Lead Investigators:

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STANDARDIZED EXERCISE REGIMENS FOR THE STEPS
PROJECT FINDING THE STARTING POINT
PROGRESSING FORWARD
COMBINED SECTIONS MEETING 2005 New Orleans,
LA February 23-27, 2005

• Lead Investigators
• David A. Brown, PT, PhD
• Northwestern University, Chicago, IL
• Sara Mulroy, PT, PhD
• Rancho Los Amigos National Rehabilitation Center,
  Downey, CA
• Katherine J. Sullivan, PT, PhD
• University of Southern California, Los Angeles,
  CA

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Dr. David Brown, PhD, PT Northwestern University
Dr. Sara Mulroy, PhD, PT Rancho Los Amigos
National Rehabilitation Center
Dr. Katherine Sullivan, PhD, PT University of
Southern California
Lead Investigators
Project Coordinator Tara Klassen, PT, NCS
Intervention Therapists
Evaluation Therapists
Tara Klassen, PT, NCS Robbin Howard, DPT Didi
Matthews, DPT Bernadette Currier, PT Nicole
Furno, PTA Nicole Korda, PT Carolina Carmona, PT
Arlene Yang, MPT, NCS Betsy King, MPT Craig
Newsam, DPT Barbara Lopetinsky, PT Allie
Hyngstom, PT Sheila Schindler-Ivens, PhD, PT Lynn
Rogers, PT
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Background and significance

• Post-stroke, muscular weakness contributes to
  decreased walking velocity and endurance, and
  increased disability.
• Perry et al., 1995 Richards Olney, 1996
  Mulroy et al., 2003
• Lower extremity strengthening exercises and
  task-specific training result in improved walking
  ability in individuals post-stroke.
• Teixeira-Salmela et al., 1999 Sullivan et al.,
  2002 Patton et al, 2004
• No studies have examined the combined effect of
  task-specific training with strength training, or
  the effect of different strengthening protocols
  on gait outcomes.

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Specific Aims - General

• To determine the effectiveness of specific
  strength training programs to promote locomotor
  recovery after stroke.

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STEPS Interventions

• Standardized
• Structured intervention based on principles of
  exercise (i.e.,specificity, intensity,
  progression)
• Controlled frequency (4x/wk) and duration (6 wks)
• Combined task-specific training with strength
  programs that can be used by physical therapist
  in the clinic.

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STEPS Research Design

• Inclusion criteria
• Unilateral stroke, onset 4 mos 5yrs, able to
  ambulate 10 m with/without assistive device with
  no more than standby assist, slower than before
  stroke
• Recruitment goal
• 80 individuals across 3 clinical sites
• Intervention parameters
• 24 sessions, 4 days/wk, 6 wks
• Measurements
• Baseline, after 12- and 24-sessions, 6 mos
  follow-up
• Primary outcome gait velocity and endurance (10m
  and 6-min walk)
• Secondary outcomes LE strength, balance, QOL

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Interventions

• Exercise Conditions
• Body-weight supported treadmill training (BWSTT)
• Task-specific, repetitive practice of walking

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Interventions

• Exercise Conditions
• Locomotor-based strength training (LBST)
• Limb-loaded, pedaling exercise

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Interventions

• Exercise Conditions
• Muscle-specific strength training (MSST)
• Progressive resistive exercise for hip, knee, and
  ankle

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Interventions

• Exercise Conditions
• Low intensity upper limb ergometry (SHAM)

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Intervention Pairs

• BWSTT/SHAM
• Effect of BWSTT alone (task-specific strength
  training)
• LBST/SHAM
• Effect of LBST alone (locomotor-based strength
  training)
• LBST/BWSTT
• Function based strength training (combined
  effects of task-specific and locomotor-based
  strength training)
• MSST/BWSTT
• Muscle specific strength training (combined
  effects of task-specific and traditional PRE
  program)

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What are the exercise parameters that ensure a
training effect?

• Dose-response
• Frequency number of training sessions in a week
• Intensity within session attributes (i.e., time
  in activity, level of activity) important to
  training specificity (i.e., strengthening, power,
  energy expenditure) and progression
• Duration of training total number of training
  sessions

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BWSTT Evidence from the literature

• 40 BWS decreased over training more effective.
• Visintin et al., 1998
• Faster speeds (2.0 mph) more effective.
• Sullivan et al, 2002 Pohl et al., 2002
• 4-5 min bouts (20 total min) at faster speeds
  can be tolerated by patients with chronic stroke.
• Sullivan et al, 2002 Pohl et al., 2002
• Minimum of 12 sessions to get training effect.
• Sullivan et al, 2002

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BWSTT Progression

• BWSTT INTERVENTION SESSION 1
• Optimal goal
• step at a treadmill speed of 2.0 mph,
• up to maximum trainer assistance to enable proper
  gait kinematics,
• body weight support between 30-40 of the
  subjects weight,
• four, 5 minute walking periods.
• INITIAL BWSTT TRAINING PARAMETERS
• Body weight support 30
• Treadmill speed 2.0 mph
• Trainer assistance no assistance to maximum
  assistance
• Proper gait kinematics upright posture, normal
  values of extension/flexion of hip/knee/ankle,
  and coordinating limb movement to achieve
  symmetrical limb cadence and equal step length.

