Case studies – what do you see/what would you do? Strategy ...Locomotor control and recovery...
71
Locomotor control and recovery following neurological injury T. George Hornby, PT, PhD Associate Professor, Dept of Physical Therapy University of Illinois at Chicago Research Scientist Sensory Motor Performance Program Rehabilitation Institute of Chicago Outline • Case studies – what do you see/what would you do? • Normal and impaired gait in neurologic patients • Definitions and measures • Biomechanical principles • Kinematics and kinetics, muscular and metabolic requirements • Strategy for clinical interventions Case 1: History • 52 year old male; L ICH (subcortical, ICH) – hypertension, dysphagia, aphasia, acute kidney failure – medications:: simvastatin, nifedipine, dilatin, digoxin, phenobarbital, clozapine, metoprolol • Social hx: – Lived alone prior to stroke – Admitted to nursing home after medically stable post-stroke/minimal rehabilitation • Started intensive rehabilitation (study) 4 months post-stroke • Baseline assessments – FIM: Mod assist for all transfers and ambulation – 5 x sit to stand: unable – Berg Balance Scale Score: 5/56 – self-selected gait speed: 0 m/s (unable to ambulate) – 6 minute walk distance: 0 feet (unable to ambulate)
Transcript of Case studies – what do you see/what would you do? Strategy ...Locomotor control and recovery...
Loco
mot
or c
ontr
ol a
nd re
cove
ry
follo
win
g ne
urol
ogic
al in
jury
T.
Geo
rge
Hor
nby,
PT,
PhD
As
soci
ate
Prof
esso
r, De
pt o
f Phy
sical
The
rapy
U
nive
rsity
of I
llino
is at
Chi
cago
Re
sear
ch S
cien
tist
Sens
ory
Mot
or P
erfo
rman
ce P
rogr
am
Reha
bilit
atio
n In
stitu
te o
f Chi
cago
Out
line
•Ca
se st
udie
s –
wha
t do
you
see/
wha
t wou
ld y
ou d
o?
•
Nor
mal
and
impa
ired
gait
in n
euro
logi
c pa
tient
s •
Defin
ition
s and
mea
sure
s •
Biom
echa
nica
l prin
cipl
es
•Ki
nem
atic
s and
kin
etic
s, m
uscu
lar a
nd m
etab
olic
re
quire
men
ts
•
Stra
tegy
for c
linic
al in
terv
entio
ns
Case
1: H
istor
y
•52
yea
r old
mal
e; L
ICH
(sub
cort
ical
, ICH
) –
hype
rten
sion,
dys
phag
ia, a
phas
ia, a
cute
kid
ney
failu
re
–m
edic
atio
ns::
simva
stat
in, n
ifedi
pine
, dila
tin, d
igox
in, p
heno
barb
ital,
cloz
apin
e, m
etop
rolo
l
•So
cial
hx:
–
Live
d al
one
prio
r to
stro
ke
–Ad
mitt
ed to
nur
sing
hom
e af
ter m
edic
ally
stab
le p
ost-
stro
ke/m
inim
al
reha
bilit
atio
n
•St
arte
d in
tens
ive
reha
bilit
atio
n (s
tudy
) 4 m
onth
s pos
t-st
roke
•Ba
selin
e as
sess
men
ts
–FI
M:
Mod
ass
ist fo
r all
tran
sfer
s and
am
bula
tion
–5
x sit
to st
and:
una
ble
–Be
rg B
alan
ce S
cale
Sco
re: 5
/56
–se
lf-se
lect
ed g
ait s
peed
: 0 m
/s (u
nabl
e to
am
bula
te)
–6
min
ute
wal
k di
stan
ce: 0
feet
(una
ble
to a
mbu
late
)
Case
2: H
istor
y
•59
yea
r old
mal
e (>
300
lbs)
; L th
alam
ic/B
G s
trok
e; m
ass e
ffect
/mid
line
shift
–
acut
e re
nal i
nsuf
ficie
ncy/
hydr
onep
hros
is, H
TN, C
HF,
a-fib
, ast
hma,
LE
veno
us s
tasis
ul
cers
–
Med
icat
ions
: Pr
oton
ix, T
obra
dex,
Nor
vasc
, Vas
otec
, Kep
pra,
Hyd
rala
zine
•
Soci
al h
x:
–Ad
mitt
ed to
nur
sing
hom
e af
ter m
edic
ally
stab
le p
ost-
stro
ke
–Fa
mily
una
ble
to a
ssist
pat
ient
; liv
ed w
ith w
ife p
rior
•
Asse
ssm
ents
–
FIM
: M
od a
ssist
for a
ll tr
ansf
ers a
nd m
obili
ty it
ems
–Se
lf –
sele
cted
gai
t spe
ed: 0
m/s
(una
ble
to a
mbu
late
) –
Berg
Bal
ance
Sca
le S
core
: 7/5
6 –
6 m
inut
e w
alk
dist
ance
: 0 fe
et (u
nabl
e to
am
bula
te)
–5
x sit
to st
and:
una
ble
Basic
def
initi
ons o
f wal
king
•
Mos
t nat
ural
mea
ns o
f mov
ing
from
one
loca
tion
to
anot
her o
ver a
shor
t dist
ance
•Rh
ythm
ic a
ltern
atin
g m
ovem
ents
of t
he tr
unk
& li
mbs
w
hich
resu
lt in
the
forw
ard
prog
ress
ion
of th
e ce
nter
of
grav
ity
•
“Con
trol
led
falli
ng”
•Fo
rwar
d pr
ogre
ssio
n/st
ance
stab
ility
requ
ires e
nerg
y fr
om
mus
cles
, tru
nk le
an to
giv
e pa
ssen
ger u
nit s
uffic
ient
mom
entu
m
•Co
nser
vatio
n of
ene
rgy
–
cycl
ic e
xcha
nge
betw
een
grav
itatio
nal a
nd k
inet
ic e
nerg
y –
effic
ient
redi
rect
ion
of “
falli
ng”
into
stea
dy st
ate
forw
ard
prog
ress
ion
Pass
enge
r vs L
ocom
otor
Uni
ts
-Pa
ssen
ger u
nit –
hea
d ,n
eck,
trun
k, a
rms,
pel
vis
-70
% B
W, r
espo
nsib
le fo
r it’s
ow
n po
stur
al in
tegr
ity
-Al
igne
d w
ith fo
rwar
d til
t/pr
ovid
es m
omen
tum
-Lo
com
otor
Uni
t – le
gs, p
elvi
s -
11
artic
ulat
ions
, 57
mus
cles
, bon
y “l
ever
s”
-Al
tern
atin
g lim
b fu
nctio
n:
-Su
ppor
t/pr
ogre
ss th
e pa
ssen
ger u
nit
-W
ith re
lief o
f BW
, sw
ings
to n
ew “
posit
ion”
-Bi
omec
hani
cal s
ubco
mpo
nent
s of
gai
t (Ku
o an
d D
onel
an 2
010
PTJ)
-
Forw
ard
Prog
ress
ion
-St
ance
Sta
bilit
y -
Ener
gy C
onse
rvat
ion
Loco
mot
or fu
nctio
n –
forw
ard
prog
ress
ion
•Pr
opul
sion
–
redi
rect
ing
COM
gr
avita
tiona
l ene
rgy
to
kine
tic e
nerg
y
–In
vert
ed p
endu
lar m
otio
n
–Sh
ock
abso
rptio
n re
dire
cted
to
pro
pulsi
on
Loco
mot
or fu
nctio
n –
forw
ard
prog
ress
ion
•Pr
opul
sion
–
redi
rect
ing
COM
gr
avita
tiona
l ene
rgy
to
kine
tic e
nerg
y
–In
vert
ed p
endu
lar m
otio
n
–Sh
ock
abso
rptio
n re
dire
cted
to
pro
pulsi
on
Loco
mot
or fu
nctio
n –
forw
ard
prog
ress
ion
•Pr
opul
sion
–
redi
rect
ing
COM
gr
avita
tiona
l ene
rgy
to
kine
tic e
nerg
y
–In
vert
ed p
endu
lar m
otio
n
–Sh
ock
abso
rptio
n re
dire
cted
to
pro
pulsi
on
•Li
mb
swin
g
•Pr
ogre
ssio
n of
non
-wt
bear
ing
limb
– pe
ndul
ar
mot
ion
•Pr
epar
atio
n to
acc
ept w
eigh
t
Loco
mot
or fu
nctio
n –
Stan
ce
Stab
ility
–
Stan
ce S
tabi
lity
•M
aint
ain
uprig
ht p
ostu
re
– re
lianc
e on
pas
sive
(ske
leta
l) vs
act
ive
(mus
cula
r) st
ruct
ures
to
supp
ort w
eigh
t
•Re
duce
cen
ter o
f mas
s m
ovem
ent o
utsid
e of
la
tera
l bas
e of
sup
port
Pass
ive
wal
king
dev
ices
•
http
://w
ww
.you
tube
.com
/wat
ch?v
=e2Q
2Lx8
O6C
g&fe
atur
e=re
late
d •
http
://w
ww
.you
tube
.com
/wat
ch?v
=_2p
AMe_
5VeY
&fe
atur
e=re
late
d
Loco
mot
or fu
nctio
n –
Ener
gy
Cons
erva
tion
–In
vert
ed p
endu
lum
of s
tanc
e,
pend
ulum
mot
ion
of sw
ing
–E.
g., s
tanc
e kn
ee k
inem
atic
s •
Low
cos
ts w
ith sl
ight
kne
e fle
xion
dur
ing
stan
ce
•Ex
cess
ive
knee
fle
xion
incr
ease
s
cost
–E.
g., s
win
g kn
ee k
inem
atic
s •
Knee
flex
ion
larg
ely
pass
ive
– in
tera
ctio
n to
rque
s •
Knee
ext
ensio
n –k
nee
flexo
rs
not e
xten
sors
to d
ecel
erat
e sh
ank
Ener
getic
s of L
ocom
otio
n
–Re
dire
ctin
g CO
M (s
tep-
to-s
tep
tran
sitio
ns)
•St
ance
: Ene
rgy
cost
s of b
raki
ng
-In
itial
con
tact
(ecc
entr
ic)
-Re
boun
d (s
light
retu
rn o
f kne
e ex
t)
•Pr
opul
sion
: -
Ener
gy c
ost o
f red
irect
ing
“up”
-
Push
-off
from
opp
osite
lim
b
–Sw
ing:
•
Incr
ease
spee
d by
incr
easin
g st
ep
freq
uenc
y •
Hig
h fr
eque
ncie
s al
so in
crea
se c
osts
Ener
getic
s of L
ocom
otio
n
–w
alki
ng sp
eeds
and
sp
atio
tem
pora
l pa
tter
ns a
t low
est
met
abol
ic c
osts
–In
crea
ses i
n bo
th st
ep
freq
uenc
y an
d st
ride
leng
th to
min
imize
co
sts
Ener
getic
s of L
ocom
otio
n
–St
abili
ty
•Re
lativ
ely
stab
le in
A-P
pla
ne :
smal
l per
turb
atio
ns a
ccou
nted
for b
y al
tere
d co
llisio
n an
d pr
opul
sive
forc
es
•Le
ss st
able
in fr
onta
l pla
ne –
smal
l per
turb
atio
ns =
larg
e di
stur
banc
es
–Ac
tive
stab
ility
con
trol
»
Posit
ion
of to
rso
– hi
p ac
tivity
»
Ankl
e in
vers
ion/
ever
sion
»La
tera
l foo
t pla
cem
ent (
min
imize
d by
stab
ilizi
ng p
elvi
s du
ring
gait)
–R.
Kra
m (U
Col
orad
o –
J G
otts
chal
l, A
Gra
bow
ski)
–Pr
ogre
ssio
n •
Prop
ulsi
on (4
2-48
%)
•Sw
ing
(10-
20%
)
–St
ance
Sta
bilit
y
•St
ance
/bod
y w
eigh
t sup
port
(25-
28%
) •
Late
ral S
tabi
lity
(6%
)
–
Resi
dual
– w
ork
of lu
ngs/
hear
t
Ener
getic
s of L
ocom
otio
n
Spat
iote
mpo
ral D
escr
iptio
ns
•Sp
atia
l: St
ride
vs st
ep le
ngth
; ste
p w
idth
•
Tem
pora
l: Ca
denc
e: st
eps/
min
(inv
erse
of s
tep
time)
•
Gai
t vel
ocity
•
Stan
dard
ized
mea
sure
s: 1
0 m
wal
k (s
peed
); 2-
12 m
in w
alk
(dist
ance
) •
Corr
elat
es w
ith fa
ll ris
k, fe
ar o
f fal
ls, q
ualit
y of
life
, str
engt
h, b
alan
ce,
part
icip
atio
n, c
omm
unity
am
bula
tion
•Pe
lvis
–Li
mite
d m
ovem
ent
•H
ip
–Ki
nem
atic
s •
Stan
ce
–Fl
exed
30°
at h
eel s
trik
e –
Body
mov
es o
ver f
ixed
foot
to
peak
ext
ensio
n (1
0 ° p
rior t
o to
e of
f)
•Sw
ing
–Fl
exio
n be
gins
dur
ing
pre-
swin
g –
Peak
flex
ion
durin
g sw
ing
–
Mus
cle
activ
ity/p
ower
•
Stan
ce/lo
adin
g (h
ip e
xt)
•Sw
ing
–In
itiat
ion
– hi
p fle
x –
Term
inat
ion
– hi
p ex
t
•Kn
ee
–Ki
nem
atic
s •
Stan
ce
–5°
flex
ion
at h
eel s
trik
e –
Flex
dur
ing
load
ing
resp
onse
–
Exte
nds d
urin
g m
idst
ance
•
Swin
g –
Flex
ion
begi
ns d
urin
g te
rmin
al
stan
ce
–Pe
ak fl
exio
n du
ring
swin
g (a
bout
60
°) “
shor
tens
” lim
b
–M
uscl
e ac
tivity
/pow
er
•St
ance
/load
ing
– kn
ee e
xt
•Sw
ing
–In
itiat
ion
– no
t muc
h (k
nee
flex
may
be)
–Te
rmin
atio
n –
knee
ext
and
flex
•An
kle
–
Kine
mat
ics
•St
ance
–
Dors
iflex
ion
durin
g lo
adin
g re
spon
se
–Pl
anta
rfle
x du
ring
mid
stan
ce to
to
e-of
f •
Swin
g –
DF to
neu
tral
pos
ition
–
Dors
iflex
es to
neu
tral
pos
ition
du
ring
swin
g
–M
uscl
e ac
tivity
/pow
er
•St
ance
/load
ing
– D
Fs in
itial
ly, P
F fo
r pus
hoff
•
Swin
g –
Initi
atio
n - D
Fs
–Te
rmin
atio
n - D
Fs
Gai
t Kin
etic
s
•M
easu
red
by fo
rce
plat
e (s
tanc
e)
•
Estim
ated
by
join
t ac
cele
ratio
ns
(sw
ing)
•Fo
rces
–
Vert
ical
–
Ante
rior/
post
erio
r –
Med
ial l
ater
al
Join
t an
gles
Join
t m
omen
ts
Join
t po
wer
s
Kine
mat
ics a
nd K
inet
ics
Ener
getic
s and
tota
l act
ivity
–
Mus
cula
r for
ces g
ener
ated
rapi
dly,
off
quic
kly
(min
imal
co-
activ
atio
n)
–Tr
ansm
issio
n fr
om p
oten
tial-k
inet
ic e
nerg
y (in
vert
ed p
endu
lum
)
–Re
lianc
e on
“in
tera
ctio
n”, n
on-m
uscu
lar t
orqu
es
•Kn
ee fl
exio
n ea
rly-s
win
g la
rgel
y pa
ssiv
e
•Kn
ee e
xten
sion
late
-sw
ing
also
pas
sive
(ham
strin
gs “
brak
es”)
•
Relia
nce
on p
assiv
e tis
sues
dur
ing
stan
ce
Wha
t hap
pens
follo
win
g ne
urol
ogic
al in
jury
?
•De
crea
sed
stab
ility
(sta
nce,
ant
erio
r-po
ster
ior o
r lat
eral
CO
M o
ver B
OS)
–
Decr
ease
d ga
it sp
eed/
dist
ance
an
d ba
lanc
e
–In
crea
sed
risk
for f
alls
–Re
lianc
e on
dev
ices
/bra
ces
•
Alte
red
gait
kine
mat
ics
–De
crea
sed
sagi
ttal
mot
ion
–In
crea
sed
fron
tal p
lane
m
ovem
ents
Wha
t hap
pens
follo
win
g ne
urol
ogic
al in
jury
?
–De
crea
sed
spee
d/ga
it ve
loci
ty
–De
crea
sed
pow
er g
ener
atio
n at
m
ore
impa
ired
mus
cles
(ank
le <
hi
p)
–Co
mpe
nsat
e w
ith le
ss im
paire
d jo
ints
Hip
pow
er
Ankl
e po
wer
Pa
retic
N
on-P
aret
ic
Wha
t hap
pens
follo
win
g ne
urol
ogic
al in
jury
? •
Dec
reas
ed e
ffici
ency
/end
uran
ce
–B
iom
echa
nica
l (in
effic
ient
pot
entia
l to
kine
tic e
nerg
y tra
nsfe
r or
extra
neou
s m
ovem
ents
) – s
tep-
leng
th a
sym
met
ry in
crea
sed
cost
? –
Mus
cula
r act
ivity
(co-
activ
atio
n, s
tiffe
ning
for p
ostu
re/s
tabi
lity)
? –
Mus
cle
met
abol
ic p
rope
rties
(dec
reas
ed o
xida
tive
capa
city
)
•P
ost-s
troke
•
< 0.
9 m
/s; ~
0.35
ml O
2/kg/
m; M
oore
et a
l 201
0 )
•S
troke
– 2
500-
4000
ste
ps/d
ay
•
Pos
t- in
com
plet
e S
CI (
Sar
af e
t al 2
010)
•
“com
mun
ity w
alke
rs”
- ~
0.37
ml O
2/kg/
m –
400
0 st
eps/
day
•no
n-co
mm
unity
wal
kers
– ~
1.0
ml O
2/kg/
m –
100
0 st
eps/
day
•In
tact
sub
ject
s –-
0.20
-0.2
5 m
l O2/k
g/m
; 600
0-80
00 s
teps
/day
Mul
roy
et a
l 201
0 –
STEP
S tr
ial
Chan
ges w
ith w
alki
ng tr
aini
ng
•Im
prov
ed g
ait e
ffici
ency
(Moo
re e
t al 2
010,
Aw
ad e
t al 2
015)
•Im
prov
ed d
aily
step
ping
(Moo
re e
t al 2
010)
Chan
ges i
n ki
nem
atic
s with
wal
king
tr
aini
ng
•Sa
gitt
al k
inem
atic
s sca
le w
ith sp
eed
•Im
prov
ed te
mpo
ral s
ymm
etry
, som
e sp
atia
l sym
met
ry
•an
kle
dors
iflex
ion/
plan
tarf
lexi
on R
OM
(in
high
er fu
nctio
ning
) •
hip
flexi
on/e
xt R
OM
– o
ften
com
pens
ator
y fo
r sm
alle
r ank
le c
hang
es
•In
crea
sed
knee
flex
ion/
ROM
– c
ombi
ned
inte
rven
tions
? –
SCI (
Fiel
d-Fo
te a
nd Te
pava
c 20
02 v
s Noo
ijen
et a
l 200
9)
–St
roke
(Dal
y et
al 2
004)
•Ci
rcum
duct
ion
diffi
cult
as w
ell (
Lew
ek e
t al 2
009)
Stra
tegi
es fo
r Int
erve
ntio
ns?
•Fo
cus o
n ga
it fu
nctio
n (s
peed
/dist
ance
)?
–Pr
imar
y bi
omec
hani
cal d
eter
min
ants
(sta
nce,
pro
pulsi
on, s
win
g, la
tera
l st
abili
ty)
–Sp
atio
tem
pora
l pat
tern
s, se
lect
ed h
ip/a
nkle
sagi
ttal
kin
emat
ics/
kine
tics
scal
e
•Fo
cus o
n ga
it ki
nem
atic
s?
–Kn
ee fl
exio
n, c
ircum
duct
ion,
ank
le d
orsif
lexi
on re
calc
itran
t –
Cont
ribut
ions
to g
ait f
unct
ion,
bio
mec
hani
cal s
ubco
mpo
nent
s?
–Ef
fect
iven
ess
of st
rate
gies
to n
orm
alize
kin
emat
ics?
•Pa
tient
’s go
als?
Out
line
•Ca
se st
udie
s –
wha
t do
you
see/
wha
t wou
ld y
ou d
o?
•
Nor
mal
and
impa
ired
gait
in n
euro
logi
c pa
tient
s •
Defin
ition
s and
mea
sure
s •
Biom
echa
nica
l prin
cipl
es
•Ki
nem
atic
s and
kin
etic
s, m
uscu
lar a
nd m
etab
olic
re
quire
men
ts
•
Stra
tegy
for c
linic
al in
terv
entio
ns
Evol
utio
n of
Reh
abili
tatio
n St
rate
gies
Car
ey L
. Hol
lera
n M
PT, D
HS,
NC
S C
linic
al P
ract
ice
Lead
er –
Neu
rolo
gic
Phys
ical
The
rapy
Se
nsor
y M
otor
Per
form
ance
R
ehab
ilita
tion
Inst
itute
of C
hica
go
Age
nda
• Ev
olut
ion
of re
habi
litat
ion
stra
tegi
es
• Ev
iden
ce b
ehin
d st
rate
gies
• W
alki
ng re
cove
ry li
tera
ture
EL
EV
T
OR
V
1990
s N
euro
plas
ticity
1900
s Sh
errin
gton
.
