Use of an intensive task-oriented gait training program in a series of patients with acute cerebrovascular accidents.

Key Words: Acute stroke, Gait, Hemiplegia, Physical therapy.

To walk again following a stroke is an important goal shared by patients of all ages. The severity of the central nervous system lesion[1] or age[2] can affect the patient's gait relearning potential, and environmental and training conditions also influence motor recovery.[1,3] there is, for example, general agreement that early rehabilitation promotes the quality of the recovery[1,3,4] and that the intensity of physical therapy is important,[5,6] especially in the first months following stroke. Perhaps the most critical factor is the training. Recent reports[7-9] suggest that the best way to learn an activity is to practice that activity, that is, to use task-oriented training. The recent finding that balance training while standing could improve balance symmetry without improving the symmetry of hemiparetic limb movements during walking further supports the specificity of training concept.[10] If we assume that recovery poststroke involves the relearning of motor behaviors, the rehabilitation program of choice should promote motor learning by task-specific practice.[4,9,11] The purposes of this case report are (1) to describe the application of an intensive task-oriented physical therapy program for gait relearning in a group of patients with an acute stroke and (2) to report the patients' ability to comply with the program.

Case Report

Cases

Ten patients with hemiplegia (5 women, 5 men), with a mean age of 69.8 years (SD=7.3, range=60-75), were enrolled in this program. The patients were screened in the Emergency Department of the l'Hopital de l'Enfant Jesus (Quebec City, Quebec, Canada). A nurse identified patients between 40 and 80 years of age with an acute stroke resulting from a suspected infarct of the middle cerebral artery. This infarct was confirmed by computerized tomography 5 to 7 days after the stroke. These patients were conscious at onset of the stroke but had an established or developing hemiplegia corresponding to the middle band of the triage system described by Garraway et al.[12] Patients who were unconscious at stroke onset (lower band) and those who were conscious at stroke onset but able to walk without human assistance (upper band) were excluded from the program. Patients with receptive aphasia or other clinical problems that either incapacitated them prior to the stroke or would interfere with the rehabilitation process were also excluded. All participating patients signed an informed consent statement. The functional level and the sensorimotor performance of the patients, as measured 5 to 7 days after stroke with the Barthel Index[13] and the Fugl-Meyer stroke assessment scale,[14] are reported in Table 1. On the basis of the scores obtained from the initial Barthel Index evaluation, the patients were placed in either a poor (score <20) or a good (score [is greater than or equal to] 20) prognosis group. [TABULAR DATA 1 OMITTED]

The Physical Therapy Program

Two daily physical therapy sessions, each of 60 minutes' duration, were planned for each patient from about the eighth day after stroke, 5 days a week, for a 5-week period. In addition to the special gait-related training (SGT) activities included in the training program, conventional therapy, consisting of passive movements, positioning, and facilitatory procedures,[15,16] was also provided at each session. The main objective of the program was to promote gait relearning by means of intensive SGT activities introduced early in the rehabilitation process. It was thus important to practice different activities preparatory to independent standing and walking. Dependent on the patient's degree of disablement, a tilt table or parallel bars were used in combination with a limb-load monitor(*) (LLM) to promote early standing and to ensure symmetrical weight distribution. An air splint was also used to help stabilize the paretic knee in patients who were unable to fully control their knees during standing. Preparatory exercises for walking were done using the Kinetron II, ([dagger]) an isokinetic device that allows extension of one lower extremity while the other lower extremity flexes at the hip and knee. This isokinetic actuator provides an accommodating resistance throughout the entire range of motion, and the amount of resistance can be progressively increased by selecting lower training velocities and by increasing the amount of weight bearing (eg, by changing from a sitting to a standing position). The Kinetron was thus used for training reciprocal lower-limb movements and for muscle strengthening during an activity that we thought simulated natural walking.

