“i just want to implement something”– lived alone prior to stroke ... in variable contexts,...

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“I just want to implement something”

Systematic implementation of high intensity stepping training in inpatient neurologic rehabilitation

Molly Holthus, DPT

Abbey Plawecki, PT

Maghan Bretz, PT, NCS

Chris Henderson, PT, PhD, NCS

T. George Hornby, PT, PhD

Objectives

1. Demonstrate understanding of evidence supporting high intensity training techniques and parameters

2. Identify and apply strategies to implement high intensity training in inpatient rehab

3. Understand barriers to implementation and strategies to address them

4. Incorporate feedback from outcome measures and heart rate data to guide clinical decision making

5. Accurately document high intensity training sessions within for inpatient rehabilitation

Patient Cases

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Case 1• 52 yo male; subacute L ICH (subcortical)

• PMH: HTN

• CVA deficits: dysphagia, aphasia, acute kidney failure

• Relevant meds: simvastatin, nifedipine, dilatin, digoxin, phenobarbital, clozapine, metoprolol

• Social hx: – Lived alone prior to stroke

– Admitted to nursing home after medically stable post‐stroke/minimal rehabilitation

– Impulsive, aphasic

– Unable to ambulate or perform stair climbing (required to live with family)

Case 1

Initial evaluation

• FIM: modA for transfers and ambulation

• 10MWT: 0 m/s (unable to ambulate)

• Berg Balance Scale: 5/56

• 6MWT: 0 feet (unable to ambulate)

• 5xSTS: unable

Case 2• 59 yo male; subacute L thalamic/BG stroke; mass

effect/midline shift

• PMH: Obesity (> 300 lbs), HTN, CHF, pleural effusions, a fib, LE venous stasis ulcers, asthma

• CVA deficits: acute renal insufficiency

• Relevant meds: Protonix, Tobradex, Norvasc, Vasotec, Keppra, Hydralazine

• Social hx: • Admitted to nursing home after medically stable post‐stroke

• Family unable to assist patient; lived with wife prior

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Case 2

Initial evaluation

• FIM: modA transfers and mobility items

• 10MWT: 0 m/s

• Berg Balance Scale: 7/56

• 6MWT: 0 feet

• 5xSTS: unable

Case 3

• 67 yo female, 1 year post R MCA infarct

• PMH: HTN, HL

• CVA deficits: L neglect and visual field cut

• Social hx:• 20 days acute inpatient rehab

• SNF ~4 months prior to discharge home

Biomechanical Subcomponents of Gait

Basic definitions of walking:

• Most natural means of moving from one location to another over a short distance

• Rhythmic alternating movements of the trunk & limbs which result in the forward progression of the center of gravity

• “Controlled falling”• Forward progression/stance stability requires energy from

muscles, trunk lean to give passenger unit sufficient momentum

• Conservation of energy • Cyclic exchange between gravitational and kinetic energy• Efficient redirection of “falling” into steady state forward

progression

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‐ Passenger unit – head ,neck, trunk, arms, pelvis ‐ 70% BW, responsible for its own postural integrity

‐ Aligned with forward tilt/provides momentum

‐ Locomotor Unit – legs, pelvis‐ 11 articulations, 57 muscles, bony “levers”

‐ Alternating limb function:

‐ Support/progress the passenger unit

‐ With relief of BW, swings to new “position”

‐ Biomechanical considerations in gait‐ Forward Progression

‐ Stance Stability

‐ Energy Conservation


Forward progression

• Propulsion – Redirecting COM

gravitational energy to kinetic energy

– Inverted pendular motion

• Limb swing • Progression of non‐wt

bearing limb – pendularmotion

• Preparation to accept weight


• Stance Stability• Maintain upright posture –

reliance on passive (skeletal) vs active (muscular) structures to support weight

• Reduce center of mass movement outside of lateral base of support

• Two categories:

1. Upright stability

2. Lateral stability


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Energy Conservation

• Patients walk at speed of reduced energy (typically)

• Reduced co‐contraction (more in elderly)

• Stability /movement through learned strategies to minimize effort

• Perturbations result in altered gait strategies to minimize cost (Selinger 2015)


How much energy can be conserved?

• Insufficient propulsion stepping in place/slow• Primary determinant of walking

• Energy cost of redirecting ‘up’ and push‐off from contralateral limb

• Insufficient limb swing limited or absent limb advancement• ↑ speed by ↑ step frequency (also ↑ costs)

• Insufficient stance stability buckling or limb collapse

• Insufficient lateral stability loss of balance• Relatively stable in AP direction w/ small perturbations accounted for by altered

collision and propulsive forces

• Relatively unstable in ML direction w/ small perturbations large disturbances


• Grabowski 2005, Gottschall 2003 & 2005• Propulsion (42‐48%)

• Limb Swing (10‐20%)

• Stance Stability (25‐28% cost)

• Lateral Stability (6%)

• Residual – work of lungs/heart


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Take home message:

• Four biomechanical subcomponents1. Propulsion

2. Limb swing

3. Stance stability

4. Lateral stability

• ≥ 1 subcomponent frequently affected following neurologic injury


Rehabilitation Strategies

• What can we do to help these patients?

