Inpatient Rehabilitation and Post-Discharge Outcomes With High Intensity Gait Training (HIGT) of Patients With Stroke (HIGT)

Inpatient Rehabilitation and Post-Discharge Outcomes With High Intensity Gait Training (HIGT) of Patients With Stroke

Inpatient Rehabilitation and Post-Discharge Outcomes of Patients With Stroke Participating in High Intensity Gait Training

Stroke is a major cause of disability, with 2-3% of Americans reporting stroke related impairments (Tsao 2022). Following stroke, over half of Medicare patients are discharged to post-acute care facilities or receive home-based health care (Tsao 2022). Inpatient rehabilitation guidelines are lacking, with many interventions based on research of patients with chronic stroke. There is great need for randomized clinical trials during the early subacute period (Bernhardt 2017, Jordan 2021). Clinical practice guidelines recommend high intensity gait training (HIGT) for ambulatory patients with chronic stroke (Hornby 2020). Outpatient HIGT protocols incorporating variable stepping demonstrate equivalent effectiveness to forward stepping protocols (Hornby 2019) and have yielded superior results to lower intensity therapies (Hornby 2019, Hornby 2016). Research suggests that HIGT with variable stepping is feasible during inpatient rehabilitation (Hornby 2015, Moore 2020). Pre-post studies suggest that participation in HIGT during inpatient rehabilitation yields greater improvements in walking without an increase in adverse events. (Moore 2020). Despite this, there are no randomized controlled trials evaluating HIGT in the inpatient setting. The subacute phase of stroke recovery may be a critical time for neuroplasticity (Dromerick 2021). Not only might rehabilitation interventions be more effective when initiated earlier (Biernaskie 2004, Dromerick 2021) but because inpatient rehabilitation represents the transition from hospital to home, interventions during this timeframe have the potential to improve discharge disposition, enhance quality of life, and reduce utilization of post-discharge services. In this randomized controlled study, investigators will determine how participation in HIGT during inpatient rehabilitation affects balance, ambulation, and quality of life after 14 and/or 21 days of inpatient rehabilitation, and 8 weeks post-discharge. Investigators will also determine if HIGT reduces health care burden with a cost-effectiveness analysis.

HIGT will be performed 4-6 times per week in place of conventional physical therapy. The patient's heart rate(HR)and blood pressure(BP) will be measured throughout each session. If the HR or BP is out of the acceptable range, patients will undergo standard physical therapy for that session, and the medical team will be contacted. Target HR zones will be calculated with the Karvonen formula. The first session goal is to reach a target HR range that is 50-60% of heart rate reserve. The goal for subsequent sessions is to reach 70-80% of heart rate reserve. Rate of perceived exertion (RPE) will also be utilized. The primary therapist will design an individualized HIGT treatment program with a combination of speed dependent treadmill activities, activity-based treadmill activities, stair training, and over ground activities. The patient will be reminded during each session to ask for a rest as needed. Standing rests are preferred over sitting rests, but either may be utilized.

The conventional physical therapy sessions are what a patient would normally receive during their rehabilitation. Physical therapy sessions are usually 60-90 minutes per day for 5 days each week, and possibly one 30-minute session on a 6th day. Physical therapy sessions are focused on gait, balance, and strengthening activities to address goals related to functional mobility. Clinicians administering therapy to patients in this arm will not be given instructions on the types of therapies they administer; however, they will not be permitted to do HIGT with patients. Therapists will be permitted to use other devices such as Ekso exoskeleton, Lite Gait, Rifton Tram Body Weight Support Devices, and Electrical Stimulation devices including the XCITE and RT300.

Used to assess walking speed over a short distance at the patient's self determined speed that is as fast as they can safely walk..

Used to assess walking speed over a short distance at the patient's self determined speed that is as fast as they can safely walk..

Used to assess walking speed over a short distance at the patient's self determined speed that is as fast as they can safely walk..

Used to assess walking endurance and aerobic capacity. The total distance the patient walks over six minutes is recorded.

Used to assess walking endurance and aerobic capacity. The total distance the patient walks over six minutes is recorded.

Used to assess walking endurance and aerobic capacity. The total distance the patient walks over six minutes is recorded.

The Stroke Impact Scale (SIS) is a self report questionnaire that uses 9 categories to assess disability and quality of life after having had a stroke.

This will include the cost of home health care, outpatient therapies, subacute nursing facility and hospital readmissions

Measures functional lower extremity strength and movement patterns used to complete functional movements

Measures functional lower extremity strength and movement patterns used to complete functional movements

Measures functional lower extremity strength and movement patterns used to complete functional movements

A five point scale used to categorize a patient's ambulation status, ranging from independent walking outside to non-functional walking.

A five point scale used to categorize a patient's ambulation status, ranging from independent walking outside to non-functional walking.

A five point scale used to categorize a patient's ambulation status, ranging from independent walking outside to non-functional walking.

Inclusion Criteria: adults (≥18 years) recovering from a unilateral cerebral infarct with resultant hemiparesis occurring less than three months prior. Patients must have an expected length of stay of at least 14 days. Exclusion Criteria: are older than 85 years of age have evidence of intracranial hemorrhage on head imaging have had a brainstem, cerebellar or bilateral hemisphere stroke are medically unstable are pregnant have chronic cardiorespiratory disease on oxygen angina unstable arrhythmias ischemic cardiomyopathy (Ejection Fraction <50%) unable to follow 2 steps commands accurately neurological comorbidities that affect gait Parkinson's severe polyneuropathy unable to walk at least 150 feet premorbid dependent assistance level for transfer from a chair to a bed as assessed by physical therapy.

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