As soon as a patient was able to stand and take a few steps, walking was started on the treadmill.([double dagger]) Treadmill training was initiated at two velocities: 0.045 and 0.09 m/s. The velocity was progressively increased according to individual capacity. A safety harness consisting of a climber's belt and a pulley system (Fig. 1) was used to guard against falls. Other safety modifications, such as padding of the front panel and the treadmill rails, were made. The training was carried out by two physical therapists from the hospital at which the study was carried out. Generally, a patient was treated by the same therapist over the 5-week program. A detailed description of the physical therapy program is reported in the "Treatment Progression" section.

Data Collection, Reduction, and Analysis

The number of time units (1 unit= 5 minutes) devoted to each activity was computed by the treating therapist after each treatment and recorded. Information concerning the progression of the SGT activities (eg, patient's position, training velocity, number and duration of training periods) was also recorded. The patient's reactions to SGT activities (eg, acceptance, fear, difficulties), as well as the number of and reasons for treatment sessions missed were noted. The patient's tolerance, as determined by the two experienced therapists (7 and 10 years' experience, respectively, with patients who have had a stroke), served as a guide to modulate the duration of the physical therapy sessions and the progression of the SGT activities. Compliance with the treatment protocol was assessed by comparing the patient's actual treatment time with the total expected time as planned initially in the program (ie, total of 50, 1-hour treatments, performed twice daily, 5 days per week, over the 5-week treatment period). The descriptive statistics presented in Tables 2 through 5 demonstrate the patients' compliance with the treatment protocol, the relative time dedicated to SGT activities, and the progression of SGT activities over the 5-week period. Spearman rank-order correlation coefficients were used to study the relationship between specified gait training variables.

Compliance with Treatment Protocol

All but one patient, who had an infection, completed the 5-week physical therapy program. Characteristics of these patients are given in Table 1. The weekly compliance with the treatment protocol for the group is reported in Table 2. The mean number of weekly physical therapy sessions was quite high (9-9.6), except for week 1 (7.1), primarily because three patients started therapy later than 8 days after stroke (Tab. 1). During the first week, the mean treatment duration was almost 45 minutes (or 90 minutes daily), and it thereafter increased up to 55.5 minutes at week 3. Increases in the mean percentage of time dedicated to SGT activities were also observed up to week 4 (Tab.2).

Individual compliance with the treatment protocol is reported in Table 3. The table displays the differences among the patients in terms of number of treatments as well as total therapy time over the 5-week period. The highest treatment compliance was seen in patient 212. The lowest treatment compliance was seen in patient 205, who had an advanced diabetic condition with circulatory problems in the paretic foot and who cooperated poorly with the therapy sessions. These conditions likely explain the patient's lower compliance level. It should be noted that reasons for missing a treatment session included a concomitant appointment (eg, for roentgenograph, electrocardiograph, computed tomography scan, occupational therapy) or problems (eg, level of glycemia, nausea) related to associated medical conditions. In no case did the treatment session have to be discontinued because of the intensity or the nature of the program.

Treatment Progression

Figure 2 presents the mean time (in minutes) dedicated weekly to each of the SGT activities (Fig. 2A-C) and to conventional gait training (Fig. 2D). Only three patients (101, 106, and 108) required the use of a tilt table; they were the same three patients who needed a knee orthosis (the air splint) during early standing and walking activities. The LLM was also used while standing on the tilt table, during walking in the parallel bars, and during free gait. The amount of weight bearing, monitored by the LLM on the paretic side, was gradually increased from 30% to 50% of the total body weight.

