Locomotor Experience Applied Post-Stroke Research Articles

Hierarchical Properties and Functional Staging of the Fugl-Meyer Assessment Lower Extremity Scale

<h3>Research Objectives</h3> This study aimed (1) to investigate the hierarchical properties of FMA-LE and Brunnstrom stages, and (2) to develop a functional staging, a graphical plot, of FMA-LE and its relationships to low (0–21), high (22–34) FMA-LE cut-off scores. <h3>Design</h3> Secondary analysis of cross-sectional data. <h3>Setting</h3> Outpatient rehabilitation settings. <h3>Participants</h3> The Locomotor Experience Applied Post-stroke (LEAPS) trial data included 408 patients with stroke with a mean age of 62 years old (SD = 12.7, range = 25 to 98). The mean onset of stroke was 64 days (SD = 8.5, range = 43 to 112). About 55% of the sample were male. The majority (80%) of the sample had an ischemic stroke. Approximately half of the sample had brain lesions in the right hemisphere, followed by the left hemisphere (35%), brainstem (15%), and bilateral (2%). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The 17-item FMA-LE assesses lower extremity motor function including reflex activity, movement within and outside synergy patterns, and speed/coordination. It has two subscales: Lower Extremity and Speed/Coordination, which are scored on a 3-level ordinal scale (0 = none; 1 = partial; 2 = full). The total summed score of 34 points indicates normal function. <h3>Results</h3> Overall, the item difficulty hierarchical order of the FMA-LE reflected the Brunnstrom stages. The items from easy to difficult were reflex activity items, followed by items assessing flexor and extensor synergy, and movement with little/no synergies. The ‘normal reflex activity', ‘knee flexion to 90° (hip at 0°)', ‘coordination/speed' items represented the most difficult items. The two-level functional staging was judged to be clinically logical and to provide insight for clinical interpretation of patient progress. We further provided the functional staging for the clinical interpretation across all FMA-LE scores. <h3>Conclusions</h3> Our findings suggest that the FMA-LE items reflect the lower extremity motor recovery stage. This study demonstrates how functional staging can be used to translate a standardized assessment into a useful, evidence-based tool for making clinical practice decisions. <h3>Author(s) Disclosures</h3> The authors declare that there is no conflict of interest.

Hierarchical Properties of the Fugl-Meyer Assessment Upper Extremity Scale for People After Stroke

<h3>Research Objectives</h3> This study aimed (1) to investigate the hierarchical properties of FMA-UE and Brunnstrom stages, and (2) to develop a functional staging, a graphical plot, of FMA-UE and its relationships to severe (0–28), moderate (29–42), and mild (43–66) FMA-UE cut-off scores. <h3>Design</h3> Secondary analysis of cross-sectional data. <h3>Setting</h3> Outpatient rehabilitation settings. <h3>Participants</h3> The Locomotor Experience Applied Post-stroke (LEAPS) trial data included 408 patients with stroke with a mean age of 62 years old (SD = 12.7, range = 25 to 98). The mean onset of stroke was 64 days (SD = 8.5, range = 43 to 112). About 55% of the sample were male. The majority (80%) of the sample had an ischemic stroke. Approximately half of the sample had brain lesions in the right hemisphere, followed by the left hemisphere (35%), brainstem (15%), and bilateral (2%). Although most of the sample was White (58%), other racial groups were represented: Black (22%), Asian (13%), Native Hawaiian or other Pacific Islander (5%), and American Indian/Alaska Native (1%). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The 33-item FMA-UE has four subsections: (1) shoulder-arm, (2) wrist, (3) hand, and (4) coordination and speed designed to measure impairment from proximal to distal, reflexive to voluntary, and synergistic to isolated voluntary movement. <h3>Results</h3> Overall, the item difficulty hierarchical order of the FMA-UE reflected the Brunnstrom stages. The items from easy to difficult were reflex activity items, followed by items assessing flexor and extensor synergy, movement combining synergies, and movement out of synergy. The ‘normal reflex activity', ‘shoulder flexion 90-180°', ‘coordination/speed' items represented the most difficult items. The three-level functional staging was judged to be clinically logical and to provide insight for clinical interpretation of patient progress. <h3>Conclusions</h3> Our findings suggest that the FMA-UE items reflect the upper extremity motor recovery stage. This study demonstrates how functional staging can be used to translate a standardized assessment into a useful, evidence-based tool for making clinical practice decisions. <h3>Author(s) Disclosures</h3> The authors declare that there is no conflict of interest.

