Pierce Boyne

Estimating clinically important change in gait speed in people with stroke undergoing outpatient rehabilitation.

Background and Purpose: Gait speed is commonly used to assess walking ability in people with stroke. It is not clear how much change in gait speed reflects an important change in walking ability. The purpose of this study was to estimate clinically important changes in gait speed by using 2 different anchors for what is considered “important”: stroke survivors and physical therapists perceptions of change in walking ability. Methods: Participants underwent outpatient physical therapy (mean 56 days post-stroke) after a first-time stroke. Self-selected gait speed was measured at admission and discharge. At discharge, participants and their physical therapists rated their perceived change in walking ability on a 15-point ordinal Global Rating of Change (GROC) scale. Estimated important change values for gait speed were calculated by using receiver operating characteristics curves, with the participants and physical therapists GROC as the anchors. Results: The mean (SD) initial gait speed of all participants was 0.56 (0.22) m/s. The estimated important change in gait speed ranged from 0.175 m/s (participants perceived change in walking ability) to 0.190 m/s (physical therapists perceived change in walking ability), depending on the anchor. Discussion and Conclusions: During the subacute stage of recovery, individuals poststroke who experience improvements in gait speed of 0.175 m/s or greater are likely to exhibit a meaningful improvement in walking ability. The estimated clinically important change value of 0.175 m/s can be used by clinicians to set goals and interpret change in individual patients and by researchers to compare important change between groups.

Tongue-Based Biofeedback for Balance in Stroke: Results of an 8-Week Pilot Study

OBJECTIVE To assess balance recovery and quality of life after tongue-placed electrotactile biofeedback training in patients with stroke. DESIGN Prospective multicenter research design. SETTING Outpatient rehabilitation clinics. PARTICIPANTS Patients (N=29) with chronic stroke. INTERVENTIONS Patients were administered 1 week of therapy plus 7 weeks of home exercise using a novel tongue based biofeedback balance device. MAIN OUTCOME MEASURES The Berg Balance Scale (BBS), Timed Up and Go (TUG), Activities-Specific Balance Confidence (ABC) Scale, Dynamic Gait Index (DGI), and Stroke Impact Scale (SIS) were performed before and after the intervention on all subjects. RESULTS There were statistically and clinically significant improvements from baseline to posttest in results for the BBS, DGI, TUG, ABC Scale, and some SIS domains (Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, Social, Physical, Recovery domains). Average BBS score increased from 35.9 to 41.6 (P<.001), and DGI score, from 11.1 to 13.7 (P<.001). Time to complete the TUG decreased from 24.7 to 20.7 seconds (P=.002). Including the BBS, DGI, TUG, and ABC Scale, 27 subjects improved beyond the minimal detectable change with 95% certainty (MDC-95) or minimal clinically important difference (MCID) in at least 1 outcome and 3 subjects improved beyond the MDC-95 or MCID in all outcomes. CONCLUSIONS Electrotactile biofeedback seems to be a promising integrative method to balance training. A future randomized controlled study is needed.

High-Intensity Interval Training in Stroke Rehabilitation

Abstract After stroke, people with weakness enter a vicious cycle of limited activity and deconditioning that limits functional recovery and exacerbates cardiovascular risk factors. Conventional aerobic exercise improves aerobic capacity, function, and overall cardiometabolic health after stroke. Recently, a new exercise strategy has shown greater effectiveness than conventional aerobic exercise for improving aerobic capacity and other outcomes among healthy adults and people with heart disease. This strategy, called high-intensity interval training (HIT), uses bursts of concentrated effort alternated with recovery periods to maximize exercise intensity. Three poststroke HIT studies have shown preliminary effectiveness for improving functional recovery. However, these studies were varied in approach and the safety of poststroke HIT has received little attention. The objectives of this narrative review are to (1) propose a framework for categorizing HIT protocols; (2) summarize the safety and effectiveness evidence of HIT among healthy adults and people with heart disease and stroke; (3) discuss theoretical mechanisms, protocol selection, and safety considerations for poststroke HIT; and (4) provide directions for future research.

Speed-dependent body weight supported sit-to-stand training in chronic stroke: a case series.

BACKGROUND AND PURPOSE Body weight support (BWS) and speed-dependent training protocols have each been used for poststroke gait training, but neither approach has been tested in the context of sit-to-stand (STS) training. This study evaluated the feasibility and outcomes of speed-dependent BWS STS training for 2 persons with chronic stroke. CASE DESCRIPTIONS Two individuals 68 and 75 years old, and 2.3 and 8.7 years post-ischemic stroke, respectively, participated. Both exhibited right hemiparesis, required moderate (25%-50%) assistance for STS, and ambulated household distances with assistive devices. INTERVENTION Participants performed speed-dependent BWS STS training 3 days/week for 45 to 60 minutes until able to perform STS independently. Gait parameters, the Stroke Impact Scale Mobility Domain (SIS-mobility), and the 3-Repetition STS test (3RSTS) were assessed before and after intervention. OUTCOMES Each participant completed more than 750 STS repetitions over the course of the intervention, achieving independence in 8 to 11 sessions. Aside from muscle soreness, no adverse effects occurred. Participants also exhibited increased gait velocity (0.17-0.24 m/s and 0.25-0.42 m/s), SIS-mobility score (78-88 and 63-66), and decreased 3RSTS time (18-8 seconds and 40-21 seconds). DISCUSSION Speed-dependent BWS STS training appears to be a feasible and promising method to increase STS independence and speed for persons with chronic stroke. In this small case series, a potential transfer effect to gait parameters was also observed. Future randomized controlled study is warranted to evaluate efficacy and long-term effects.

