Locomotor Training Not Better Than Home Rehab After Stroke

Susan Jeffrey

May 26, 2011

May 26, 2011 — 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 compared with locomotor training.

Results of this randomized trial, known as the Locomotor Experience Applied Post-Stroke or LEAPS, are published in the May 26 issue of the New England Journal of Medicine. They were first presented at the International Stroke Conference in February in Los Angeles, California, and were reported by Medscape Medical News.

"The sophisticated program was not superior," lead investigator Pamela Duncan, PhD, from Duke University in Durham, North Carolina, concluded after her presentation at that time. "All groups achieved similar important gains in walking speed, motor recovery, balance, functional status, and quality of life."

"As compared with locomotor training, home exercise requires less expensive equipment, its implementation requires a smaller number of staff members, less training is required for physical therapists, and patients are more likely to comply with the regimen," the study authors conclude in their paper. "Collectively, our results suggest that home exercise is a more pragmatic form of therapy with fewer risks."

The trial also showed that recovery of walking ability continued to occur up to 1 year after the stroke, and patients who started rehabilitation as late as 6 months after their stroke were able to improve walking ability, a finding that would appear to defy conventional wisdom that recovery occurs early and then slows.

However, they note, because those who started therapy at 2 months had early gains that persisted at 1 year, "these results suggest that interventions at 2 months may accelerate walking gains after stroke."

Locomotor Training

In the LEAPS trial, investigators enrolled 408 participants and stratified them by the extent of their walking impairment; patients with moderate impairment were able to walk 0.4 to 0.8 meters per second; those with severe impairment, less than 0.4 meters per second. They were then randomized to 1 of 3 treatment groups.

Dr. Pamela Duncan

Investigators compared the effectiveness of locomotor training, consisting of body weight–supported treadmill training with walking practice, started at 2 different stages: 2 months after stroke (early locomotor training) and 6 months after stroke (late locomotor training).  

Locomotor training was then compared against an equivalent schedule of home exercise managed by a physical therapist, with the aim of improving patients' flexibility, range of motion, strength, and balance. 

The primary outcome of LEAPS was the proportion of patients in each group showing improvement in walking at 1 year after the stroke.

The investigators had hypothesized that locomotor training, especially early locomotor training, would be superior to a home exercise program, the study authors note. However, all groups did equally well, achieving similar gains in walking speed, motor recovery, balance, social participation, and quality of life. 

At 1 year, 52.0% of all participants had increased functional walking ability. No significant differences in improvement were found between early locomotor training and home exercise (adjusted odds ratio [OR] for the primary outcome, 0.83; 95% confidence interval [CI], 0.50 – 1.39) or between late locomotor training and home exercise (adjusted OR, 1.19; 95% CI, 0.72 – 1.99).

All groups had similar improvements in walking speed, motor recovery, balance, functional status, and quality of life. Neither the delay in initiating the late locomotor training nor the severity of the initial impairment affected the outcome at 1 year.

A total of 10 therapy-related serious adverse events were reported, occurring in 2.2% of participants undergoing early locomotor training, 3.5% of the late locomotor training group, and 1.6% of those assigned to home exercise.

Compared with the home exercise group, each of the locomotor training groups reported a higher frequency of dizziness or faintness during treatment (P = .008). Among those with severe walking impairment, multiple falls were more common in the group receiving early locomotor training than in the other 2 groups (P = .02).

"Given the rapid adoption in clinical practice of commercially available lifts and robot-assisted treadmill steppers, it is imperative to compare the effectiveness of these task-specific interventions with that of less complex but structured therapies," the study authors conclude. "At 1 year after stroke, our findings did not establish the superiority of locomotor training on a treadmill that included bodyweight support over home-based physical therapy that emphasized strength and balance, regardless of whether locomotor training was started 2 or 6 months after the stroke. The home exercise program had fewer risks and may be more feasible."

In addition, they write, the rate of multiple falls among the severely impaired participants in the early locomotor training group suggests therapy aimed at improving balance should be incorporated into training programs designed to improve walking ability.

Evidence-Based Recommendations

Ralph Sacco, MD, professor and chairman of neurology at the University of Miami, Miller School of Medicine, in Florida, and current president of the American Heart Association, pointed out that in this trial, the more sophisticated locomotor rehabilitation approach was not significantly better than a home-based exercise program.

"Although this well-done, innovative trial shows no difference, it demonstrates that progressive home physical therapy can lead to significant functional improvements among stroke patients who had marked walking impairments at baseline," Dr. Sacco told Medscape Medical News. "By 1 year, 52% had an improved functional status."

We need to increase access to home physical therapy programs for our stroke patients who too often do not get adequate rehabilitation after a stroke.

"We need to increase access to home physical therapy programs for our stroke patients who too often do not get adequate rehabilitation after a stroke," he added. "Home physical therapy can really make a difference in the quality of life among our stroke survivors. We need more rehabilitation studies and trials such as LEAPS to advance our evidence-based recommendations on stroke recovery."

"More than 4 million stroke survivors experience difficulty walking," said Walter Koroshetz, MD, National Institute of Neurological Disorders and Stroke deputy director in a statement. "Rigorously comparing available physical therapy treatments is essential to determine which is best. The results of this study show that the more expensive, high-tech therapy was not superior to intensive home strength and balance training, but both were better than lower intensity physical therapy." 

The study was funded by the National Institute of Neurological Disorders and Stroke and the National Center for Medical Rehabilitation Research. Dr. Duncan has received funding from Glaxo SmithKline, Allergan, Wyeth, and Accordia. Dr. Sacco and Dr. Koroshetz have disclosed no relevant financial relationships.

N Engl J Med. 2011;364:2026-2036. Abstract

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