Stroke Patients May Regain Function Just as Easily at Home
WEDNESDAY, May 25 -- Home-based exercise managed by a physical therapist is just as effective at restoring stroke patients' walking ability as a formal rehabilitation program using a specialized treadmill, a new study indicates.
The results also defy conventional wisdom that stroke recovery peaks at six months, demonstrating that patients who began rehabilitation even six months after their stroke continued to improve their walking for up to a year.
"It's a fantastic study, rigorously done," said Dr. Richard B. Libman, chief of vascular neurology at Long Island Jewish Medical Center in New Hyde Park, N.Y. "It's incredibly important . . . not to write patients off after a certain period of time has elapsed. Patients have the potential to improve way after the point where we thought they couldn't."
Researchers, calling it the largest stroke rehabilitation study ever done in the United States, randomly assigned more than 400 stroke patients with moderate or severe walking impairments to one of three study groups, two involving "locomotor" training and one involving home exercise. The patients were recruited from inpatient rehab facilities in California and Florida and had an average age of 62. Slightly more than half were men.
All received 36 supervised, 90-minute sessions over a period of 12 to 16 weeks, in addition to usual care.
Those in "locomotor" training attended a formal rehabilitation program where they used a treadmill while wearing a harness that offered partial body-weight support. Following treadmill training, they practiced walking. The early locomotor group started training two months post-stroke; the other locomotor participants began six months after their stroke. For the home-exercise group, a physical therapist focused on enhancing patients' flexibility, range of motion, strength and balance to improve walking ability, starting two months post-stroke.
Study author Pamela Woods Duncan, a professor of community and family medicine at Duke University School of Medicine, said she and her team were surprised to find that patients in the home exercise group did as well as those in locomotor training, which they thought would produce superior results.
Indeed, at the end of one year, more than half (52 percent) of all study participants had improved their walking ability, with similar gains among all three groups. No differences were found among those who had started treadmill training two months or six months after their stroke.
"I think it's an extremely important study," Duncan said. "Those at home had equal outcomes . . . and fewer minor adverse events," such as dizziness and falls.
She and the other researchers also noted that the progressive home exercise program involved less expensive equipment, less training for physical therapists, fewer clinical staff members and better patient compliance.
"Collectively, our results suggest that home exercise is a more pragmatic form of therapy with fewer risks," they wrote.
Libman called the study, published May 26 in the New England Journal of Medicine, "practically revolutionary" for its potential to change standard stroke rehabilitation care.
"I think it's going to change the management of stroke, and third-party payers are going to be extremely interested in the results of the study," he said. "I think it will save a huge amount of money for the healthcare system and be psychologically and emotionally beneficial for patients."
Participants' improvement measurements were based on how well they could walk independently by the end of the study. Severely impaired patients were considered improved if they were able to walk around the inside of a house, while patients already mobile at home were considered improved if they progressed to walking independently in the community.
Not only did the physical therapy patients recover walking ability as well as the locomotor group, they were also less likely to drop out of treatment -- 3 percent vs. 13 percent of the locomotor group.
Minor adverse events, mostly falls, were reported by about 56 percent of participants, with no significant differences among groups. Patients who started locomotor therapy at two months and were severely impaired, however, were more likely to report multiple falls.
Dr. Walter Koroshetz, deputy director of the U.S. National Institute of Neurological Disorders and Stroke (NINDS), said few studies have compared stroke therapies and provided evidence "in such very rigorous fashion."
"So this is probably the tip of the iceberg," he said. "It's precedent-setting . . . with very practical results."
Funding for the study was provided by NINDS and the National Center for Medical Rehabilitation Research.
To learn more about strokes, visit the U.S. National Institute of Neurological Disorders and Stroke.
Posted: May 2011
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