1980
-199
0s
Task
orie
nted
tra
inin
g
1940
-197
0s
Neu
rode
velo
pmen
tal
App
roac
hes 19
60-1
970s
PN
F
Evol
utio
n of
Reh
abili
tatio
n A
ppro
ache
s Ev
olut
ion
of R
ehab
ilita
tion
App
roac
hes
• Tr
aditi
onal
app
roac
h co
mm
onal
ities
– Ef
forts
dire
cted
tow
ards
m
inim
izin
g sp
astic
ity
– Av
oida
nce
of e
xerti
on to
pr
even
t aug
men
tatio
n of
sp
astic
ity
– A
bnor
mal
mov
emen
t mus
t be
min
imiz
ed in
ord
er to
retra
in
norm
al m
ovem
ent p
atte
rns
Evol
utio
n of
Reh
abili
tatio
n St
rate
gies
– Fu
nctio
nal t
asks
rela
ting
to m
obili
ty
• G
ait t
rain
ing
with
BW
S an
d TM
•
Prog
ress
ion
of fu
nctio
nal t
asks
•
Stre
ngth
, fle
xibi
lity,
bal
ance
, and
car
diov
ascu
lar
endu
ranc
e
• Ta
sk o
rient
ed o
r Mot
or re
lear
ning
(Sch
umw
ay-C
ook
&
Wol
laco
tt, 2
012
Evol
utio
n of
Reh
abili
tatio
n A
ppro
ache
s •
Neu
ropl
astic
ity (K
leim
& Jo
nes,
2008
) •
Bra
in e
ncod
es e
xper
ienc
e an
d le
arns
new
beh
avio
rs
• D
amag
ed b
rain
rele
arns
lost
beh
avio
r
• N
udo
et a
l, 19
96
• C
ortic
al st
imul
atio
n
pre
and
pos
t tra
inin
g
UE
task
Age
nda
• Ev
olut
ion
of re
habi
litat
ion
stra
tegi
es
• Ev
iden
ce b
ehin
d st
rate
gies
• W
alki
ng re
cove
ry li
tera
ture
Evid
ence
- EB
RSR
•
Lang
ham
mer
et a
l, 20
00
Con
clus
ion:
The
rest
orat
ive
(Bob
ath)
app
roac
h re
sults
in lo
nger
leng
ths
of st
ay a
nd o
ffers
no
adva
ntag
e ov
er o
ther
ther
apy
appr
oach
es.
Evid
ence
– sy
stem
atic
revi
ews
• Ve
rbee
k et
al 2
004
– “s
trong
evi
denc
e fa
vorin
g in
tens
ive
high
repe
titiv
e ta
sk-
orie
nted
and
task
-spe
cific
trai
ning
in a
ll ph
ases
pos
t-stro
ke”
– “s
trong
evi
denc
e fo
r unf
avor
able
effe
cts o
f ND
T on
mot
or
func
tion
(syn
ergy
), ga
it sp
eed,
spat
iote
mpo
ral g
ait p
atte
rn
func
tions
…”
Evid
ence
•
Focu
s on
prog
ress
ion
alon
g de
velo
pmen
t seq
uenc
e or
focu
s on
impa
irmen
ts
– M
ulitc
ente
r Po
st-s
trok
e R
ehab
ilita
tion
Out
com
es
Proj
ect (
PSR
OP)
(Hor
n 20
05)
• 17
7 pe
ople
in in
patie
nt re
hab
with
seve
re st
roke
and
ad
mis
sion
Loc
omot
ion/
wal
k le
vel 1
•
Gai
t tra
inin
g tim
e in
1st
blo
ck o
f the
rapy
pre
dict
ed
prog
ress
ion
to im
prov
emen
t to
Loco
mot
ion
FIM
≥4
Evid
ence
1. U
se it
or l
ose
it 2. U
se it
and
impr
ove
it 3. S
peci
ficity
mat
ters
4. R
epet
ition
mat
ters
5. I
nten
sity
mat
ters
6.
Tim
e m
atte
rs
7. S
alie
nce
mat
ters
8. A
ge m
atte
rs
9. T
rans
fere
nce
10
. Inte
rfer
ence
Prin
cipl
es o
f Neu
ropl
astic
ity (K
leim
& J
ones
, 200
8)
Evid
ence
Evid
ence
Ev
iden
ce –
Spe
cific
ity
• Sp
ecifi
city
– T
ype
of p
ract
ice
– St
eppi
ng p
ract
ice
impr
oves
step
ping
per
form
ance
(Hes
se e
t al
199
5, P
ohl e
t al 2
002,
Sul
livan
et a
l 200
2, M
oore
et a
l, 20
10)
– N
on-s
tepp
ing
prac
tice
• B
alan
ce tr
aini
ng im
prov
es b
alan
ce (A
u-Ye
ung,
Hui
-Cha
n et
al
2009
) •
Stre
ngth
trai
ning
impr
oves
stre
ngth
(Pat
ten
et a
l 200
4; Ja
yara
man
et
al 2
013;
Dam
iano
et a
l 199
8;20
10)
• Sm
alle
r effe
cts o
n w
alki
ng
• Pr
epar
ator
y ac
tiviti
es (p
re-g
ait)
(Wei
nste
in, 1
989)
•
Con
vent
iona
l the
rapi
es (M
oore
et a
l 201
0, H
ornb
y et
al,
2015
)
Evid
ence
– S
peci
ficity
and
am
ount
•
Lang
et a
l, 20
09
– IP
/OP
post
-stro
ke re
habi
litat
ion
– M
ultip
le a
ctiv
ities
aim
ed a
t bod
y/st
ruct
ures
and
act
ivity
le
vel
Cat
egor
y R
epet
ition
s (m
ean)
U
E Fu
nctio
nal
32
LE F
unct
iona
l 6
Step
s 35
7 St
airs
38
Tr
ansf
ers
11
Bal
ance
27
Evid
ence
•
Moo
re e
t al 2
010
– Tr
acke
d in
divi
dual
s in
PT
– Tr
aine
d in
divi
dual
s in
forw
ard
step
ping
on
tread
mill
up
to
85%
of m
ax H
R fo
r 4 w
eeks
Evid
ence
– S
peci
ficity
and
am
ount
Moo
re e
t al,
2010
Con
tribu
tions
of A
mou
nt o
f Pra
ctic
e
Con
tribu
tions
of A
mou
nt o
f Pra
ctic
e Ev
iden
ce –
Rep
etiti
on
• R
epet
ition
- A
mou
nt o
f ste
ppin
g pr
actic
e
– Tr
aditi
onal
trea
dmill
trai
ning
with
BW
S pr
ovid
es la
rge
amou
nts o
f ste
ppin
g (B
arbe
au e
t al,
2003
; Dea
n et
al 2
010,
A
da e
t al,
2010
)
– D
ose
appe
ars t
o be
rela
ted
to re
spon
ses (
Moo
re, 2
010;
H
olle
ran
et a
l, 20
14; H
ornb
y et
al,
2015
a; H
ornb
y et
al,
2015
b)
• D
ose
: ~ 4
000
step
s
– Fa
ster
is b
ette
r (Po
hl e
t al 2
002,
Sul
livan
et a
l, 20
02) 2)
Age
nda
• Ev
olut
ion
of re
habi
litat
ion
stra
tegi
es
• Ev
iden
ce b
ehin
d st
rate
gies
• W
alki
ng re
cove
ry li
tera
ture
Impr
ovin
g w
alki
ng a
fter i
njur
y •
Use
resi
dual
des
cend
ing,
spin
al a
nd a
ffere
nt c
ircui
ts to
fa
cilit
ate
rein
forc
emen
t of s
ynap
tic c
onne
ctiv
ity o
f loc
omot
or
circ
uits
–
Wal
king
trai
ning
(gai
t tra
inin
g, lo
com
otor
trai
ning
) has
be
en sh
own
to b
e su
perio
r to
“non
-wal
king
” in
terv
entio
ns
(i.e.
ND
T, P
NF
– H
esse
et a
l 199
5, W
erni
g et
al 1
995,
Poh
l et
al 2
002)
–
How
do
you
do th
is??
!?!?
!
Theo
ries o
f how
to p
rovi
de w
alki
ng tr
aini
ng
• G
uide
lines
for L
ocom
otor
Tra
inin
g
– D
eriv
ed a
nd tr
ansl
ated
from
find
ings
in b
asic
scie
nce
on
neur
obio
logi
cal c
ontro
l of w
alki
ng
– Se
nsor
y in
put a
ssoc
iate
d w
ith lo
com
otio
n pr
ovid
ed to
the
neur
al a
xis a
nd c
ircui
try g
ener
ates
step
ping
resp
onse
(B
ehrm
an a
nd H
arke
ma
2000
; Wer
nig
et a
l 199
5)
EMG
mim
icki
ng “
norm
al”
loco
mot
or a
ctiv
ity
Patie
nts c
an g
ener
ate
loco
mot
or p
atte
rn si
mila
r to
“nor
mal
”, b
ut m
ay n
ot a
lway
s rec
over
vol
ition
al st
eppi
ng
over
grou
nd a
nd/o
r don
’t w
alk
norm
ally
.
Theo
ry fo
r pro
vidi
ng w
alki
ng tr
aini
ng
Gui
delin
es fo
r Loc
omot
or
Trai
ning
(Beh
rman
/Har
kem
a):
1.
Max
imize
load
ing
on L
Es
2.Pr
ovid
e se
nsor
y in
put c
onsis
tent
wi
th w
alki
ng a
ctiv
ity
3.O
ptim
ize p
ostu
re a
nd k
inem
atic
s fo
r eac
h ta
sk.
4.M
axim
ize in
depe
nden
ce a
nd
reco
very
of m
ovem
ents/
m
inim
ize c
ompe
nsat
ion
Nor
mal
izin
g ki
nem
atic
s and
pro
gres
s to
adap
tabi
lity:
Hes
se e
t al,
1995
; Wer
nig
et
al 1
995;
Beh
rman
and
Har
kem
a, 2
000;
Vis
intin
et a
l, 19
98; S
ulliv
an e
t al,
2007
Theo
ry fo
r pro
vidi
ng w
alki
ng tr
aini
ng
1. M
axim
ize
load
ing
on L
E’s
a) D
ietz
et a
l, 19
95;
Har
kem
a et
al,
1997
2. P
rovi
de se
nsor
y in
put
cons
iste
nt w
ith w
alki
ng
activ
ity
a) D
eLeo
n 19
98, 1
999
b) H
ow p
reci
se d
oes t
he
sens
ory
inpu
t nee
d to
be?
3. O
ptim
ize
post
ure
and
kine
mat
ics f
or e
ach
task
. a) K
inem
atic
s and
pos
ture
re
late
d to
sens
ory,
guid
ing
them
redu
ces
inte
nsity
(Hor
nby
et a
l ,
2008
; Isr
ael e
t al,
2006
)
4. M
axim
ize
inde
pend
ence
an
d re
cove
ry o
f m
ovem
ents
/ min
imiz
e co
mpe
nsat
ion
Get
ting
in th
e ba
llpar
k: G
loba
s et a
l, 20
12; A
da e
t al,
2010
; Dea
n et
al,
2010
; Mac
ko e
t al,
2005
; Ada
et a
l, 20
03; H
ornb
y et
al,
2008
Evid
ence
- W
alki
ng
• N
o ex
plic
it fo
cus o
n ki
nem
atic
s –
Sign
ifica
nt
impr
ovem
ents
in
mea
sure
s inc
ludi
ng
• G
ait s
peed
•
Bal
ance
•
Tim
ed d
ista
nce
• Pe
ak tr
eadm
ill sp
eed
• Pe
ak m
etab
olic
ca
paci
ty
• Ex
plic
it fo
cus o
n ki
nem
atic
s and
pro
gres
s to
ada
ptab
ility
–
Sign
ifica
nt
impr
ovem
ents
in
mea
sure
s inc
ludi
ng
• G
ait s
peed
•
Bal
ance
•
Tim
ed d
ista
nce
• Pe
ak tr
eadm
ill sp
eed
• Pe
ak m
etab
olic
ca
paci
ty
Evid
ence
- W
alki
ng
• Ya
gura
et a
l, 20
06
– B
WS
vs B
WS
plus
faci
litat
ion
– Fa
cilit
atio
n di
d no
t add
sign
ifica
ntly
to lo
com
otor
ou
tcom
es
– R
equi
red
mor
e th
erap
ists
’ ass
ista
nce
Evid
ence
Sum
mar
y 1.
Mot
or le
arni
ng a
ppro
ach
supe
rior t
o tra
ditio
nal a
ppro
ache
s
2.
Dat
a in
dica
tes a
step
wis
e pr
ogre
ssio
n in
diff
icul
ty o
f tas
ks
may
not
be
supe
rior t
o pr
actic
ing
high
er o
rder
task
s
3.
Rep
etiti
on is
impo
rtant
, but
diff
icul
t to
acco
unt f
or
impo
rtanc
e of
inte
nsity
Spec
ifici
ty v
s am
ount
•
Ada
et a
l, 20
10
– Su
bacu
te st
roke
–
Ove
rgro
und
vs tr
eadm
ill
wal
king
–
Res
ults
: TM
wal
king
safe
, fe
asib
le, a
nd re
sulte
d in
mor
e pe
ople
wal
king
inde
pend
ently
an
d ea
rlier
• A
mou
nt m
ay b
e m
ore
impo
rtant
ea
rlier
Spec
ifici
ty v
s am
ount
•
Com
bs-M
iller
et a
l, 20
14
– O
verg
roun
d vs
BW
S tre
adm
ill
– C
hron
ic st
roke
(> 1
yea
r) w
ith th
e
abi
lity
to w
alk
– R
esul
ts: O
G si
gnifi
cant
ly g
reat
er
impr
ovem
ents
than
TM
in
com
forta
ble
wal
king
vel
ocity
pos
t-tra
inin
g an
d at
follo
w-u
p
•
Spec
ifici
ty m
ay b
e m
ore
impo
rtant
late
r
Wal
king
trai
ning
Inco
rpor
atin
g In
tens
ity in
to W
alki
ng
Inte
rven
tions
Patr
ick
Hen
ness
y, P
T, M
PT, N
CS
Adap
ted
from
orig
inal
lect
ure
by T
Geo
rge
Hor
nby,
PT,
Ph
D Sp
inal
Cor
d In
jury
Ser
vice
Lo
com
otor
Rec
over
y La
b, S
enso
ry M
otor
Per
form
ance
Pr
ogra
m
Reha
bilit
atio
n In
stitu
te o
f Chi
cago
Pres
enta
tion
obje
ctiv
es
•
Part
I:
–Pr
ovid
e fr
eque
ntly
use
d de
finiti
ons o
f int
ensit
y –
Disc
uss t
he p
hysio
logi
cal r
atio
nale
for h
igh
inte
nsity
pra
ctic
e
–Di
spla
y su
ppor
tive
data
and
trai
ning
par
amet
ers f
or h
igh-
inte
nsity
trai
ning
pos
t-st
roke
•Pa
rt II
: –
Conc
erns
rega
rdin
g hi
gh in
tens
ity p
ract
ice
post
-str
oke
–
Sum
mar
y an
d re
-em
phas
is on
ava
ilabl
e da
ta
Wha
t is
the
defin
ition
of i
nten
sity
?
•Am
ount
of t
ime
focu
sed
on e
ach
trai
ning
pro
cedu
re
(Win
stei
n et
al 2
003)
•
Num
ber o
f hou
rs o
f con
secu
tive
ther
apy
in a
day
(Pag
e, 2
003)
•
Num
ber o
f tra
inin
g se
ssio
ns p
er w
eek
(Hes
se, 2
011)
•Fr
eque
ncy
of re
petit
ions
of d
esire
d m
ovem
ent i
n a
sess
ion
(Tan
aka,
200
4)
“Bio
mec
hani
cal”
def
initi
on
•W
ebst
er’s:
Mag
nitu
de o
f a q
uant
ity (a
s for
ce o
r ene
rgy)
per
un
it of
are
a, c
harg
e, m
ass,
or t
ime
•Ex
erci
se p
resc
riptio
n -P
ower
requ
ired
to p
erfo
rm a
n ac
tivity
(w
orkl
oad)
–
wor
k pe
r uni
t tim
e –
forc
e x
velo
city
•Sp
eed
of a
ctio
n pe
rfor
med
(if m
ass i
s sam
e)
•In
crea
se fo
rce
(if sp
eed
is sa
me)
As D
efin
ed in
Exe
rcis
e Pr
escr
iptio
n
Chan
ging
mus
cula
r dem
ands
dur
ing
anae
robi
c or
aero
bic e
xerc
ise
Incr
easin
g lo
ad (w
eigh
t) o
r sam
e lo
ad m
oved
fast
er
Chan
ging
pow
er (s
peed
, inc
line,
resis
tanc
e –
bike
/UBE
)
Expe
cted
Phy
siol
ogic
Res
pons
e to
Incr
ease
d Ex
erci
se
Inte
nsity
Expe
cted
Phy
siol
ogic
Res
pons
e to
Incr
ease
d Ex
erci
se
Inte
nsity
•In
crea
ses i
n VO
2 driv
en b
y in
crea
ses
in c
ardi
ac o
utpu
t (CO
) and
O2
extr
actio
n fr
om b
lood
–
Incr
ease
CO
•
driv
en b
y H
R an
d S
trok
e Vo
lum
e
• sy
stol
ic B
P –
Incr
ease
O2 e
xtra
ctio
n •
driv
en b
y p
erfu
sion
(vas
odila
tion)
an
d m
uscl
e m
etab
olism
•
simila
r dia
stol
ic B
P
•
Incr
ease
ven
tilat
ion
•In
crea
se b
ody
heat
/sw
eat p
rodu
ctio
n
Hig
h In
tens
ity (a
erob
ic)
trai
ning
Card
iova
scul
ar e
ffect
s:
↑Car
diop
ulm
onar
y fx
n ↑M
etab
olic
cap
acity
&
effic
ienc
y
Mus
cula
r effe
cts:
↑F
orce
gen
erat
ion
↑Fat
igue
resis
tanc
e
↑L
ocom
otor
func
tion
CN
S ef
fect
s:
↑Neu
rotra
nsm
itter
rele
ase
↑Neu
rotro
phic
(gro
wth
) fac
tors
•Fr
eque
ncy
•
Inte
nsity
–
hear
t rat
e re
serv
e (H
RR)
–he
art r
ate
max
(HRm
ax)
–ra
te o
f per
ceiv
ed e
xert
ion
(RPE
) •
Tim
e
•
Type
(Spe
cific
ity)
Pr
inci
ples
of N
euro
plas
ticity
: (Kl
eim
& Jo
nes,
200
8)
FITT
Prin
cipl
e (A
yers
and
Sar
iscsa
ny, 2
011)
Mon
itorin
g In
tens
ity a
nd E
xerc
ise
Resp
onse
M
onito
ring
Inte
nsity
and
Exe
rcis
e Re
spon
se
–H
eart
Rat
e Re
serv
e –
Trai
ning
hea
rt ra
te =
[(H
Rmax
– H
Rres
t) *
%tr
aini
ng in
tens
ity] +
Hrr
est
•
HRm
ax –
sig
nific
ant i
nter
-indi
vidu
al v
aria
bilit
y –
220-
age
–20
8-(.7
xage
) (Ta
naka
et a
l 200
1)
–Al
l pre
dict
ion
equa
tions
oft
en re
veal
larg
e in
accu
raci
es in
som
e pa
tient
s (>
10
beat
s/m
in)
–%
HRm
ax d
oes n
ot c
onsi
der r
estin
g H
R
•Bo
rg R
PE -
ratin
gs o
f “ex
ertio
n” v
s “di
fficu
lty”
Hig
h in
tens
ity e
xerc
ise
prot
ocol
s fo
llow
ing
neur
olog
ical
inju
ry
•Ta
sk-s
peci
fic a
erob
ic tr
eadm
ill tr
aini
ng (
Mac
ko e
t al 2
005)
–
Expe
rimen
tal :
40m
inut
es o
n TM
(60-
70%
HRR
) –
Cont
rol :
35m
in st
retc
hing
, 5m
in b
outs
on
TM (3
0-40
% H
RR)
•Ta
sk-o
rient
ed tr
aini
ng v
s “th
erap
eutic
exe
rcise
” (O
uter
man
s et a
l 201
0)
–E:
Rep
eate
d w
alki
ng-r
elat
ed “
wor
k st
atio
ns”
(70-
80%
HR
rese
rve)
–
C: m
atch
ed th
erap
y tim
e, lo
wer
wor
kloa
d, le
ss re
petit
ions
•Fa
st v
s slo
w-w
alki
ng o
r vs e
quiv
alen
t dur
atio
n co
ntro
l –
Sulli
van
et a
l 200
2, P
ohl e
t al 2
002,
Moo
re e
t al 2
010
•
Sepa
ratin
g pr
actic
e/re
petit
ion
from
inte
nsity
–
Hol
lera
n et
al 2
015
- int
ensit
y m
anip
ulat
ed b
y ad
ding
resis
tanc
e du
ring
trea
dmill
wal
king
at m
atch
ed sp
eed
–Iv
ey e
t al 2
015
– lo
w in
tens
ity g
roup
trai
ned
long
er to
mat
ch w
ork
load
–
Hor
nby
et a
l 200
8 –
Robo
tic v
s the
rapi
st a
ssist
ed w
alki
ng
•Ro
botic
ass
isted
step
ping
vs t
hera
pist
ass
isted
in
terv
entio
ns (H
ornb
y et
al 2
008,
Hid
ler e
t al 2
009)
–G
reat
er im
prov
emen
ts in
ther
apist
-ass
isted
trai
ning
in g
ait
spee
d an
d w
alki
ng fu
nctio
n –
Mor
e or
equ
ival
ent s
tepp
ing
prac
tice
durin
g ro
botic
-ass
isted
tr
aini
ng
–W
hy?