Kinetron training was started for most patients (n=7) during week 1. The training was provided once a day (5 days per week) over the next 4 weeks to reach a mean maximum weekly duration of 70.5 minutes (or 14.1 minutes per day) at week 4 (Fig. 2B), including rest periods (about 2 minutes of rest for 1 minute of training). Kinetron training was progressed, first by increasing the amount of weight bearing by changing the training position and then by decreasing the training velocity. Thus, the patients were first taught to move their lower limbs reciprocally while sitting in the wheelchair with the hips and knees flexed about 90 degrees and facing the Kinetron. From this position, the movements consisted mainly of hip flexion and extension through 10 to 20 degrees' excursion. This training was usually started during week 1 (Tab. 4) at a time when transfers from wheelchair to bed were still difficult. The second step, which consisted of training while seated on the Kinetron, was initiated when the patient was able to transfer from the bed to the wheelchair with assistance. When seated on the Kinetron, the patients were encouraged to make the movements with the hips and knees more extended and through a larger excursion (30 [degrees]-45 [degrees]). This second step was achieved within the first week by half the patients. The third step, which consisted of training with the patients standing on the Kinetron with full weight bearing, was introduced when the patients were able to stand between the parallel bars while bearing partial weight. Only two patients (113 and 201) were able to reach the third step during week 1 (Tab. 4); the other patients achieved the third step between weeks 2 and 4, or failed to do so (patient 205; Tab. 4).

Table 5 presents the data for other variables monitored during Kinetron training. The minimum and maximum velocities (in centimeters per second) at which the patients exercised over the 5-week training period varied among the patients (training velocity on the Kinetron corresponds to the linear velocity of the displacement of the pedals over an adjustable range). Kinetron training was started at a velocity that was comfortable for the patient. The initial training velocities ranged from 50 to 90 cm/s, with the most frequent velocities being between 70 and 90 cm/s (n=7/9). The progression was made by reducing the velocity, which allowed the development of higher force, and by increasing the number and the duration of the training periods. It can be seen, however, that from week 2, the mean weekly duration of Kinetron training remained relatively stable (Tab. 5, Fig. 2B). No attempt was made to determine whether the Kinetron actually moved at the speed settings used; the velocities are those at which the machine was set to move. [TABULAR DATA 5 OMITTED]

Prior to walking on the treadmill, preparatory exercises were done with the patient sitting in a wheelchair at the end of the treadmill. The aim of these exercises was to enable the patients to follow the moving treadmill. The therapist guided the patients into producing reciprocal leg movements with proper foot placements. In most cases, it was also necessary for the therapist to manually guide the foot placements in the early phase of training on the treadmill. Once this goal was attained in sitting and the patient had demonstrated the capacity to take a few steps with assistance in the parallel bars, walking on the treadmill was initiated. As illustrated in Figure 2C, treadmill training was started during week 1 for two patients (113, 201). By week 2, all patients (except patient 106, who started treadmill training during week 3) were already able to walk on the treadmill. Training on the treadmill was possible at this early stage because of the safety harness, which protected the patient from falls. Nonetheless, two persons were always present: the therapist and another individual who stood by the patient and close to the treadmill control panel for safety purposes. This procedure allowed the therapist to fully concentrate on movement training and the application of manual assistance or guidance to the paretic lower leg and foot when necessary.

For training, the velocity of the treadmill was started very low (0.045-0.09 m/s), and therapy progression consisted mainly of velocity increments (Fig. 3A), with the training duration remaining about the same from week 3 to week 5 (Fig. 2C). Although most patients started the treadmill training at a similar velocity (0.045-0.09 m/s), the maximum velocities attained varied among the patients (X [bar]=0.38 m/s, SD=0.24 m/s). The maximum velocity of treadmill training attained (Fig. 3A) was highly correlated (Spearman's rho=.90) with the total number of hours of treadmill training (Fig. 3B). Although treadmill training, like Kinetron training, was done once daily, the time devoted to treadmill training was almost twice that of Kinetron training (Fig. 2C). Because treadmill gait training was less demanding than Kinetron resisted movements, 1-minute rest periods (rather than 2 minutes) for each minute of training were sufficient. The speed of the treadmill was not checked as part of the study.

The mean weekly treatment duration remained quite stable from week 3 to week 5 (Fig. 2C). In addition to the time spent on SGT activities, the patients also received conventional gait training (parallel bars, free gait). As shown in Figure 2D, the mean weekly time devoted to such activities ranged from 22.5 to 55.5 minutes and represented about 33% of the treadmill gait training time.

