Locomotor Training After Stroke No Better Than Physical Therapy

Allison Gandey

February 16, 2011

February 16, 2011 (Los Angeles, California) — Results from the largest clinical trial to date in rehabilitation after stroke show that although all patients achieved similar gains in walking ability, physical therapy was more practical with fewer risks.

In an interesting twist, the trial known as the Locomotor Experience Applied Post-Stroke or LEAPS had disappointing results for the specialized training that first prompted the study.

"The sophisticated program was not superior," lead investigator Pamela Duncan, PhD, from Duke University in Durham, North Carolina, told reporters attending a news conference. "All groups achieved similar important gains in walking speed, motor recovery, balance, functional status, and quality of life."

Locomotor training was not superior.

Presenting late-breaking science here at the International Stroke Conference 2011, Dr. Duncan showed that 53% of patients participating in either of the rehabilitation programs had improved functional walking ability 1 year after stroke.

The finding defies conventional wisdom that recovery occurs early and slows. In fact, even patients who started rehabilitation as late as 6 months after stroke were able to improve their walking.

"This is a very important trial," said Ralph Sacco, MD, from the Miller School of Medicine at the University of Miami and president of the American Heart Association, who moderated the press conference here. He complimented the sheer size of the study, which included 408 stroke patients from multiple US-based rehabilitation centers.

The patients all had residual paresis in the lower extremity and were able to walk 10 feet with no more than 1 person assisting. They had 10-meter walking speeds of less than 0.8 miles per second. Community mobility is possible at this rate, Dr. Duncan noted. Patients who are limited to the home tend to have walking speeds less than 0.4 miles per second.

Patients in the trial were randomized to 3 groups — early or late locomotor training and physical therapy at home. All participants were assigned 36 sessions, lasting 75 to 90 minutes.

Dr. Pamela Duncan

The home program encouraged people to walk and focused on progressive strength and balance exercises. In addition to usual care, the locomotor training involved treadmill training with body weight support.

Previous studies suggested these devices, also called commercial lifts or robot-assisted treadmill steppers, are effective in helping stroke patients walk. But this is the first time the approach has been tested on a large scale.

Six months after stroke, the early locomotor training group and those in the home program had similar gains in walking speed and these sustained at 1 year. The early locomotor training patients improved to 0.25 miles per second ± 0.21 compared with 0.23 ± 0.20 for those in the home program.

Patients in the late locomotor training group improved as well, but not as quickly. At 6 months, their walking speed was 0.13 ± 0.14 miles per second.

Although comparable in outcomes to the home-based approach, the locomotor training was associated with a small increased risk for adverse events, such as dizziness and feeling faint while exercising. Patients in this program — especially those with more severe walking limitations — were at increased risk for multiple falls.

Table. Overall Falls in LEAPS

Fall Type Rate, %
Single fall 58
Multiple falls 34
Fall resulting in injury 6

LEAPS = Locomotor Experience Applied Post-Stroke

There were more multiple falls in the early locomotor training group than late or home program, but it didn't reach statistical significance (P < .07).

The at-home group was the most likely to stick with the program. Only 3% dropped out compared with 13% in the locomotor training groups. Dr. Duncan pointed out the physical therapy program was progressive, intensive, and repetitive.

The home exercise programs require less expensive equipment, less training for therapists, and fewer clinical staff members. Dr. Duncan's team is currently pursuing another study analyzing cost.

What we see here is that even patients with significant problems in walking and even those who begin rehabilitation late do recover over time.

Asked by Medscape Medical News to comment, Jeffrey Saver, MD, director of the University of California at Los Angeles Stroke Unit, called this "a transformative trial result. This study confirms the importance of structured and progressive rehabilitation," he said. "What we see here is that even patients with significant problems in walking and even those who begin rehabilitation late do recover over time."

When it's time to refer patients, Dr. Saver suggests this study confirms that in addition to assessing mobility, clinicians should also evaluate the risk for falls and plan accordingly.

This study was funded by the National Institute of Neurological Diseases and Stroke and the National Center for Medical Rehabilitation Research. Dr. Duncan has received funding from Glaxo SmithKline, Allergan, Wyeth, and Accordia.

International Stroke Conference (ISC) 2011: Abstract LB11. Presented February 11, 2011.

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