Repe
titio
n vs
Inte
nsity
Met
abol
ic m
uscl
e ac
tivity
dur
ing
robo
tic v
s the
rapi
st-a
ssis
ted
wal
king
0481216
exer
cise
base
line
(sit
ting)
base
line
(sta
ndin
g)re
cove
ry(s
ittin
g)
02
40
24
68
02
40
**
*
base
line
ther
apis
t-ass
iste
dro
bot-a
ssist
ed
time
(min
)
Prot
ocol
I –
“jus
t wal
k”:
-Lar
ge d
iffer
ence
s in
met
abol
ic c
osts
of w
alki
ng
-Red
uced
hip
flex
or m
uscl
e ac
tivity
Prot
ocol
II: “
wal
k as
har
d as
you
can
” - E
quiv
alen
t met
abol
ic c
ost
early
, but
a q
uick
dro
p-of
f
(Isr
ael e
t al 2
006)
“P
rinci
ple
of L
azin
ess”
– A
D Ku
o
0481216
exer
cise
base
line
(sit
ting)
base
line
(sta
ndin
g)re
cove
ry(s
ittin
g)
02
40
24
68
02
40
**
*
*
base
line
ther
apis
t-ass
iste
dro
bot-a
ssis
ted
time
(min
)
LEAP
S TR
IAL
•
Early
and
Lat
e LT
vs H
ome-
base
d PT
pro
gram
s –
Sim
ilar f
requ
ency
and
dur
atio
n of
sess
ions
–
Expe
rimen
tal:
LT in
clud
ing
trea
dmill
step
ping
with
BW
S
•20
-30
min
utes
per
sess
ion
on tr
eadm
ill, u
p to
3.2
km
/hr
(2
mi/h
r)
•15
min
utes
ove
rgro
und
afte
r 4th
wee
k •
LT g
roup
s pro
gres
sed
in d
urat
ion,
BW
S, a
ssist
ance
•N
o di
ffere
nces
in o
utco
mes
mea
sure
s at
6 m
onth
s •
Ave
max
spee
d du
ring
LT =
3.2
km
ph; m
inim
um B
WS
was
11
%
•m
ean
mid
poin
t HR
of e
ach
sess
ion
–Lo
com
otor
trai
ning
(ear
ly) =
90
beat
s/m
in
–RP
E <
13, H
R <
110
beat
s/m
in (B
MC
Met
hods
pap
er,
LEAP
S CS
M p
rese
ntat
ion
2011
) (D
unca
n, 2
011)
HR
data
dur
ing
6 m
in w
alk
test
•17
subj
ects
with
suba
cute
or c
hron
ic st
roke
, < 0
.9 m
/s
over
grou
nd w
alki
ng sp
eed
•H
R co
llect
ed e
ach
min
ute
durin
g 6
min
wal
k at
sel
f-se
lect
ed
pace
HR
data
dur
ing
6 m
in w
alk
test
•17
subj
ects
with
suba
cute
or c
hron
ic st
roke
, < 0
.9 m
/s
over
grou
nd w
alki
ng sp
eed
•H
R co
llect
ed e
ach
min
ute
durin
g 6
min
wal
k at
sel
f-se
lect
ed
pace
HR
data
dur
ing
6 m
in w
alk
test
•17
subj
ects
with
suba
cute
or c
hron
ic st
roke
, < 0
.9 m
/s
over
grou
nd w
alki
ng sp
eed
•H
R co
llect
ed e
ach
min
ute
durin
g 6
min
wal
k at
self-
sele
cted
pa
ce
Com
paris
on o
f int
ensi
ty o
f oth
er st
udie
s to
LEA
PS
inte
rven
tions
•M
acko
et a
l 200
5, L
uft e
t al 2
008,
Glo
bas e
t al 2
012
–In
vest
igat
ion
of ta
sk-s
peci
fic a
erob
ic tr
eadm
ill tr
aini
ng
–Ae
robi
c w
alki
ng e
xerc
ise (6
0-70
% h
eart
rate
rese
rve)
•
Out
erm
ans e
t al 2
010
–In
vest
igat
ion
of ta
sk-o
rient
ed tr
aini
ng
–Re
peat
ed w
alki
ng-r
elat
ed w
ork
stat
ions
(70-
80%
HR
rese
rve)
•Pa
ng e
t al 2
005
–
Inve
stig
atio
n of
com
mun
ity b
ased
fitn
ess
prog
ram
–
Inst
ruct
ed to
stay
with
in H
R zo
ne (7
0-80
% H
R re
serv
e)
•
Fast
vs s
low
-wal
king
and
/or v
s con
trol
–
Prog
ress
ive
trai
ning
of s
peed
s ba
sed
on H
R –
Pohl
et a
l 200
2, M
oore
et a
l 201
0, H
ornb
y et
al 2
008
(up
to 8
5% H
Rmax
)
Aero
bic
Exer
cise
vs C
ontr
ol
•Pa
ng e
t al 2
013:
Met
a-an
alys
is of
RCT
s co
mpa
ring
aero
bic
trai
ning
to c
ontr
ol g
roup
•
Aero
bic
trai
ning
favo
red
for i
mpr
oved
–
VO2
peak
–
6MW
T –
gait
spee
d
Cas
e Vi
deo
•Re
ggie
vid
eo
•In
tens
ive
varia
ble
step
ping
pro
toco
l (H
olle
ran
et a
l 201
3)
•Ta
rget
trai
ning
zone
of 7
0-80
%H
RR o
r 15-
18 B
org
RPE
Pres
enta
tion
obje
ctiv
es
•
Part
I:
–Pr
ovid
e fr
eque
ntly
use
d de
finiti
ons o
f int
ensit
y –
Disc
uss t
he p
hysio
logi
cal r
atio
nale
for h
igh
inte
nsity
pra
ctic
e
–Di
spla
y su
ppor
tive
data
and
trai
ning
par
amet
ers f
or h
igh-
inte
nsity
trai
ning
pos
t-st
roke
•Pa
rt II
: –
Conc
erns
rega
rdin
g hi
gh in
tens
ity p
ract
ice
post
-str
oke
–
Sum
mar
y an
d re
-em
phas
is o
n av
aila
ble
data
Pote
ntia
l dra
wba
cks
of h
igh
inte
nsity
trai
ning
•N
euro
mus
cula
r con
cern
s –
Re-e
nfor
cing
abn
orm
al
mov
emen
t pat
tern
s an
d –
Incr
ease
d sp
astic
ity
•Ca
rdio
vasc
ular
con
cern
s
Pote
ntia
l dra
wba
cks
of h
igh
inte
nsity
trai
ning
: su
ppor
tive
findi
ngs
Incr
easi
ng sp
astic
ity
•In
crea
sed
spas
ticity
for t
he
shor
t ter
m d
urin
g tr
aini
ng is
ex
pect
ed (K
line
et a
l 200
7)
•
Spas
ticity
may
redu
ce o
ver
time
with
trai
ning
or d
oes
not c
hang
e (W
irz e
t al 2
005)
•BW
STT
has b
een
show
n to
re
duce
spas
ticity
in c
hron
ic
SCI a
s com
pare
d to
tilt
tabl
e (H
icks
201
1)
Re-e
nfor
cing
abn
orm
al
mov
emen
ts
•Ev
iden
ce fo
r im
prov
ed g
ait
patt
ern
over
long
term
(Kuy
s 20
10, H
ornb
y 20
08)
•
Impr
oved
mus
cle
timin
g/ac
tivat
ion
patt
erns
is
not l
inke
d to
impr
oved
w
alki
ng fu
nctio
n (D
en O
tter
et
al 2
006)
Pote
ntia
l dra
wba
cks
of h
igh
inte
nsity
trai
ning
•N
euro
mus
cula
r con
cern
s
•Ca
rdio
vasc
ular
con
cern
s –
Incr
ease
d ris
k of
car
diov
ascu
lar e
vent
or r
epea
t str
oke
AC
SM re
com
men
datio
ns fo
r car
diov
ascu
lar d
isea
se
(CVD
)
•Ad
vers
e re
spon
ses t
o di
scon
tinue
exe
rcise
–
DBP≥
110
mm
Hg
–SB
P >1
0mm
Hg
durin
g ex
erci
se w
ith
wor
kloa
d –
Sign
ifica
nt v
entr
icul
ar o
r atr
ial a
rrhy
thm
ias
–Se
cond
or t
hird
deg
ree
hear
t blo
ck
–Si
gns/
sym
ptom
s of e
xerc
ise in
tole
ranc
e in
clud
ing
angi
na, m
arke
d dy
spne
a,
and
ECG
cha
nges
sugg
estin
g isc
hem
ia
ACSM
con
trai
ndic
atio
ns to
initi
atin
g tr
aini
ng in
CVD
•
Uns
tabl
e an
gina
•
Unc
ontr
olle
d hy
pert
ensi
on —
–
rest
ing
syst
olic
blo
od p
ress
ure
(SBP
)>18
0 m
m H
g an
d/or
rest
ing
dias
tolic
BP
(DBP
) >11
0 m
m H
g •
Ort
host
atic
BP
drop
of >
20 m
m H
g w
ith sy
mpt
oms
• S
igni
fican
t aor
tic s
teno
sis
• U
ncon
trol
led
atria
l or v
entr
icul
ar a
rrhy
thm
ias
• U
ncon
trol
led
sinu
s tac
hyca
rdia
(>12
0 be
ats /
min
) •
Unc
ompe
nsat
ed h
eart
failu
re
• T
hird
-deg
ree
atrio
vent
ricul
ar (A
V) b
lock
with
out p
acem
aker
•
Act
ive
peric
ardi
tis o
r myo
card
itis
• R
ecen
t em
bolis
m
• A
cute
thro
mbo
phle
bitis
•
Acu
te sy
stem
ic il
lnes
s or f
ever
•
Unc
ontr
olle
d di
abet
es m
ellit
us
• S
ever
e or
thop
edic
con
ditio
ns th
at w
ould
pro
hibi
t exe
rcise
•
Oth
er m
etab
olic
con
ditio
ns, s
uch
as a
cute
thyr
oidi
tis, h
ypok
alem
ia,
•hy
perk
alem
ia, o
r hyp
ovol
emia
(unt
il ad
equa
tely
trea
ted )
Cite
d Re
com
men
datio
ns in
Tra
inin
g In
tens
ity
•AH
A Sc
ient
ific
Stat
emen
t
–Re
com
men
datio
n of
gra
ded
exer
cise
test
with
ECG
(typ
ical
ly tr
eadm
ill
prot
ocol
s)
–40
-70%
HRR
/ 50-
80%
HR
max
–
20-6
0min
sess
ions
, 3-7
days
/wee
k –
RPE
11-1
4 –
With
out e
xerc
ise E
CG “
light
er in
tens
ity e
xerc
ise s
houl
d be
pre
scrib
ed”
•
ACSM
gui
delin
es -
RPE
14-1
6 (lo
wer
in e
arly
stag
es o
f car
diac
reha
b)
•*i
nclu
de A
CSM
exe
rcise
HR
•M
acko
200
5, P
ang
and
Eng
2003
–
Gra
ded
exer
cise
trai
ning
per
form
ed 6
0-70
% H
RR
–Co
mm
unity
set
ting:
70-
80%
HRR
–
Gra
dual
ly w
ork
tow
ards
3-5
, 40
min
ute
sess
ions
/wee
k
Risk
for c
ardi
ovas
cula
r eve
nt?
Pang
et a
l 201
3 –
no in
crea
se in
risk
to p
atie
nt p
ost-
stro
ke
follo
win
g hi
gh in
tens
ity tr
aini
ng a
s com
pare
d to
low
inte
nsity
co
ntro
l con
ditio
ns (p
rimar
ily in
chr
onic
stro
ke)
Hor
nby
2015
– n
o in
crea
se in
risk
in th
e in
patie
nt su
bacu
te
stro
ke p
opul
atio
n as
com
pare
d to
stan
dard
reha
bilit
atio
n in
terv
entio
ns
AHA
Reco
mm
enda
tions
for E
CG g
rade
d ex
erci
se st
ress
test
ing
prio
r to
trai
ning
Refe
renc
es
•Am
eric
an c
olle
ge o
f spo
rts m
edic
ine
9th e
d. A
csm
's gu
idel
ines
for e
xerc
ise te
stin
g an
d pr
escr
iptio
n. L
ippi
ncot
t Will
iam
s an
d W
ilkin
s; 2
000.
•G
ordo
n N
F, G
ulan
ick
M, C
osta
F, F
letc
her G
, Fra
nklin
BA,
Rot
h EJ
, She
phar
d T;
Am
eric
an H
eart
Ass
ocia
tion
Coun
cil o
n Cl
inic
al C
ardi
olog
y, S
ubco
mm
ittee
on
Exer
cise
, Ca
rdia
c Re
habi
litat
ion,
and
Pre
vent
ion;
the
Coun
cil o
n Ca
rdio
vasc
ular
Nur
sing;
the
Coun
cil o
n N
utrit
ion,
Phy
sical
Act
ivity
, and
Met
abol
ism; a
nd th
e St
roke
Cou
ncil.
Ph
ysic
al a
ctiv
ity a
nd e
xerc
ise re
com
men
datio
ns fo
r str
oke
surv
ivor
s: a
n Am
eric
an H
eart
Ass
ocia
tion
scie
ntifi
c st
atem
ent f
rom
the
Coun
cil o
n Cl
inic
al C
ardi
olog
y,
Subc
omm
ittee
on
Exer
cise
, Car
diac
Reh
abili
tatio
n, a
nd P
reve
ntio
n; th
e Co
unci
l on
Card
iova
scul
ar N
ursin
g; th
e Co
unci
l on
Nut
ritio
n, P
hysic
al A
ctiv
ity, a
nd
Met
abol
ism; a
nd th
e St
roke
Cou
ncil.
Circ
ulat
ion.
200
4 Ap
r 27;
109(
16):2
031-
41.
•H
olle
ran
CL, S
trau
be D
D, K
inna
ird C
R, L
eddy
AL,
Hor
nby
TG. F
easib
ility
and
Pot
entia
l Effi
cacy
of H
igh-
Inte
nsity
Ste
ppin
g Tr
aini
ng in
Var
iabl
e Co
ntex
ts in
Sub
acut
e an
d Ch
roni
c St
roke
. Neu
rore
habi
l Neu
ral R
epai
r. 20
14 F
eb 1
0.
•Ka
ntak
SS,
Win
stei
n CJ
. Lea
rnin
g-pe
rfor
man
ce d
istin
ctio
n an
d m
emor
y pr
oces
ses
for m
otor
skill
s: a
focu
sed
revi
ew a
nd p
ersp
ectiv
e. B
ehav
Bra
in R
es. 2
012
Mar
1;
228(
1):2
19-3
1.
•Kl
eim
JA, J
ones
TA.
Prin
cipl
es o
f exp
erie
nce-
depe
nden
t ne
ural
pla
stic
ity: i
mpl
icat
ions
for r
ehab
ilita
tion
afte
r bra
in d
amag
e. J
Spee
ch L
ang
Hea
r Res
. 200
8 Fe
b;51
(1):S
225-
39.
•Ku
ys S
, Bra
uer S
, Ada
L. R
outin
e ph
ysio
ther
apy
does
not
indu
ce a
car
dior
espi
rato
ry tr
aini
ng e
ffect
pos
t-st
roke
, reg
ardl
ess
of w
alki
ng a
bilit
y. P
hysio
ther
Res
Int.
2006
De
c;11
(4):2
19-2
7.
•Lu
ft A
R, M
acko
RF,
For
rest
er L
W, V
illag
ra F
, Ive
y F,
Sor
kin
JD, W
hita
ll J,
McC
ombe
-Wal
ler S
, Kat
zel L
, Gol
dber
g AP
, Han
ley
DF. T
read
mill
exe
rcise
act
ivat
es su
bcor
tical
ne
ural
net
wor
ks a
nd im
prov
es w
alki
ng a
fter
stro
ke: a
rand
omiz
ed c
ontr
olle
d tr
ial.
Stro
ke. 2
008
Dec;
39(1
2):3
341-
50.
•M
acKa
y-Ly
ons M
J, M
akrid
es L
. Car
diov
ascu
lar s
tres
s du
ring
a co
ntem
pora
ry st
roke
reha
bilit
atio
n pr
ogra
m: i
s th
e in
tens
ity a
dequ
ate
to in
duce
a tr
aini
ng e
ffect
? Ar
ch
Phys
Med
Reh
abil.
200
2 O
ct;8
3(10
):137
8-83
.
•M
acka
y-Ly
ons M
J1, M
akrid
es L
. Lon
gitu
dina
l cha
nges
in e
xerc
ise c
apac
ity a
fter
stro
ke. A
rch
Phys
Med
Reh
abil.
200
4 O
ct;8
5(10
):160
8-12
.
•M
ang
CS, C
ampb
ell K
L, R
oss C
J, Bo
yd L
A. P
rom
otin
g ne
urop
last
icity
for m
otor
reha
bilit
atio
n af
ter s
trok
e: c
onsid
erin
g th
e ef
fect
s of a
erob
ic e
xerc
ise a
nd g
enet
ic
varia
tion
on b
rain
-der
ived
neu
rotr
ophi
c fa
ctor
. Phy
s The
r. 20
13 D
ec;9
3(12
):170
7-16
.
•M
ehta
S, P
erei
ra S
, Jan
zen
S, M
ays
R, V
iana
R, L
obo
L, T
ease
ll RW
. Car
diov
ascu
lar c
ondi
tioni
ng fo
r com
fort
able
gai
t spe
ed a
nd to
tal d
istan
ce w
alke
d du
ring
the
chro
nic
stag
e of
stro
ke: a
met
a-an
alys
is. T
op S
trok
e Re
habi
l. 20
12 N
ov-D
ec;1
9(6)
:463
-70.
Refe
renc
es
•M
icha
el K
, Mac
ko R
F. A
mbu
lato
ry a
ctiv
ity in
tens
ity p
rofil
es, f
itnes
s, a
nd fa
tigue
in c
hron
ic st
roke
. Top
Str
oke
Reha
bil.
2007
Mar
-Apr
;14(
2):5
-12.
•M
icha
el K
M, A
llen
JK, M
acko
RF.
Red
uced
am
bula
tory
act
ivity
aft
er st
roke
: the
role
of b
alan
ce, g
ait,
and
card
iova
scul
ar fi
tnes
s. A
rch
Phys
Med
Re
habi
l. 20
05 A
ug;8
6(8)
:155
2-6.
•M
oore
JL, R
oth
EJ, K
illia
n C,
Hor
nby
TG. L
ocom
otor
trai
ning
impr
oves
dai
ly st
eppi
ng a
ctiv
ity a
nd g
ait e
ffici
ency
in in
divi
dual
s po
stst
roke
who
hav
e re
ache
d a
"pla
teau
" in
reco
very
. Str
oke.
201
0 Ja
n;41
(1):1
29-3
5.
• A
yers
S, S
aris
csan
y, M
. Ph
ysic
al E
duca
tion
for L
ifelo
ng F
itnes
s - 3
rd E
ditio
n: T
he P
hysic
al B
est T
each
ers
Gui
de.
Hum
an K
inet
ics:
201
1.
• B
arbe
au H
. Loc
omot
or tr
aini
ng in
neu
rore
habi
litat
ion:
em
ergi
ng re
habi
litat
ion
conc
epts
.
•
N
euro
reha
bil N
eura
l Rep
air.
2003
Mar
;17(
1):3
-11.
Rev
iew
.
• B
arbe
au H
, Visi
ntin
M. O
ptim
al O
utco
mes
Obt
aine
d w
ith B
ody-
Wei
ght S
uppo
rt C
ombi
ned
with
Tre
adm
ill T
rain
ing
in S
trok
e Su
bjec
ts. A
rch
Phys
Med
Re
habi
l. 2
003;
84:
145
8-14
65.
• B
oyd
LA, W
inst
ein
CJ. I
mpa
ct o
f exp
licit
info
rmat
ion
on im
plic
it m
otor
-seq
uenc
e le
arni
ng fo
llow
ing
mid
dle
cere
bral
art
ery
stro
ke. P
hys T
her.
2003
;83:
976-
989
• D
obki
n B.
et a
l. W
eigh
t-su
ppor
ted
trea
dmill
vs
over
-gro
und
trai
ning
for w
alki
ng a
fter
acu
te in
com
plet
e SC
I. N
euro
logy
. 20
06; 6
6: 4
84-4
93.
• G
ordo
n N
F, G
ulan
ick
M, C
osta
F, F
letc
her G
, Fra
nklin
BA,
Rot
h EJ
, She
phar
d T.
Phy
sical
act
ivity
and
exe
rcise
reco
mm
enda
tions
for s
trok
e su
rviv
ors:
an
am
eric
an h
eart
ass
ocia
tion
scie
ntifi
c st
atem
ent f
rom
the
coun
cil o
n cl
inic
al c
ardi
olog
y, su
bcom
mitt
ee o
n ex
erci
se, c
ardi
ac re
habi
litat
ion,
and
pr
even
tion;
the
coun
cil o
n ca
rdio
vasc
ular
nur
sing;
the
coun
cil o
n nu
triti
on, p
hysic
al a
ctiv
ity a
nd m
etab
olism
; and
the
stro
ke c
ounc
il. S
trok
e.
2004
;35:
1230
-124
0.
• H
esse
S, R
eite
r F, J
ahnk
e M
, Daw
son
M, S
arko
die-
Gya
n T,
Mau
ritz K
H. A
sym
met
ry o
f gai
t ini
tiatio
n in
hem
ipar
etic
str
oke
subj
ects
. Arc
h Ph
ys M
ed
Reha
bil.
1997
;78:
719-
724
• H
ornb
y TG
, Cam
pbel
l DD,
Kah
n JH
, Dem
ott T
, Moo
re JL
, Rot
h H
R. E
nhan
ced
gait-
rela
ted
impr
ovem
ents
aft
er th
erap
ist- v
ersu
s ro
botic
-ass
isted
lo
com
otor
trai
ning
in su
bjec
ts w
ith c
hron
ic st
roke
: A ra
ndom
ized
con
trol
led
stud
y. S
trok
e. 2
008;
39:1
786-
1792
.
• H
ornb
y TG
, Str
aube
DS,
Kin
naird
CR,
Hol
lera
n CL
, Ech
auz A
J, Ro
drig
uez
KS, W
agne
r EJ,
Nar
ducc
i EA.