Discussion

The results of this study show that an intensive gait relearning program is well tolerated shortly after stroke. The program provided patients with twice as much therapy time as is usually given in an institution.[17,18] Moreover, clinical reports[19-21] estimate that the duration of daily physical therapy sessions generally ranges from 30 to 45 minutes. In a study in which the actual amount of therapy time was monitored,[17] the mean daily treatment durations (started within 4 days after stroke) were 25.8 and 33.4 minutes for two groups of patients in a stroke unit and in a medical unit, respectively.

The practice of initiating rehabilitation as early as possible is not new. Early rehabilitation has been associated with reduced patient fatality and improved quality of survivorship following a stroke.[13,23,24] Moreover, it has been found that the time between stroke onset and initiation of intensive rehabilitation specifically affected factors such as transfers and ambulation training.22 Our study demonstrates that patients can successfully cope with task-oriented (balance and gait) activities from the first week after stroke. In this study, physical therapy was initiated at the earliest on the seventh day poststroke (Tab. 1). Treatment perhaps should be started earlier but was delayed because of the methodological constraints of a clinical trial that included this group of patients. Had the treatment sessions been started earlier than 7 days poststroke, we believe that the patients would have been able to cope with the program because it was adapted to the individual's disability level. As it is becoming more common for patients to be referred to physical therapy within 48 hours poststroke, results such as these strongly suggest that early therapy should not be limited to positioning and passive mobilization procedures, but should include exercises directed at enhancing balance and walking.

In terms of applicability, perhaps the most critical aspect of this early and intensive physical therapy program is the comprehensive, but progressive, nature of the task-oriented training. The program also included the use of adjunctive therapeutic devices such as the tilt table, a feedback system (the LLM), an isokinetic apparatus (Kinetron), and a treadmill. It is well known that before the ultimate objective of independent gait is attained, many requirements have to be fulfilled. Balance in standing is a first requisite. When balance is strongly impaired, standing can be practiced using a tilt table. In this study, only three patients required this type of training during week 1. This activity was found to be quite stimulating, especially when combined with weight-shifting exercises using a feedback system such as the LLM. These exercises helped to provide sensory inputs associated with standing. In a recent report,[25] the use of the tilt table for improving orthostatic blood pressure in patients with acute stroke was shown to be beneficial.

Kinetron and treadmill training were also started for many patients during the first week. Because some patients had difficulty in transferring or did not have good balance in standing, training was started in the wheelchair. These preliminary exercises allowed the patients to learn how to initiate bilateral reciprocal leg movements and how to place their feet in response to the moving treadmill belt without having to control their balance. Treadmill training provides specific advantages that are related to the built-in controls and digital display of the velocity, the distance, and the time; such information can provide important feedback mechanisms. These controls not only allow for progressive walking programs tailored to each patient's requirements[26] but also inform the patient about performance (ie, walking speed, distance covered, duration) so that the patient can be challenged to reach further achievements. The treadmill also provides a means of increasing the patient's awareness of walking, because the patient receives feedback and instruction concerning the control of foot and leg movements while walking at a steady, comfortable pace. The combination of these advantages renders treadmill training very attractive to the patients.

The Kinetron and treadmill training can also be expected to reduce muscle weakness (not measured in this study) that develops after stroke even on the nonparetic side.[27-29] The finding that, in comparison with controls, treadmill-trained elderly patients following a hip fracture had stronger hip muscles accompanied by a higher gait velocity and longer stride lengths,[26] suggests that treadmill training is more effective than conventional gait training for muscle strengthening and the optimization of gait spatiotemporal variables in elderly patients.