Development of a Berg Balance Scale Short Form Using an Artificial Neural Network (ANN) Approach

Research Objectives To develop a short form of the Berg Balance Scale (BBS-ML) using a machine learning approach. Design Cross-sectional study. Setting General community. Participants A sample of 408 patients with stroke from the Locomotor Experience Applied Post-stroke (LEAPS) study was used to develop the short form. An independent sample of 226 patients with stroke in Taiwan was used for cross-validation. Interventions Not applicable. Main Outcome Measures Berg Balance Scale (BBS). Results We applied feature selection algorithms to identify the most useful items for developing a short form. The highest-rated items, ranging from top 4 to top 8, were selected to develop 5 initial versions of short forms (i.e., 4-, 5-, 6-, 7-, and 8-item BBS-ML short forms). The R-squares were 0.91, 0.94, 0.97, 0.96, and 0.98 for the 4-, 5-, 6-, 7-, and 8-item BBS-ML, respectively. The 95% limits of agreements (LoAs) were 15.6, 12.5, 9.6, 10.8, and 8.3, respectively. The possible scoring points (PSPs) were 32, 32, 35, 35, and 36, respectively. The 6-item version was determined as the final version of the BBS-ML because it showed relatively high predictive power of the BBS sum scores, relatively small differences with the observed BBS scores, and the highest PSP. Conclusions The BBS-ML appears to be a promising alternative to improve the efficiency of administrations for busy users. Author(s) Disclosures The authors declare that there is no conflict of interest. To develop a short form of the Berg Balance Scale (BBS-ML) using a machine learning approach. Cross-sectional study. General community. A sample of 408 patients with stroke from the Locomotor Experience Applied Post-stroke (LEAPS) study was used to develop the short form. An independent sample of 226 patients with stroke in Taiwan was used for cross-validation. Not applicable. Berg Balance Scale (BBS). We applied feature selection algorithms to identify the most useful items for developing a short form. The highest-rated items, ranging from top 4 to top 8, were selected to develop 5 initial versions of short forms (i.e., 4-, 5-, 6-, 7-, and 8-item BBS-ML short forms). The R-squares were 0.91, 0.94, 0.97, 0.96, and 0.98 for the 4-, 5-, 6-, 7-, and 8-item BBS-ML, respectively. The 95% limits of agreements (LoAs) were 15.6, 12.5, 9.6, 10.8, and 8.3, respectively. The possible scoring points (PSPs) were 32, 32, 35, 35, and 36, respectively. The 6-item version was determined as the final version of the BBS-ML because it showed relatively high predictive power of the BBS sum scores, relatively small differences with the observed BBS scores, and the highest PSP. The BBS-ML appears to be a promising alternative to improve the efficiency of administrations for busy users.

Locomotor Training and Home Exercise Program to Improve Gait: Who May Benefit?

<h3>Research Objectives</h3> To determine the demographic, behavioral, and pathophysiological factors associated with the effectiveness of locomotor training and home exercise program in stroke survivors. <h3>Design</h3> This study was a secondary data analysis on the data collected from the Locomotor Experience Applied Post-Stroke (LEAPS) trial. The association rule, a data mining technique, was applied for the analysis. <h3>Setting</h3> General community. <h3>Participants</h3> We analyzed all 408 stroke survivors in the LEAPS trial. <h3>Interventions</h3> The participants were randomly assigned to receive three interventions: (1) Early Locomotor Training (ELT, started 2 months post-stroke); (2) Late Locomotor Training (LLT, started 6 months post-stroke); (3) Home Exercise Program (HEP, started 2 months post stroke). <h3>Main Outcome Measures</h3> Improvement of self-selected comfortable speed. <h3>Results</h3> Based on threshold we set for the Apriori algorithm, participants in the ELT who tended to perform better were white females, aged below 65 years, had private insurance, had a bachelor's degree or some college education, had no cardiovascular symptoms, and did not participate in physical activity on a weekly basis. Participants in the HEP who tended to perform better were white males, aged below 65 years, who had high school education GED, history of prior history of transient ischemic attack (TIA), and physical activity at least 3 times per week. No reliable association rules were identified in the LLT group. <h3>Conclusions</h3> The effectiveness of ELT and HEP may be predicted by patients' gender, race, age, education level, physical activity level, type of health insurance, cardiovascular symptoms, and/or history of TIA. The results may contribute to clinical decision making when selecting appropriate interventions such as locomotor training for stroke survivors. <h3>Author(s) Disclosures</h3> The authors declare that there is no conflict of interest.