E L E V TO R

V

1990sNeuroplasticity

1900sSherrington.

1980-1990sTask oriented

training

1940-1970sNeurodevelopmental

Approaches

• NDT / Bobath• Brunnstrom

1960-1970sPNF

Waybackthen

Right about now

Rehabilitation Strategies

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Rehabilitation Strategies: Evidence

• Kollen, 2009• Bobath/NDT not superior to any other approach

• Verbeek, 2014• “Strong evidence for unfavorable effects of NDT on

motor function (synergy), gait speed, spatiotemporal gait pattern functions…”

• “Effects are mostly restricted to the actually trained functions and activities”

• “strong evidence favoring intensive, high repetition, task‐oriented and task‐specific training in all phases post‐stroke”

• Neuroplasticity• Brain encodes experience and learns new behaviors

• Damaged brain relearns lost behavior

• Merzenich, 1984• Finger amputation

Evolution of Rehabilitation Strategies

• Nudo, 1996

Evolution of Rehabilitation Strategies

Without rehab With rehab

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EvidenceSpecificity

IntensityRepetition

Specificity

IntensityRepetition

Specificity

Specificity

IntensityRepetition

Repetitions during typical outpatient PT session post-stroke

Active/passive exercise 12-100

Balance and pre-gait 12-20

Transfers 10

Gait 300-800

UE exercise

11%

Stretching8%

Active LE exercise

27%

Transfers1%

Balance15%

Stairs4%

Gait34%

Lang, 2007 & 2009

Moore, 2010

• What do we do in clinical practice?

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• Specificity – Type of practice• Stepping practice improves stepping performance (Hesse 1995;

Pohl 2002; Sullivan 2002; Moore 2010; Hornby 2016)

• Non‐stepping practice

• Balance training improves balance (Au‐Yeung 2009)

• Strength training improves strength (Patten 2004; Jayaraman 2013; Damiano 1998,2010)

• Sit‐to‐stand (Boyce 2010)

• Small effects on walking (Locomotor CPG)

Specificity: Evidence

Specificity

IntensityRepetition

Specificity – How specific?

• Preparatory activities (pre‐gait)?• improve pre‐gait, not walking (Winstein 1989)

Specificity

IntensityRepetition


• Practice normal movements?

Specificity

IntensityRepetition

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• Practice normal movements?• Interven ons to ↓ spas city

• Avoid exer on to prevent ↑ spasticity

• Abnormal movement must be ↓ in order to retrain normal movement patterns

Specificity

IntensityRepetition

Evidence ‐ Walking

• Early studies on facilitation ‐ normalizing gait (Wernig 1995, Hesse 1995, Visintin 1998, Sullivan 2002)

• Few studies that tried to isolate the effects of normalizing gait vs more practice

• Yagura, 2006• BWS vs BWS + facilitation

• Facilitation did not add significantly to locomotor outcomes

• Required more therapists’ assistance

Changes in locomotor performance

• “Optimizing kinematics” or just walk them:• Subacute and chronic stroke

• Gait speed changes very similar with either approach

• SCI

• Varies substantially with chronicity & initial function, but…

• No difference between “practicing normal locomotion” vs just walking them (Dobkin 2006)

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Walking therapies that optimize kinematics

• Robotic-assisted training can provide many of the inputs thought to improve walking

• Minimize compensatory strategies

• Practice normal kinematics• Data to support similar EMG

activity during robotic-assisted training

• Problems• Reduced workload by patient• No awareness of altered motor

patterns• VERY COSTLY!!• Worse than therapist-assisted

walking on TM or TM/OG strategies focused on walking for ambulatory patients (Hornby 2008; Hidler 2009)

• Types of variability− Kinematic variability (Cai 2007; Hornby 2008; Lewek 2009)

Contributions of errors and variability to learning

(Israel 2006; Hornby 2008; Lewek 2009)

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60

0

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40

30

20

10

60

0

post-4 weeks 6 month follow-up

Therapist-assisted

Robotic-assisted

post-4 weeks 6 month follow-up

* **

*

Gait speed (less impaired subjects) Gait speed (more impaired subjects)

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4

-2

-4

-6

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4

-2

-4

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Therapist-assisted

Robotic-assisted

Paretic single limb stance time(% gait cycle)

post-4 weeks 6 month follow-up post-4 weeks 6 month follow-up

Step length symmetry (%)

Evidence ‐ Walking

• Explicit focus on kinematics • Progress to adaptability• Significant improvements in

measures including:• Gait speed• Balance• Timed distance• Peak treadmill speed• Peak metabolic

capacity• Limited measures of

kinematic changes

• No explicit focus on kinematics

• Continually challenge difficulty

• Significant improvements in measures including:

• Gait speed• Balance• Timed distance• Peak treadmill speed• Peak metabolic

capacity• Limited measures of

kinematic changes –please see later in presentation

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• Walk forward? (Shah 2012; Hornby 2019)

− Kinematic variability (Cai 2007; Hornby 2008; Lewek 2009)

− Environmental variability overground/stairs (van den Brand 2012)

− Task variability forward vs sideways vs backwards (Shah 2012)

Specificity

IntensityRepetition

• Augmenting errors during learning may enhance magnitude/accelerate learning (Bastian 2006; Reisman 2010)

If errors are good . . . .