Limitations and Conclusions

The results of our study clearly demonstrate that early and intensive gait-related training is feasible and that it can be very well tolerated by patients who are moderately to severely involved following a stroke. Moreover, such an early gait training program has been shown (in a pilot randomized controlled trial) to be more effective than conventional physical therapy for promoting locomotor recovery in patients following an acute stroke.[30] The application of this type of program to a larger population of patients who have had strokes, however, should be made with caution, especially for patients with severe heart conditions or high blood pressure. In patients with severe disabilities, partial reduction of the body weight might help in promoting more normal movements and muscle activation patterns, as has been demonstrated in patients with spinal cord injury.[31,32] It is important to emphasize that although a treadmill can provide stimulation for gait relearning, gait training should not be restricted to the treadmill. Patients should practice walking on a variety of surfaces[4,9] in order to generalize the effects of training.

Acknowledgments

We thank Mrs Alice Lajeunesse, RN, and Mrs Lyse Laroche for their assistance in the accrual of the patients and Mr Daniel Tardif and Mr Langis Gagnon for their technical assistance.

References

[1] Held JM. Recovery of function after brain damage: theoretical implications for therapeutic intervention. In: Carr JH, Shepherd RB, Gordon J, et al, eds. Movement Science: Foundation for Physical Therapy in Rehabilitation. Rockville, Md: Aspen Publishers Inc; 1987: 155-177. [2] Levin HS, Ewing-Cobbs L, Benton AL. Age and recovery from brain damage: a review of clinical studies. In: Schieff SW, ed. Aging and Recovery of Function in the Central Nervous System. New York, NY. Plenum Publishing Corp; 1984. [3] Bach-Y-Rita P. Brain plasticity as a basis for therapeutic procedures. In: Bach-y-Rita P, ed. Recovery of Function. Baltimore, Md: University Park Press; 1980:225-263. [4] Carr JH, Shepherd RB. A motor learning model for rehabilitation. In: Carr JH, Shepherd RB, Gordon J, et al, eds. Movement Science: Foundations for Physical Therapy in Rehabilitation. Rockville, Md: Aspen Publishers Inc; 1987: 31-91. [5] Smith DS, Goldberger E, Ashburn A. Remedial therapy after stroke: a randomized clinical trial. Br Med J. 1981;282:517-520. [6] Sivienus J, Pyorala K, Heinoven OP. The significance of intensity of rehabilitation of stroke: a controlled trial. Stroke. 1985;16: 928-931 [7] Gentile AM. Skill acquisition: action, movement and neuromuscular processes. In: Carr JH, Shepherd RB, Gordon J, et al, eds. Movement Science: Foundations for Physical Therapy in Rehabilitation. Rockville, Md: Aspen Publishers Inc; 1987:93-154. [8] Duncan PW, Badke MB. Therapeutic strategies for rehabilitation of motor deficits. In: Duncan PW, Badke MB, eds. Stroke Rehabilitation: The Recovery of Motor Function. Chicago, Ill: Year Book Medical Publishers Inc; 1987:161-197. [9] Winstein CJ. Motor learning considerations in stroke rehabilitation. In: Duncan PW, Badke MB, eds. Stroke Rehabilitation: The Recovery of Motor Control. Chicago, Ill: Year Book Medical Publishers Inc; 1987:109-134. [10] Winstein CJ, Gardner ER, McNeal DR, et al. Standing balance training: effects on balance and locomotion in hemiparetic adults. Arch Phys Med Rehabil. 1989;70:755-762. [11] Schmidt R. Motor Control and Learning.. A Behavioral Emphasis. Champaign, Ill: Human Kinetics Publishers Inc; 1982. [12] Garraway WM, Akhtar AJ, Smith DL, Smith ME. The triage of stroke rehabilitation. J Epidemiol Community Health. 