Impo
rtan
ce o
f spe
cific
ity, a
mou
nt, a
nd in
tens
ity
of lo
com
otor
trai
ning
to im
prov
e am
bula
tory
func
tion
in p
atie
nts
post
stro
ke. T
op S
trok
e Re
habi
l. 20
11 Ju
l-Aug
;18(
4):2
93-3
07.
• K
leim
JA, J
ones
TA.
Prin
cipl
es o
f exp
erie
nce-
depe
nden
t neu
ral p
last
icity
: im
plic
atio
ns fo
r reh
abili
tatio
n af
ter b
rain
dam
age.
J Sp
eech
Lan
g H
ear R
es.
2008
Feb
;51(
1):S
225-
39.
Refe
renc
es
•
Billi
nger
SA,
Are
na R
, Ber
nhar
dt J,
Eng
JJ, F
rank
lin B
A, Jo
hnso
n CM
, Mac
Kay-
Lyon
s M, M
acko
RF,
Mea
d G
E, R
oth
EJ, S
haug
hnes
sy M
, Tan
g A.
Phy
sical
Ac
tivity
and
Exe
rcise
Rec
omm
enda
tions
for S
trok
e Su
rviv
ors.
Str
oke.
201
4;45
:253
2-25
53
• L
ewek
MD,
Cru
z TH
, Moo
re JL
, Rot
h H
R, D
hahe
r YY,
Hor
nby
TG. A
llow
ing
intr
alim
b ki
nem
atic
var
iabi
lity
durin
g lo
com
otor
trai
ning
pos
tstr
oke
impr
oves
kin
emat
ic c
onsis
tenc
y: A
subg
roup
ana
lysis
from
a ra
ndom
ized
clin
ical
tria
l. Ph
ys T
her.
2009
;89:
829-
839
• M
acko
RF,
Ivey
FM
, For
rest
er L
W, H
anle
y D,
Sor
kin
JD, K
atze
l LI,
Silv
er K
H, G
oldb
erg
AP. T
read
mill
exe
rcise
reha
bilit
atio
n im
prov
es a
mbu
lato
ry
func
tion
and
card
iova
scul
arfit
ness
in p
atie
nts w
ith c
hron
ic s
trok
e: A
rand
omiz
ed, c
ontr
olle
d tr
ial.
Stro
ke. 2
005;
36:2
206-
2211
•Ka
wah
ira K
, Shi
mod
ozon
o M
, Oga
ta A
, Tan
aka
N. A
dditi
on o
f int
ense
repe
titio
n of
faci
litat
ion
exer
cise
to m
ultid
iscip
linar
y re
habi
litat
ion
prom
otes
m
otor
func
tiona
l rec
over
y of
the
hem
iple
gic
low
er li
mb.
J Re
habi
l Med
200
4;36
(4):1
59 –
164
.
• P
esca
tello
LS,
et a
l. Am
eric
an C
olle
ge o
f Spo
rts M
edic
ine
posit
ion
stan
d. E
xerc
ise a
nd h
yper
tens
ion.
Med
Sci
Spo
rts
Exer
c. 2
004;
36:5
33–5
53.
•Pa
ng M
Y, E
ng JJ
, Daw
son
AS, G
ylfa
dótt
ir S.
The
use
of a
erob
ic e
xerc
ise tr
aini
ng in
impr
ovin
g ae
robi
c ca
paci
ty in
indi
vidu
als w
ith st
roke
: a m
eta-
anal
ysis.
Clin
Reh
abil.
200
6 Fe
b;20
(2):9
7-11
1.
•Pa
ng M
Y, C
harle
swor
th S
A, L
au R
W, C
hung
RC.
Usin
g ae
robi
c ex
erci
se to
impr
ove
heal
th o
utco
mes
and
qua
lity
of li
fe in
stro
ke: e
vide
nce-
base
d ex
erci
sepr
escr
iptio
n re
com
men
datio
ns. C
ereb
rova
sc D
is. 2
013;
35(1
):7-2
2.
•Re
snic
k B,
Mic
hael
K, S
haug
hnes
sy M
, Nah
m E
S, K
obun
ek S
, Sor
kin
J, O
rwig
D, G
oldb
erg
A, M
acko
RF.
Infla
ted
perc
eptio
ns o
f phy
sical
act
ivity
aft
er
stro
ke: p
airin
g se
lf-re
port
with
phy
siolo
gic
mea
sure
s. J
Phys
Act
Hea
lth. 2
008
Mar
;5(2
):308
-18.
•St
ates
RA,
Pap
pas E
, Sal
em Y
. Ove
rgro
und
phys
ical
ther
apy
gait
trai
ning
for c
hron
ic st
roke
pat
ient
s with
mob
ility
def
icits
. Coc
hran
e Da
taba
se S
yst
Rev.
200
9 Ju
l 8;(3
):CD0
0607
5.
Amer
ican
Col
lege
of S
port
s Med
icin
e. A
CSM
’s g
uide
lines
for e
xerc
ise te
stin
g an
d pr
escr
iptio
n. 9
th e
ditio
n. B
altim
ore:
Lip
pinc
ott W
illia
ms a
nd W
ilkin
s;
2000
..
Ada,
L.,
C. M
. Dea
n, J.
M. H
all,
J. Ba
mpt
on, a
nd S
. Cro
mpt
on. A
trea
dmill
and
ove
rgro
und
wal
king
pro
gram
impr
oves
wal
king
in p
erso
ns re
sidin
g in
the
com
mun
ity a
fter
stro
ke
•Po
hl M
, Meh
rhol
z J,
Rits
chel
C,
Ruck
riem
S.
Spee
d-De
pend
ent T
read
mill
Tra
inin
g in
Am
bula
tory
Hem
ipar
etic
Str
oke
Patie
nts.
Str
oke.
200
2; 3
3:
553-
558.
•Je
ffrey
F Is
rael
, Don
ielle
D C
ampb
ell,
Jenn
ifer H
Kah
n an
dT G
eorg
e H
ornb
y. M
etab
olic
Cos
ts a
nd M
uscl
e Ac
tivity
Pat
tern
s Dur
ing
Robo
tic- a
nd
Ther
apist
-Ass
isted
Tre
adm
ill W
alki
ng in
Indi
vidu
als W
ith In
com
plet
e Sp
inal
Cor
d In
jury
Phys
ical
The
rapy
Nov
embe
r 200
6 vo
l. 86
no. 1
1 14
66-1
478
Refe
renc
es
•Sc
hmid
t R, L
ee T
. Mot
or c
ontr
ol a
nd le
arni
ng: A
beh
avio
ral e
mph
asis
Las A
ngel
es: H
uman
Kin
etic
s; 2
005.
Shum
way
-Coo
k A,
Bra
uer S
, Woo
llaco
tt M
. Pr
edic
ting
the
Prob
abili
ty fo
r Fal
ls in
Com
mun
ity-D
wel
ling
Old
er A
dults
Usin
g th
e Ti
med
Up
& G
o Te
st.
Phys
The
r. 2
000;
80(
9): 8
96-9
03.
Step
hens
on JL
, De
Serr
es S
J, La
mon
tagn
e A.
The
effe
ct o
f arm
mov
emen
ts o
n th
e lo
wer
lim
b du
ring
gait
afte
r a st
roke
. Gai
t Pos
ture
. 201
0;31
:109
-11
5.
Step
hens
on JL
, Lam
onta
gne
A, D
e Se
rres
SJ.
The
coor
dina
tion
of u
pper
and
low
er li
mb
mov
emen
ts d
urin
g ga
it in
hea
lthy
and
stro
ke in
divi
dual
s. G
ait
Post
ure.
200
9;29
:11-
16.
•Su
lliva
n K,
Kno
wlto
n B,
Dob
kin
B. S
tep
Trai
ning
with
Bod
y W
eigh
t Sup
port
: Effe
ct o
f Tre
adm
ill S
peed
and
Pra
ctic
e Pa
radi
gms o
n Po
stst
roke
Lo
com
otor
Rec
over
y. A
rch
Phys
Med
Reh
abil.
200
2; 8
3: 6
83-6
91.
Sulli
van
KJ, B
row
n DA
, Kla
ssen
T, M
ulro
y S,
Ge
T, A
zen
SP, W
inst
ein
CJ; f
or th
e Ph
ysic
al T
hera
py C
linic
al R
esea
rch
Net
wor
k (P
TClin
ResN
et).E
ffect
s of
ta
sk-s
peci
fic lo
com
otor
and
stre
ngth
trai
ning
in a
dults
who
wer
e am
bula
tory
aft
er s
trok
e: re
sults
of t
he S
TEPS
rand
omiz
ed c
linic
al tr
ial.
Phys
The
r. 20
07 8
7(12
):158
0-60
2; d
iscus
sion
1603
-7.
Visin
tin, M
., H
. Bar
beau
, N. K
orne
r-Bi
tens
ky, a
nd N
. E. M
ayo.
A n
ew a
ppro
ach
to re
trai
n ga
it in
stro
ke p
atie
nts t
hrou
gh b
ody
wei
ght s
uppo
rt a
nd
trea
dmill
stim
ulat
ion.
Str
oke.
29:
1122
-112
8, 1
998.
Wer
nig
A, M
ülle
r S, N
anas
sy A
, Cag
ol E
. Lau
fban
d th
erap
y ba
sed
on 'r
ules
of s
pina
l loc
omot
ion'
is e
ffect
ive
in sp
inal
cor
d in
jure
d pe
rson
s.
Eur J
N
euro
sci.
1995
Apr
1;7
(4):
•Pa
ge, S
J. In
tens
ity v
ersu
s ta
sk-s
peci
ficity
aft
er st
roke
: how
impo
rtan
t is i
nten
sity?
823
-9. A
m J
Phys
Med
Reh
abil.
200
3 Se
p;82
(9):7
30-2
.
•H
esse
S1,
Wel
z A,
Wer
ner C
, Que
ntin
B, W
issel
J. C
ompa
rison
of a
n in
term
itten
t hig
h-in
tens
ity v
s con
tinuo
us lo
w-in
tens
ity p
hysio
ther
apy
serv
ice
over
12
mon
ths i
n co
mm
unity
-dw
ellin
g pe
ople
with
stro
ke: a
rand
omiz
ed tr
ial.
Clin
Reh
abil.
201
1 Fe
b;25
(2):1
46-5
6.
•St
olle
r O, d
e Br
uin
ED, K
nols
RH, H
unt K
J. Ef
fect
s of
car
diov
ascu
lar e
xerc
ise e
arly
aft
er st
roke
: sys
tem
atic
revi
ew a
nd m
eta-
anal
ysis.
BM
C N
euro
l. 20
12 Ju
n 22
;12:
45.
•St
oqua
rt G
, Det
rem
bleu
r C, L
ejeu
ne T
M. T
he re
ason
s why
stro
ke p
atie
nts e
xpen
d so
muc
h en
ergy
to w
alk
slow
ly. G
ait P
ostu
re. 2
012
Jul;3
6(3)
:409
-13
•Ta
naka
H, M
onah
an K
D, S
eals
DR. A
ge-p
redi
cted
max
imal
hea
rt ra
te re
visit
ed. J
Am
Col
l Car
diol
. 200
1 Ja
n;37
(1):1
53-6
.
•va
n de
Por
t IG
, Woo
d-Da
uphi
nee
S, L
inde
man
E, K
wak
kel G
. Effe
cts
of e
xerc
ise tr
aini
ng p
rogr
ams
on w
alki
ng c
ompe
tenc
y af
ter s
trok
e: a
syst
emat
ic
revi
ew. A
m J
Phys
Med
Reh
abil.
200
7 N
ov;8
6(11
):935
-51.
•H
olle
ran
CL, R
odrig
uez
KS, E
chau
z A, L
eech
KA,
Hor
nby
TG. P
oten
tial C
ontr
ibut
ions
of T
rain
ing
Inte
nsity
on
Loco
mot
or P
erfo
rman
ce in
Indi
vidu
als
With
Chr
onic
Str
oke.
Jour
nal o
f Neu
rolo
gy P
hysic
al T
hera
py. 2
015;
39:
95-
103.
•Iv
eyFM
Haf
er-M
acko
CM
acko
RFEx
erci
seRe
habi
litat
ion
Afte
rStr
oke
The
Jour
nalo
fthe
Amer
ican
Soci
ety
forE
xper
imen
talN
euro
Ther
apeu
tics
Mot
or A
dapt
atio
ns a
nd A
fter
effe
cts
– m
akin
g pa
tient
s loo
k w
orse
to
look
bet
ter?
T.
Geo
rge
Hor
nby,
PT,
PhD
As
soci
ate
Prof
esso
r, De
pt o
f Phy
sical
The
rapy
U
nive
rsity
of I
llino
is at
Chi
cago
Re
sear
ch S
cien
tist
Sens
ory
Mot
or P
erfo
rman
ce P
rogr
am
Reha
bilit
atio
n In
stitu
te o
f Chi
cago
Maj
or P
oint
s 1.
Mot
or a
dapt
atio
n an
d af
tere
ffect
s - l
earn
ing
a ne
w
sens
orim
otor
task
2.Va
riabi
lity
and
tria
l and
err
or p
ract
ice
is im
port
ant f
or
mot
or le
arni
ng.
3.
Elim
inat
ion
of e
rror
s dur
ing
prac
tice
may
lim
it im
prov
emen
ts in
pat
ient
’s w
ith n
euro
logi
c da
mag
e/di
seas
e.
4.
Patie
nts w
ith a
var
iety
of n
euro
logi
c di
agno
ses c
an
utili
ze tr
ial a
nd e
rror
pra
ctic
e to
adj
ust m
ovem
ent.
Defin
ition
s of c
hang
es in
mot
or
beha
vior
Tr
ansit
ions
im
med
iate
cha
nge
in b
ehav
ior
driv
en b
y pr
ior e
xper
ienc
e an
d th
e ab
ility
to p
redi
ct th
at n
ew
dem
ands
will
exc
eed
“cur
rent
stat
e” (f
eed-
forw
ard
stra
tegi
es)
Adap
tatio
ns
Gra
dual
cha
nge
in b
ehav
ior t
hat r
esul
ts fr
om e
xper
ienc
e (“
feed
back
st
rate
gies
”)
Driv
en b
y de
man
ds th
at e
xcee
d “c
urre
nt st
ate”
Lear
ning
Re
lativ
ely
perm
anen
t cha
nges
Re
sulti
ng fr
om re
peat
ed e
xpos
ure
(ada
ptat
ion
may
be
a pr
ecur
sor)
Adap
tatio
n to
a v
isual
per
turb
atio
n •
Prism
s ins
erte
d in
to
eyeg
lass
es
–Di
spla
ce v
isual
fiel
d –
Lead
s to
initi
al e
rror
s in
m
ovem
ent a
ccur
acy
Prism
ada
ptat
ion
•
T. T
hach
(Mar
tin e
t al.
1996
) –
Blac
k –
prio
r to
prism
exp
osur
e –
Whi
te –
dur
ing
prism
exp
osur
e –
Gra
y –
rem
oval
of p
rism
“see
” di
rect
ion
“thr
ow”
dire
ctio
n
Afte
reffe
cts i
n pt
s with
cer
ebel
lar d
amag
e
Inta
ct
subj
ects
C
ereb
ella
r in
jury
Role
of C
ereb
ellu
m a
s a “
Com
para
tor”
•
Effe
rent
cop
y of
fe
edfo
rwar
d m
otor
co
mm
and
•
Affe
rent
cop
y of
pe
riphe
ral f
eedb
ack
•
Gen
erat
e fe
edba
ck m
otor
co
rrec
tion
and
new
fe
edfo
rwar
d co
mm
and
on
next
mov
emen
t att
empt
8
With
ext
ensiv
e tr
aini
ng, t
hrow
ing
with
wed
ge p
rism
s ca
n be
com
e a
skill
.
Repe
ated
ad
apta
tion
resu
lts
in le
arni
ng –
w
hich
allo
w fa
ster
tr
ansit
ions
Maj
or P
oint
s 1.
Mot
or a
dapt
atio
n an
d af
tere
ffect
s - l
earn
ing
a ne
w
sens
orim
otor
task
2.Va
riabi
lity
and
erro
rs in
mov
emen
t and
lear
ning
.
3.El
imin
atio
n of
err
ors d
urin
g pr
actic
e m
ay li
mit
impr
ovem
ents
in p
atie
nt’s
with
neu
rolo
gic
dam
age/
dise
ase.
4.Pa
tient
s with
a v
arie
ty o
f neu
rolo
gic
diag
nose
s can
ut
ilize
tria
l and
err
or p
ract
ice
to a
djus
t mov
emen
t.
“Var
iabi
lity”
and
allo
win
g er
rors
in
mor
e co
mm
on m
ovem
ents
•
C on
ly
grou
p >
C+
•
Impr
oved
C+
V gr
oup
on
rete
ntio
n
“Var
iabi
lity”
and
allo
win
g er
rors
: si
mpl
e ex
ampl
es
•C
only
gr
oup
> C+
•Im
prov
ed
C+V
grou
p on
re
tent
ion
A li
ttle
pra
ctic
e A
lot o
f pra
ctic
e A
lot o
f var
iabl
e pr
actic
e
“Var
iabi
lity”
and
allo
win
g er
rors
: si
mpl
e ex
ampl
es
A lit
tle p
ract
ice
A lo
t of p
ract
ice
A lo
t of v
aria
ble
prac
tice
Impr
oved
free
th
row
s w
ith a
lo
t of v
aria
ble
prac
tice
•Er
rors
and
var
iabi
lity
may
be
impo
rtan
t in
lear
ning
−
Varia
ble
vs C
onst
ant P
ract
ice
−
Rand
om v
s Blo
cked
Pra
ctic
e (i.
e., C
onte
xtua
l In
terf
eren
ce)
−
Gre
ater
err
ors a
ssoc
iate
d w
ith a
llow
ing
varia
bilit
y
Oth
er fa
ctor
s?
•Ty
pes o
f var
iabi
lity
−Ki
nem
atic
var
iabi
lity
(Cai
200
7; H
ornb
y 20
08, L
ewek
200
9)
Con
trib
utio
ns o
f err
ors a
nd
vari
abili
ty to
lear
ning
•Ty
pes o
f var
iabi
lity
−Ki
nem
atic
var
iabi
lity
(Cai
200
7; H
ornb
y 20
08, L
ewek
200
9)
Con
trib
utio
ns o
f err
ors a
nd
vari
abili
ty to
lear
ning
(Isr
ael e
t al 2
006,
Hor
nby
et a
l 200
8, L
ewek
et a
l 200
9)
50 40 30 20 1060 0
50 40 30 20 1060 0po
st-4
week
s6
mon
thfo
llow-
up
Ther
apist
-ass
isted
Robo
tic-a
ssist
ed
post
-4we
eks
6m
onth
follo
w-up
**
**
Gai
tspe
ed(le
ssim
paire
dsu
bjec
ts)
Gai
tspe
ed(m
ore
impa
ired
subj
ects
)
•Ty
pes o
f var
iabi
lity
−Ki
nem
atic
var
iabi
lity
(Cai
200
7; H
ornb
y 20
08, L
ewek
200
9)
Con
trib
utio
ns o
f err
ors a
nd
vari
abili
ty to
lear
ning
(Isr
ael e
t al 2
006,
Hor
nby
et a
l 200
8, L
ewek
et a
l 200
9)
024 -2 -4 -6
024 -2 -46
**
Ther
apis
t-ass
iste
dR
obot
ic-a
ssis
ted
Pare
ticsi
ngle
limb
stan
cetim
e( %
gait
cycl
e)
post
-4w
eeks
6m
onth
follo
w-u
ppo
st-4
wee
ks6
mon
thfo
llow
-up
Step
leng
thsy
mm
etry
(%)
•Au
gmen
ting
erro
rs d
urin
g le
arni
ng m
ay e
nhan
ce
mag
nitu
de/a
ccel
erat
e le
arni
ng (s
plit-
belt
trea
dmill
st
eppi
ng; B
astia
n 20
06, R
eism
an 2
010)
If er
rors
are
goo
d . .
. .
•Au
gmen
ting
erro
rs d
urin
g le
arni
ng m
ay e
nhan
ce
mag
nitu
de/a
ccel
erat
e le
arni
ng (s
plit-
belt
trea
dmill
st
eppi
ng; B
astia
n 20
06, R
eism
an 2
010)
If er
rors
are
goo
d . .
. .
Appl
icat
ion
of e
rror
aug
men
tatio
n –
Split
bel
t tr
eadm
ill fo
r ste
p-le
ngth
asy
mm
etry
pos
t-st
roke
Durin
g w
alki
ng o
n sp
lit-b
elt t
read
mill
Reism
an e
t al,
2007
– p
ilot c
ase
serie
s in
Reism
an N
NR
2013
•Ty
pes o
f var
iabi
lity
−Ki
nem
atic
var
iabi
lity
(Cai
200
7; H
ornb
y 20
08, L
ewek
200
9)
−En
viro
nmen
tal v
aria
bilit
y –
over
grou
nd/s
tairs
(van
den
Bra
nd 2
012)
−Ta
sk v
aria
bilit
y –
forw
ard
vs si
dew
ays v
s bac
kwar
ds (S
hah
2012
)
•W
hat t
ypes
of v
aria
bilit
y/er
rors
are
app
ropr
iate
for
patie
nts?
How
to w
e ge
t mor
e er
rors
?
Tria
l and
err
or p
ract
ice
– sp
ecifi
catio
ns
•G
oal-d
irect
ed, s
alie
nt ta
sk (B
astia
n et
al.
2006
)
•Be
abl
e to
det
ect t
heir
erro
r –
May
be
com
prom
ised
in th
ose
with
mem
ory
or se
nsor
y de
ficits
(Alze
imer
s- L
i and
Liu
201
2, se
nsor
y- G
hez e
t al.