Abstract P198: Daily Step Count at Two Months is the Strongest Predictor of Daily Steps at One Year Post-Stroke

For survivors of stroke, walking can improve endurance, community participation and decrease risk of subsequent stroke. Unfortunately, survivors take 4000 fewer steps per day compared to other adults. Early identification of survivors prone to long-term inactivity would be valuable, as interventions could be implemented to improve physical activity (PA) levels and reduce subsequent stroke risk. Secondary data from the Locomotor Experience Applied Post Stroke (LEAPS) trial was used. Included participants had walking speeds of &lt;0.80 m/s at 2 months post-stroke. Daily steps were assessed at 2 months and 1 year post-stroke using an activity monitor. Stepwise regression was used to predict daily step counts at 1 year based on modifiable (walking speed, endurance, balance, balance confidence, daily step counts) and nonmodifiable (age at time of stroke, gender, race, ethnicity, initial stroke severity, side of stroke and LEAPS intervention group) factors. Data was available for 206 survivors, mean age=63 (13) years, 43% female (88/206), mean walking speed=.41 (.22) m/s, mean step count=2922 (2749) steps per day. The strongest predictor of daily steps at 1 year was daily steps at 2 months (p=&lt;0.001, adjusted R 2 =.34). For every 1-step increase at 2 months, there was an increase of .54 (95% CI .38, .71) steps at 1 year. The next strongest predictor was walking endurance (Six Minute Walk), which significantly increased adjusted R 2 by .02 (p=.009). For every 1-meter increase in Six Minute Walk distance at 2 months, there was an increase of 8 (95% CI 2, 14) steps at 1 year. Together, baseline steps and Six Minute Walk distance explained 36% of the variance in daily steps at 1 year. No other factors significantly added to the prediction model. Daily steps at 2 months post-stroke was the strongest predictor (explaining 34% of the variance) of steps at 1 year. Survivors with low daily steps early after stroke may benefit from targeted walking interventions to increase PA and long term health outcomes.

Sleep problems worsen health-related quality of life and participation during the first 12 months of stroke rehabilitation

Objective: Evaluate the impact of self-reported sleep problems on post-stroke recovery. Design: Cross-sectional secondary analysis of longitudinal data from the Locomotor Experience Applied Post-Stroke (LEAPS) rehabilitation and recovery study (phase-III single-blind randomized controlled clinical trial). Group medians were compared for three sleep problem groups across three time points. Setting: Outpatient and in-home physical therapy. Subjects: Adults during the first year following stroke (n = 408, 380, 360 at 2, 6, 12 months, respectively). Interventions: The original study compared effects of locomotor training with body weight support in the year post-stroke. This analysis evaluated function in three sleep/functional-impact groups: no sleep problems, sleep problems with no-to-minimal-impact and sleep problems with moderate-to-quite-a-bit of impact. Main measures: Participants’ responses regarding if they had “a sleep problem, such as insomnia” and, if so, what the impact was on their function. Stroke Impact Scale subscales for strength, hand function, mobility, ADLs, memory, communication, emotion, participation, and percent recovery. Results: About 25% of people with stroke reported sleep difficulty, 10% perceived sleep problems negatively impact function. Groups self-reporting worse sleep performed worse in all functional subscales (except self-perceived percent recovery) during the first year post-stroke. Conclusion: Self-reported poor sleep adversely effects post-stroke functional recovery.

Locomotor Training and Strength and Balance Exercises for Walking Recovery After Stroke: Response to Number of Training Sessions.

