10/13/2017. Walking the Walk... The potential effects of exercise dose on functional recovery in patients with physical disabilities: Introduction

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1 The potential effects of exercise dose on functional recovery in patients with physical disabilities: Introduction T. George Hornby, PT, PhD Research Scientist, Professor Physical Medicine and Rehabilitation Indiana University School of Medicine Rehabilitation Hospital of Indiana Acknowledgements Locomotor Recovery Laboratory Abi Leddy, DPT, MSCI, NCS Jane Woodward, DPT, NCS Jennifer Kahn, DPT, NCS Kristan Leech DPT Mark Connolly, BS Catherine Kinnaird, MS Gordhan Mahtani, MS Collaborators/Colleagues Michael Lewek, PT, PhD Catherine Lang, PT, PhD Darcy Reisman, PT, PhD RIC Physical Therapists Nicole Williams DPT Ryan Pelo DPT Raquel Santiago DPT Mike Klonowski DPT, PCS Heather Scholten, DPT Holly Paczan, DPT Deb Tobias, DPT Administrators/Physicians Elliot Roth, MD Richard Harvey, MD Linda Lovell, BS Kara Kozub, MS Jennifer Smith, MS Nicole Sedam, OTL/R Walking the Walk... Introduction Theory and Rationale Development and Application of a Training Paradigm Briefly... Knowledge Translation Strategies and Clinical Implementation 1

2 Outline Introduction Theory and Rationale Patient s goals Constraints of PT practice Rationale for specific training strategies Fundamentals for application Development and Application of a Training Paradigm Knowledge Translation Strategies Implementation Patient s Goals I can t get my feet underneath me!! I m not going to church with this cane!! I walk like a pimp.... I m not a pimp!! My leg is weak, I want to get stronger I want to go out to the store on my own Constraints of PT Practice COORDINATION FLEXIBILITY BALANCE STRENGTH SPASTICITY Locomotion 2

PT Practice We re looking for someone who can stretch with this job? Are you flexible??? 3

3 Constraints of PT Practice COORDINATION FLEXIBILITY BALANCE STRENGTH SPASTICITY Wheelchair Transfers Locomotion Standing Stairs Constraints of PT Practice COORDINATION FLEXIBILITY BALANCE STRENGTH SPASTICITY Wheelchair Transfers Locomotion Standing Stairs Constraints of PT Practice We re looking for someone who can stretch with this job? Are you flexible??? 3

Distribution of PT Activities Practice of multiple activities to improve multiple impairments/functional limitations Derived from outpatient observations (Moore et al, 2010, Stroke) # specific task

4 Distribution of PT Activities Practice of multiple activities to improve multiple impairments/functional limitations Derived from outpatient observations (Moore et al, 2010, Stroke) # specific task repetitions during clinical therapy (Lang et al 2009, APMR) Gait 357 Steps/stairs 36 Balance 27 Active LE exercise 27 Passive LE exercise 12 Transfers 11 UE exercise 12 Constraints of PT practice: tradition/education Minimize abnormal movement patterns Normalize motor patterns Decrease Intensity = risk for cardiovascular event, decrease spasticity(mackay 2003, Kline 2007) Standardized progression of task difficulty Stability Limited variability Constrained environment Mobility Increased variability Unconstrained Environment Outline Introduction Theory and Rationale Patient s goals Constraints of PT practice Rationale for specific training strategies Fundamentals for application Development and Application Knowledge Translation Implementation 4

Rationale for specific training interventions Specific factors that influence

Use it and improve it 3. Specificity Matters 4. Repetition Matters 5.

