute sessions per week.
The locomotor program consisted of treadmill walking with the patient’s body weight fully or partially supported by a harness. As patients progressed, the harness supported less and less of their weight, until they were able to walk on the treadmill independently. This required two or three therapists for every patient.
The home-based program focused on strength and balance, with encouragement to walk every day. Exercises were intensive and challenging, including many repetitions and resistance training for lower-extremity muscles. One therapist was able to conduct the session, said Dr. Duncan, professor of physical therapy at Duke University, Durham, N.C.
At baseline, the patients’ mean age was 62 years, and 83% had suffered an ischemic stroke. At randomization, the mean time from stroke was 64 days.
Mobility was severely impaired in 53% of patients, who had a mean gait speed of less than 0.4 meters per second (m/s). The rest of the patients were moderately impaired with respect to walking, with a mean gait speed of 0.4-0.8 m/s. They took a median of 1,700 steps daily. "Overall, these patients were taking [fewer than] 20% of the 10,000 steps required to maintain physical health," Dr. Duncan said.
The final analysis included 139 patients who were randomized to early outpatient training, 126 to the early at-home training, and 143 who were wait-listed.
"At 6 months, we found a statistically – and clinically – significant difference between the two early-intervention groups and the wait-listed group," Dr. Duncan said. Patients in the locomotor-training program and the home exercise program improved similarly: The mean gait speed increases were 0.25 m/s and 0.23 m/s, respectively. However, by 6 months the wait-listed group had improved by a mean of only 0.13 m/s. "Both early groups also improved in their activities of daily living and quality of life scores, with the wait-listed group improving about half as much," she added.
Photo credit: Courtesy Dr. Pamela Duncan
The LEAPS trials compared locomotor physical therapy to an intensive, in-home program (HEP).
Falls were another important end point of the LEAPS trial. "Individuals who are increasing mobility after stroke are at risk of falling," Dr. Duncan said. "Overall, we saw a 58% incidence of falls from 2 months to 1 year after the stroke." Most of these were single falls, but 34% of patients experienced multiple falls; 6% resulted in injury.
There were significantly more falls in the early locomotor-training group than in either the home exercise group or the late-intervention group. "This was largely attributed to multiple falls in the group of most severely disabled patients," Dr. Duncan said at the meeting, which was sponsored by the American Heart Association.
There were 10 patients who experienced serious adverse events, all of which were cardiovascular symptoms or blurred vision; all required hospital admission. They were similarly distributed, with three in the early-locomotor program, five in the late-locomotor program, and two in the home exercise program. Nine of the 10 patients returned to their walking programs after discharge. Minor adverse events occurred in 56% of patients.
Although both early-intervention groups were significantly improved at 6 months, compared with the wait-listed group, the late starters caught up quickly: At 12 months, the wait-listed patients had improved their gait speed by 0.25 m/s – the same rate as those in early therapy. These late improvements counter "the widely held assumption and reports that most functional improvements after stroke are complete by 6 months," Dr. Duncan said.