1981;35:39-44. [13] Mahoney FD, Barthel BW. Rehabilitation of the hemiplegic patient: a clinical evaluation. Arch Phys Med Rehabil 1954;35:359-362. [14] Fugl-Meyer AR, Jaasko L, Leymon 1, et al. The post-stroke hemiplegic patient, I: a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13-31. [15] Bobath B. Adult Hemiplegia: Evaluation and Treatment. 2nd ed. London, England: Heinemann Medical Books Ltd; 1978. [16] Brunnstrom S. Movement Therapy in Hemiplegia, New York, NY: Harper & Row, Publishers Inc; 1970. [17] Garraway WM, Akhtar AJ, Prescott RJ, Hockey L. Management of acute stroke in the elderly: preliminary results of a controlled trial. Br Med J. 1980;280:1040-1043. [18] Smith ME, Garraway WM, Smith DL, Akhtar AJ. Therapy impact on functional outcome in a controlled trial of stroke rehabilitation. Arch Phys Med Rehabil. 1982;63:21-24. [19] Stern PH, McDowell F, Miller JM, Robinson M. Effects of facilitation exercise techniques in stroke rehabilitation. Arch Phys Med Rehabil. 1970;51:526-531. [20] Loggigian MK, Samuels MA, Falconer J. Clinical exercise trial for stroke patients. Arch Phys Med Rehabil. 1983;64:364-367. [21] Lord JP, Hall K. Neuromuscular rehabilitation versus traditional program for stroke rehabilitation. Arch Phys Med Rehabil. 1986;67; 88-91. [22] Novack TA, Satterfield WT, Kelsey L, et al. Stroke onset and rehabilitation: time lag as a factor in treatment outcome. Arch Phys Med Rehabil. 1984;65:316-319. [23] Truscott L, Kretschmann CM, Toole JF, Pajak TF. Early rehabilitative care in community hospitals: effects on quality of survivorship following a stroke. Stroke. 1974;5:623-629. [24] Feigenson JS, McCarthy ML, Meese PD, et al. Stroke rehabilitation: factors predicting outcome and length of stay--an overview. NY State J Med. 1977;77:1426-1429. [25] Asberg KH. Orthostatic tolerance training of stroke patients in general medical wards. Scand J Rehabil Med. 1989;21:179-185. [26] Baker PA, Evans OM, Lee C. Treadmill gait retraining following fractured neck of femur. Arch Phys Med Rehabil. 1991;72:649-652. [27] Knutsson E, Martensson A. Dynamic motor capacity in spastic paresis and its relation to prime mover dysfunction, spastic reflexes and antagonist co-contraction. Scand J Rehabil Med 1980;12:93-106. [28] Colebatch JG, Gandevia SC. The distribution of muscular weakness in upper motor neuron lesions affecting the arm. Brain. 1989; 112:749-763. [29] Bourbonnais D, Vanden Noven S. Weakness in patients with hemiparesis. Am J Occup Ther 1989;43:313-319. [30] Malouin F, Richards CL, Wood-Dauphinee S, Williams JI. Effects of an intense task-oriented gait-training program in acute stroke patients: a pilot study. In: Woollacott M, Horak F, eds. Posture and Gait: Control Mechanisms. Portland, Ore: University of Oregon Books; 1992;2:407-410. [31] Barbeau H, Fung J, Stewart J, Visitin M. Impairment of spastic paraparetic gait: implications for new rehabilitation strategies. In: Proceedings of the Fifth Biennial Conference of the Canadian Society for Biomechanics; August 16-19, 1988, Ottawa, Canada. 1988: 12-16. [32] Visitin M, Barbeau H. The effects of body weight support on the locomotor pattern of spastic paretic patients. Can J Neurol Sci. 1989; 16:315-325.

Commentary

We applaud the authors for providing us with some exciting considerations for the early treatment of patients who have experienced stroke. We believe it is of utmost importance for physical therapists to be open to alternative treatment approaches and to evaluate carefully the methods we use for treatment. In current practice in the United States, the time available for treating patients who have had a stroke is limited to 7 to 10 days in an acute care hospital and to 21 to 28 days in a rehabilitation facility. With the current constraints on expenditure for health care and the demand for patients to achieve functional ability as soon as possible, we must explore early and aggressive methods of treatment.