Transference 10. Interference Transference 10.

physiology Similar determinants for cardiovascular and muscular plasticity Common

5 Rationale for specific training interventions Specific factors that influence neuroplasticity (Kleim and Jones 2008) 1. Use it or lose it 2. Use it and improve it 3. Specificity Matters 4. Repetition Matters 5. Intensity Matters 6. Time Matters 7. Salience Matters 8. Age Matters 9. Transference 10. Interference Rationale for specific training interventions Specific factors that influence neuroplasticity (Kleim and Jones 2008) 1. Use it or lose it 2. Use it and improve it 3. Specificity Matters 4. Repetition Matters 5. Intensity Matters 6. Time Matters 7. Salience Matters 8. Age Matters 9. Transference 10. Interference Similar practice paradigms in fields of motor control and exercise physiology Similar determinants for cardiovascular and muscular plasticity Common themes of previous and emerging evidence 5

Common themes of previous and emerging evidence Contributions of Specificity of Practice Stepping practice improves stepping performance Animals (vs no

balance (Au Yeung, Hui Chan et al 2009) Strength training improves strength (Patten et al 2004; Jayaraman et al 2013) Smaller effects on walking

6 Common themes of previous and emerging evidence Contributions of Specificity of Practice Stepping practice improves stepping performance Animals (vs no interventions or standing): Deleon 1998, 1999 Humans: SCI Wernig et al 1995, Stroke Hesse et al 1995 Non stepping practice Balance training improves balance (Au Yeung, Hui Chan et al 2009) Strength training improves strength (Patten et al 2004; Jayaraman et al 2013) Smaller effects on walking Contributions of Amount of Practice Animal studies 1000 steps > 100 steps; Cha et al 2007 Human studies steps; Moore et al 2010, Pohl et al 2002, Sullivan et al

Contributions of Amount of Practice Animal studies 1000 steps > 100 steps; Cha et al 2007 Human studies 2000 6000 steps; Moore et al 2010, Pohl et al 2002, Sullivan et al 2002 Dose Clinical PT

2012) Fastest speeds (Sullivan 2002, Pohl 2002) Greater neuromuscular demands (Hornby 2008, Holleran 2015) Lower stepping intensities may not generate sufficient gains in stepping (Duncan

7 Contributions of Amount of Practice Animal studies 1000 steps > 100 steps; Cha et al 2007 Human studies steps; Moore et al 2010, Pohl et al 2002, Sullivan et al 2002 Dose Clinical PT Locomotor Training Response Contributions of Amount of Practice Animal studies 1000 steps > 100 steps; Cha et al 2007 Human studies steps; Moore et al 2010, Pohl et al 2002, Sullivan et al 2002 Dose Clinical PT Locomotor Training Response Contributions of Intensity of Practice Aerobic treadmill walking improves selected walking measures (Macko 2005, Moore 2010, Globas 2012) Fastest speeds (Sullivan 2002, Pohl 2002) Greater neuromuscular demands (Hornby 2008, Holleran 2015) Lower stepping intensities may not generate sufficient gains in stepping (Duncan 2011) 7

Implementation of large amounts of high intensity stepping practice Benefits (Macko 2005, Moore 2010, Globas 2012) Consistent improvements in 6 min walk test Consistent improvements in aerobic

8 Implementation of large amounts of high intensity stepping practice Benefits (Macko 2005, Moore 2010, Globas 2012) Consistent improvements in 6 min walk test Consistent improvements in aerobic capacity or gait economy Limitations (Macko 2005, Moore 2010, Globas 2012) Inconsistent changes in comfortable walking speed and community stepping Small improvements in balance Limited improvements in transfers What else you got? Other factors? Errors and variability are important in learning Variable vs Constant Practice Random vs Blocked Practice (i.e., Contextual Interference) Greater errors associated with allowing variability Contributions of errors and variability to learning Types of variability Kinematic variability (Cai 2007; Hornby 2008, Lewek 2009) 8

Contributions of errors and variability to learning Types of variability Kinematic variability (Cai 2007; Hornby 2008, Lewek 2009) Hornby et al Stroke 2008 Contributions

0 0 * * -2-2 -4-4 Therapist assisted Robotic assisted -6 Hornby et al Stroke 2008 Contributions of errors and variability to learning Types of variability Kinematic

9 Contributions of errors and variability to learning Types of variability Kinematic variability (Cai 2007; Hornby 2008, Lewek 2009) Hornby et al Stroke 2008 Contributions of errors and variability to learning Types of variability Kinematic variability (Cai 2007; Hornby 2008, Lewek 2009) % single limb stance 4 Step length asymmetry * * Therapist assisted Robotic assisted -6 Hornby et al Stroke 2008 Contributions of errors and variability to learning Types of variability Kinematic variability (Cai 2007; Hornby 2008, Lewek 2009) Environmental variability overground/stairs (van den Brand 2012) Task variability forward vs sideways vs backwards (Shah 2012) 9

