Strength Training Effectiveness PostStroke STEPS

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Strength Training Effectiveness Post-Stroke
(STEPS)

• 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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Multi-site Multi-institution
Visit us at http//pt.usc.edu/clinresnet
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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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Specific Aims - General

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

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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)
• Goal-directed, therapist supervised, aerobic
  activity

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Intervention Pairs

• BWSTT/SHAM (N 20)
• Effect of BWSTT alone (task-specific strength
  training)
• LBST/SHAM (N 20)
• Effect of LBST alone (locomotor-based strength
  training)
• LBST/BWSTT (N 20)
• Function based strength training (combined
  effects of task-specific and locomotor-based
  strength training)
• MSST/BWSTT (N 20)
• Muscle specific strength training (combined
  effects of task-specific and traditional PRE
  program)

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Progress to date

• Final recruitment and intervention sessions
• Data management
• Data analysis
• Dissemination and publication
• Special projects
• Follow up projects

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Recruitment
Total Subject Enrollment by Month of Study
Recruitment schedule revised January 2004.
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Subject Demographics
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Data management

• Data entry
• Data checking

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Data analysis

• Data survey
• Data comparisons
• Formal analyses

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STEPS Outline
In Person Screening Evaluation
Phone Screen
Baseline Evaluation (Within 1 week pre
intervention)
Stratified by severity gt0.5 m/s or lt 0.5 m/s
Group Assignment Group A BWS treadmill and U/E
cycling Group B L/E loaded cycling and U/E
cycling Group C BWS treadmill and L/E loaded
cycling Group D BWS treadmill and L/E
weights Training 1 hour/day x 4 days/week x 6
weeks (BWS body weight support)
Randomization
Selected Specialized Testing (20 Subjects at
USC/Rancho and 20 Subjects at NWU)
BWSTT Progression Data 31 subjects
Mid term evaluation Post 12 treatments (3rd
week)
Post evaluation (Within 1 week post 24th
treatment)
Selected Specialized Testing (20 Subjects at
USC/Rancho and 20 Subjects at NWU)
Follow up evaluation 6 month
Study Completed
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BWSTT Progression Data

• N 31 subjects

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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 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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Rancho Los Amigos National Rehabilitation Center

• Gait Analysis Data
• N20

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Results Subject Characteristics
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Results Subjects
Not Improved
Improved
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Results Ankle Motion Change

p0.04
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Results Hip Motion Change


p0.05
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Results Ankle Power Change

p0.05
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Puller Experiments (Mark Rogers PI)
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Dissemination Future Publications
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Dissemination Other

• CSM 2004, CPTA 2004, CSM 2005
• Clinical department inservices
• Academic inservices
• Spinoffs of Project
• NIDDR Field-Initiated Grant Proposal (Brown)
  pending decision
• SBIR with Afferent Corp. (Brown)

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LEAPS Project (RCT)

• Locomotor Experience Applied Post-Stroke
• Multi-Center NCT
• National Institutes of Health
• NINDS

Pamela Duncan, Ph.D., P.T., FAPTA (PI) Andrea
Behrman, Ph.D., P.T. (Co-PI) University of
Florida Katherine Sullivan, Ph.D., P.T.
(Co-PI) Stanley Azen, Ph.D. Director DMC of
PTClinResNet University of Southern California