Application of error augmentation – Split belt treadmill for step‐length asymmetry post‐stroke

During walking on split‐belt treadmillReisman, 2007; 2013

↑ symmetry during training↓ symmetry afterwards

↓ symmetry during training↑ symmetry afterwards

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Differences in theoretical frameworks of locomotor training paradigms

Guidance Assist-as-needed

Unassisted Error augmentation

Specificity

IntensityRepetition

• Animal studies ‐ 1000 steps > 100 steps (Cha 2007)

• Human studies – 2000‐6000 steps (Moore 2010; Pohl 2002; Sullivan 2002)

• Clinical PT generally < 400 steps (Lang 2009; Scrivener 2012)

Specificity

IntensityRepetitionRepetition ‐ Evidence

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• Moore, 2010• Tracked individuals in PT

• Highest tolerable walking speed until heart rate = 80‐85% of age predicted max or RPE = 17

Specificity

IntensityRepetitionRepetition ‐ Evidence

Clinical PT Locomotor Training

Repetition ‐ EvidenceSpecificity

IntensityRepetition

Clinical PT Locomotor Training


IntensityRepetition

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• Repetition ‐ Amount of stepping practice• Traditional BWSTT provides large amounts of stepping (Barbeau

2003; Dean 2010; Ada 2010)

• Dose appears to be related to responses (Moore 2010; Holleran2014; Hornby 2015a; Hornby 2015b)

• Dose : ~ 4000 steps – just treadmill

• 2500 steps in subacute stroke with stepping training in variable contexts, 1000 w/ conventional

• 1500 step/session difference – 2‐3 steps per meter

• Over 40 sessions

• 60,000 step difference

• Or 20‐30 km difference?

• Faster is better (Pohl 2002; Sullivan 2002)43


IntensityRepetition

Specificity

IntensityRepetition

• Rate of work (power) related to energy expended (i.e., oxygen consumption – VO2)

• Remember the FITT principle

• Correlated with heart rate and perceived exertion

• NOT number of visits, visits/week, minutes, minutes/day doesn’t tell us anything about how much practice was actually provided

• Many good things associated with aerobic intensity activities

• Increased aerobic capacity

• Increased neural activation neurotrophin synthesis

• Increased speed increased repetition

Specificity

IntensityRepetitionIntensity – Definition

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“Typical” definitions• Webster’s: Magnitude of a quantity (as force or

energy) per unit of area, charge, mass, or time

• Exercise prescription• Power required to perform an activity (workload)

• Work per unit time• force x velocity

• Speed of action performed (if mass is same)• Increased treadmill speed, increased rate of

cycling• Increase speed of upper extremity movements

• Increase force (if speed is same)• Increased weight/mass• Increased incline

Current Practice Patterns: Intensity

• Intensity of therapy greater than 60% HR max (MacKay Lyons, 2002)

• PT sessions = 2.8 ± 0.9min • OT sessions = 0.70 ± 0.2min

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Is it possible to do more?

High intensity exercise regimens following neurological injury

• Task-specific aerobic training (treadmill exercise) – Mackoet al 2005

• Experimental : Aerobic walking exercise (70-80% heart rate reserve)

• Control : Stretching, brief walking bouts, light exercise

• Task-oriented training (Outermans et al 2010) or “therapeutic exercise” (Duncan et al 2003)

• E: Repeated walking-related “work stations” (70-80% HR reserve)

• C: matched therapy time, less work (lower workload)

• Fast vs slow-walking or vs equivalent duration control• Sullivan et al 2002, Pohl et al 2002, Moore et al 2010

• Tough to separate intensity and increased practice!

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Contributions of intensity in other studies

• Effects of robotic assisted stepping vs therapist assisted interventions (Hornby et al 2008, Hidler et al 2009)

• Greater improvements in therapist-assisted training

• More or equivalent stepping practice during robotic-assisted training

• Why?50

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60

0

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30

20

10

60

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post-4 weeks 6 month follow-up post-4 weeks 6 month follow-up

Therapist-assisted

Robotic-assisted

* **

*

Metabolic and muscle activity during robotic-vs. therapist assisted walking (Israel et al 2006)

0

4

8

12

16

exercisebaseline(sitting)

baseline(standing)

recovery(sitting)

0 2 4 0 2 4 6 8 0 2 40

**

*

baselinetherapist-assistedrobot-assisted

time (min)

0

4

8

12

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exercisebaseline(sitting)

baseline(standing)

recovery(sitting)

0 2 4 0 2 4 6 8 0 2 40

* * *

*

baselinetherapist-assistedrobot-assisted

time (min)

Protocol I – “just walk”:-Large differences in metabolic costs of walking-Reduced hip flexor muscle activity

Protocol II: walk as hard as you can- Equivalent early, but people start slacking

