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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.