Aug. 22, 2003 DALLAS, Aug. 15 – Stroke survivors who received therapist-supervised, progressive therapy after completing in-hospital rehabilitation significantly improved their endurance, balance and walking ability, according to a small study reported in today's rapid access issue of Stroke: Journal of the American Heart Association.
This study goes beyond the commonly held therapy paradigm that stroke patients achieve their most dramatic recovery within the first 30 days after stroke, says lead author Pamela W. Duncan, Ph.D., a physical therapist professor at the University of Florida, Gainesville, Fla.
"We demonstrated that by providing a home-based exercise program that's much more aggressive than what is typically prescribed, stroke survivors can improve their walking ability, balance and cardiovascular endurance," says Duncan, who is also director of the Brooks Center for Rehabilitation Studies, and director of the Department of the Veterans Affairs Rehab Outcomes Research Center in Gainesville.
The study is the first to incorporate multiple components – strength, balance, endurance and upper extremity function – into a comprehensive stroke recovery program, she says. Stroke is the leading cause of disability in older Americans, and falls are a major problem for stroke survivors, according to Duncan.
"After hospital discharge, stroke survivors continue to improve," she says. "But available therapy is highly variable. Additional therapy often lasts only a few weeks and lacks progression in intensity and task complexity. We investigated the effect of structured, progressive intervention on recovery."
Researchers studied 92 stroke survivors (average age 70) from the Kansas City Stroke Registry one to four months after their stroke. Each had mild to moderate stroke deficits and had completed in-hospital rehabilitation. All survivors underwent tests for motor function, strength, balance and endurance at the start of the study. Participants were randomly assigned to one of two groups. One received the structured, progressive exercise program and was designated as the "intervention" group. The "usual care" group had varied levels of therapies ranging from no additional therapy to limited physical or occupational therapy.
Those in the intervention group performed progressively intensive exercises focusing on their strength, balance, cardiovascular endurance and use of their arms and hands in 36 supervised sessions during the 12-week study. Forty-six percent of survivors in the usual care group did not receive any therapy. The remainder received an average of 8.7 physical therapy visits and an average of 10.4 occupational therapy visits. The usual care therapy mostly consisted of balance and mobility exercises, upper extremity function and range of motion function. Endurance training was rarely incorporated and the therapy was not progressive, Duncan notes.
Both groups showed improvement when tested again after three months. However, those in the intervention group improved significantly more in several key areas – balance, endurance and mobility. They scored 4.36 points higher on balance tests compared to their baseline tests. Participants in the usual care group scored 1.70 points higher than their baseline scores.
The intervention group bicycled during stress tests an average 1.39 minutes longer than they could at enrollment, while the usual care group bicycled an average 0.16 minutes longer than their enrollment times. Patients in the intervention group walked an average 61.61 meters (about 200 feet) farther in six minutes compared to their baseline; and usual care participants walked an average of 33.59 meters (110 feet) farther.
The difference in gains in strength and extremity function was not significant between the two groups. Upper extremity gains were better for the intervention group compared to usual care among patients who were only mildly paralyzed.
But Duncan says it's challenging to implement this type of program. "Who's going to pay for it? And how do we create community-based models of exercise so that patients who have had a stroke can accept responsibility for continuing to exercise after stroke?"
Researchers acknowledge that the study consisted of a small number of participants and the data may not be applicable to all stroke rehabilitation. Duncan suggests that future studies focus on determining whether people could do similar exercise programs without therapist supervision, and if the benefits are sustained or further improve if continued beyond 12 weeks.
Co-authors are Stephanie Studenski, M.D., M.P.H.; Lorie Richards, Ph.D.; Steven Gollub, M.D.; Sue Min Lai, Ph.D.; Dean Reker, Ph.D.; Subashan Perera, Ph.D.; Joni Yates, M.P.H.; Victoria Koch, M.P.H.; Sally Rigler, M.D., M.P.H; and Dallas Johnson, Ph.D.
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