May 25, 2011 -- When it comes to helping stroke patients walk again, low-tech, home-based approaches to rehabilitation may work just as well as specialized treadmill training in a rehab facility, a new study shows.
The key to the success, researchers say, appears to be the intensity and frequency of the exercise, not where it's performed or even how long after stroke patients wait to start physical therapy.
The study is said to be the largest study on stroke rehabilitation ever conducted in the U.S. It found that about half of 408 participants, who were partially paralyzed when they started therapy, were able to walk longer distances at faster speeds a year after their strokes, whether they received physical therapy for 90 minutes three times a week for three months at home or on a body-weight-supported treadmill in a rehab facility.
What's more, participants who started their rehabilitation programs later, about six months after their strokes, saw just as much improvement as those who began rehab just eight weeks after the event.
"There's a lot of optimism in this study," says study researcher Pamela W. Duncan, PhD, PT, a professor of nursing and physical therapy at Duke University in Durham, N.C. "Patients can recover after a stroke and they can recover later than we thought they could recover in the past. But it's going to take very structured, intensive interventions to do that."
The study is published in the New England Journal of Medicine.
Effects of a Stroke
About two-thirds of people who experience a stroke have limited ability to walk, at least initially.
Those who do manage to get back on their feet often find it can be slow-going and hazardous. Studies show that having a stroke quadruples the risk of falling and elevates the risk of breaking a hip after a fall by 10 times.
There has been no consensus about the best way to help people recover their gait. But one therapy -- body-weight-supported treadmill training -- has become increasingly common in rehab facilities.
In this kind of treadmill training, patients are supported by a harness over a treadmill while therapists help them move their weakened legs. Over time, the harness supports less body weight until the patient is able to stand and walk on his or her own.
"This was, to my knowledge, the first large-scale, rigorously done trial showing that patients could make just as much progress, in terms of walking, with intensive home physical therapy as with the much more expensive inpatient rehab using treadmills and other complex equipment than are available at home," says Richard B. Libman, MD, chief of the division of vascular neurology at Long Island Jewish Medical Center, in New Hyde Park, N.Y.
Other experts, however, said they were surprised and unconvinced by the results.
"To see that, in this study, that the body weight support wasn't superior to home exercises was a little bit surprising," says Susan Linder, a research physical therapist with the Cleveland Clinic in Ohio. "Because everything that we have thought really indicates that patients really learn better not just on the treadmill, but with this body weight support."
Linder says the results of the study are clouded by the fact that more than 80% of study participants in all groups also received additional physical therapy, usually in outpatient facilities, on top of the gait training work they were assigned for the study.
"What isn't controlled for is what physical therapy interventions they were receiving outside of the study," Linder tells WebMD.
Treadmill Training vs. Home Exercise
For the study, patients over age 18 with one weakened leg after a recent stroke were recruited from six rehabilitation facilities in California and Florida.
To be included, they had to be able to walk at least 10 feet with minimal help and to tolerate exercise. They also had to be living at home or were expected to return home after therapy.
Four hundred eight patients qualified for the study. The average age of study participants was 62.
Two months after their strokes, they were randomly assigned to one of three groups: early treadmill training, later treadmill training, or home exercise.
All participants received 30 to 36 sessions of physical therapy for 90 minutes, three days per week. The early treadmill training group and home exercise group started their regimens two months after their strokes. The late treadmill training group began six months after their strokes.
In the treadmill training sessions, patients were strapped into a harness that partially supported their body weight. A physical therapist helped them move their weakened leg as they walked for 20 to 30 minutes on a treadmill. They followed that with practicing walking on the ground for another 15 minutes. The rest of the session was used for warm-up and stretching exercises.
In the home exercise sessions, a physical therapist worked with participants to improve balance, strength, and flexibility. Sessions became progressively more challenging. Home exercisers were encouraged to walk daily, but walking was not part of their structured training.
By one year after their strokes, 52% of participants had improved by one functional level, meaning that if they walked more slowly than about 1 mile per hour before the study, they were able to walk at least as fast as a mile per hour after their exercise training. If they walked between about 1 and 2 miles per hour before the study, they were able to walk at least as briskly as 2 miles per hour afterward.
Those are significant improvements, Linder says.
"If you looked at what typical walking speed is for an older adult, it really is around 2 miles per hour or faster, so that's really achieving what age norms would be," Linder says.
At walking speeds less than a mile an hour, Linder says, it's hard to do basic thinks like cross a street before traffic lights change.
All groups also had similar improvements in motor recovery, balance, functional status, and quality of life.
There were slightly more falls and adverse events in the treadmill exercisers, though the rates were low across all groups.
One major difference between groups was the retention rate.
There were fewer dropouts in the home-based program; just 3% in that group stopped their exercise, compared to 13% in the early treadmill training group and 17% in late treadmill training arm.
"It is highly encouraging that they're more compliant, more adherent," says Libman. "Lots of people would go home if they could choose to."