Contributions of errors and variability to learning Augmenting errors during learning may enhance magnitude/accelerate learning (split belt treadmill stepping; Bastian 2006, Reisman 2010) Tailoring

10 Contributions of errors and variability to learning Augmenting errors during learning may enhance magnitude/accelerate learning (split belt treadmill stepping; Bastian 2006, Reisman 2010) Tailoring errors for other walking subcomponents? Limb swing? Propulsion? Postural stability/balance? Outline Introduction Theory and Rationale Patient s goals Constraints of PT practice Rationale for specific training strategies Fundamentals for application Development and Application Knowledge Translation Implementation Outline Introduction Theory and Rationale Patient s goals Constraints of PT practice Rationale for specific training strategies Fundamentals for application Development and Application Knowledge Translation Implementation 10

How can we apply what we know? Priorities and sacrifices If realistic goal is to improve walking function...... need to focus on walking activities How can we apply what we know?

11 How can we apply what we know? Priorities and sacrifices If realistic goal is to improve walking function need to focus on walking activities How can we apply what we know? Intensity of interventions High training intensity as safe as regular PT (Pang 2013) Does spasticity increase over long term? (Wirz 2005) Allowing/encouraging errors and variability What they look like may be okay? Variable stepping may improve other functions (Horn 2005) How can we apply what we know? Intensity of interventions High training intensity as safe as regular PT (Pang 2013) Does spasticity increase over long term? (Wirz 2005) Allowing/encouraging errors and variability What they look like may be okay? Variable stepping may improve other functions (Horn 2005) Stability Limited variability Constrained environment Mobility Increased variability Unconstrained Environment 11

12 Outline Introduction Theory and Rationale Development and Application of a Training Paradigm Knowledge Translation Strategies Implementation Outline Introduction Theory and Rationale Development and Application Developing the Training Program Preliminary study Randomized Clinical Trial Knowledge Translation Implementation Development of Training Paradigm Large Amounts of Task Specific Practice Focus on continuous reciprocal stepping Focus only on continuous reciprocal stepping Aerobic intensity Training HR zone (THR) = 70 80% Heart Rate Reserve (HRR) BORG Ratings of Perceived Exertion (RPE) Variability Multidirectional stepping Multiple environments Random order practice 12

13 Focus Only on Stepping Biomechanical subcomponents of walking Defining Successful walking Limb swing advancement Propulsion Positive step length Directional advancement Stance control Preventing limb/trunk collapse Lateral/frontal stability Maintain upright Success = Continuous stepping Failure= 3 5 consecutive errors Gait kinematics were not a primary concern (Holleran, NNR 2014, appendix) Progressing Biomechanical Subcomponents of Walking Propulsion Stance Control Limb Advancement Stability & Balance Outline Introduction Theory and Rationale Development and Application Developing the Training Program Preliminary study Study Design Intervention description Results Randomized Clinical Trial Knowledge Translation Implementation 13

14 Feasibility and Efficacy of High Intensity Variable Stepping Training : Pilot Study Subjects: Subacute (1 6mo) and chronic stroke (>6mo) 18 75yo MMSE score 23/30 Moderate assistance or better to ambulate < 0.9 m/s self selected walking speed (SSV) (Holleran, NNR 2014) Pilot Study: Intervention Protocol Target 40 1hour sessions over 8 10 weeks Week 1 2: Forward treadmill training Weeks 3 8: Variable, multi directional training Half treadmill: 25% speed training, 25% dynamic balance Half overground: 25% speed/balance, 25% stairs Methods: Design & Outcome Measures Chronic Subacute Daily stepping activity Stepwatch Accelerometers worn during all waking hours 5 14 days Pre/Post intervention Within session intensity measures (HR, RPE) 6 Minute Walk Test (6MWT) Overground gait speed Self selected velocity (SSV) Fastest velocity (FV) Spatiotemporal gait symmetry Single limb stance time (%) Step length symmetry (%) 14