Within-session Responses to High-intensity Interval Training in Chronic Stroke

UNLABELLED Poststroke hemiparesis often leads to a vicious cycle of limited activity, deconditioning, and poor cardiovascular health. Accumulating evidence suggests that exercise intensity is a critical factor determining gains in aerobic capacity, cardiovascular protection, and functional recovery after stroke. High-intensity interval training (HIT) is a strategy that augments exercise intensity using bursts of concentrated effort alternated with recovery periods. However, there was previously no stroke-specific evidence to guide HIT protocol selection. PURPOSE This study aimed to compare within-session exercise responses among three different HIT protocols for persons with chronic (>6 months after) stroke. METHODS Nineteen ambulatory persons with chronic stroke performed three different 1-d HIT sessions in a randomized order, approximately 1 wk apart. HIT involved repeated 30-s bursts of treadmill walking at maximum tolerated speed, alternated with rest periods. The three HIT protocols were different on the basis of the length of the rest periods, as follows: 30 s (P30), 60 s (P60), or 120 s (P120). Exercise tolerance, oxygen uptake (V˙O2), HR, peak treadmill speed, and step count were measured. RESULTS P30 achieved the highest mean V˙O2, HR, and step count but with reduced exercise tolerance and lower treadmill speed than P60 or P120 (P30: 70.9% V˙O2peak, 76.1% HR reserve (HRR), 1619 steps, 1.03 m·s(-1); P60: 63.3% V˙O2peak, 63.1% HRR, 1370 steps, 1.13 m·s(-1); P120: 47.5% V˙O2peak, 46.3% HRR, 1091 steps, 1.10 m·s(-1)). P60 achieved treadmill speed and exercise tolerance similar to those in P120, with higher mean V˙O2, HR, and step count. CONCLUSIONS For treadmill HIT in chronic stroke, a combination of P30 and P60 may optimize aerobic intensity, treadmill speed, and stepping repetition, potentially leading to greater improvements in aerobic capacity and gait outcomes in future studies.

Does Aerobic Exercise and the FITT Principle Fit into Stroke Recovery

Sedentary lifestyle after stroke is common which results in poor cardiovascular health. Aerobic exercise has the potential to reduce cardiovascular risk factors and improve functional capacity and quality of life in people after stroke. However, aerobic exercise is a therapeutic intervention that is underutilized by healthcare professionals after stroke. The purpose of this review paper is to provide information on exercise prescription using the FITT principle (frequency, intensity, time, type) for people after stroke and to guide healthcare professionals to incorporate aerobic exercise into the plan of care. This article discusses the current literature outlining the evidence base for incorporating aerobic exercise into stroke rehabilitation. Recently, high-intensity interval training has been used with people following stroke. Information is provided regarding the early but promising results for reaching higher target heart rates.

Predicting Home and Community Walking Activity Poststroke

Background and Purpose— Walking ability poststroke is commonly assessed using gait speed categories developed by Perry et al. The purpose of this study was to reexamine factors that predict home and community ambulators determined from real-world walking activity data using activity monitors. Methods— Secondary analyses of real-world walking activity from 2 stroke trials. Home (100–2499 steps/d), most limited community (2500–4499 steps/d), least limited community (5000–74 999), and full community (≥7500 steps/d) walking categories were developed based on normative data. Independent variables to predict walking categories were comfortable and fast gait speed, 6-minute walk test, Berg Balance Scale, Fugl Meyer, and Stroke Impact Scale. Data were analyzed using multivariate analyses to identify significant variables associated with walking categories, bootstrap method to select the most stable model and receiver-operating characteristic to identify cutoff values. Results— Data from 441 individuals poststroke were analyzed. The 6-minute walk test, Fugl Meyer, and Berg Balance Scale combined were the strongest predictors of home versus community and limited versus unlimited community ambulators. The 6-minute walk test was the strongest individual variable in predicting home versus community (receiver-operating characteristic area under curve=0.82) and limited versus full community ambulators (receiver-operating characteristic area under curve=0.76). A comfortable gait speed of 0.49 m/s discriminated between home and community and a comfortable gait speed of 0.93 m/s discriminated between limited community and full community ambulators. Conclusions— The 6-minute walk test was better able to discriminate among home, limited community, and full community ambulators than comfortable gait speed. Gait speed values commonly used to distinguish between home and community walkers may overestimate walking activity.