1995
)
–Le
arni
ng is
enh
ance
d if
subj
ects
self-
eval
uate
mov
emen
t fo
rm o
r out
com
e (S
win
nen
et a
l, 19
90; L
iu &
Wris
berg
, 199
7)
•Ab
ility
to re
calib
rate
–
Com
prom
ised
with
spec
ific
cere
bella
r les
ions
•M
ust h
ave
an a
dapt
atio
n to
hav
e an
aft
eref
fect
Diffe
renc
es in
theo
retic
al fr
amew
orks
of
loco
mot
or tr
aini
ng p
arad
igm
s
Gui
danc
e A
ssis
t-as-
need
ed
Tria
l-and
-er
ror p
ract
ice
Erro
r au
gmen
tatio
n
Tria
l and
err
or p
ract
ice
– m
otor
le
arni
ng
•“…
I thi
nk it
[err
or a
nd e
rror
det
ectio
n] i
s one
of
the
badl
y ne
glec
ted
area
s in
mot
or le
arni
ng.
Afte
r all,
if o
ne c
an d
evel
op a
cap
abili
ty to
det
ect
one’
s ow
n er
rors
, the
n th
e le
arne
r can
pra
ctic
e w
ithou
t a te
ache
r or a
coa
ch.”
Rich
ard
Schm
idt,
2003
RQ
ES
•“F
orci
ng th
e le
arne
r to
activ
ely
deve
lop
prob
lem
-so
lvin
g st
rate
gies
inde
pend
ently
of t
he g
uida
nce
prov
ided
by…
the
ther
apist
is a
ctua
lly b
enef
icia
l fo
r mot
or le
arni
ng.”
Caro
lee
Win
stei
n, P
TJ 1
991
Tria
l and
Err
or P
ract
ice
•Cl
inic
al im
plic
atio
n
–Er
rors
may
be
help
ful f
or le
arni
ng (
Patt
on e
t al.
2004
, Rum
elha
rt e
t al.
1986
, Kaw
ato
1990
, Wol
pert
et a
l. 19
95)
–In
crea
sing
inte
nsity
may
also
incr
ease
err
or
–M
ay u
se e
xter
nal f
orce
s to
incr
ease
err
or
•
Dete
rmin
e w
heth
er th
e pa
tient
can
ada
pt to
the
“err
or”
–Ap
plic
atio
n to
spec
ific
diag
nose
s –
Sett
ing
patie
nt u
p fo
r suc
cess
–
Read
pat
ient
-spe
cific
psy
chol
ogic
al re
spon
se to
tria
ls w
ith e
rror
•Ex
plai
n to
the
patie
nt th
at th
ey m
ay lo
ok w
orse
bef
ore
they
look
be
tter
Tria
l and
Err
or P
ract
ice
Usin
g ob
ject
s in
the
envi
ronm
ent t
o cr
eate
er
rors
(hig
h st
eps,
uns
tead
y su
rfac
es, e
tc)
Vide
o
Vide
o pr
ovid
ed b
y th
e Lo
com
otor
Rec
over
y La
bora
tory
, TG
Hor
nby
Maj
or P
oint
s
1.Tr
ial a
nd e
rror
pra
ctic
e is
impo
rtan
t for
mot
or le
arni
ng.
2.
Patie
nts w
ith a
var
iety
of n
euro
logi
c di
agno
ses c
an
utili
ze tr
ial a
nd e
rror
pra
ctic
e to
adj
ust m
ovem
ent.
3.
Elim
inat
ion
of e
rror
s dur
ing
prac
tice
may
lim
it im
prov
emen
ts in
pat
ient
’s w
ith n
euro
logi
c da
mag
e/di
seas
e.
Dev
elop
men
t and
App
licat
ion
of a
W
alki
ng T
rain
ing
Prog
ram
T.
Geo
rge
Hor
nby,
PT,
PhD
Ca
rey
L. H
olle
ran,
PT,
DH
S, N
CS
Sens
ory
Mot
or P
erfo
rman
ce P
rogr
am
Reha
bilit
atio
n In
stitu
te o
f Chi
cago
•La
rge A
mou
nts o
f Tas
k Sp
ecifi
c Pr
actic
e •
Focu
s on
cont
inuo
us re
cipr
ocal
step
ping
•
Focu
s onl
y on
con
tinuo
us re
cipr
ocal
step
ping
•
Aer
obic
inte
nsity
•
Trai
ning
HR
zon
e (T
HR
) = 7
0-80
% H
eart
Rat
e R
eser
ve (H
RR
) •
15-1
8 B
OR
G R
atin
gs o
f Per
ceiv
ed E
xerti
on (R
PE)
•Va
riabi
lity
•
Mul
tidire
ctio
nal s
tepp
ing
•M
ultip
le e
nviro
nmen
ts
•R
ando
m o
rder
pra
ctic
e
Wal
king
Tra
inin
g Pa
radi
gm Sp
ecifi
city
Inte
nsity
Re
petit
ion
Wal
king
Tra
inin
g Pa
radi
gm
•B
iom
echa
nica
l su
bcom
pone
nts
of w
alki
ng
(Hol
lera
n, N
NR
201
4, a
ppen
dix)
•D
efin
ing
Succ
essf
ul
wal
king
Succ
ess =
Con
tinuo
us st
eppi
ng
Failu
re=
3-5
con
secu
tive
erro
rs
Gai
t kin
emat
ics w
ere
not a
pri
mar
y co
ncer
n
–Po
sitiv
e st
ep le
ngth
–D
irect
iona
l adv
ance
men
t
–Pr
even
ting
limb/
trunk
co
llaps
e
–La
tera
l/fro
ntal
stab
ility
–M
aint
ain
uprig
ht
–Li
mb
swin
g ad
vanc
emen
t
–Pr
opul
sion
–St
ance
con
trol
Prog
ress
ing
Biom
echa
nica
l Sub
com
pone
nts
of W
alki
ng
Prop
ulsio
n Li
mb
Adva
ncem
ent
Stab
ility
&
Bala
nce
Stan
ce
Cont
rol
Exam
ples
of i
ncre
asin
g ta
sk
varia
bilit
y/di
fficu
lty
•Sw
ing
phas
e co
mpl
etio
n
–G
uida
nce/
Ass
ist a
s nee
ded:
•
If c
anno
t sw
ing
limb
inde
pend
ently
, pro
vide
man
ual/e
last
ic
assi
stan
ce (H
esse
et a
l 199
5, G
otts
chal
l and
Kra
m 2
005)
•
Red
uce
assi
stan
ce a
s tol
erat
ed
–
Tria
l and
err
or/E
rror
aug
men
tatio
n:
•A
dd le
g w
eigh
ts/s
tepp
ing
over
obj
ects
/ela
stic
resi
stan
ce (L
am e
t al
2008
, 200
9, S
evin
et a
l 200
9)
Prog
ress
ing
Bio
mec
hani
cal S
ubco
mpo
nent
s of
Wal
king
Lim
b Ad
vanc
emen
t Pr
opul
sion
Stab
ility
&
Bala
nce
Stan
ce
Cont
rol
Exam
ples
of i
ncre
asin
g ta
sk
varia
bilit
y/di
fficu
lty
•W
eigh
t bea
ring
–G
uida
nce/
Ass
ist a
s nee
ded:
•
If c
anno
t bea
r wei
ght d
urin
g st
eppi
ng (e
.g.,
knee
“bu
ckle
s”)
prov
ide
body
wei
ght s
uppo
rt (V
isin
tin e
t al 1
998)
•
Red
uce
wei
ght s
uppo
rt as
tole
rate
d (B
arbe
au a
nd V
isin
tin 2
003,
G
rabo
wsk
i et a
l 200
5)
•A
ssis
tive
devi
ces
–Tr
ial a
nd e
rror
/Err
or a
ugm
enta
tion:
•
Add
wei
ghte
d ve
st –
incr
ease
s neu
rom
uscu
lar a
ctiv
ity to
mai
ntai
n up
right
pos
ture
(Um
berg
er e
t al 2
010)
•
Red
uce
use/
chan
ge a
ssis
tive
devi
ce
Prog
ress
ing
Bio
mec
hani
cal S
ubco
mpo
nent
s of
Wal
king
Lim
b Ad
vanc
emen
t Pr
opul
sion
Stab
ility
&
Bala
nce
Stan
ce
Cont
rol
Exam
ples
of i
ncre
asin
g ta
sk
varia
bilit
y/di
fficu
lty
•
Prop
ulsi
on
–G
uida
nce/
Ass
ist a
s nee
ded:
•
Ass
ista
nce
at p
elvi
s to
ensu
re fo
rwar
d pr
ogre
ssio
n (tr
eadm
ill
or o
verg
roun
d)
–
Tria
l and
err
or/E
rror
aug
men
tatio
n:
•R
esis
ted
wal
king
(ela
stic
resi
stan
ce a
t pel
vis/
trunk
) •
Add
ing
mas
s inc
reas
es p
ropu
lsiv
e de
man
ds
Prog
ress
ing
Bio
mec
hani
cal S
ubco
mpo
nent
sof
Wal
king
Lim
b Ad
vanc
emen
t Pr
opul
sion
Stab
ility
&
Bala
nce
Stan
ce
Cont
rol
Prog
ress
ing
Bio
mec
hani
cal S
ubco
mpo
nent
s of
Wal
king
Lim
b Ad
vanc
emen
t Pr
opul
sion
Stab
ility
&
Bala
nce
Stan
ce
Cont
rol
Exam
ples
of i
ncre
asin
g ta
sk
varia
bilit
y/di
fficu
lty
•La
tera
l/sag
ittal
stab
ility
–
Gui
danc
e/A
ssis
t as n
eede
d:
•Pr
ovid
e st
abili
zatio
n of
trun
k if
cann
ot m
aint
ain
uprig
ht p
ostu
re
•Ph
ysic
al a
ssis
tanc
e, e
last
ic a
ssis
tanc
e (h
old
hips
forw
ard/
in p
lace
; Su
lliva
n et
al 2
002)
•
Ass
istiv
e de
vice
(Che
n et
al 2
005)
–Tr
ial a
nd e
rror
/Err
or a
ugm
enta
tion
•
unst
able
or n
arro
w su
rfac
es (D
omin
go a
nd F
erris
, 200
8, 2
009)
•
back
war
d/si
dest
eppi
ng, r
unni
ng (A
da e
t al 2
003)
•
obst
acle
s, du
al p
hysi
cal t
asks
•
exte
rnal
ly a
pplie
d ho
rizon
tal f
orce
s (G
otts
chal
l and
Kra
m 2
003)
Prog
ress
ing
Bio
mec
hani
cal S
ubco
mpo
nent
s of
Wal
king
Lim
b Ad
vanc
emen
t Pr
opul
sion
Stab
ility
&
Bala
nce
Stan
ce
Cont
rol
Out
line
•In
trodu
ctio
n –
Theo
ry a
nd R
atio
nale
•D
evel
opm
ent a
nd A
pplic
atio
n –
Wal
king
Tra
inin
g Pa
radi
gm
–R
ando
miz
ed C
linic
al T
rial –
Ver
y In
tens
ive
Early
W
alki
ng p
ost-S
troke
(VIE
WS)
•K
now
ledg
e Tr
ansl
atio
n
•Im
plem
enta
tion
R
ando
miz
ed C
ontro
lled
Tria
l
•Su
bjec
ts
–Su
bacu
te*
–
Age
18-
75
–Si
ngle
uni
late
ral s
troke
–
MM
SE ≥
23
–m
od A
or a
mbu
late
< 0
.9 m
/s
(SSV
) –
Stra
tific
atio
n pr
ior t
o ra
ndom
izat
ion
(wal
king
sp
eed)
* –
N=3
2 re
quire
d fr
om e
ffect
si
zes
•In
terv
entio
n –≤
40 1
hour
sess
ions
ove
r 8-1
0 w
eeks
–
1 w
eek
forw
ard
TM tr
aini
ng
–7
wee
ks v
aria
ble
train
ing
•O
utco
mes
ass
essm
ent
–Pr
imar
y: S
SV &
6M
WT
– S
econ
dary
: 5X
sit-t
o-st
and,
B
erg
Bal
ance
Sca
le
(H
ornb
y et
al,
2015
)
VIE
WS:
Des
ign
Exp
erim
enta
l •
No
conc
urre
nt p
hysic
al th
erap
y •
Focu
sed
step
ping
trai
ning
up
to 4
0 1
hr se
ssio
ns
•H
igh
aero
bic
inte
nsity
(70-
80%
H
RR
) •
Skill
ed v
aria
ble
task
pra
ctic
e on
tre
adm
ill a
nd o
ver g
roun
d
Con
trol
•
Enco
urag
ed to
con
tinue
d ph
ysic
al
ther
apy
•Su
pple
men
tal s
essio
ns to
ach
ieve
40
sess
ions
•
Mul
tiple
act
iviti
es, l
imite
d pr
actic
e of
any
sing
le ta
sk (
Lang
, 200
9)
–B
alan
ce, S
treng
th, P
RO
M,
Tran
sfer
s –
Wal
king
: 800
-100
0 –
step
s/se
ssio
n=20
0 +
1500
step
s (in
itial
wal
king
spee
ds) (
Moo
re,
2010
) •
30-4
0% H
RR
(Mac
kay-
Lyon
s 20
03)
Base
line
Expe
rimen
tal
Cont
rol
p-va
lue
Dem
ogra
phic
s N=15
N=17 A
ge
57±1
2 60
±9.2
0.
31
Day
s pos
t-stro
ke 1
14±5
6 89
±44
0.16
Im
pair
men
ts
LE
Fugl
-Mey
er
20±5
.8
21±6
.2
0.63
P
HQ
-9
4.3±
3.5
3.2±
3.3
0.74
VIE
WS:
Gro
up C
ompa
rison
s
0.31
0.16
0.63
0.74
Bas
elin
e E
xper
imen
tal
Con
trol
p-
valu
e
Dem
ogra
phic
s
ses
sion
s, n
34±8
.9
33±8
.9
0.31
ste
ps/d
ay
4046
±259
6 25
72±1
689
<000
1
ste
ps/s
essi
on
2358
±860
94
8±48
9 <0
.001
ave
rage
pea
k R
PE18
±1.2
15
±1.8
0.
03
ave
rage
pea
k H
RR
74
±8.7
40
±5.4
<0
.001
VIE
WS:
Gro
up C
ompa
rison
s
0.31
<000
1
<0.0
01
0.03
<0.0
01
VIE
WS:
Gro
up C
ompa
rison
s
•Se
lf-se
lect
ed v
eloc
ity (0
.27±
0.22
vs
0.0
9±0.
09 m
/s)
•Fa
stes
t pos
sibl
e ve
loci
ty
(0.2
8±0.
20 v
s 0.1
1±0.
15 m
/s)
Sign
ifica
nt d
iffer
ence
in w
alki
ng m
easu
res (
p<0.
01)
•6
min
wal
k te
st (1
14±1
11 v
s
29
±32
m)
Betw
een
grou
p di
ffere
nces
wel
l abo
ve M
CID
for w
alki
ng o
utco
mes
VIE
WS:
Res
ults
Onl
y co
ntro
l gro
up p
ract
iced
tran
sfer
s and
bal
ance
, but
de
mon
stra
ted
no g
reat
er g
ains
than
exp
erim
enta
l gro
up
No
sign
ifica
nt b
etw
een
grou
p di
ffere
nce
in c
hang
es in
no
n-w
alki
ng m
easu
res
(p=0
.66)
(p=0
.95)
VIE
WS:
Res
ults
R
elat
ions
hip
betw
een
step
ping
dos
age
vs o
utco
mes
Am
ount
of p
ract
ice
rela
ted
to im
prov
emen
ts in
wal
king
VIE
WS:
Res
ults
R
elat
ions
hip
betw
een
peak
trai
ning
inte
nsity
vs o
utco
mes
In
tens
ity o
f pra
ctic
e re
late
d to
impr
ovem
ents
in w
alki
ng
“Wha
t abo
ut th
eir q
ualit
y of
gai
t?”
–G
reat
er h
ip fl
exio
n (3
0⁰±12 ⁰
to 3
7⁰ ±14⁰ *)
–G
reat
er k
nee
flexi
on-(3
7⁰ ±1
5⁰ to -43⁰ ±21⁰
*) –
Gre
ater
tota
l hip
RO
M –
kne
e an
d an
kle
vary
–Ch
ange
s in
fron
tal p
lane
de
viat
ions
•
Hip
abd
uctio
n –
2.8⁰*
•H
ip h
ikin
g (2
⁰)* •
Circ
umdu
ctio
n (4
cm
)
“Wha
t abo
ut th
eir q
ualit
y of
gai
t?”
– p
eak
hip
abdu
ctio
n
•5
of 2
3 pa
tient
s de
mon
stra
ted
hip
abdu
ctio
n >
5⁰ •
Posit
ivel
y co
rrel
ated
with
pea
k tr
eadm
ill sp
eed,
strid
e le
ngth
•
Neg
ativ
ely
corr
elat
ed w
ith b
asel
ine
low
er e
xtre
mity
Fug
l-Mey
er
•Do
they
eve
n ha
ve th
e ne
urom
uscu
lar s
ubst
rate
to w
alk
norm
ally
?
Case
1: H
istor
y
•52
yea
r old
mal
e; L
ICH
(sub
cort
ical
, ICH
) –
hype
rten
sion,
dys
phag
ia, a
phas
ia, a
cute
kid
ney
failu
re
–m
edic
atio
ns::
simva
stat
in, n
ifedi
pine
, dila
tin, d
igox
in, p
heno
barb
ital,
cloz
apin
e, m
etop
rolo
l
•So
cial
hx:
–
Live
d al
one
prio
r to
stro
ke
–Ad
mitt
ed to
nur
sing
hom
e af
ter m
edic
ally
stab
le p
ost-
stro
ke/m
inim
al
reha
bilit
atio
n
•St
arte
d in
tens
ive
reha
bilit
atio
n (s
tudy
) 4 m
onth
s pos
t-st
roke
•Ba
selin
e as
sess
men
ts
–FI
M:
Mod
ass
ist fo
r all
tran
sfer
s and
am
bula
tion
–5
x sit
to st
and:
una
ble
–Be
rg B
alan
ce S
cale
Sco
re: 5
/56
–se
lf-se
lect
ed g
ait s
peed
: 0 m
/s (u
nabl
e to
am
bula
te)
–6
min
ute
wal
k di
stan
ce: 0
feet
(una
ble
to a
mbu
late
)
Case
2: H
istor
y
•59
yea
r old
mal
e (>
300
lbs)
; L th
alam
ic/B
G s
trok
e; m
ass e
ffect
/mid
line
shift
–
acut
e re
nal i
nsuf
ficie
ncy/
hydr
onep
hros
is, H
TN, C
HF,
a-fib
, ast
hma,
LE
veno
us s
tasis
ul
cers
–
Med
icat
ions
: Pr
oton
ix, T
obra
dex,
Nor
vasc
, Vas
otec
, Kep
pra,
Hyd
rala
zine
•So
cial
hx:
–
Adm
itted
to n
ursin
g ho
me
afte
r med
ical
ly st
able
pos
t-st
roke
–
Fam
ily u
nabl
e to
ass
ist p
atie
nt; l
ived
with
wife
prio
r
•
Asse
ssm
ents
–
FIM
: M
od a
ssist
for a
ll tr
ansf
ers a
nd m
obili
ty it
ems
–Se
lf –
sele
cted
gai
t spe
ed: 0
m/s
(una
ble
to a
mbu
late
) –
Berg
Bal
ance
Sca
le S
core
: 7/5
6 –
6 m
inut
e w
alk
dist
ance
: 0 fe
et (u
nabl
e to
am
bula
te)
–5
x sit
to st
and:
una
ble
Out
line
•In
trodu
ctio
n –
Theo
ry a
nd R
atio
nale
•D
evel
opm
ent a
nd A
pplic
atio
n –
Wal
king
Tra
inin
g Pa
radi
gm
–R
ando
miz
ed C
linic
al T
rial –
Ver
y In
tens
ive
Early
W
alki
ng p
ost-S
troke
(VIE
WS)
•K
now
ledg
e Tr
ansl
atio
n
•Im
plem
enta
tion
Cl
inic
al D
ecisi
on-M
akin
g fo
r W
alki
ng T
rain
ing
Inte
rven
tions
Pa
tric
k H
enne
ssy,
PT,
NCS
, Jan
e W
oodw
ard,
PT,
NCS
, Ca
rey
Hol
lera
n, P
T, N
CS, T
. Geo
rge
Hor
nby,
PT,
PhD
Lect
ure
Out
line
•Pr
ogno
stic
lite
ratu
re fo
r wal
king
reco
very
in
stro
ke a
nd S
CI
•St
rate
gies
for l
ocom
otor
trai
ning
–
Revi
ewin
g bi
omec
hani
cal s
ubco
mpo
nent
s of
gai
t –
Disc
ussin
g gr
adin
g ch
alle
nge
of ta
sk
•Co
nsid
erat
ions
for i
mpl
emen
tatio
n •
Case
Stu
dies
Lect
ure
Out
line
•Pr
ogno
stic
lite
ratu
re fo
r wal
king
reco
very
in
stro
ke a
nd S
CI
•St
rate
gies
for l
ocom
otor
trai
ning
–
Revi
ewin
g bi
omec
hani
cal s
ubco
mpo
nent
s of
gai
t –
Disc
ussin
g gr
adin
g ch
alle
nge
of ta
sk
•Co
nsid
erat
ions
for i
mpl
emen
tatio
n •
Case
Stu
dies
Is w
alki
ng a
ppro
pria
te fo
r my
patie
nt?