Limb Advancement Stance Control Propulsion Stability & Balance Progressing

15 Progressing Biomechanical Subcomponents of Walking Propulsion Stance Control Limb Advancement Stability & Balance Progressing Biomechanical Subcomponents of Walking Limb Advancement Stance Control Propulsion Stability & Balance Progressing Biomechanical Subcomponents of Walking Limb Advancement Stance Control Propulsion Stability & Balance 15

step/session sub acute (n=10) : 2845 ± 869 Significant changes in real world stepping (Pre BSL to F/U

16 Progressing Biomechanical Subcomponents of Walking Limb Advancement Stance Control Propulsion Stability & Balance Progressing Biomechanical Subcomponents of Walking Limb Advancement Stance Control Propulsion Stability & Balance Results: Stepping Activity Average step/session chronic (n=12) : 2967 ± 722 Average step/session sub acute (n=10) : 2845 ± 869 Significant changes in real world stepping (Pre BSL to F/U testing) 16

17 Primary locomotor outcomes SSV: chronic = 0.23 m/s; subacute = 0.33 m/s (ES=1.34, 1.64) MCID= 0.16m/s 6MWT: chronic = 90m subacute = 144m, (ES=1.49, 1.47) MCID=50m Primary locomotor outcomes No relation between initial walking status and improvements Relationship between stepping dosage vs primary outcomes Gait kinematics (spatiotemporal and joint excursions) Improved stride length/cadence and gait symmetry Δ paretic single limb stance (% gait cycle; FV); 21±8.7 to 27±7.1** (normal is 40%) Average Δ step length symmetry (FV): 63±35 to 82±10%* (normal is 100%) Increased hip/knee ROM, consistency Frontal plane increase in swing phase hip abduction (p<0.05) greatest increase in those with higher gait speed gains and lower initial Fugl Meyer 17

18 Non locomotor Improvements Berg Balance Scale Improvements Chronic: 6 pts (MDC=2.5) Subacute: 8 pts (MDC=6.0) Non ambulatory patients (n=3): 21 points Five Times Sit to Stand Improvements 25% or 12.0 seconds chronic (MDC=3.6seconds) 40% or 5.9 seconds subacute (MDC=3.6seconds) (Straube et al, PTJ 2014) Outline Introduction Theory and Rationale Development and Application Developing the Training Program Preliminary study Randomized Clinical Trial Very Intensive Early Walking post Stroke (VIEWS submitted) Knowledge Translation Implementation Randomized Controlled Trial: Subjects: Subacute* Age Single unilateral stroke MMSE 23 mod A or ambulate < 0.9 m/s (SSV) Stratification prior to randomization (walking speed)* N=32 required from effect sizes Intervention 40 1hour sessions over 8 10 weeks 1 week forward TM training* 7 weeks variable training Outcomes assessment Primary: SSV & 6MWT Secondary: 5X sit to stand, Berg Balance Scale (Hornby et al, submitted) 18

19 VIEWS: Design Control Encouraged to continued physical therapy Supplemental sessions to achieve 40sessions Multiple activities, limited practice of any single task (Lang, 2009) Balance, Strength, PROM, Transfers Walking: steps/session formula based on gait speed steps/session= steps (initial walking speeds) (Moore, 2010) 30 40%HRR (Mackay Lyons 2003) Experimental Focused stepping training up to 40 1 hr sessions High aerobic intensity (70 80%HRR) Skilled variable task practice on treadmill and overground No concurrent physical therapy VIEWS: Group Comparisons Baseline Experimental Control p value Demographics N=15 N=17 Age 57±12 60± Days post-stroke 114±56 89± Impairments LE Fugl-Meyer 20±5.8 21± PHQ-9 4.3± ± Training sessions, n 34±8.9 33± steps/day 4046± ±1689 <0001 steps/session 2358± ±489 <0.001 average peak RPE 18±1.2 15± average peak HRR 74±8.7 40±5.4 <0.001 VIEWS: Group Comparisons Significant difference in walking measures (p<0.01) Self selected velocity (0.27±0.22 vs 0.09±0.09 m/s) Fastest possible velocity (0.28±0.20 vs 0.11±0.15 m/s) 6 min walk test (114±111 vs 29±32 m) Between group differences well above MCID for walking outcomes 19