Israel et al 2006Principle of Laziness – AD Kuo, U Mich

More recent data

• Holleran et al 2015 JNPT• Unilateral stroke (> 6

months)• High intensity vs low

intensity training results in differential improvements in 6MWT, FV, and peak treadmill testing

• Brazg et al 2017 NNR (in press)

• Chronic SCI (> 1 year)• High intensity vs low


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More recent data

• Holleran et al 2015 JNPT• Unilateral stroke (> 6

months)• High intensity vs low


• Brazg et al 2017 NNR (in press)

• Chronic SCI (> 1 year)• High intensity vs low


Contributions of intensity in other studies (LEAPS trial, Duncan 2011)

• Early and Late LT • 0 minute sessions, 3X week for 36 sessions • LT including treadmill stepping with partial BWS

• 20-30 minutes per session on treadmill• Up to 3.2 km/hr (2 miles/hr, 0.89 m/s)• 15 minutes overground after 4th week

• Home Exercise program • “designed as a active control, not a high-intensity,

task-specific walking program”• Progression managed by physical therapy; goals of

increasing flexibility, strength, coordination, and static/dynamic balance

• MINIMAL WALKING PRACTICE

LEAPS Locomotor Training vsHome Exercise Interventions• No differences in outcomes measures at 6 months

• Similar “dose” of training except for all locomotor training vs no walking training

• No differences in time of sessions (76-83 mins/ session)• LT groups progressed in duration, BWS, assistance• Ave max speed = 3.2 kmph; minimum BWS was 11%• mean midpoint HR of each session

• Locomotor training (early) = 90 beats/min• Home exercise = 72 beats/min

• RPE < 13, HR < 110 beats/min (BMC Methods paper, LEAPS CSM presentation 2011)

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Comparison of intensity of other studies to LEAPS interventions?

• Macko 2005, Luft 2008, Globas 2012• Investigation of task-specific aerobic training (treadmill

exercise)• Aerobic walking exercise (60-70% heart rate reserve)

• Outermans 2010• Investigation of task-oriented training• Repeated walking-related work stations (70-80% HR reserve)

• Pang 2005 • Investigation of community based fitness program• Instructed to stay within HR zone (70-80% HR reserve)

• Fast vs slow-walking and/or vs control • Progressive training of speeds based on HR• Pohl 2002, Moore 2010 (up to 85%max)

HR data during 6 min walk test• 17 subjects with subacute or chronic stroke, < 0.9 m/s

overground walking speed

• HR collected each minute during 6 min walk at self-selected pace




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Pang et al 2013: Changes in VO2peak-aerobic vs control groups (effect sizes)

Pang et al 2013: Changes in 6 min walk -aerobic vs control groups (effect sizes)

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Pang et al 2013: Changes in gait speed -aerobic vs control groups (effect sizes)

• Therapists perceptions/use of aerobic exercise in patientspost-stroke (Boyne 2017; Doyle 2013)• 80-90% of PTs believe aerobic exercise should be incorporated

into practice (less in acute stroke)• Prescribed by ~20% of PTs – dose of prescription not indicated

• “majority of PTs prescribed standing, sitting/lying exercise, and overground walking for aerobic exercise”

• Light intensity most common in acute and outpatient stroke, moderate in subacute stroke

• Barriers/limitations• Safety – lack of ECG testing as primary barriers• Potential patient factors (severity of injury, other goals,

mobility/fitness levels)• Organizational - Equipment, personnel

Barriers/limitations

Potential drawbacks of high intensity training

• Neuromuscular concerns• Overtraining (??) – Sullivan et al 2007• Increased spasticity (short-term; Kline et al 2007)

• Cardiovascular concerns• Monitor heart rate, blood pressure, autonomic responses• Ratings of Perceived Exertion with Beta blockers or reduce

max HR by 10 beats/min)

• Orthopedic concerns• Knee hyperextension• Ankle plantarflexion/inversion

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• “My patients don’t look good at high intensity”

• Greater difficulty –more mistakes/errors

• Generation of spastic motor responses

• Reticulospinal inputs augments involuntary/spastic behaviors (Kline et al 2007)


• Primary tenant of traditional theories of rehabilitation is to:

• Normalize movement patterns

• Inhibit tone/spastic motor behaviors (reducing spasticity)


• Focus on research evidence

• Typically greater motor improvements than low intensity

• Improves gait patterns over long term (Kuys2010, Hornby et al 2008)

• Data to indicate spasticity reduces long-term with training or does not change (Wirzet al 2005; Moore et al 2010)

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Potential drawbacks of high intensity training• Neuromuscular concerns

• Overtraining (??) – Sullivan et al 2007• Increased spasticity (short-term; Kline et al 2007)

• Cardiovascular concerns• Monitor heart rate, blood pressure, autonomic

responses• Ratings of Perceived Exertion with Beta blockers (or

reduce max HR by 10-15 beats/min)


ACSM recommendations for cardiovascular disease (CVD)

• Adverse responses to discontinue exercise• DBP ≥ 110mm Hg

• SBP > 10mm Hg during exercise with workload

• Significant ventricular or atrial arrhythmias

• 2nd or 3rd degree heart block

• Signs/symptoms of exercise intolerance including angina, marked dyspnea, and ECG changes suggesting ischemia