How Much Change in the Stroke Impact Scale-16 Is Important to People Who Have Experienced a Stroke?

Abstract Background: The Stroke Impact Scale-16 (SIS-16) is used clinically and in research to measure quality of life after stroke. There are no studies that have estimated how much change on the SIS-16 is an important amount of change. The aim of this study was to estimate the minimal clinically important difference (MCID) of the SIS-16. Method: SIS-16 scores of participants receiving services at 2 outpatient physical therapy clinics who met inclusion and exclusion criteria (n = 36) were taken at baseline and discharge. At discharge, participants and their physical therapists rated their perceived amount of recovery on a Global Rating of Change (GROC) scale. Estimated MCID values were calculated for the SIS-16 using receiver operating characteristics curves with the GROC as anchors. Results: There was no difference in baseline characteristics between participants who reported important improvement and those who did not. There was a fair relationship between change in SIS-16 scores and participants’ (0.41) and physical therapists’ (0.38) GROC scores. Change in SIS-16 scores was significantly greater in participants who reported an important amount of change on the GROC scale and those who did not. Estimated MCID of the SIS-16 ranged from 9.4 to 14.1 depending on the anchor. Conclusion: The estimated MCID values presented in this study provide a way for clinicians to evaluate meaningful change in individual patients and for researchers to evaluate meaningful change between groups.

High-Intensity Interval Training and Moderate-Intensity Continuous Training in Ambulatory Chronic Stroke: Feasibility Study

Background Poststroke guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve aerobic capacity and mobility after stroke. High-intensity interval training (HIT) has been shown to be more effective than MCT among healthy adults and people with heart disease. However, HIT and MCT have not been compared previously among people with stroke. Objective The purpose of this study was to assess the feasibility and justification for a definitive randomized controlled trial (RCT) comparing HIT and MCT in people with chronic stroke. Design A preliminary RCT was conducted. Setting The study was conducted in a cardiovascular stress laboratory and a rehabilitation research laboratory. Patients Ambulatory people at least 6 months poststroke participated. Intervention Both groups trained 25 minutes, 3 times per week, for 4 weeks. The HIT strategy involved 30-second bursts at maximum-tolerated treadmill speed alternated with 30- to 60-second rest periods. The MCT strategy involved continuous treadmill walking at 45% to 50% of heart rate reserve. Measurements Measurements included recruitment and attendance statistics, qualitative HIT acceptability, adverse events, and the following blinded outcome variables: peak oxygen uptake, ventilatory threshold, metabolic cost of gait, fractional utilization, fastest treadmill speed, 10-Meter Walk Test, and Six-Minute Walk Test. Results During the 8-month recruitment period, 26 participants consented to participate. Eighteen participants were enrolled and randomly assigned to either the HIT group (n=13) or the MCT group (n=5). Eleven out of the 13 HIT group participants attended all sessions. Participants reported that HIT was acceptable and no serious adverse events occurred. Standardized effect size estimates between groups were moderate to very large for most outcome measures. Only 30% of treadmill speed gains in the HIT group translated into overground gait speed improvement. Limitations The study was not designed to definitively test safety or efficacy. Conclusions Although further protocol optimization is needed to improve overground translation of treadmill gains, a definitive RCT comparing HIT and MCT appears to be feasible and warranted.

Preliminary safety analysis of high-intensity interval training (HIIT) in persons with chronic stroke

The purpose of this study was to assess safety via electrocardiographic (ECG), blood pressure (BP), heart rate (HR), and orthopedic responses to 3 different high-intensity interval training (HIIT) protocols in persons with stroke. Eighteen participants (10 male; 61.9 + 8.3 years of age; 5.8 + 4.2 years poststroke) completed a symptom-limited graded exercise test (GXT) with ECG monitoring to screen for eligibility and determine HR peak. The 3 HIIT protocols involved repeated 30 s bursts of treadmill walking at maximum speed alternated with rest periods of 30 s (P30), 1 min (P60), or 2 min (P120). Sessions were performed in random order and included 5 min warm up, 20 min HIIT, and 5 min cool down. Variables measured included ECG activity, BP, HR, signs and symptoms of cardiovascular intolerance, and orthopedic concerns. Generalized linear mixed models and Tukey-Kramer adjustment were used to compare protocols using p < 0.05. No signs or symptoms of cardiovascular intolerance, significant arrhythmias, ST segment changes, or orthopedic responses resulted in early termination of any HIIT session. HIIT elicited HRs in excess of 88% of measured HRpeak including 6 (P30), 8 (P60), and 2 (P120) participants eliciting a HR response above their GXT HRpeak. Both maximum BP and HR were significantly higher in P30 and P60 relative to P120. Preliminary data indicate that persons with chronic stroke who have been prescreened with an ECG stress test, a symptom-limited GXT, and a harness for fall protection may safely participate in HIIT, generating substantially higher HRs than what is seen in traditional moderate intensity training.