Evidence-based guidelines are needed to inform rehabilitation practice, including the effect of number of exercise training sessions on recovery of walking ability after stroke. The objective of this study was to determine the response to increasing number of training sessions of 2 interventions-locomotor training and strength and balance exercises-on poststroke walking recovery. This is a secondary analysis of the Locomotor Experience Applied Post-Stroke (LEAPS) randomized controlled trial. Six rehabilitation sites in California and Florida and participants' homes were used. Participants were adults who dwelled in the community (N=347), had had a stroke, were able to walk at least 3 m (10 ft) with assistance, and had completed the required number of intervention sessions. Participants received 36 sessions (3 times per week for 12 weeks), 90 minutes in duration, of locomotor training (gait training on a treadmill with body-weight support and overground training) or strength and balance training. Talking speed, as measured by the 10-Meter Walk Test, and 6-minute walking distance were assessed before training and following 12, 24, and 36 intervention sessions. Participants at 2 and 6 months after stroke gained in gait speed and walking endurance after up to 36 sessions of treatment, but the rate of gain diminished steadily and, on average, was very low during the 25- to 36-session epoch, regardless of treatment type or severity of impairment. Results may not generalize to people who are unable to initiate a step at 2 months after stroke or people with severe cardiac disease. In general, people who dwelled in the community showed improvements in gait speed and walking distance with up to 36 sessions of locomotor training or strength and balance exercises at both 2 and 6 months after stroke. However, gains beyond 24 sessions tended to be very modest. The tracking of individual response trajectories is imperative in planning treatment.

The Effects of Stroke Type, Locus, and Extent on Long-Term Outcome of Gait Rehabilitation

Background. Paresis in stroke is largely a result of damage to descending corticospinal and corticobulbar pathways. Recovery of paresis predominantly reflects the impact on the neural consequences of this white matter lesion by reactive neuroplasticity (mechanisms involved in spontaneous recovery) and experience-dependent neuroplasticity, driven by therapy and daily experience. However, both theoretical considerations and empirical data suggest that type of stroke (large vessel distribution/lacunar infarction, hemorrhage), locus and extent of infarction (basal ganglia, right-hemisphere cerebral cortex), and the presence of leukoaraiosis or prior stroke might influence long-term recovery of walking ability. In this secondary analysis based on the 408 participants in the Locomotor Experience Applied Post-Stroke (LEAPS) study database, we seek to address these possibilities. Methods. Lesion type, locus, and extent were characterized by the 2 neurologists in the LEAPS trial on the basis of clinical computed tomography and magnetic resonance imaging scans. A series of regression models was used to test our hypotheses regarding the effects of lesion type, locus, extent, and laterality on 2- to 12-month change in gait speed, controlling for baseline gait speed, age, and Berg Balance Scale score. Results. Gait speed change at 1 year was significantly reduced in participants with basal ganglia involvement and prior stroke. There was a trend toward reduction of gait speed change in participants with lacunar infarctions. The presence of right-hemisphere cortical involvement had no significant impact on outcome. Conclusions. Type, locus, and extent of lesion, and the loss of substrate for neuroplastic effect as a result of prior stroke may affect long-term outcome of rehabilitation of hemiparetic gait.

Concordance and discordance between measured and perceived balance and the effect on gait speed and falls following stroke

Objective: To ascertain the existence of discordance between perceived and measured balance in persons with stroke and to examine the impact on walking speed and falls. Design: A secondary analysis of a phase three, multicentered randomized controlled trial examining walking recovery following stroke. Subjects: A total of 352 participants from the Locomotor Experience Applied Post-Stroke (LEAPS) trial. Methods: Participants were categorized into four groups: two concordant and two discordant groups in relation to measured and perceived balance. Number and percentage of individuals with concordance and discordance were evaluated at two and 12 months. Walking speed and fall incidence between groups were examined. Main measures: Perceived balance was measured by the Activities-Specific Balance Confidence scale, measured balance was determined by the Berg Balance Scale and gait speed was measured by the 10-meter walk test. Results: Discordance was present for 35.8% of participants at two months post stroke with no statistically significant change in proportion at 12 months. Discordant participants with high perceived balance and low measured balance walked 0.09 m/s faster at two months than participants with concordant low perceived and measured balance (p < 0.05). Discordant participants with low perceived balance and high measured balance walked 0.15 m/s slower than those that were concordant with high perceived and measured balance (p ⩽ 0.0001) at 12 months. Concordant participants with high perceived and measured balance walked fastest and had fewer falls. Conclusions: Discordance existed between perceived and measured balance in one-third of individuals at two and 12 months post-stroke. Perceived balance impacted gait speed but not fall incidence.