ACSM contraindications to initiating training in CVD• Uncontrolled hypertension (SBP > 180 and/or DBP > 110)

• Unstable angina

• Orthostatic BP drop of >20 mm Hg with symptoms

• Significant aortic stenosis

• Uncontrolled atrial or ventricular arrhythmias

• Uncontrolled sinus tachycardia (>120 beats /min)

• Uncompensated heart failure

• Third‐degree atrioventricular (AV) block without pacemaker

• Active pericarditis or myocarditis

• Recent embolism

• Acute thrombophlebitis

• Acute systemic illness or fever

• Uncontrolled diabetes mellitus

• Severe orthopedic conditions that would prohibit exercise

• Other metabolic conditions, such as acute thyroiditis, hypokalemia,

• hyperkalemia, or hypovolemia (until adequately treated)

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Cited Recommendations in Training Intensity

• AHA Scientific Statement

• Recommendation of graded exercise test with ECG (typically treadmill protocols)

• 40‐70% HRR/ 50‐80% HR max

• 20‐60min sessions, 3‐7days/week

• RPE 11‐14

• Without exercise ECG “lighter intensity exercise should be prescribed”

• ACSM guidelines ‐ RPE 14‐16 (lower in early stages of cardiac rehab), 50‐60% HR max to 80%

• Macko 2005, Pang and Eng 2003

• Graded exercise training performed 60‐70% HRR

• Community setting: 70‐80% HRR

• Gradually work towards 3‐5, 40 minute sessions/week

Risk for cardiovascular event?

Pang et al 2013 – no increase in risk to patient post‐stroke following high intensity training as compared to low intensity control conditions (primarily in chronic stroke)

Hornby 2015 – no increase in risk in the inpatient subacute stroke population as compared to standard rehabilitation interventions

AHA Recommendations for ECG graded exercise stress testing prior to training

Cardiovascular concerns– Monitor heart rate, blood pressure, autonomic

responses• 200/110 mmHg to start, < 80/60 mmHg• 240/110mmHg during, drop of > 20/10 mmHg is technical

limit• HR within predicted maximum allowable (up to 85%)

– Watch for hypotension during rest breaks (esp SCI)• Lightheadedness, dizziness• Lethargic, decreased responsiveness• Get more supine/legs up

– Watch for hypertension throughout (CVA, extreme SCI)

• Pounding headache, restlessness, nausea/vomiting• Red face/skin blotching (autonomic dysreflexia)

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Potential drawbacks of high intensity training• Neuromuscular concerns

• Overtraining (??) – Sullivan et al 2007• Increased spasticity (short-term; Kline et al 2007)

• Cardiovascular concerns• Monitor heart rate, blood pressure, autonomic responses• Ratings of Perceived Exertion with Beta blockers (or

reduce max HR by 10-15 beats/min)


Orthopedic concerns• Knee hyperextension

• Use Swedish knee cage as possible• Very little (non-existent) data on knee ligamentous injury

with high intensity training• Encourage practice of slight knee flexion during stance

with intermittent lower speeds

• Ankle plantarflexion/inversion• Use AFO/PLS as necessary• Stability M/L often more necessary• Dorsiflexion last LE group to return

• Loading with osteoarthritis, back pain• Use BWS as needed for pain tolerance but . . . • Need to practice unsupported at some point

Application of these principles to ambulatory post‐stroke

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How can we apply what we know?

Priorities and sacrifices If realistic goal is to improve walking function . . . . . . need to focus on walking activities

• Subjects:

• Subacute (1‐6mo) and chronic stroke (>6mo)

• 18‐75yo

• MMSE score ≥23/30

• Moderate assistance or better to ambulate < 0.9 m/s self‐selected walking speed (SSV)

(Holleran, NNR 2014)

Feasibility and Efficacy of High Intensity Variable Stepping Training : Pilot Study

Pilot Study: Intervention Protocol

• Target 40 1hour sessions over 8‐10 weeks

• Week 1‐2: Forward treadmill training

• Weeks 3‐8: Variable, multi‐directional training• Half treadmill: 25% speed training, 25% dynamic balance

• Half overground: 25% speed/balance, 25% stairs

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Progressing Biomechanical Subcomponents of Walking

PropulsionLimb

Advancement

Stability & Balance

Stance Control

Training Paradigm

Unsuccessfulstepping

Successful stepping

Limb advancement

Manual or elastic assistance

Ankle weights, resisted tband, stepping over obstacles

WBing during stance

BWS Weighted vest, ↓UE support

Propulsion (gait speed)

Manual or elastic assistance at pelvis

↓UE support, ↑walking speeds, ↑incline, elastic resistance at pelvis

Sagittal/frontalplane stability

Stabilization at pelvisby manual or elastic assistance, use of handrails

↓UE support, progressing to backwards or sideways, steppingover/around obstacles, uneven/compliant surfaces, dual tasking

What about in IP rehab where individuals cannot walk?

