Lessons Learned: The Difficulties of Incorporating Intensity Principles Into Inpatient Stroke Rehabilitation

Abstract

Objective: The objective of this study was to determine the feasibility of a rehabilitation approach focusing on cardiovascular, strength, and gait training intensity in the inpatient rehabilitation setting after a new onset of stroke. We additionally aimed to determine the efficacy of this intensity-based program on rehabilitation outcomes compared with usual care.

Design: Participants were pseudo-randomized to an intensity-based program focusing on gait, cardiovascular, and strength training or to usual care. Outcomes included FIM, 10-meter walk, 2-minute walk, timed Up and Go test, 5-time sit-to-stand test, and Tinetti balance assessment.

Intervention: The intervention consisted of 6 20-minute sessions per week dedicated to intensity of activity: 2 each for walking, cardiovascular training, and strength training.

Participants: Patients (N=49) with new onset stroke admitted to inpatient rehabilitation over the course of 1 year.

Setting: Four inpatient rehabilitation facilities with comprehensive neurologic rehabilitation teams.

Results: Thirty-five individuals (16 intervention, 19 controls) completed all testing. Subject compliance to the intensity intervention demonstrated completion of approximately half the prescribed sessions. All outcomes improved significantly from admission to discharge, and a significant interaction between treatment group and time was observed for the 2-minute walk and the Tinetti balance assessment. The 2-minute walk, Tinetti balance assessment, 10-meter walk, and FIM demonstrated between-group effect sizes greater than 0.60 in favor of the intervention group.

Conclusions: The intensity-based protocol was safe, and several measures demonstrated efficacy when compared with usual care. Results may have been limited by poor program compliance, showing a need to identify and ameliorate obstacles to integration of comprehensive intensity-based programs addressing endurance, strength, and gait training. Applying physiological principles of exercise to acute stroke rehabilitation demonstrates great promise for improving independent physical function.

Keywords: 10-mw, 10-meter walk test; 2MWT, 2-minute walk test; 5xSTS, 5 times sit to stand; CFIR, Consolidated Framework for Implementation Research; Exercise; Rehabilitation; SSWS, self-selected walking speed; Stroke; Walking.

Fig 1

Interactions for 2-minute walk distance (left) and the Tinetti balance assessment tool (right). No significant differences were present at baseline, but a significant interaction (P<.05) is present for both variables.