Likelihood of Myocardial Infarction during Stroke Rehabilitation Preceded by Cardiovascular Screening and an Exercise Tolerance Test: The Locomotor Experience Applied Post-Stroke (LEAPS) Trial

Coronary artery disease is highly prevalent in patients with stroke, but because revascularization does not improve major clinical outcomes in patients with stable coronary artery disease relative to intensive medical therapy, routine evaluation for this disease is not warranted in stroke patients. However, it might be warranted in patients destined to undergo vigorous physical therapy. The Locomotor Experience Applied Post-Stroke study, a randomized controlled trial of 408 participants that tested the relative efficacy of two rehabilitation techniques on functional walking level, provided the opportunity to address this question. The study aims to test the efficacy of screening for cardiovascular disease and an exercise tolerance test in assuring safety among patients undergoing vigorous rehabilitation for gait impairment. All participants were screened for serious cardiovascular and pulmonary conditions. At six-weeks poststroke, they also completed a cardiovascular screening inventory and underwent an exercise tolerance test involving bicycle ergometry. Participants received 36, 90-min sessions of a prescribed physical therapy (three per week), initiated at either two-months or six-months poststroke. Twenty-nine participants were excluded on the basis of the cardiac screening questionnaire, and 15 failed the exercise tolerance test for cardiovascular reasons. No participant experienced a cardiac event during a treatment session. Two participants experienced myocardial infarctions, but continued in the trial. In three additional participants, myocardial infarctions caused or contributed to death. The combination of a negative cardiac screen and the absence of exercise tolerance test failure appeared to have a high negative predictive value for cardiac events during treatment, despite the likelihood of a high prevalence of coronary artery disease in our population.

Effects of Task-Specific and Impairment-Based Training Compared With Usual Care on Functional Walking Ability After Inpatient Stroke Rehabilitation

Background. After inpatient stroke rehabilitation, many people still cannot participate in community activities because of limited walking ability. Objective. To compare the effectiveness of 2 conceptually different, early physical therapy (PT) interventions to usual care (UC) in improving walking 6 months after stroke. Methods. The Locomotor Experience Applied Post-Stroke (LEAPS) study was a single-blind, randomized controlled trial conducted in 408 adults with disabling hemiparetic stroke. Participants were stratified at baseline (2 months) by impairment in walking speed: severe (<0.4 m/s) or moderate (0.4 to <0.8 m/s). Between 2 and 6 months, they received either only UC (n = 143) or UC plus 36 therapist-provided sessions of either (1) walking training on a treadmill using body-weight support and practice overground at clinics (locomotor training program [LTP], n = 139) or (2) impairment-based strength and balance exercise at home (home exercise program [HEP], n = 126). Results. LTP participants were 18% more likely to transition to a higher functional walking level: severe to >0.4 m/s and moderate to >0.8 m/s than UC participants (95% confidence interval [CI] = 7%-29%), and HEP participants were 17% more likely to transition (95% CI = 5%-29%). Mean gain in walking speed in LTP participants was 0.13 m/s greater (95% CI = 0.09-0.18) and in HEP participants, 0.10 m/s greater (95% CI = 0.05-0.14) than in UC participants. Conclusions. Progressive PT, using either walking training on a treadmill and overground, conducted in a clinic, or strength and balance exercises conducted at home, was superior to UC in improving walking, regardless of severity of initial impairment.