A re
view
of p
rogn
ostic
fact
ors &
clin
ical
pre
dict
ion
rule
s in
post
-str
oke
wal
king
func
tion
Pred
ictio
n ru
les f
or lo
com
otor
reco
very
fo
llow
ing
stro
ke
•
Veer
beek
et a
l (N
NR)
, 201
1
•Th
e EP
OS
Stud
y
•Pa
tient
s’ in
depe
nden
t sitt
ing
bala
nce
and
leg
stre
ngth
in fi
rst 3
da
ys p
redi
cted
wal
king
func
tion
at 6
mon
ths
98
% w
alke
d in
depe
nden
tly (F
AC>4
) at 6
mon
ths w
ith M
I>25
or
1.In
depe
nden
t sitt
ing
edge
of b
ed fo
r 30
seco
nds (
TCT-
sittin
g)
2.Vi
sible
con
trac
tion
in h
ip fl
exor
s, k
nee
exte
nsor
s and
dor
sifle
xors
OR
Man
ual r
esist
ance
aga
inst
one
of t
he m
uscl
es
•
27%
wal
ked
inde
pend
ently
if cr
iteria
not
met
at 3
day
s pos
t-st
roke
•
10%
wal
ked
inde
pend
ently
if cr
iteria
not
met
at 9
day
s pos
t-st
roke
Pred
ictio
n ru
les f
or lo
com
otor
reco
very
fo
llow
ing
stro
ke
•Bl
and
et a
l (PT
J), 2
012
•Cl
inic
al p
redi
ctio
n ru
le to
diff
eren
tiate
hou
seho
ld fr
om
com
mun
ity w
alke
rs a
t disc
harg
e fr
om in
patie
nt re
hab
•Cr
oss-
valid
ated
, ret
rosp
ectiv
e co
hort
stud
y
•Lo
wer
adm
it ba
lanc
e (B
BS≤2
0) a
nd w
alki
ng fu
nctio
n (F
IM-
wal
k ≤2
) ind
icat
es a
hig
h lik
elih
ood
of o
nly
achi
evin
g ho
useh
old
ambu
latio
n sp
eeds
•Pr
esto
n et
al 2
011
•In
itial
ly n
on-a
mbu
lato
ry s
trok
e pa
tient
s m
anag
ed in
re
habi
litat
ion
or a
cute
car
e un
its
•Pr
obab
ility
of i
ndep
ende
nt w
alki
ng
–60
% (9
5% C
I 47-
74%
) at 3
mon
ths (
9 st
udie
s)
–65
% (9
5% C
I 53%
–77%
) at 6
mon
ths (
3 st
udie
s)
–91
% (9
5% C
I 81%
–100
%) a
t 12m
onth
s (1
stud
y)
Syst
emat
ic R
evie
w o
f Str
oke
Pred
icto
rs
Syst
emat
ic R
evie
w o
f Str
oke
Pred
icto
rs
Kwak
kel a
nd c
olle
ague
s su
gges
ted
pred
icto
rs (1
996)
•
age
•pr
evio
us st
roke
•
urin
ary
cont
inen
ce
•co
nsci
ousn
ess a
t ons
et
•di
sorie
ntat
ion
in ti
me
and
plac
e •
seve
rity
of p
aral
ysis
•sit
ting
bala
nce
•ad
miss
ion
ADL
scor
e
•le
vel o
f soc
ial s
uppo
rt
•m
etab
olic
rate
of g
luco
se o
utsid
e th
e in
farc
t are
a in
hyp
erte
nsiv
e pa
tient
s
Mei
jer a
nd c
olle
ague
s (20
03)
•in
suffi
cien
t qua
lity
of d
ata
to p
rovi
de
pred
ictio
ns
•so
me
evid
ence
for p
oore
r out
com
es w
ith:
•lo
w in
itial
ADL
func
tioni
ng
•hi
gh a
ge
•co
gniti
ve d
istur
banc
e •
pare
sis o
f the
lim
bs
•re
duce
d in
itial
leve
l of c
onsc
ious
ness
•
prev
ious
hem
iple
gia
•ho
mon
ymou
s hem
iano
pia
•vi
sual
ext
inct
ion
•co
nstr
uctio
nal a
prax
ia
•no
adm
issio
n to
a st
roke
uni
t •
non-
lacu
nar s
trok
e •
visu
ospa
tial c
onst
ruct
ion
prob
lem
s •
urin
ary
inco
ntin
ence
•
fem
ale
gend
er
Clin
ical
take
-hom
e fr
om a
vaila
ble
stro
ke li
tera
ture
? •
Low
er in
itial
func
tiona
l sta
tus h
as b
een
iden
tifie
d as
hav
ing
low
er p
roba
bilit
y of
ach
ievi
ng in
depe
nden
t wal
king
at
disc
harg
e fr
om in
patie
nt re
hab
or in
long
term
follo
w-u
p
•Av
aila
ble
body
of l
itera
ture
has
not
trac
ked
inte
rven
tions
re
ceiv
ed d
urin
g re
habi
litat
ion
• “d
iffer
ence
s in
obje
ctiv
es a
nd h
eter
ogen
eity
in st
roke
pat
ient
s re
spon
sible
for t
he la
ck o
f acc
urac
y in
pre
dict
ing
func
tiona
l ou
tcom
e, b
ut a
lso th
e m
etho
dolo
gica
l fla
ws i
n pu
blish
ed
prog
nost
ic re
sear
ch”
Pred
icto
rs fo
r loc
omot
or re
cove
ry fo
llow
ing
SCI
In
itial
AIS
exa
m
•Sa
cral
Spa
ring
(Ole
son)
•
Anal
sens
atio
n
(M
arin
o 20
04)
•LE
pin
pric
k (O
leso
n)
•LE
MS
scor
es
–Q
uadr
icep
s (C
roze
r)
–H
ip fl
exor
s (H
usse
y)
Lim
itatio
ns
•Sm
all s
ampl
e siz
es
•N
ot c
ross
-val
idat
ed
•Ca
nnot
iden
tify
prob
abili
ty o
f wal
king
ba
sed
on in
divi
dual
ex
am fi
ndin
gs
Clin
ical
pre
dict
ion
rule
for l
ocom
otor
re
cove
ry fo
llow
ing
SCI
AI
S te
stin
g ad
min
ister
ed w
ithin
15
days
and
1 y
ear p
ost-
inju
ry
Inde
pend
ent w
alki
ng (S
CIM
) use
d as
prim
ary
outc
ome
1.Lo
wer
Ext
rem
ity M
otor
Sco
res (
0-5)
for q
uadr
icep
s and
pla
ntar
flexo
rs
2.Se
nsor
y sc
orin
g (li
ght t
ouch
) for
L3
and
S1 d
erm
atom
es (0
- non
e, 1
= im
paire
d,
2 =
norm
al)
3.Ag
e (>
or <
65)
Ra
nge
Wei
ghte
d Co
effic
ient
M
in
Max
Age ≥6
5 ye
ars
0-1
-10
-10
0 M
otor
L3
0-
5 2
0 10
M
otor
S1
0-
5 2
0 10
Se
nsor
y L3
0-
2 5
0 10
Se
nsor
y S1
0-
2 5
0 10
To
tal
-10
40
(van
Mid
dend
orp,
201
1)
Patie
nt C
ase
Exam
ple
•34
yo
mal
e T1
2 AI
S B
SCI s
/p p
edes
tria
n vs
car
•
9 da
ys p
ost S
CI to
adm
issio
n (A
IS e
xam
10
days
pos
t)
•24
day
s pos
t SCI
to in
itiat
ing
wal
king
Ra
nge
Wei
ghte
d Co
effic
ient
CP
R Sc
ore
Age ≥6
5 ye
ars
0 -1
0 0
Mot
or L
3
0 2
0 M
otor
S1
0
2 0
Sens
ory
L3
1 5
5 Se
nsor
y S1
2
5 10
To
tal
15
(van
Mid
dend
orp,
201
1)
Patie
nt C
ase
Exam
ple
•4-
5x/w
eek
up to
45m
inut
es o
f wal
king
with
targ
et
trai
ning
inte
nsity
•
Wee
kly
LEM
S re
-ass
essm
ent
•Lo
wer
ext
rem
ity m
otor
retu
rn id
entif
ied
8 da
ys p
ost
initi
atin
g w
alki
ng tr
aini
ng
•Di
scha
rged
from
inpa
tient
reha
b am
bula
ting
>200
’ w
ith su
perv
ision
+ A
D/br
acin
g (M
od I
in C
omm
unity
w
ithin
4 m
onth
s po
st-S
CI
•Co
nsid
erat
ions
Lect
ure
Out
line
•Pr
ogno
stic
lite
ratu
re fo
r wal
king
reco
very
in
stro
ke a
nd S
CI
•St
rate
gies
for l
ocom
otor
trai
ning
–
Revi
ewin
g bi
omec
hani
cal s
ubco
mpo
nent
s of
gai
t –
Disc
ussin
g gr
adin
g ch
alle
nge
of ta
sk
•Co
nsid
erat
ions
for i
mpl
emen
tatio
n •
Case
Stu
dies
Vide
o ex
ampl
e 1
Wha
t gai
t var
iabl
es d
o yo
u m
anip
ulat
e?
Grad
ing
chal
leng
e w
ithin
the
cont
ext o
f st
eppi
ng tr
aini
ng
Biom
echa
nica
l Sub
com
pone
nts o
f Wal
king
Lim
b Sw
ing
Prop
ulsio
n St
abili
ty &
Ba
lanc
e St
ance
co
ntro
l
Cons
ider
atio
ns
•Co
gniti
on/la
ngua
ge
–Fe
edba
ck a
nd C
omm
unic
atio
n st
rate
gies
•An
ticip
ated
disc
harg
e se
ttin
g/pl
ans
–
POC
carr
yove
r aft
er d
ischa
rge
–Tr
aini
ng fa
mily
/car
egiv
ers
–Pa
tient
adv
ocac
y/di
rect
ion
of c
are
•
Oth
er m
edic
al is
sues
–
Card
iova
scul
ar, r
espi
rato
ry, m
etab
olic
stat
us
–Sk
in a
nd w
ound
s •
Line
/med
ical
equ
ipm
ent m
anag
emen
t –
PEG
,trac
h,ve
nt, I
V,
–Pa
ddin
g/m
odify
ing
harn
ess f
or P
EG,
–Ca
thet
er c
onsid
erat
ions
Ort
hope
dic
conc
erns
O
rtho
tics &
Ass
istiv
e De
vice
s
•Ce
rvic
al/t
hora
cic
ort
hose
s (H
alo,
Som
i, TL
SO,
etc.
) and
oth
er o
rtho
pedi
c co
nsid
erat
ions
•
Low
er e
xtre
mity
bra
cing
–
Tria
l vs p
erm
anen
t bra
cing
–
Brac
ing
chan
ges f
or h
igh
inte
nsity
trai
ning
•
Upp
er e
xtre
mity
con
sider
atio
ns
–Sl
ings
, Giv
-Moh
r, sh
ould
er c
uff -
–
Fing
er/g
rasp
func
tion
with
out p
ain
(str
appi
ng to
ha
ndra
ils)
Lect
ure
Out
line
•Pr
ogno
stic
lite
ratu
re fo
r wal
king
reco
very
in
stro
ke a
nd S
CI
•St
rate
gies
for l
ocom
otor
trai
ning
–
Revi
ewin
g bi
omec
hani
cal s
ubco
mpo
nent
s of
gai
t –
Disc
ussin
g gr
adin
g ch
alle
nge
of ta
sk
•Co
nsid
erat
ions
for i
mpl
emen
tatio
n •
Case
Stu
dies
Case
Stu
dy: I
npat
ient
Reh
ab
•63
yo
mal
e •
Righ
t int
race
rebr
al
thal
amic
and
bas
al
gang
lia h
emor
rhag
e w
ith IV
H
•PM
H: H
TN
•W
ork-
up: E
F 60
% m
ild
LVH
and
mild
atr
ial
enla
rgem
ent
•Im
pairm
ents
: –
0 to
2-/
5 LL
E st
reng
th
–Li
ght t
ouch
and
pr
oprio
cept
ion:
Ab
sent
–
Impa
ired
dyna
mic
sit
ting
bala
nce
•G
oals
: Hou
seho
ld
ambu
latio
n an
d st
airs
Vid
eo
Out
com
e M
easu
res
FIM
Tr
ansf
er
FIM
Am
b FI
M
Stai
rs
6MW
T 10
MW
T BB
S
Wee
k 1
Max
A
17’ T
A N
T N
T N
T 4/
56
Wee
k 1.
5 60
’ max
A,
hem
i-W
Wee
k 2
Mod
A
Max
A
12 st
eps
mod
A
114’
max
A,
hem
i-W
.13
m/s
m
ax A
7/
56
Wee
k 3
Min
A
Mod
A
12 st
eps
mod
A
185’
mod
A,
LBQ
C
.18m
/s
Mod
A
10/5
6
Wee
k 4
CS
Min
A
28 st
eps
mod
A
227’
,min
A,
LBQ
C .2
3 m
/s
Min
A
14/5
6
6 m
onth
f/
u 31
1’ C
S,
SBQ
C .2
7 m
/s
CS
28/5
6
FITT
Prin
cipl
e •
Wee
k 1
and
2 –
Freq
uenc
y: 4
-5x/
wee
k
–In
tens
ity:
•G
oal t
arge
t HR
rang
e: 1
04-1
27bp
m (7
0-85
% H
Rmax
) ad
just
ed fo
r bet
a-bl
ocks
, RPE
≥14
•
Actu
al H
R ra
nge:
75-
102b
pm (5
0-68
% H
Rmax
), RP
E 12
-15
–Ti
me:
30
or 6
0 m
in se
ssio
ns
•Am
b 15
-20
min
s
–Ty
pe:
•Tr
eadm
ill: F
irst 5
trai
ning
sess
ions
(6 to
tal)
•St
airs
: 2 se
ssio
ns
•O
verg
roun
d: 1
sess
ion
HR
Calc
ulat
or
FITT
Prin
cipl
e •
Wee
k 1
and
2 –
Freq
uenc
y: 4
-5x/
wee
k
–In
tens
ity:
•G
oal t
arge
t HR
rang
e: 1
00-1
24bp
m (7
0-85
%) a
djus
t for
be
ta-b
lock
s, R
PE ≥
14
•Ac
tual
HR
rang
e: 7
5-10
2bpm
(50-
68%
), RP
E 12
-15
–Ti
me:
30
or 6
0 m
in s
essi
ons
•Am
b 15
-20
min
s
–Ty
pe:
•Tr
eadm
ill: 6
trai
ning
ses
sion
s
•St
airs
: 2 s
essi
ons
•
Ove
rgro
und:
1 s
essi
on
Trea
dmill
and
Ove
rgro
und
Out
com
e M
easu
res
FIM
Tr
ansf
er
FIM
Am
b FI
M
Stai
rs
6MW
T 10
MW
T BB
S
Wee
k 1
Max
A
17’ T
A N
T N
T N
T 4/
56
Wee
k 1.
5 60
’ max
A,
hem
i-W
Wee
k 2
Mod
A
Max
A
12 st
eps
mod
A
114’
max
A,
hem
i-W
.13
m/s
m
ax A
7/
56
Wee
k 3
Min
A
Mod
A
12 st
eps
mod
A
185’
mod
A,
LBQ
C
.18m
/s
Mod
A
10/5
6
Wee
k 4
CS
Min
A
28 st
eps
mod
A
227’
,min
A,
LBQ
C .2
3 m
/s
Min
A
14/5
6
6 m
onth
f/
u 31
1’ C
S,
SBQ
C .2
7 m
/s
CS
28/5
6
FITT
Prin
cipl
e •
Wee
k 3
and
4 –
Freq
uenc
y: 7
-12x
/wee
k –
Inte
nsity
: •
Goa
l tar
get H
R ra
nge:
100
-124
bpm
(70-
85%
) adj
ust f
or b
eta-
bloc
ks, R
PE ≥
14
•Ac
tual
HR
rang
e: 8
0-12
0bpm
(54-
81%
), RP
E 13
-16
–Ti
me:
30
or 6
0 m
in se
ssio
ns
•Am
b 26
min
s –
Type
: •
Trea
dmill
: 4 se
ssio
ns
–Va
riabl
e/er
ror a
dapt
atio
n •
Stai
rs: 5
sess
ions
•
Ove
rgro
und:
11
sess
ions
–
Varia
ble/
erro
r ada
ptat
ion
•Fa
mily
Tra
inin
g: 4
sess
ions
Out
com
e M
easu
res
FIM
Tr
ansf
er
FIM
Am
b FI
M
Stai
rs
6MW
T 10
MW
T BB
S
Wee
k 1
Max
A
17’ T
A N
T N
T N
T 4/
56
Wee
k 1.
5 60
’ max
A,
hem
i-W
Wee
k 2
Mod
A
Max
A
12 st
eps
mod
A
114’
max
A,
hem
i-W
.13
m/s
m
ax A
7/
56
Wee
k 3
Min
A
Mod
A
12 st
eps
mod
A
185’
mod
A,
LBQ
C
.18m
/s
Mod
A
10/5
6
Wee
k 4
CS
Min
A
28 st
eps
mod
A
227’
,min
A,
LBQ
C .2
3 m
/s
Min
A
14/5
6
6 m
onth
f/
u 31
1’ C
S,
SBQ
C .2
7 m
/s
CS
28/5
6
Vide
o
Key
Fact
ors
•Su
ppor
tive
Fam
ily
•Co
nsist
ent g
ait t
rain
ing
stra
tegi
es a
mon
gst P
T te
am
•Pa
tient
mot
ivat
ion
–Ex
plic
it go
als
–Ad
ditio
nal P
T se
ssio
ns
•Ea
rly im
plem
enta
tion
of g
ait t
rain
ing
Case
Stu
dy 2
: Out
patie
nt
•67
yo
fem
ale
•1
year
pos
t R M
CA in
farc
t –
20 d
ays a
cute
inpa
tient
reha
b –
SNF
~4 m
onth
s pr
ior t
o di
scha
rge
hom
e
•PM
H: H
TN, H
LD
•Le
ft n
egle
ct a
nd v
isual
fiel
d cu
t
Base
line
Test
ing
Out
com
e M
easu
res
5XST
S
BBS
6MW
T (S
SV)
Gai
tMat
SS
V
Base
line
unab
le
17/5
6 15
8’ w
ith
SBQ
C, C
GA
.08m
/s
Post
4
Wee
ks
28.9
sec
31/5
6 26
6’ w
ith
SBQ
C, C
GA
.31m
/s
Post
8
Wee
ks
13.1
sec
34/5
6
423’
with
SB
QC,
CG
A
.28m
/s
6 M
onth
Fo
llow
-up
unab
le
26/5
6 34
5’ w
ith
SBQ
C, C
GA
Inte
rven
tion
–Fr
eque
ncy:
4-5
x/w
eek
–In
tens
ity:
•G
oal t
arge
t HR
rang
e: 1
33-1
43bp
m (7
0-80
%H
RR) a
djus
t for
be
ta-b
lock
s, R
PE ≥
14
•Ac
tual
HR
rang
e: 1
38-1
45bp
m R
PE 1
5-17
–Ti
me:
60
min
sess
ions
•
Amb
up to
40
min
s
–Ty
pe:
•Tr
eadm
ill sp
eed-
depe
nden
t (25
%)
•Tr
eadm
ill v
aria
ble
(25%
) •
Stai
rs (2
5%)
•O
verg
roun
d va
riabl
e (2
5%)
Out
com
e M
easu
res
5XST
S
BBS
6MW
T (S
SV)
Gai
tMat
SS
V
Base
line
unab
le
17/5
6 15
8’ w
ith
SBQ
C, C
GA
.08m
/s
Post
4
Wee
ks
28.9
sec
31
/56
266’
with
SB
QC,
CG
A .3
1m/s
Post
8
Wee
ks
13.1
sec
34
/56
42
3’ w
ith
SBQ
C, C
GA
.28m
/s
6 M
onth
Fo
llow
-up
unab
le
26/5
6 34
5’ w
ith
SBQ
C, C
GA
.20m
/s
Key
fact
ors:
•Ad
ditio
nal s
trat
egie
s nee
ded
for:
–Fe
ar o
f fal
ling
–Ap
preh
ensiv
e of
new
cha
lleng
es
–De
cond
ition
ed a
nd re
quire
d re
sts
–Ad
ditio
nal t
ime
to c
ompl
ete
test
s
•M
otiv
atio
n?
•Su
ppor
tive
fam
ily
Que
stio
ns??
Refe
renc
es:
Ada
L, D
ean
CM, H
all J
M, B
ampt
on J,
Cro
mpt
on S
. A tr
eadm
ill a
nd o
verg
roun
d w
alki
ng p
rogr
am im
prov
es w
alki
ng in
pe
rson
s re
sidi
ng in
the
com
mun
ity a
fter
stro
ke: a
pla
cebo
-con
trol
led,
rand
omize
d tr
ial.
Arch
Phy
s M
ed R
ehab
il 20
03;8
4:14
86-9
1 Ba
rbea
u H
, Vis
intin
M. O
ptim
al O
utco
mes
Obt
aine
d w
ith B
ody-
Wei
ght S
uppo
rt C
ombi
ned
with
Tre
adm
ill T
rain
ing
in
Stro
ke S
ubje
cts.
Arc
h Ph
ys M
ed R
ehab
il. 2
003;
84:
145
8-14
65
Barb
eau
H. L
ocom
otor
trai
ning
in n
euro
reha
bilit
atio
n: e
mer
ging
reha
bilit
atio
n co
ncep
ts.N
euro
reha
bil N
eura
l Rep
air.
2003
Mar
;17(
1):3
-11.
Rev
iew
Ch
en G
, Pat
ten
C, K
otha
ri DH
, Zaj
ac F
E. G
ait d
evia
tions
ass
ocia
ted
with
pos
t-st
roke
hem
ipar
esis:
impr
ovem
ent d
urin
g tr
eadm
ill w
alki
ng u
sing
wei
ght s
uppo
rt, s
peed
, sup
port
stif
fnes
s, a
nd h
andr
ail h
old.
Gai
t & p
ostu
re 2
005;
22:5
7-62
Do
min
go A
, Fer
ris D
P Ef
fect
s of
phy
sical
gui
danc
e on
sho
rt-t
erm
lear
ning
of w
alki
ng o
n a
narr
ow b
eam
. Gai
t Pos
ture
. 20
09 N
ov;3
0(4)
:464
-8.