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BWSTT Progression

• BWSTT INTERVENTION SESSIONS 2 12
• Goal for training sessions 2-12 is to
• Re-train the subjects gait at a minimum
  treadmill speed of 2.0 mph
• With the minimum amount of body weight support
• Minimum amount of trainer assistance to enable
  proper gait kinematics
• Total of 20 minutes
• Each session is started at the maximum treadmill
  speed, minimum body weight support and minimum
  amount of trainer assistance that was achieved in
  the previous session.
• Evidence of progression in at least one of the
  training parameters (treadmill speed, body weight
  support, or trainer assistance) should be
  attempted in every training session.

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Evidence for tolerance progression
 

• Results from
• 31 individuals with stroke
• Assigned to 1 of 3 BWSTT programs for 12 sessions

 
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Evidence for tolerance progression

• Tolerance (cardiovascular guidelines)
• Resting
• SBPlt180 and DBPlt110
• HR lt100
• SBP does not gt 20 with standing
• Exercise
• SBP rises to gt200 mm Hg
• DBP rises to gt110 mm Hg
• SBP drops gt20 mm Hg from resting, sitting BP
• HR does not exceed 80 of age predicted maximum
  (80 of 220-age)
• Results
• One participant withdrawn abnormal BP response
  to exercise.
• One participant session stopped exceeded MD
  recommended guideline, meds adjusted.
• Several patients within guidelines but sought MD
  consult for hypertension management.
• Progression (BWS, speed, walking time)
• Significant decrease (plt.001) for all training
  parameters

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MSST Evidence from the literature

• Increase in lower extremity muscle strength
  without adverse increase in spasticity.
• Brown Kautz, 1998 Teixeira-Salmela et al.,
  1999 Sharp Brouwer, 1997
• Increase in lower extremity strength and
  functional ability.
• Weiss et al., 2000 Teixeira-Salmela et al.,
  1999, 2001
• Wide variability in type of exercises, frequency,
  duration, and intensity of programs.
• No post-stroke studies have accounted for the
  effects of synergistic movement when designing a
  strength program further research required to
  determine most suitable strength training
  protocol for individuals post-stroke.

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MSST Progression

• Each exercise for the muscle group begins with
  specifically targeting the isolated muscle(s).
  Therefore, the baseline exercise position
  requires the patient to move in an antigravity
  range, deviating from synergy.
• If the patient cannot perform the movement
  deviating from synergy, a decrease in progression
  will be recommended that incorporates movement
  patterns within synergy.
• If the patient can complete the antigravity
  movement that deviates from synergy, then
  progressive resistive loading will begin from
  this position.

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Example of Hip Extensor exercise progression

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Exercise 1E Active Assisted Bilateral
Bridge Is the patient able to perform 10
repetitions?
Exercise 1E Progression Is the patient able to
perform 10 repetitions?
YES
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Evidence for MSST progression

• Results from
• 10 participants

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STEPS exercise protocols

• Developed with best available evidence.
• BWST and MSST tolerated by individuals with
  chronic stroke with evidence of exercise
  progression.
• Available at

http//pt.usc.edu/clinresnet/
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References Kautz SA, Brown DA. Relationships
between timing of muscle excitation and impaired
motor performance during cyclical lower extremity
movement in post-stroke hemiplegia. Brain 121 (
Pt 3)515-26, 1998. Mulroy S, Gronley J, Weiss W,
Newsam C, Perry J. Use of cluster analysis for
gait pattern classification of patients in the
early and late recovery phases following stroke.
Gait Posture 18(1)114-25, 2003. Patten C,
Lexall J, Brown H. Weakness and strength training
in persons with poststroke hemiplegia Rationale,
method, and efficacy. Journal of Rehabilitation
Research Development 2004 41(3A)293-312. Perry
J, Garrett M, Gronley JK, Mulroy SJ.
Classification of walking handicap in the stroke
population. Stroke 1995 26(6)982-989. Pohl MM.
Speed-dependent treadmill training in ambulatory
hemiparetic stroke patients a randomized
controlled trial. Stroke 33(2)553-8, 2002.
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Richards CL, Olney S. Hemiparetic gait following
stroke Part II Recovery and physical therapy.
Gait and Posture 1996 4149-162. Sharp SA,
Brouwer BJ. Isokinetic strength training of the
hemiparetic knee effects on function and
spasticity. Arch Phys Med Rehabil 1997
78(11)1231-6. Sullivan K, Knowlton B, Dobkin B.
Step training with body weight support Effect of
treadmill speed and practice paradigms on
poststroke locomotor recovery. Archives of
Physical Medicine and Rehabilitation 2002
83(5)683-691. Teixeira-Salmela LF, Olney SJ,
Nadeau S, Brouwer B. Muscle strengthening and
physical conditioning to reduce impairment and
disability in chronic stroke survivors. Arch Phys
Med Rehabil 1999 80(10)1211-1218. Visintin M,
Barbeau H, Korner-Bitensky N, Mayo NE. A new
approach to retrain gait in stroke patients
through body weight support and treadmill
stimulation. Stroke 1998 29(6)1122-8. Weiss A,
Suzuki T, Bean J, Fielding RA. High intensity
strength training improves strength and
functional performance after stroke. American
Journal of Physical Medicine Rehabilitation
79(4)369-76 quiz 391-4, 2000-Aug.