Characterizing and Identifying Risk for Falls in the LEAPS Study

Better understanding of fall risk poststroke is required for developing screening and prevention programs. This study characterizes falls in the Locomotor Experience Applied Post-Stroke (LEAPS) randomized clinical trial, describes the impact of 2 walking recovery interventions on falls, and examines the value of clinical assessments for predicting falls. Community-dwelling ambulatory stroke survivors enrolled in LEAPS were assessed 2 months poststroke. Falls were monitored until 12 months poststroke and participants were characterized as multiple or injurious (M/I); single, noninjurious; or nonfallers. Incidence and time to M/I falls were compared across interventions (home exercise and locomotor training initiated 2 months [early-LTP] or 6 months [late-LTP] poststroke). Predictive value of 2-month clinical assessments for falls outcome was assessed. Among the 408 participants, 36.0% were M/I, 21.6% were single, noninjurious, and 42.4% were nonfallers. Most falls occurred at home in the first 3 months after assessment. Falls incidence was highest for those with severe walking impairment who received early-LTP (P=0.025). Berg Balance Scale score ≤ 42/56 was the single best predictor of M/I falls. As individuals with stroke improve in walking capacity, risk for M/I falls remains high. Individuals walking <0.4 m/s are at higher risk for M/I falls if they receive early-LTP training. Berg Balance Scale score at 2 months poststroke is useful for informing falls risk, but it cannot account for the multifactorial nature of the problem. Falls prevention in stroke will require multifactorial risk assessment and management provided concomitantly with exercise interventions to improve mobility. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00243919.

Improving Outcomes After Stroke By LEAPS (Locomotor Experience Applied Post-Stroke) and Bounds

Stroke is a chronic, lasting condition. Over 795 000 persons have a new stroke each year.1 The vast majority survive, with those in the seventh decade living an average of 7 years thereafter,1 most with some form of loss of function and limitation of activity.2 Increasing evidence suggests that these deficits are not fixed, but instead that the brain is plastic, that a number of different therapies have the potential to improve brain structure and function once the acute stroke period passes and stroke injury is fixed, and that this plasticity can reduce poststroke disability. Brain plasticity is facilitated by repeated practice. This is true during development, during learning, in times of health, and after brain injury such as stroke. This principle is the foundation of poststroke treatments applied across behavioral modalities such as neglect, aphasia, or weakness. Evidence suggests that the responsiveness of the brain to such intervention declines with time poststroke.3 However, many patients long past stroke can nonetheless benefit from repeated practice such as with an activity-based regimen that is initiated even months after stroke onset. For example, the Extremity Constraint Induced Therapy Evaluation (EXCITE) trial was a landmark study that found that constraint-induced therapy improved upper extremity motor function when initiated 3 to 9 months after stroke onset.4 It is in this context that the Locomotor Experience Applied Post-Stroke (LEAPS) trial was initiated. The LEAPS trial focused on improving gait after stroke by comparing 2 different activity-based therapies and 2 different time points. Gait is a priority because it is commonly affected by stroke, gait improvements after stroke are linked to better quality of life,5 and hemiplegic patients rank recovery of gait as their top priority.6 Importantly, gait velocity is linked to level of social participation.7 A typical …

Meaningful Gait Speed Improvement During the First 60 Days Poststroke: Minimal Clinically Important Difference

When people with stroke recover gait speed, they report improved function and reduced disability. However, the minimal amount of change in gait speed that is clinically meaningful and associated with an important difference in function for people poststroke has not been determined. The purpose of this study was to determine the minimal clinically important difference (MCID) for comfortable gait speed (CGS) associated with an improvement in the modified Rankin Scale (mRS) score for people between 20 to 60 days poststroke. This was a prospective, longitudinal, cohort study. The participants in this study were 283 people with first-time stroke prospectively enrolled in the ongoing Locomotor Experience Applied Post Stroke (LEAPS) multi-site randomized clinical trial. Comfortable gait speed was measured and mRS scores were obtained at 20 and 60 days poststroke. Improvement of >or=1 on the mRS was used to detect meaningful change in disability level. Mean (SD) CGS was 0.18 (0.16) m/s at 20 days and 0.39 (0.22) m/s at 60 days poststroke. Among all participants, 47.3% experienced an improvement in disability level >or=1. The MCID was estimated as an improvement in CGS of 0.16 m/s anchored to the mRS. Because the mRS is not a gait-specific measure of disability, the estimated MCID for CGS was only 73.9% sensitive and 57.0% specific for detecting improvement in mRS scores. We estimate that the MCID for gait speed among patients with subacute stroke and severe gait speed impairments is 0.16 m/s. Patients with subacute stroke who increase gait speed >or=0.16 m/s are more likely to experience a meaningful improvement in disability level than those who do not. Clinicians can use this reference value to develop goals and interpret progress in patients with subacute stroke.