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  • New APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

    In this review: Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury
    (Journal of Neurologic Physical Therapy, January, 2020)

    The message
    A new clinical practice guideline (CPG) supported by APTA and developed by the APTA Academy of Neurologic Physical Therapy concludes that when it comes to working with individuals who experienced an acute-onset central nervous system (CNS) injury 6 months ago or more, aerobic walking training and virtual reality (VR) treadmill training are the interventions most strongly tied to improvements in walking distance and speed. Other interventions such as strength training, circuit training, and cycling training also may be considered, authors write, but providers should avoid robotic-assisted walking training, body-weight supported treadmill training, and sitting/standing balance that doesn't employ augmented visual inputs.

    The study
    The final recommendations in the CPG are the result of an extensive process that began with a scan of nearly 4,000 research abstracts and subsequent full-text review of 234 articles, further narrowed to 111 randomized controlled trials (RCTs), all focused on interventions related to CNS injuries, with outcome data that included measures of walking distance and speed. CPG panelists evaluated the data and developed recommendations, which were informed by data on patient preferences and submitted for expert and stakeholder review.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Academy of Neurologic Physical Therapy — in the development stages such as drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).

    Findings

    • Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate maximum) walking training was associated with the strongest evidence for improvements in walking speed and distance.
    • Walking training using VR also fared well, due in part to the ability of a VR treadmill system to allow "safe practice of challenging walking activities," something that's hard to do in a more traditional hospital or clinic setting.
    • Strength training, while not included among the interventions that should be performed, was designated as an intervention that may be considered. Authors cite inconsistent evidence on the connection between strength training and improved walking speed and distance, but they acknowledge potential benefits.
    • Also among the list of interventions that "may be considered": circuit training, as well as cycling training. In both cases, authors cite a paucity of evidence related to how the interventions affect walking speed and distance. They note that these interventions may be revisited during a future reevaluation of the CPG.
    • Body-weight supported treadmill training was labeled as an intervention that should not be performed in order to increase walking speed and distance, with authors finding little evidence supporting the approach, which is often associated with a greater cost. However, they write, the individuals included in the studies reviewed for the CPT were able to ambulate over ground without the use of a body-weight support device, and "different results may occur in those who are nonambulatory or unable to ambulate without the use of [body-weight support]."
    • Both static and dynamic (nonwalking) balance training and robotic-assisted walking training were also characterized as interventions that should not be performed. Authors acknowledge the ways that postural stability and balance are associated with fall risk and reduced participation, but they were unable to find sufficient evidence to support these particular interventions as effective in increasing walking speed and distance (although static and dynamic balance training with VR fared a bit better). As for robotic-assisted walking training, CPG authors note that while ineffective for individuals with CNS who were already ambulatory, "this recommendation … may not apply to nonambulatory individuals or those who require robotic assistance to ambulate."

    Why it matters
    Authors note that "the implementation of evidence-based interventions in the field of rehabilitation has been a challenge," and they believe that the new CPG offers a real opportunity for clinicians to "integrate available research into their practice patterns." Further, they believe that the CPG has arrived at an important moment in the evolution of health care, with its greater emphasis on evidence for the cost-effectiveness and outcomes of various interventions.

    More from the study
    The CPG also offers tips for clinicians to implement its recommendations, including acquiring equipment to help providers monitor vital signs, implementing "automatic prompts in electronic medical records that will facilitate obtaining orders to attempt higher-intensity training strategies," providing training sessions for clinicians, establishing organizational policies to promote use and documentation of the recommended interventions, and simply keeping a few copies of the study on hand for easy reference.

    Keep in mind …
    Authors acknowledged that the CPG has a few limitations. While the review of RCTs only is a strength, they write, some of those studies involved small sample sizes, and many lacked details on intervention dosage. Additionally, the CPG does not fully address the potential costs associated with its recommendations — specifically VR — which could impact a clinic's ability to implement a particular intervention. Authors also acknowledge that walking speed and distance are not the only important outcomes related to mobility among individuals with CNS injury, and that other factors such as dynamic stability while walking, peak walking capacity, and community mobility may be incorporated in an assessment of walking function.

    Comments

    • If there is little evidence to support an intervention, is there evidence to show that it doesn't work or a paucity of evidence? If there is a paucity of evidence, should the recommendation still be that the intervention should NOT be used?

      Posted by John Garzione on 1/8/2020 6:34 PM

    • Thanks for the comment. The CPG only detailed the evidence on interventions described in the literature that were utilized in at least 4 studies (RCTs), with gait speed and endurance as primary or secondary outcome measures. Interventions with less evidence were not provided a recommendation. For anyone with some interest, I would strongly recommend reading through the CPG, with specific attention to the appendix tables, which briefly delineate the evidence utilized to generate the recommendations.

      Posted by T. George Hornby on 1/9/2020 11:50 AM

    • I have to say - saying not to use a body weight support system during therapy is a little strange when you’re not considering people who can’t fully tolerate standing. I wouldn’t say this does not work when you’re not even taking this population into consideration. And in a world of pdpm and financial cuts ... how are you suppose to walk someone without support who have really poor trunk control and balance when you have to be one therapist doing gait training - good luck!

      Posted by Jessica Belanger on 1/11/2020 12:47 PM

    • Thanks for your comment. As indicated in the published guidelines and above, the recommendation to not perform BWSTT was derived from RCTs with studies that utilized gait speed and endurance as primary outcomes. Hence most participants were able to ambulate, although the amount of physical assistance needed to walk overground varied. Providing assistance for BWS and (importantly) assistance at the limbs to facilitate swing and stance phase, is largely consistent with most protocols of BWSTT articles. If patients can walk on their own, this guideline indicates that such assistance for BWS or at the limbs is not necessary. That said, this guideline did not use walking independence as an outcome, and hence this recommendation does not apply to patients early post-CNS injury with greater impairments. While this is in the article as well, if we deviate from the actual recommendations and extrapolate to patients who cannot walk without substantial assistance, then using the general principle of providing large amounts of task-specific practice may facilitate recovery, but that may be difficult without BWS and physical assistance. In those cases, I would suggest some BWS and physical assistance as needed, but as little as needed. Factors associated with better outcomes during walking pracitce including making the task engaging (salient) but also monitor cardiovascular demands to ensure safety and with attempts to higher intensities - which are two strategies that are recommended in this CPG. I would strongly recommend reading the CPG and, if attending CSM, there is an educational session on this topic.

      Posted by T. George Hornby on 1/13/2020 7:55 PM

    • Thank you to the writers of this CPG, the development of this and other guidelines is so valuable and their publications ought to be of great significance to clinicians. My question is whether a similar CPG is planned to address interventions for patients less than 6 months post stroke, etc.?

      Posted by Aaron Thrush on 1/21/2020 12:25 PM

    • A CPG related to interventions that optimize walking outcomes in subacute stroke, SCI, and TBI is currently being developed with support from the ANPT and APTA. The project leads are Mark G. Bowden, PT, PhD (Medical University of South Carolina, Charleston, SC) and Jim V. Lynskey, PT, PhD (Creighton University, Phoenix, AZ).

      Posted by T. George Hornby on 1/25/2020 12:51 PM

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