Dom
ingo
A, F
erris
DP
The
effe
cts
of e
rror
aug
men
tatio
n on
lear
ning
to w
alk
on a
nar
row
bal
ance
bea
m. E
xp B
rain
Res
. 20
10 O
ct;2
06(4
):359
-70
Got
tsch
all J
S, K
ram
R. E
nerg
y co
st a
nd m
uscu
lar a
ctiv
ity re
quire
d fo
r pro
puls
ion
durin
g w
alki
ng. J
App
l Phy
siol
20
03;9
4:17
66-7
2 G
rabo
wsk
i A e
t al.
Inde
pend
ent m
etab
olic
cos
ts o
f sup
port
ing
body
wei
ght a
nd a
ccel
erat
ing
body
mas
s du
ring
wal
king
. ou
rnal
of A
pplie
d Ph
ysio
logy
Feb
ruar
y 1,
200
5 vo
l. 98
no.
2 5
79-5
83
Har
kem
a SJ
et a
l. H
uman
lum
bosa
cral
spi
nal c
ord
inte
rpre
ts lo
adin
g du
ring
step
ping
. J N
euro
phys
iol.
1997
Fe
b;77
(2):7
97-8
11.
Hes
se S
et a
l. [D
evel
opm
ent o
f a g
ait t
rain
er w
ith re
gula
ted
serv
o-dr
ive
for r
ehab
ilita
tion
of lo
com
otor
dis
able
d pa
tient
s]. B
iom
ed T
ech
(Ber
l). 1
997
Jul-A
ug;4
2(7-
8):1
96-2
02
Hes
se S
, Rei
ter F
, Jah
nke
M, D
awso
n M
, Sar
kodi
e-Gy
an T
, Mau
ritz
KH. A
sym
met
ry o
f gai
t ini
tiatio
n in
hem
ipar
etic
str
oke
subj
ects
. Arc
h Ph
ys M
ed R
ehab
il. 1
997;
78:7
19-7
24
Hol
lera
n et
al,
Feas
ibili
ty a
nd P
oten
tial E
ffica
cy o
f Hig
h-In
tens
ity S
tepp
ing
Trai
ning
in V
aria
ble
Cont
exts
in S
ubac
ute
and
Chro
nic
Stro
ke. N
euro
reha
bilit
atio
n an
d N
eura
l Rep
air.
2014
In P
ress
Ki
m, C
M, E
ng, J
J. Sy
mm
etry
in v
ertic
al g
roun
d re
actio
n fo
rce
is a
ccom
pani
ed b
y sy
mm
etry
in te
mpo
ral b
ut n
ot d
istan
ce
varia
bles
of g
ait i
n pe
rson
s w
ith st
roke
. Gai
t Pos
ture
. 200
3 Au
g;18
(1):2
3-8.
Refe
renc
es:
Kwak
kel G
, Wag
enaa
r R, K
olle
n BJ
, Lan
khor
st G
J. Pr
edic
ting
disa
bilit
y in
stro
ke –
a c
ritic
al re
view
of t
he li
tera
ture
. Age
Ag
eing
199
6; 2
5:47
9–86
. La
m T
et a
l. Tr
eadm
ill-b
ased
loco
mot
or tr
aini
ng w
ith le
g w
eigh
ts to
enh
ance
func
tiona
l am
bula
tion
in p
eopl
e w
ith
chro
nic
stro
ke: a
pilo
t stu
dy. J
Neu
rol P
hys
Ther
. 200
9 Se
p;33
(3):1
29-3
5 La
m T
, Wirz
M, L
unen
burg
er L
, Die
tz V
. Sw
ing
phas
e re
sista
nce
enha
nces
flex
or m
uscl
e ac
tivity
dur
ing
trea
dmill
lo
com
otio
n in
inco
mpl
ete
spin
al c
ord
inju
ry. N
euro
reha
bil N
eura
l Rep
air 2
008;
22:4
38-4
6.
Mei
jer R
, Ihn
enfe
ldt D
S, v
an L
imbe
ek J,
Ver
meu
len
M, d
e H
aan
RJ. P
rogn
ostic
fact
ors
in th
e su
bacu
te p
hase
aft
er st
roke
fo
r the
futu
re re
side
nce
afte
r six
mon
ths
to o
ne y
ear.
A sy
stem
atic
revi
ew o
f the
lite
ratu
re. C
lin R
ehab
il 20
03;
17:5
12–2
0.
Pres
ton
E1, A
da L
, Dea
n CM
, Sta
nton
R, W
addi
ngto
n G
. Wha
t is
the
prob
abili
ty o
f pat
ient
s w
ho a
re n
onam
bula
tory
aft
er
stro
ke re
gain
ing
inde
pend
ent w
alki
ng?
A sy
stem
atic
revi
ew. I
nt J
Stro
ke. 2
011
Dec;
6(6)
:531
-40.
Sa
vin
DN1,
Mor
ton
SM, W
hita
ll J.
Gen
eral
izatio
n of
impr
oved
step
leng
th sy
mm
etry
from
trea
dmill
to o
verg
roun
d w
alki
ng in
per
sons
with
stro
ke a
nd h
emip
ares
is. C
lin N
euro
phys
iol.
2013
Nov
8. p
ii: S
1388
-245
7(13
)011
67-X
. Su
lliva
n K,
Kno
wlto
n B,
Dob
kin
B. S
tep
Trai
ning
with
Bod
y W
eigh
t Sup
port
: Effe
ct o
f Tre
adm
ill S
peed
and
Pra
ctic
e Pa
radi
gms
on P
osts
trok
e Lo
com
otor
Rec
over
y. A
rch
Phys
Med
Reh
abil.
200
2; 8
3: 6
83-6
91.
Um
berg
er B
R. S
tanc
e an
d sw
ing
phas
e co
sts
in h
uman
wal
king
. J R
Soc
Inte
rfac
e. 2
010
Sep
6;7(
50):1
329-
40.
van
Mid
dend
orp,
JJ e
t al.
A c
linic
al p
redi
ctio
n ru
le fo
r am
bula
tion
outc
omes
aft
er tr
aum
atic
spi
nal c
ord
inju
ry: a
lo
ngitu
dina
l coh
ort s
tudy
. Lan
cet.
2011
Mar
19;
377(
9770
):100
4-10
Ve
erbe
ek JM
et a
l. Is
acc
urat
e pr
edic
tion
of g
ait i
n no
nam
bula
tory
stro
ke p
atie
nts
poss
ible
with
in 7
2 ho
urs
post
stro
ke?
The
EPO
S st
udy.
Neu
rore
habi
l Neu
ral R
epai
r. 20
11 M
ar-A
pr;2
5(3)
:268
-74.
Vi
sint
in, M
., H
. Bar
beau
, N. K
orne
r-Bi
tens
ky, a
nd N
. E. M
ayo.
A n
ew a
ppro
ach
to re
trai
n ga
it in
stro
ke p
atie
nts
thro
ugh
body
wei
ght s
uppo
rt a
nd tr
eadm
ill st
imul
atio
n. S
trok
e. 2
9:11
22-1
128,
199
8
Kno
wle
dge
Tran
slat
ion
Stra
tegi
es
Jenn
ifer M
oore
PT,
DH
S, N
CS
C
linic
al P
ract
ice
Lead
er, N
euro
logi
c P
hysi
cal T
hera
py
Reh
abili
tatio
n In
stitu
te o
f Chi
cago
Kno
wle
dge
Tran
slat
ion
(KT)
the
dyna
mic
and
iter
ativ
e pr
oces
s th
at
incl
udes
the
synt
hesi
s, d
isse
min
atio
n,
exch
ange
and
eth
ical
ly s
ound
ap
plic
atio
n of
kno
wle
dge
to im
prov
e he
alth
, pro
vide
mor
e ef
fect
ive
heal
th
serv
ices
and
pro
duct
s, a
nd s
treng
then
th
e he
alth
car
e sy
stem
.
- Can
adia
n In
stitu
te o
f Hea
lth R
esea
rch
2
Evi
denc
e-B
ased
Pra
ctic
e (E
BP
) inte
grat
ion
of th
e be
st re
sear
ch
evid
ence
with
cl
inic
al e
xper
tise
and
patie
nt v
alue
s an
d ci
rcum
stan
ces
to m
ake
clin
ical
dec
isio
ns.
3
Kno
wle
dge
Tran
slat
ion:
pr
oces
s us
ed to
im
plem
ent t
he
evid
ence
.
Clin
icia
n
Coo
rdin
ated
pro
cess
be
twee
n al
l st
akeh
olde
rs
The
Cha
lleng
e of
K
now
ledg
e Tr
ansl
atio
n (K
T)
• >
17 y
ears
for e
vide
nce
to b
e us
ed c
linic
al p
ract
ice
(Mor
ris, 2
011)
• K
T is
mul
ti-fa
cete
d (S
traus
s, 2
009)
•
Pat
ient
•
Indi
vidu
al C
linic
ian
• O
rgan
izat
iona
l lea
ders
/sta
keho
lder
s •
Pol
itica
l •
Eco
nom
ic
4
Mon
itor
Kno
wle
dge
Use
Sust
ain
Kno
wle
dge
Use
Eva
luat
eO
utco
mes
Ada
ptK
now
ledg
eto
Loc
al C
onte
xt
Ass
ess
Bar
rier
s to
K
now
ledg
e U
se
Sele
ct, T
ailo
r,Im
plem
ent
Inte
rven
tion
s
Iden
tify
Pro
blem
Iden
tify
, Rev
iew
,Se
lect
Kno
wle
dge
Pro
duct
s/To
ols
Synt
hesi
s
Kno
wle
dge
Inqu
iry
KN
OW
LE
DG
E C
RE
AT
ION
Gra
ham
200
6K
now
ledg
e-to
-Act
ion
Fra
mew
ork
KT
Wor
kshe
et In
stru
ctio
ns
Tran
slat
ion
to c
linic
al p
ract
ice:
Cha
lleng
es a
nd s
olut
ions
tow
ards
im
plem
entin
g tra
inin
g in
terv
entio
ns in
th
e cl
inic
al s
ettin
g.
Mon
itor
Kno
wle
dge
Use
Sust
ain
Kno
wle
dge
Use
Eva
luat
eO
utco
mes
Ada
ptK
now
ledg
eto
Loc
al C
onte
xt
Ass
ess
Bar
rier
s to
K
now
ledg
e U
se
Sele
ct, T
ailo
r,Im
plem
ent
Inte
rven
tion
s
Iden
tify
Pro
blem
Iden
tify
, Rev
iew
,Se
lect
Kno
wle
dge
Pro
duct
s/To
ols
Synt
hesi
s
Kno
wle
dge
Inqu
iry
KN
OW
LE
DG
E C
RE
AT
ION
Gra
ham
200
6K
now
ledg
e-to
-Act
ion
Fra
mew
ork
Iden
tify
the
prob
lem
: Ti
ps
• Sta
rt w
ith a
cle
ar s
tate
men
t of t
he p
robl
em
• Eng
age
repr
esen
tativ
es fr
om s
take
hold
er g
roup
s • D
eter
min
e pr
oces
s to
iden
tify
prob
lem
•
Cha
rt au
dits
•
Sur
veys
(cur
rent
pra
ctic
e, p
ersp
ectiv
es, o
rgan
izat
iona
l cl
imat
e)
• O
bser
vatio
n •
Com
pete
ncy
asse
ssm
ent (
skill
s or
kno
wle
dge
ques
tionn
aire
s)
• Fo
cus
grou
ps
Hig
h In
tens
ity T
rain
ing
for
Ste
ppin
g (H
ITs)
P
robl
em:
Are
pat
ient
s ad
mitt
ed to
in
patie
nt re
habi
litat
ion:
•
Ass
esse
d w
ith a
sta
ndar
d ga
it an
d ba
lanc
e as
sess
men
t ba
ttery
? •
Trea
ted
with
a h
igh
inte
nsity
gai
t tra
inin
g in
terv
entio
n th
at:
• M
axim
izes
ste
ppin
g pr
actic
e •
Ach
ieve
s hi
gh a
erob
ic in
tens
ities
•
Pro
vide
s va
riabi
lity
in s
tepp
ing
task
s w
ith p
rogr
essi
on o
f act
iviti
es
• M
onito
red
with
an
outc
ome
mea
sure
men
t bat
tery
? 10
Iden
tify
the
prob
lem
• D
efin
e th
e pr
oble
m
• C
urre
nt P
ract
ice
• 10
% o
f pat
ient
s ha
d an
out
com
e m
easu
rem
ent a
dmin
iste
red
(Moo
re e
t al,
2010
)
• 35
7 st
eps/
sess
ion
(Lan
g et
al,
2009
); 88
6 st
eps/
sess
ion
(Moo
re e
t al,
2010
)
• D
esire
d P
ract
ice
(Moo
re e
t al,
2010
; Hol
lera
n et
al,
2014
; Stra
ube
et a
l, 20
14 )
• R
outin
e ad
min
istra
tion
of o
utco
me
mea
sure
s •
Max
imiz
e hi
gh in
tens
ity s
tepp
ing
• Va
riabi
lity
of lo
com
otor
tas
ks
• D
efin
e m
easu
rabl
e ob
ject
ives
for t
he p
roje
ct
HIT
s O
bjec
tives
• Ide
ntify
bar
riers
to p
rovi
ding
HIT
s in
inpa
tient
re
habi
litat
ion
• Im
plem
ent K
T in
terv
entio
ns ta
rget
ing
the
iden
tifie
d ba
rrie
rs
• Det
erm
ine
the
impa
ct o
f HIT
s on
clin
icia
ns’
beha
vior
s &
pat
ient
out
com
es
• Spe
cific
inte
rven
tion
goal
:
• M
axim
ize
the
num
ber o
f ste
ps (c
ount
ed b
y pe
dom
eter
s)
• A
chie
ve h
igh
aero
bic
inte
nsity
with
70-
85%
HR
Max
(doc
umen
ted)
12
Ada
pt K
now
ledg
e to
Loc
al C
onte
xt
Con
side
ratio
ns
Exam
ples
•
Pro
tect
inte
grity
of e
vide
nce
• E
ngag
e st
akeh
olde
rs
• Tr
ansp
aren
t rep
ortin
g of
lim
itatio
ns A
pplic
atio
n to
inpa
tient
pop
ulat
ions
: •
Com
mun
icat
ion
impa
irmen
ts
• In
crea
sed
num
ber o
f com
orbi
ditie
s
• Im
paire
d co
gniti
on
Mul
tilev
el A
ppro
ach
to E
xam
inin
g
Faci
litat
ors
and
Bar
riers
•
Inno
vatio
n: A
dvan
tage
s, li
mita
tions
, fea
sibi
lity
• In
divi
dual
: A
ttitu
de, m
otiv
atio
n to
cha
nge
•
Soc
ial:
Opi
nion
s of
col
leag
ues,
cul
ture
, lea
ders
hip
• O
rgan
izat
iona
l: R
esou
rces
, cap
acity
14
Faci
litat
ors
to H
ITs
Faci
litat
ors:
• O
rgan
izat
iona
l and
soc
ial:
•
Visi
on
• In
itial
ly im
plem
ente
d in
“abi
lity
lab”
•
Sta
keho
lder
invo
lvem
ent
• Ind
ivid
ual:
• C
linic
ians
kne
w e
xpec
tatio
ns/v
isio
n •
Pat
ient
s ex
pect
ed a
“nov
el” t
reat
men
t
15
Bar
riers
to H
ITs
• K
now
ledg
e &
ski
lls:
• G
ener
al a
pplic
atio
n •
Med
ical
ly c
ompl
ex a
nd v
ery
impa
ired
patie
nts
• D
iffer
ence
in p
ract
ice
belie
fs:
Focu
sing
ses
sion
s on
gai
t tra
inin
g
• Lo
gist
ics:
•
Sch
edul
ing
•
Rea
dine
ss fo
r PT
whe
n se
ssio
n st
arts
•
Tim
e lo
st s
ettin
g pa
tient
s up
•
Stre
amlin
ed d
ocum
enta
tion
16
Sel
ect K
T In
terv
entio
ns
•
KT
inte
rven
tions
: no
t rig
orou
sly
stud
ied
• P
rofe
ssio
nal i
nter
vent
ions
•
Pat
ient
dire
cted
inte
rven
tions
•
Org
aniz
atio
nal i
nter
vent
ions
•
Fina
ncia
l inc
entiv
e
• Ta
rget
sta
ted
barr
iers
and
faci
litat
ors
• M
ultip
le c
ompo
nent
KT
inte
rven
tions
HIT
s K
T In
terv
entio
ns
18
Mon
itor k
now
ledg
e us
e •
Con
duct
sur
veys
, foc
us g
roup
s, d
iscu
ssio
ns, o
r ob
serv
atio
ns
• C
hang
es in
kno
wle
dge,
und
erst
andi
ng, a
ttitu
des
• A
ctua
l cha
nges
in b
ehav
ior o
r pra
ctic
e
• H
ITs
Exa
mpl
es:
• O
bser
vatio
n an
d m
onito
ring
of m
easu
rem
ents
and
ste
ppin
g ac
tivity
•
Cas
e di
scus
sion
s an
d pr
oble
m s
olvi
ng
• C
ompl
ianc
e du
ring
team
con
fere
nce
repo
rting
: •
Out
com
e m
easu
res
•
Pat
ient
resp
onse
to H
ITs
prog
ram
Eva
luat
e O
utco
mes
at
Vario
us L
evel
s •
Pat
ient
•
Impr
ovem
ent i
n fu
nctio
nal o
utco
me
• Le
ngth
of s
tay
• S
atis
fact
ion
• C
linic
ian
• C
hang
es in
dec
isio
n-m
akin
g / p
ract
ice
beha
vior
s •
Obs
erva
tion
• C
hart
audi
ts
• E
ffici
ency
• O
rgan
izat
iona
l or p
roce
ss le
vel
• O
vera
ll pa
tient
out
com
es
• R
eim
burs
emen
t **
HIT
s ou
tcom
es w
ill b
e pr
esen
ted
by C
arey
Hol
lera
n
Stra
tegi
es to
Sus
tain
Use
•
Lead
ersh
ip
• O
rgan
izat
iona
l goa
ls/v
isio
n fo
r im
plem
enta
tion
of e
vide
nce
• In
terv
iew
ing
stra
tegi
es:
• “T
ell m
e ab
out t
he O
Ms
you
use
in p
ract
ice.
How
did
you
lear
n ab
out t
hem
? H
ow d
o th
ey im
pact
you
r dec
isio
n-m
akin
g?”
• “T
ell m
e ab
out t
he la
st in
terv
entio
n st
udy
you
read
. D
id it
impa
ct
your
pra
ctic
e? W
hy o
r why
not
?”
• Fi
nanc
ial s
uppo
rts: D
esire
d ch
ange
as
com
pone
nt o
f m
erit
incr
ease
s
• In
tegr
ate
into
rout
ine
clin
ical
pra
ctic
es/p
roce
sses
•
Team
con
fere
nce
repo
rting
and
man
dato
ry d
ocum
enta
tion
• Jo
urna
l and
edu
catio
n in
serv
ices
on
the
topi
c
Tips
for S
ucce
ss
• Col
labo
ratio
n be
twee
n st
akeh
olde
rs to
impl
emen
t pr
ojec
t
• Cle
arly
sta
ted
visi
on b
y le
ader
ship
• Tai
lore
d K
T in
terv
entio
ns to
add
ress
bar
riers
• Ong
oing
mon
itorin
g an
d m
easu
rem
ent o
f ou
tcom
es
22
Kno
wle
dge-
to-A
ctio
n Fr
amew
ork
For m
ore
info
rmat
ion:
23
Impl
emen
tatio
n of
a h
igh
inte
nsity
st
eppi
ng p
rogr
am in
inpa
tient
po
st-s
troke
reha
bilit
atio
n C
arey
L. H
olle
ran
MPT
, DH
S, N
CS
Clin
ical
Pra
ctic
e Le
ader
for N
euro
logi
c Ph
ysic
al T
hera
py
Reh
abili
tatio
n In
stitu
te o
f Chi
cago
1
Ack
now
ledg
emen
ts
•Lo
com
otor
Rec
over
y La
bora
tory
–
Prin
cipa
l Inv
estig
ator
•
T. G
eorg
e H
ornb
y PT
, PhD
–
Staf
f •
Abi
Led
dy, D
PT, M
SCI,
NC
S •
Patri
ck H
enne
ssy
MPT
, NC
S •
Jane
Woo
dwar
d, D
PT, N
CS
•C
hris
toph
er T
hom
pson
DPT
, PhD
•
Kris
tan
Leec
h D
PT, P
hD
•M
ark
Con
nolly
, BS
•C
athe
rine
Kin
naird
, MS
•G
ordh
an M
ahta
ni, M
S
•R
IC P
hysi
cal T
hera
pist
s –
Nic
ole
Will
iam
s, D
PT
–Ry
an P
elo,
DPT
–
Raq
uel S
antia
go, D
PT
–M
ike
Klo
now
ski,
DPT
, PC
S –
Hea
ther
Sch
olte
n, D
PT
–H
olly
Pac
zan,
DPT
–
Deb
Tob
ias,
DPT
•A
dmin
istra
tors
/Phy
sici
ans
–El
liot R
oth,
MD
–
Ric
hard
Har
vey,
MD
–
Lind
a Lo
vell,
BS
–K
ara
Koz
ub, M
S –
Jenn
ifer S
mith
, MS
–N
icol
e Se
dam
, OTL
/R
2
Age
nda
•Th
eory
and
ratio
nale
•
Impl
emen
tatio
n M
etho
ds
–St
ruct
ure
and
plan
ning
–
Dat
a an
alys
is
•
Res
ults
–
Cha
ract
eris
tics o
f sam
ple
–O
utco
me
asse
ssm
ent c
hang
es
–C
orre
latio
n an
d re
gres
sion
ana
lyse
s
3
Wal
king
reco
very
4
Sp
ecifi
city
Inte
nsity
Re
petit
ion
Wal
king
Rec
over
y •
Spec
ifici
ty –
Typ
e of
pra
ctic
e –
Step
ping
pra
ctic
e im
prov
es st
eppi
ng p
erfo
rman
ce (H
esse
et
al 1
995,
Poh
l et a
l 200
2, S
ulliv
an e
t al 2
002,
Moo
re e
t al,
2010
)
–N
on-s
tepp
ing
prac
tice
•B
alan
ce tr
aini
ng im
prov
es b
alan
ce (H
ui-C
han
et a
l 20
09)
•St
reng
th tr
aini
ng im
prov
es st
reng
th (
Patte
n et
al 2
004;
Ja
yara
man
et a
l 201
3)
•Sm
alle
r effe
cts o
n w
alki
ng
5
004;
Spec
ifici
ty Inte
nsity
Re
petit
ion
Wal
king
Rec
over
y •
Rep
etiti
on -
Am
ount
of s
tepp
ing
prac
tice
–Tr
aditi
onal
BW
S pr
ovid
es la
rge
amou
nts o
f ste
ppin
g (B
arbe
au, 2
003)
–D
ose
appe
ars t
o be
rela
ted
to re
spon
ses (
Moo
re, 2
010)
•
Dos
e : ~
400
0 st
eps
–
Fast
er is
bet
ter (
Pohl
et a
l 200
2, S
ulliv
an e
t al,
2002
)
6
Spec
ifici
ty Inte
nsity
Re
petit
ion
Wal
king
Rec
over
y •
Inte
nsity
- W
orkl
oad
or p
ower
out
put e
stim
ated
by
hear
t rat
e (H
R)
–D
efin
ition
of i
nten
sity
var
ies –
NO
T tre
atm
ent t
ime
or
repe
titio
n
–Tr
eadm
ill w
alki
ng 6
0-70
% h
eart
rate
rese
rve
(HR
R)
(Mac
ko e
t al,
2005
), up
to 8
5% H
R m
ax (M
oore
et a
l, 20
10)
7
Spec
ifici
ty Inte
nsity
Re
petit
ion
Wal
king
Rec
over
y •
Type
s of v
aria
bilit
y −
Kin
emat
ic v
aria
bilit
y (H
ornb
y 20
08)
−En
viro
nmen
tal v
aria
bilit
y –
over
grou
nd/s
tairs
(Van
Den
B
rand
et a
l, 20
12)
−
Task
var
iabi
lity
– fo
rwar
d vs
side
way
s vs b
ackw
ards
(Sha
h 20
12)
8
Sp
ecifi
city
Inte
nsity
Re
petit
ion
Con
clus
ions
•
Cur
rent
pra
ctic
e pa
ttern
s dem
onst
rate
…
–La
ck o
f tas
k sp
ecifi
c tra
inin
g re
late
d to
goa
ls
–Sm
all a
mou
nt o
f rep
etiti
ons
–R
educ
ed in
tens
ity
9
Spec
ifici
ty Inte
nsity
Re
petit
ion
Prio
rity
Shift
10
Prio
rity
Shift
11
Prio
rity
Shift
•
Clin
icia
ns c
once
rns
“I w
on’t
have
tim
e to
pra
ctic
e tra
nsfe
rs.”