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Knowledge Creation

Knowledge Creation

• Purpose: assess the feasibility and safety of HIT in inpatient rehab

• Methods:• 201 subacute CVA participants

• Admit function• FIM walk: 1 (1‐2)

• BBS: 5 (4‐22)

Knowledge Creation

• Results• No increase in incidence of adverse events

• Avg steps/day > previous report (1516 vs 249; Lang 2009)

• Target intensity achieved for 38% of session (5% duration; MacKay‐Lyons 2002)

• Steps/day best predictor of LoA at d/c

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Knowledge Creation

Straus, Tetroe, Graham; 2013

Knowledge to Action Framework

Rehabilitation Hospital of Indiana

• 64 beds

• 300+ stroke admits/year

• ~30% of total admits

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Identify Problem

• Desired practice• Prioritize activities to maximize

amount and aerobic intensity of stepping practice

• Target 75‐85% HRmax, RPE 15‐17

• Current practice• ??

Adapt Knowledge to Local Context

• Beta blockers RPEs

• Standardize OM assessments

• Educating physicians

• OT helping with transfer training

Assess Barriers / Facilitators to Knowledge Use

• Clinician barriers• Established practice patterns• Don’t my patients need to learn to stand first?• What about treating their impairments• Concerns about not teaching students other PT

interventions• Not teaching transfers• Administering OM takes time• OM not routinely assessed on low level patients• Knowledge and skills with target intervention• Documentation considerations• My patient doesn’t look normal / I’m increasing spasticity• But my patient just had a CVA/MI

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• Patient barriers• Some patients not motivated to work hard

• Patients see other patients doing non‐walking interventions

• Patient expectations for treatment

• Organizational barriers• Nursing having patients ready

• Hallways aren’t for walking (PT happens in the gym, leaving stuff everywhere)


• Clinician facilitators• Knew the expectations/vision

• Patient facilitators• Motivated to get better at walking

• Motivated to get out of hospital and go home

• Organizational facilitators• Leadership support (Admin, medical, therapy)

• Research staff available for support

Select, Tailor, Implement Interventions

Barrier Intervention

Knowledgeand skills

• Continuing education courses• Online learning modules• Co-tx with research staff• Regular meetings between staff and

researchers to discuss challenging patients

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Knowledgeand skills



Current practice and culture

• Reporting stepping and OM at team conference

• Specific day for all PTs to perform OM• Audit and feedback



Knowledgeand skills



Current practice and culture

• Reporting stepping and OM at team conference

• Specific day for all PTs to perform OM• Audit and feedback

Logistics • Research assistant manages StepWatches• Minimized therapist documentation burden:

developed data collection forms

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Monitor Knowledge Use

Evaluate Outcomes

Outcome Measures and Heart Rate Data to direct care

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StandardizationStandardization

Core Set of

Outcomes

Core Set of

Outcomes

Outcomes Team and Inservices

Outcomes Team and Inservices

Standard of Work

Standard of Work

10 meter walk test (10MWT)6 minute walk test (6MWT)Berg Balance Scale (BBS)

• 10MWT: standardized taped lines in the gym• 6MWT: “cover as much ground as you can”• BBS: Equipment and BBS forms easily

accessible in both therapy gyms

• Core set of outcomes assessed on eval, weekly, and discharge

• Stroke Unit: reassess outcomes on Wednesday

• TBI unit: reassess outcomes on Tuesday

• Document under neuro re-ed

Terminology to keep in mind

Minimal Detectable Change (MDC)

• minimal amount of change in a patient's score that ensures the change is not the result of measurement error

Minimally Clinically Important Difference

• minimal value of change in an outcome measure required for your patient to feel a difference

Walking speed

Walking speed

Body temperature

Body temperature Heart rateHeart rate

Respiratory rate

Respiratory rate

Blood pressure

Blood pressure

Oxygen saturationOxygen

saturation

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• Household Ambulator: <0.4m/s

• Limited Community Ambulator: 0.4‐0.8m/s

• Community Ambulator: >0.8m/s

10MWTMinimal Detectable Change (MDC)

Group Speed (m/s) Source

Stroke (subacute) - SSV 0.11 Perera, 2006

Minimal Clinically Important Difference (MCID)

Group Speed (m/s) Source

Stroke (subacute) -substantial change

0.10 Perera, 2006

○ “Self-selected walking velocity is the best predictor of functional amb status after stroke”(Perry)

6MWTMinimal Detectable Change (MDC)

Group Distance (ft) Source

Stroke (subacute) - FV 200 Perera, 2006

Minimal Clinically Important Difference (MCID)

Group Distance (ft) Source

Stroke (subacute) - small change - FV 66 Perera, 2006

Stroke (subacute) - substantial change - FV 164 Perera, 2006

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6MWT and Heart Rate Response

• Measure heart rate• can be an alternative outcome measure to indicate

aerobic capacity → results moderately correlated with

peak VO2 (Pang 2013)

Berg Balance Scale: Level of Evidence (I)

Level of Evidence Level 1 Strong Recommendation

Minimal Detectable Change 6.9 Entire group per Stevensen, 2001; during inpatient rehab

Cut-off Scores 45/56 Doggan et, al

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Take home from Hornby 2015 (implementation)

Admit Berg = 4-6 –unclear of improvements

2nd week Berg jumps (median 17)

Stepping practice

2nd week Berg does not jump (median 6)

I d

home

Increased probability of going

home

I d

SNF


SNF

Goal Writing

Utilizing MDCs and MCIDs for goal writing

Example: 1. Long term goal: In 4 weeks, pt will amb at > 1.0m/s to indicate community amb status and to safely cross street at crosswalk.