20 VIEWS: Results No significant changes in non walking measures (p=0.66) (p=0.95) Only control group practiced transfers and balance, but demonstrated no greater outcomes gains than experimental group VIEWS: Results Relationship between stepping dosage vs outcomes Amount of practice related to improvements in walking Gait kinematics (spatiotemporal and joint excursions) Improved stride length/cadence and gait symmetry Δ paretic single limb stance (% gait cycle; FV); 21±8.7 to 27±7.1** (normal is 40%) Average Δ step length symmetry (FV): 63±35 to 82±10%* (normal is 100%) Increased hip/knee ROM, consistency Frontal plane increase in swing phase hip abduction (p<0.05) greatest increase in those with higher gait speed gains and lower initial Fugl Meyer 20

KT is multi faceted (Strauss, 2009) Patient Individual Clinician Organizational leaders/stakeholders Political

21 Outline Introduction Theory and Rationale Development and Application Knowledge Translation Implementation Outline Introduction Theory and Rationale Development and Application Knowledge Translation Implementation The Challenge of Knowledge Translation (KT) > 17 years for evidence to be used clinical practice (Morris, 2011) KT is multi faceted (Strauss, 2009) Patient Individual Clinician Organizational leaders/stakeholders Political Economic 63 21

Select, Tailor, Implement Interventions Monitor Knowledge Use KNOWLEDGE CREATION Evaluate Outcomes Assess Barriers to Knowledge Use Adapt Knowledge to Local Context Knowledge Inquiry Synthesis

22 Select, Tailor, Implement Interventions Monitor Knowledge Use KNOWLEDGE CREATION Evaluate Outcomes Assess Barriers to Knowledge Use Adapt Knowledge to Local Context Knowledge Inquiry Synthesis Products/ Tools Identify Problem Sustain Knowledge Use Knowledge-to-Action Framework Identify, Review, Select Knowledge Graham 2006 Study Sample and Design Retrospective data analysis Implementation of clinical initiative over 16 month period No control group Inclusion Initial diagnosis of stroke (<6 months) years of age Exclusion Pregnant HIV or AIDS Incarceration Lower extremity fracture or amputation Implementation Clinician Driven Physical Therapy Staff Prioritizing walking Perform outcome measurements Nursing/PCT Staff Consistently ready for therapy Carry over of transfers Occupational Therapy Continuing to address transfers Therapy Aides Assist with increased stepping under PT guidance Administrative/Physician Support Group scheduling Moral support Research Support Assisted with initiation of program and performed data analysis 22

Implementation Stepwatch StepWatch3 TM Worn 7:30 am to 5:00 pm Paretic leg Matched with medical records and deidentified for research analysis Results Demographics Demographics Median (IQR; N)) or N

23 Implementation Stepwatch StepWatch3 TM Worn 7:30 am to 5:00 pm Paretic leg Matched with medical records and deidentified for research analysis Results Demographics Demographics Median (IQR; N)) or N (%) age 64 (55-75; 201) gender: male/female 114/87 lesion location: right 74 (39%) left 88 (44%) bilateral 32 (17%) lesion distribution: cortical 98 (49%) subcortical 32 (16%) subtentorial 21 (15%) multiple/unknown 40 (20%) lesion type: ischemic 142 (71%) hemorrhagic/unknown 59 (29%) duration post-stroke 13 (8-25; 201) Charlson Comorbidity Index 1 (0-3; 201) Results Stepping Activity 23

24 Results Stepping Activity 1516 steps 249 steps (Lang et al, 2009) Results Correlations Results Correlations 24

25 Summary Rationale and Development of Interventions based on wellestablished principles of exercise physiology and motor control Proof of concept for smaller populations, ongoing studies in larger trials Implementation strategies can we figure out how to get these and other effective strategies to therapists Thanks and questions... 25

Outline. What do we do?: Treatment of Patients Post-Stroke. What do we do?: Treatment of Patients Post-Stroke

Outline. What do we do?: Treatment of Patients Post-Stroke. What do we do?: Treatment of Patients Post-Stroke Outline Walking the walk: Translation of Scientific Findings to Improve Locomotor Recovery Post-stroke Introduction: Interventions to improve walking function for patients post stroke What do we do? What