Stepping Up Therapy for Stroke Survivors

By Lenora Dannelke

Intensive therapy following a stroke, regardless of the setting, can produce dramatic results in patients’ functional abilities.

In an age when high-tech solutions frequently offer dramatic advantages, the recently announced results of a study comparing rehab methods to improve walking ability for stroke survivors found that in-home physical therapy and exercise produced results comparable to a more sophisticated and costly treadmill program in a professional facility.

Another significant and unexpected finding of the Locomotor Experience Applied Post-Stroke (LEAPS) study was that improvement was found in patients who started rehab at two months and at six months after their strokes. Knowing that gains in functional status can be made even after a late start can be heartening news for your stroke patients and their families.

Of the nearly 800,000 Americans each year who suffer a stroke, up to two-thirds develop difficulty walking, which translates to 4 million individuals who currently face a stroke-related walking deficit, according to Pamela Woods Duncan, PT, PhD, of Duke University who was the principal investigator of the National Institutes of Health-funded LEAPS study. And that difficulty can contribute to falls, broken bones, and a general decline in health. With the goal of finding an optimal strategy to enhance walking recovery, the study was conducted at multiple sites over a five-year period and included 408 participants with an average age of 62. Although varying in degree from moderate to severe, all participants had walking impairments.

Structure and Progression
The trial specifically compared locomotor training that involved a body-weight supported treadmill, which suspends a patient over a treadmill in a harness and requires the assistance of several physical therapists plus gradual ground training, with a home-based program of strength and balance exercises with a single physical therapist. “Both are structured interventions and very progressive,” Duncan says. “Each group got interventions for 12 weeks, three times a week.”

In addition to these two randomized groups who started therapy two months poststroke, a third group was wait-listed for six months. This group received whatever was considered normal care between two and six months poststroke and was then crossed over to the locomotor program. “From two to six months, they also recovered but only half as much as the groups who were getting the more aggressive interventions. And when you crossed them over, they began to improve more,” Duncan says. “And at one year, all three groups had similar outcomes.”

Duncan says the take-home message is that the more complex and labor-intensive locomotor therapy was not superior to training received in the home. It is important, though, to note that home therapy was provided solely to avoid contaminating the exercise groups. “That therapy could be provided as an outpatient, and it would be more economical,” she says, explaining that comparison was made between the types of structured, progressive therapies rather than outpatient and home therapy outcomes. “It was the nature of the exercise not the environment that was in question.”

However, if any of your stroke patients have particular circumstances that prevent them from getting to an outpatient center, they can still expect to make equal progress with comparable in-home therapy. 

“Historically we thought that patients began to plateau within the first three months and definitely within six months. What clearly was shown in this trajectory is that with these structured, progressive interventions, they can continue their recovery. And they don’t recover a little—they recover a lot,” Duncan says. “That includes their mobility, their ability to take care of themselves, and their quality of life. That is significant.”

One issue with walking more, though, is a tendency for patients to fall more frequently. “And that can be true across all the interventions,” Duncan says. “We need to target our mobility training with more specific falls-prevention management programs.” Making sure the home environment is safe for mobility is vital, so be sure to address this issue with your patients and also be aware that possible cognitive impairments may cause them to misjudge their situations.

Involving Caregivers
Many aspects of the LEAPS study support the anecdotal evidence of therapy professionals. For example, Kay Wing, PT, DPT, NCS, GCS, founder and president of Swan Rehab in Phoenix, says, “Usual care is minimal and not intensive enough. Patients need therapy for a long time and very few are getting it. Intensity and repetition are essential for recovery.”

And, from Wing’s observations, that applies even if a patient has not received therapy for several years after a stroke. She also points out that the expense of intensive therapy translates to savings in the long run. “The cost of one fall that results in a broken hip far exceeds the cost of intensive therapy that could prevent a fall,” she notes.  

Wing urges you to discuss all aspects of poststroke care and recovery plans with both patients and their caregivers. As the wife of an outpatient suggested to Wing, “He didn’t have a stroke. We had a stroke.”

Routine therapy services provide a certain level of family education, but that role could possibly be expanded. “Can we, with good therapy education, train family members to work with the patients?” Duncan asks. “It would appear that could be an important way to manage some patients in the future.”

Reneé Moss, MD, medical director of Riverside Rehabilitation Institute in Williamsburg, Va., notes that outpatient therapy typically occurs three days per week, leaving the family members to continue exercises and activity the other four days. “Family training is paramount,” she says. “It depends on the level of impairment. Some patients may only need someone around for loss of balance, while other people need physical assistance. Before they leave our facility, we have family come in so the therapist can work with them and show them the techniques and also go over safety issues.”

When determining whether your stroke patient’s structured, progressive therapy should take place in an outpatient or home setting, consider the family circumstances. “Distance can be a big barrier. Not only do you have to get your significant other in and out of a vehicle, but if you have to drive an hour to get there, that can be a problem,” Moss says. “And with gas at almost $4 a gallon, there may be financial limitations.”

When discussing treatment plans and options with stroke patients, remain mindful of the possibility of poststroke depression. Moss suggests asking, “How’s your mood?” Or check with a caregiver whether your patient has appeared withdrawn or less motivated.

Whatever you determine to be the most appropriate intervention and setting, Duncan advises, “Approach it with a level of optimism: You can recover, and you can continue to recover. It doesn’t all have to be high tech, but it does have to be well managed by therapists, and it has to be structured and progressive.”