2. Long term: increase to >45/56 to indicate statistically significant improvement

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Indications for training

• Increase gait speed on treadmill and overground not only to increase intensity but to be training at speeds closer to “normal gait speed”

• “Lower admit balance (BBS≤20) and walking function (FIM-walk ≤2) indicates a high likelihood of only achieving household ambulation speeds” -bland et al• Useful for goal writing

Progress Updates

• Report score and indications• I.e: pt scores a 25/56, a statistically significant improvement since eval (17/56);

continues to indicate high fall risk

• Facilitates team collaboration

Case ExamplesWhat does this really look like in practice?

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Case 1

• R hemorrhagic subcortical/lacunar distribution following AVM rupture

Record admit outcome measures, even if it’s 0’s in order to best assess progress.

Initial POC: try HIT, see how it goes.

Admit Week 1 Discharge 6 month

Follow

Up

10MWT 0

6MWT 0

BBS 1

How does this reassessment of outcomes direct my POC...

Significant improvement in 10MWT and close to significant improvement in BBS (MCID for BBS is 7)...keep going with HIT


Follow

Up

10MWT 0 0.1-max A

6MWT 0 98-max A

BBS 1 7

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What did we do: (videos)

Challenged propulsion to improve gait speed: stairs

Challenged swing to improve gait speed: ankle weight

Challenged balance: no BWS, also challenge stance

We kept going and progressing HIT...met all LTGs and made significant improvements in all outcome measures


Follow

Up

10MWT 0 0.1-max A 0.48-min A

6MWT 0 98-max A 290’-min A

BBS 1 7 25/56

6‐month follow up


Follow

Up

10MWT 0 0.1-max A 0.48-min

A

1.18-

mod I

6MWT 0 98-max A 290’-min A 1720-

mod I

BBS 1 7 25/56 53/56

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In summary…

• Consistent primary therapist

• Consistent reassessment of outcomes

• Utilized outcomes to direct care

• Significant improvements in all

• Pt discharged home

Case 2

• Left hemorrhagic CVA with middle cerebral artery distribution

Record admit outcome measures, even if it’s 0’s in order to best assess progress.

Admit Week 2 Discharge

10MWT 0

6MWT 0

BBS 4

Initial POC: try HIT, see how it goes.

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What did we do (videos):

• Attempted HIT with various interventions including:

• Gait training with BWS (rifton and treadmill)

• Stairs

• Overground with LRAD

How does this reassessment of outcomes direct my POC...


10MWT 0 0

6MWT 0 14’-total

A

BBS 4 4

Consider anticipated discharge location

Take home from Hornby 2015 (implementation)

Admit Berg = 4-6 –unclear of improvements

2nd week Berg jumps (median 17)

Stepping practice

2nd week Berg does not jump (median 6)

I d

home


home

I d

SNF


SNF

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10MWT 0 0 NT

6MWT 0 14’-total

A

70’-max A

BBS 4 4 4

In summary…

• Difficulty getting pt in HR range and target RPE

• Kept attempting HIT despite no significant BBS changes by week 2

• WHY?

• Inconsistent outcome measure assessment = difficulty getting full picture of pt’s progress and continued deficits

• FIM changes:

Using HR data and RPE for feedback

Performance ≠ Learning

• Once performance of a given task has saturated or if HR is not in target range...make the task MORE CHALLENGING

Intensity

• Measured indirectly through metabolic and cardiorespiratory measures (VIEWS)

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Heart Rate

DocumentationEnsuring carryover of HIT and how to bill within insurance

guidelines

Standardization of Documentation

Carry over of

HIT

Carry over of

HIT

Standard of Work

Standard of Work

Therapeutic Activity

Therapeutic Activity

1.Binder Stickers

2.Treatment Summary Cards

3. Weekly HIT forms

1.Binder Stickers

2.Treatment Summary Cards

3. Weekly HIT forms

• Documenting blood pressure, peak HR, peak RPE, and whether or not reaching target HR zone

• Brief description of intervention

• Document HIT under therapeutic activity• “to improve gait, endurance,

dynamic balance, and overall functional mobility…”

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Carryover of HIT: binder stickers

Carryover of HIT: treatment forms (weekly)

Ascension St. Vincent Evansville

• 24 bed inpatient rehab facility

• CARF accredited – specialty areas of BI and CVA

• ~100 CVA admit/yr• Avg 7 days s/p CVA • Avg LOS 15 days • 74% d/c home

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Identify the problem

1. Consultation with a colleague

2. Observation at RIC

3. Attended “Walk the Walk”

I think we might be doing this all wrong.