“My
patie
nts w
on’t
be p
repa
red
for d
isch
arge
.”
“Don
’t m
y pa
tient
s nee
d to
lear
n to
stan
d fir
st?”
12
Out
com
es fr
om IP
Reh
ab
•H
orn
SD e
t al,
2005
(Po
st-S
troke
Reh
abili
tatio
n O
utco
mes
Pr
ojec
t Dat
abas
e)
–G
reat
er m
inut
es in
PT
gait
activ
ities
sign
ifica
ntly
as
soci
ated
with
hig
her d
isch
arge
(DC
) FIM
scor
es
–G
reat
er m
inut
es in
bed
mob
ility
and
sitti
ng c
onsi
sten
tly
asso
ciat
ed w
ith lo
wer
DC
FIM
scor
es
13
Proj
ect G
oals
•Pr
iorit
izat
ion
of a
ctiv
ities
to m
axim
ize
amou
nt a
nd a
erob
ic
inte
nsity
of s
tepp
ing
prac
tice
•
Feas
ibili
ty o
f num
ber a
nd in
tens
ity o
f ste
ppin
g re
late
d ac
tiviti
es
•Ev
alua
te p
oten
tial a
ssoc
iatio
ns o
f ste
ppin
g ac
tivity
with
lo
com
otor
and
non
-loco
mot
or o
utco
mes
14
Age
nda
•Th
eory
and
ratio
nale
–
Wal
king
reco
very
–
Cur
rent
pra
ctic
e pa
ttern
s –
Goa
ls o
f pro
ject
•
Impl
emen
tatio
n M
etho
ds
–St
ruct
ure
and
plan
ning
–
Dat
a an
alys
is
•
Res
ults
–
Cha
ract
eris
tics o
f sam
ple
–O
utco
me
asse
ssm
ent c
hang
es
–C
orre
latio
n an
d re
gres
sion
ana
lyse
s
15
Impl
emen
tatio
n - I
nter
vent
ion
•Pr
iorit
izat
ion
of st
eppi
ng p
ract
ice
–Ta
sk sp
ecifi
city
- S
tepp
ing
on tr
eadm
ill a
nd o
verg
roun
d
–In
tens
ity -
60-8
5% H
R m
ax, 1
4-17
RPE
–
Varia
bilit
y - M
ultip
le d
irect
ions
, obs
tacl
es, s
tairs
, un
even
/com
plia
nt su
rfac
es, c
urbs
•W
eekl
y as
sess
men
ts –
con
sist
ent d
ocum
enta
tion
of m
obili
ty
outc
omes
•Fa
mily
trai
ning
16
Tim
elin
e of
Act
iviti
es
Janu
ary
2012
•
Com
bine
d re
sear
ch a
nd c
linic
al p
ilot f
loor
ope
ns a
t RIC
•
Ther
apis
ts in
tere
sted
in tr
ansl
atio
n of
evi
denc
e to
clin
ic
hire
d to
PT
team
•
Clin
ical
and
rese
arch
team
ass
embl
ed
•D
evel
oped
rese
arch
pro
posa
l for
Hen
ry B
etts
Inno
vatio
n G
rant
Aw
ard
Mar
ch 2
012
•
Proj
ect s
elec
ted
as In
nova
tive A
war
d W
inne
r •
Wee
kly
colla
bora
tive
mee
tings
of c
linic
ians
and
rese
arch
ers
initi
ated
A
pril
2012
•
Trai
ning
of r
ehab
ilita
tion
aide
with
in c
linic
al e
nviro
nmen
t •
Def
ined
goa
ls a
nd p
urpo
se o
f ste
ppin
g pr
ogra
m
•C
hang
es to
ele
ctro
nic
docu
men
tatio
n fo
r ext
ract
ion
May
201
2 •
Dev
elop
ed to
ols f
or c
olle
ctio
n of
dat
a
•Fi
rst p
atie
nt b
egan
pro
gram
O
ctob
er 2
012
•Im
plem
enta
tion
on se
cond
floo
r
17
Stud
y Sa
mpl
e an
d D
esig
n •
Ret
rosp
ectiv
e da
ta a
naly
sis
–Im
plem
enta
tion
of c
linic
al in
itiat
ive
over
16
mon
th p
erio
d –
No
cont
rol g
roup
•In
clus
ion
–In
itial
dia
gnos
is o
f stro
ke (<
6 m
onth
s)
–18
-89
year
s of a
ge
•
Excl
usio
n –
Preg
nant
–
HIV
or A
IDS
–In
carc
erat
ion
–Lo
wer
ext
rem
ity fr
actu
re o
r am
puta
tion
18
Impl
emen
tatio
n –
Clin
icia
n D
riven
•
Phys
ical
The
rapy
Sta
ff –
Prio
ritiz
ing
wal
king
–
Perf
orm
out
com
e m
easu
rem
ents
•O
ccup
atio
nal T
hera
py
–R
epet
itive
task
spec
ific
UE
train
ing
–C
ontin
uing
to a
ddre
ss
trans
fers
•Th
erap
y A
ides
–
Ass
ist w
ith in
crea
sed
step
ping
und
er P
T gu
idan
ce
•N
ursi
ng/P
CT
Staf
f –
Con
sist
ently
read
y fo
r th
erap
y –
Car
ry o
ver o
f tra
nsfe
rs
•
Adm
inis
trativ
e/Ph
ysic
ian
Supp
ort
–G
roup
sche
dulin
g –
Mor
al su
ppor
t
•R
esea
rch
Supp
ort
–A
ssis
ted
with
initi
atio
n of
pr
ogra
m a
nd p
erfo
rmed
dat
a an
alys
is
19
Impl
emen
tatio
n - S
tepw
atch
•
Step
Wat
ch3TM
–W
orn
7:30
am
to 5
:00
pm
–Pa
retic
leg
–M
atch
ed w
ith m
edic
al re
cord
s an
d de
-iden
tifie
d fo
r res
earc
h an
alys
is
20
Impl
emen
tatio
n - E
nviro
nmen
t Eq
uipm
ent
•4
Trea
dmill
s with
BW
S •
Use
of t
wo
inpa
tient
floo
rs
–O
verh
ead
trolle
y –
Lite
gai
t –
Rift
on tr
am
–H
oyer
lift
•
Rot
atin
g st
airs
21
Dat
a Ex
tract
ion
Extra
cted
by
clin
ical
staf
f and
de-
iden
tifie
d fo
r res
earc
h st
aff
anal
ysis
•
Dem
ogra
phic
Info
rmat
ion
–G
ende
r –
Age
–
Dur
atio
n po
st-s
troke
–
Lesi
on si
de
–Ty
pe (i
sche
mic
/hem
orrh
agic
) –
Adv
erse
eve
nts d
urin
g le
ngth
of s
tay
–D
istri
butio
n
22
Dat
a Ex
tract
ion
•O
utco
me
asse
ssm
ents
(Adm
it an
d D
/C)
–6
MW
T
–10
MW
T –
FIM
(Bed
, Toi
let,
Wal
k, C
ombi
ned
Mot
or, C
ombi
ned
Cog
nitiv
e)
–B
ERG
bal
ance
scal
e
•Tr
aini
ng p
aram
eter
s –
Peak
HR
& d
urat
ion
–Pe
ak R
PE &
dur
atio
n
•St
eppi
ng A
ctiv
ity
23
Ana
lysi
s
24
Res
earc
h R
elat
ed Q
uest
ions
•D
id d
emog
raph
ic, i
mpa
irmen
t mea
sure
s, an
d tra
inin
g pa
ram
eter
s con
tribu
te to
mob
ility
-rel
ated
out
com
es?
•
Inde
pend
ent c
ontri
butio
ns o
f ste
ppin
g to
mob
ility
out
com
es?
•
Adv
erse
con
sequ
ence
s of a
ugm
ente
d st
eppi
ng a
ctiv
ity?
•Pr
imar
y de
term
inan
ts (v
aria
bles
) tha
t bes
t pre
dict
wal
king
w
ithou
t phy
sica
l ass
ista
nce
at D
C?
•
Prim
ary
dete
rmin
ants
of D
C to
hom
e?
25
Dat
a Ana
lysi
s •
Cor
rela
tion
anal
ysis
–
Bas
elin
e im
pairm
ents
, dem
ogra
phic
s –
Trai
ning
– a
mou
nt o
f PT,
step
ping
act
ivity
–
Out
com
es –
6M
WT,
BB
S, F
IM sc
ores
•R
elat
ive
cont
ribut
ions
of i
ndep
ende
nt p
redi
ctor
s to
outc
omes
–
Prim
ary
pred
icto
rs 6
MW
T/B
BS
impr
ovem
ents
? (s
tepw
ise
linea
r reg
ress
ions
) –
Prim
ary
pred
icto
rs o
f ass
ista
nce
at D
C, l
ocat
ion
of D
C?
(con
ditio
nal l
ogis
tic re
gres
sion
)
26
Age
nda
•Th
eory
and
ratio
nale
–
Wal
king
reco
very
–
Cur
rent
pra
ctic
e pa
ttern
s –
Goa
ls o
f pro
ject
•
Impl
emen
tatio
n M
etho
ds
–St
ruct
ure
and
plan
ning
–
Dat
a an
alys
is
•
Res
ults
–
Cha
ract
eris
tics o
f sam
ple
–O
utco
me
asse
ssm
ent c
hang
es
–C
orre
latio
n an
d re
gres
sion
ana
lyse
s
27
Dem
ogra
phic
s & B
asel
ine
Cha
ract
eris
tics
•N
onpa
ram
etric
dat
a di
strib
utio
n –
med
ian,
inte
rqua
rtile
rang
e
•D
emog
raph
ics
–N
= 2
01
–A
ge: 6
4 (5
5-75
) –
Day
s pos
t-stro
ke: 1
3 (8
-25)
•B
asel
ine
Cha
ract
eris
tics
–FI
M le
vel:
1 (1
-2)
–B
ERG
bal
ance
: 5 (4
-22)
28
Res
ults
- PT
Inte
rven
tions
Tr
aini
ng c
hara
cter
istic
s
leng
th o
f sta
y (d
ays)
28
(21-
35; 2
01)
PT se
ssio
ns/d
ay
1.1
(0.9
4-1.
3; 2
01)
PT m
in/s
essi
on (m
in)
54 (
52-5
6; 2
01)
peak
HR
/ses
sion
(% m
ax)
70 (6
2-76
; 161
)
peak
RPE
/ses
sion
16
(15-
17; 1
60)
mea
n %
sess
ion
RPE
> 1
3 38
(31-
44; 1
57)
daily
step
ping
(ste
ps/d
ay)
1516
(594
-264
5; 2
01)
29
peak
HR
/ses
sion
(% m
ax)
70 (6
2-76
; 161
)
daily
step
ping
(ste
ps/d
ay)
1516
(594
-264
5; 2
01)
Res
ults
- St
eppi
ng A
ctiv
ity
Res
ults
- St
eppi
ng A
ctiv
ity 24
9 st
eps (
Lang
et a
l, 20
09)
1516
step
s
31
Dai
ly S
tepp
ing
Act
ivity
Dur
ing
Leng
th o
f Sta
y
Adv
erse
Eve
nts
•7
Car
diov
ascu
lar e
vent
s
•7
Non
-car
diov
ascu
lar e
vent
s req
uirin
g di
scha
rge
•
10 re
turn
ed to
inpa
tient
– a
ll da
ta u
tiliz
ed
•
Perc
enta
ge c
onsi
sten
t with
nor
mat
ive
valu
es (L
angh
orne
et a
l, 20
00) a
nd e
choe
s rec
ent m
eta-
anal
yses
(Pan
g et
al,
2013
)
32
Out
com
es
•D
eliv
ered
mor
e st
eps t
han
obse
rvat
iona
l rep
orts
dem
onst
rate
(1
516
vs 2
49; L
ang
et a
l 200
9)
•
Ach
ieve
d hi
gher
inte
nsity
than
pre
viou
s inp
atie
nt
obse
rvat
iona
l stu
dies
(38%
vs 5
% d
urat
ion
of P
T; M
acK
ay-
Lyon
s 200
2)
•
Perf
orm
ed in
indi
vidu
als w
ith se
vere
def
icits
•Fo
cuse
d de
liver
y of
hig
h-in
tens
ity st
eppi
ng re
sulte
d in
no
incr
ease
d ris
k of
adv
erse
eve
nts
33
Res
ults
Out
com
e m
easu
res
Adm
issi
on
Dis
char
ge
N (%
)
6 m
in w
alk
test
(m)
15 (3
.0-6
7)
146
(44-
281)
16
6 (8
3)
6 m
in le
vel o
f ass
ista
nce
3 (2
-4)
5 (4
-5)
166
(83)
Ber
g B
alan
ce S
cale
5
(4-2
2)
34 (1
3-46
) 17
3 (8
6)
FIM
-Bed
mob
ility
2
(1-3
) 5
(3-5
) 20
1 (1
00)
FIM
-Toi
let t
rans
fers
2
(1-3
) 4
(3-5
) 20
1 (1
00)
FIM
-Wal
k 1
(1-2
) 4
(3-5
) 20
1 (1
00)
All
p =
<0.0
001
34
6 m
in w
alk
test
(m)
15 (3
.0-6
7)14
6 (4
4-28
1)16
6 (8
3)
6 m
in le
vel o
f ass
ista
nce
3 (2
-4)
5 (4
-5)
166
(83)
FIM
-Wal
k1
(1-2
)4
(3-5
)20
1 (1
00)
Ber
g B
alan
ce S
cale
5 (4
-22)
34 (1
3-46
)17
3 (8
6)
FIM
-Bed
mob
ility
2 (1
-3)
5 (3
-5)
201
(100
)
FIM
-Toi
let t
rans
fers
2 (1
-3)
4 (3
-5)
201
(100
)
- Loc
omot
or o
utco
mes
- N
on-lo
com
otor
out
com
es
Cor
rela
tions
with
DC
6M
WT
•D
emog
raph
ics a
nd im
pairm
ents
rela
te to
mob
ility
out
com
es
–A
dmit
Ber
g B
alan
ce S
cale
: 0.6
2*
–A
dmit
6MW
T: 0
.64*
–
Pare
tic le
g st
reng
th: 0
.53*
–
Dur
atio
n po
st st
roke
: - 0
.26*
–
Age
: -0.
07
•
Trai
ning
cha
ract
eris
tics
–St
eps/
day:
0.8
7*
–Pt
min
utes
/day
: 0.3
4*
–Av
erag
e H
R %
max
: 0.3
9*
–Le
ngth
of s
tay:
-0.3
1*
35
Res
ults
- C
orre
latio
ns
36
Disc
harg
e 6
min
wal
k te
st
Res
ults
- C
orre
latio
ns
Step
wis
e Li
near
Reg
ress
ion
•Pr
imar
y pr
edic
tors
for D
C 6
MW
T an
d D
C B
BS
–
–
6
•H
iera
rchi
cal l
inea
r reg
ress
ion
– st
eps/
day
inde
pend
ently
ac
coun
ts fo
r 20%
of v
aria
nce
of D
C 6
MW
T (r
2 =
0.20
)
•O
ther
out
com
es
–
Step
s/da
y w
as p
rimar
y pr
edic
tor f
or
6MW
T, D
C a
nd
BB
S (in
depe
nden
t r2 -
10-3
1% o
f var
ianc
e)
–D
C F
IM -
wal
king
, - to
ilet t
rans
fers
, - b
ed m
obili
ty
38
Res
ults
•
Cor
rela
tions
indi
cate
that
a m
odifi
able
var
iabl
e of
trai
ning
(s
tepp
ing
amou
nt) c
ould
be
mor
e im
porta
nt th
an o
ther
s
•A
mou
nt o
f ste
ps c
ould
hav
e st
rong
influ
ence
on
outc
omes
at
disc
harg
e fr
om in
patie
nt re
habi
litat
ion
–W
alki
ng e
ndur
ance
–
Bal
ance
–
Tran
sfer
s •
Initi
al le
vel o
f fun
ctio
n se
cond
arily
pre
dict
ed w
here
they
en
ded
39
Res
ults
- St
eppi
ng a
nd In
itial
LoA
Adm
it LO
A
Med
ian
step
s/da
y
Tota
l A
589.
8 (3
83-1
662)
Max
A
816.
1 (4
86-1
540)
Mod
A
1587
.3
(961
-243
6)
Min
A
2266
.1
(143
8-29
68)
CG
A o
r be
tter
3280
.3
(215
1-43
42)
Mod
I N
/A
Dis
char
ge
LOA
M
edia
n st
eps/
day
Tota
l A
212
(145
-340
)
Max
A
482
(429
-506
)
Mod
A
419
(369
-615
)
Min
A
1016
(5
39-2
010)
C
GA
or
bette
r 20
53
(129
3-28
80)
≥Mod
I 44
71
(325
3-46
19)
Cut
-off
: ~10
00 st
eps
Sens
itivi
ty 8
7% S
peci
ficity
90%
C
ut-o
ff : ~
1000
step
s Se
nsiti
vity
56%
Spe
cific
ity 8
5%
Wha
t the
hec
k do
es th
at m
ean?
Func
tiona
l Lev
elSt
eps/
day
Con
ditio
nal l
ogis
tic re
gres
sion
CG
A o
r bet
ter
(LoA
≥5)
42
Adm
it B
ERG
C
GA
or b
ette
r (L
oA≥5
)
Step
s/da
y
Con
ditio
nal l
ogis
tic re
gres
sion
DC
Hom
e vs
. O
ther
43
CG
A o
r bet
ter
(LoA
≥5)
Con
ditio
nal l
ogis
tic re
gres
sion
Adm
it B
ERG
C
GA
or b
ette
r (L
oA≥5
)
DC
Hom
e vs
. O
ther
St
eps/
day
44
Res
ults
•
The
amou
nt o
f ste
ps c
ould
affe
ct y
our p
atie
nt’s
abi
lity
to w
alk
with
out a
ssis
t
•Th
is c
ould
be
rela
ted
to w
heth
er o
r not
they
can
go
hom
e
45
Sum
mar
y •
Step
ping
- 15
16 st
eps/
days
, 5-6
x g
reat
er th
an p
ublis
hed
repo
rts (L
ang
et a
l, 20
09; S
criv
ner e
t al,
2012
)
•A
dver
se e
vent
s con
sist
ent w
ith n
orm
ativ
e da
ta (L
angh
orne
et
al, 2
000)
•C
orre
latio
ns e
cho
othe
r dat
a (M
oore
et a
l 201
0, H
olle
ran
et a
l, 20
14) w
ith st
eppi
ng d
emon
stra
ting
stro
nges
t cor
rela
tion
to
outc
omes
•St
eppi
ng a
ctiv
ity p
ossi
ble
pred
icto
r of L
oA a
t dis
char
ge a
nd
disc
harg
e lo
catio
n (h
ome
vs o
ther
faci
lity)
•Ef
fect
s on
both
loco
mot
or a
nd n
on-lo
com
otor
out
com
es
46
Lim
itatio
ns a
nd F
utur
e D
irect
ion
•
Lim
itatio
ns
–N
o co
ntro
l gro
up
–N
o lo
ng-te
rm fo
llow
up
•
Futu
re D
irect
ions
–
Ass
ess c
ompa
rativ
e ef
fect
iven
ess
47