Identify the problem

Current practice:• NDT/Neuro-IFRAH

trained clinicians• Facilitation of normal

posture and movements

• Focus on sensory feedback and handling

• Simpler tasks →complex tasks

• Generalized clinicians• Low intensity/amount

of impairment-based interventions

Desired practice:• Maximize stepping

practice

• Target high intensities

• Target biomechanical subcomponents

• Including both treadmill and overground

Clinician

Barriers: Lacking knowledge

and buy-in

Established practice patterns

Concerns for patient safety Cardiovascular Falls

Facilitators: Willingness to learn

Genuine desire to deliver the best care

Small team

2 NCS promoters that are “in the trenches”

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Clinician


Lacking knowledge/ established practice patterns

• Continuing education• Staff presentations • Mentoring and modeling • Development of Knowledge Tools

• RPE scale• HR charts• HIGT documentation forms & EMR

shortcuts • Establishment of a standardized OM assessment

Concern for patient safety

• Education on guidelines and HIT research• Purchased equipment for cardiovascular

monitoring• Added an overhead support system

Organizational Barriers:

Gym location (2nd floor)

Minimal equipment

Patients aren’t ready for therapy

Shorter LOS

More impaired patients

Facilitators:

Leadership support Developed a position

to translate evidence into practice

Encourage pursuit of knowledge

Additional staff; longer/additional sessions

Lobby for equipment

Access to leading clinicians and researchers

Teaching responsibilities

Organizational Barrier Intervention

Gym location on the 2nd

floor • More opportunity for OG training

Lack of equipment • Added an overhead harness system• Scheduling out the treadmill system • Purchased more HR monitors • Added a 2nd treadmill system

Patients aren’t ready • Coordinate sessions with nursing/OT • Task patients and family members to assist

with readiness• Techs to deliver to gym if up in the chair

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Patient

Barriers: Don’t know what exercise

feels like

Don’t like making mistakes

The harness hurts

Scared of having another stroke

Facilitators: Desire to recover the ability

to walk and get home ASAP

Patient

Barrier InterventionLack of knowledge • Setting the stage, selling the approach

• Physician education to reinforce with patients • Share results of outcome measures

Discomfort with harnessing

• Different harnessing (and more of them)• Cups, padding, arm support

Case study

• 59 yo female admitted with L weakness, facial droop and SBP >220

• PMH: morbid obesity, “occasional fluttering” in the chest, diastolic CHF, B LE edema

• PLOF: independent with self care and mobility, sedentary, married, works as a bank teller

• Transferred to IP rehab 7 days s/p CVA

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PT evaluation

LE StrengthP: 3 to 3+/5NP: WFL

Transfers modA

Ambulation 60’ modAx2

Stairs 5 steps, modAx2

10MWT0.17 m/s, modAx2

6MWT 60’, modAx2

Berg Balance Scale 6/56

Functional Gait Assessment 0/30

Exercise prescription

Frequency: BID (23 day LOS 41 total sessions)

Intensity: 75-85% of age-predicted HRmax (110-125)

Time: 90 min/day

Type: Variable walking practice (TM and OG)

Day 2 Session details:

BWS: 20% (60#)LE assist/resist: min/mod L LEBelt speed: 0.3-0.6 mphTotal TM time: 9 minBreaks: @ 4 minTotal distance: 478 feetMax HR: 104 (69%)Average HR: 92 (61%)Time spent in zone: 0 minutes

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Treadmill progression (17 sessions)

Propulsion

Lateral Stability

Stance Stability

Limb Advancement

30% BWSDay 2

< 10% BWSDay 10

0.4 mphDay 2

1.1 mphDay 8

2% gradeDay 9

1.5 mph, 2% grade

Day 18

Forward only, PUE secured

Day 2

Multi-directional

Day 18

modADay 2

2# weightDay 7

Forward only, PUE freeDay 11

Overground progression (23 sessions)

Propulsion

Lateral Stability

Stance Stability

Limb Advancement

modAx1-2Day 2

Hurrycane, SBADay 7

RampsDay 2

CurbsDay 8

StairsDay 9

Pulling sledDay 18

Forward only, level surfaces

Day 1

Unweighted PLE

Day 1

4# weightDay 8

Uneven surfaces, obstacles, multi-directional stepping

Day 7

Day 19

Session details:

BWS: none

LE assist/resist: 3# PLE

Belt speed: 1.2‐1.5 mph FWD; 0.2‐0.3 mph LAT

Total time: 11 min

Breaks: @ 5 and 9:30 min

Total distance: 885 feet

Max HR: 138 (91%)

Average HR: 116 (77%)

Time spent in zone: 13 min

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Outcomes Admission Discharge

Transfers modA SBA

Gait 60’ modAx2 >200’, SBA

Stairs 5 steps, modAx2 15 steps, CGA/minA

10MWT (walking speed)

SSV: 0.16 m/s, modAx2SSV: 0.34 m/s SBAFV: 0.51 m/s SBA

6MWT (walking endurance)

60’ modAx2 299’ SBA

Berg Balance Scale 6/5641/56

Functional Gait Assessment

0/3010/30

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“i just want to implement something”– lived alone prior to stroke ... in variable contexts,...

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