We agree with the authors that, in general, therapists have not been very aggressive with stroke treatment. Based on recent reports and clinical observation, it appears that clinicians are exploring other exercise methods for stroke rehabilitation. Clinicians have reported using Kinetron(*) training,[1] treadmill training,[2] bicycle training,[3,4] and various methods of strength and exercise training[5-7] for rehabilitating patients who have neurological disorders. We believe that this article is timely in that it proposes an aggressive treatment for patients in the acute period after stroke. This is a period of recovery when many clinicians believe patients are fragile neurologically and physiologically and may not tolerate intensive exercise.

Clearly, the purpose of this report was not to test the efficacy of the proposed treatment. We believe, however, that the article does generate many ideas for clinical practice and for a series of well-designed clinical case studies or clinical research trials. The purposes of this report were to describe the exercise program and to report patient tolerance for the program. As presented, however, this case report does not provide the reader with sufficient information on subject selection, subject characteristics, and procedures to be very valuable for therapists wanting to apply the treatment. Additional description, omitted in this case report, would have provided valuable information for clinical therapists. We hope this article stimulates those therapists wanting to conduct meaningful case studies to continue investigating the utility and tolerance of early intensive treatment. As Rothstein states in Measurement in Physical Therapy, "Our profession is burdened with untested dogma, untested not only by research, but also by careful scrutiny of clinical practice that uses meaningful measures."[8] this commentary, we will share with the reader information that we believe is important for providing useful clinical information and measures in a case report, and we will discuss the implications of the proposed training program on clinical practice.

Case reports can be a rich source of information for physical therapists dealing with a large variability among patients. The value of a case report is in an adequate description of the patients and their responses to treatment. We believe several areas of information omitted from this report would have increased its value to the reader. We believe that because of the early application of intensive treatment and the authors' desire to report tolerance, cardiac status should be a criterion for participation and a description of the patients' cardiac status should have been included in the patient characteristics. Were all patients included in the study regardless of ability or cardiac status? We would like to know just how impaired these patients were. Given the same pathology, stroke is a very heterogeneous clinical syndrome with a variety of neurological presentations. Patients who have had a stroke present many comorbid diseases, cardiac disease being the primary comorbid condition. Some patients may be able to tolerate the "intensive program," and others may not be able to tolerate the program. What were the characteristics of the patients included and excluded? What seems important here is to identify the characteristics of the patients who could tolerate the treatment and the characteristics of those patients who could not tolerate the program. What are the cardiac risks of an early "intensive program"? We ask these questions because we believe the approach presented is exciting, but we are left pondering the specifics.

Case reports should also report objective, reliable, and valid responses to treatment. The authors state the purposes of their report were to describe the application of an early and intensive task-oriented treatment program and to report the patients' tolerance for the program. if the authors are interested in the patients' tolerance to treatment, we believe additional information about patient position, assistance, training speeds, training time, and patient responses would be invaluable. Did the authors monitor heart rate, blood pressure, exertion scale, or any other physiologic characteristics? What was the limiting factor to exercise time and intensity, and what were the criteria for progressing intensity?

We base our concern for selecting patients and monitoring cardiac response in patients with stroke on the prevalence of cardiac disease in patients with stroke.[9,10] The slow and laborious walking and reduced mobility associated with hemiplegia may not just be due to weakness but to poor cardiopulmonary fitness as well. Treadmill walking and Kinetron exercise has appeal for these patients in that they provide an opportunity for cardiovascular training. Rehabilitation of patients with stroke most often focuses on the motor deficits alone. Many of these patients have decreased cardiovascular function that should not be ignored. With proper monitoring, these patients could safely participate in an intensive training program, as this report suggests.

The authors reported that they also recorded the patients' acceptance, fear, and difficulties. These subjective observations would have been helpful to clinicians beginning a program such as this. As the authors stated, the therapists who monitored the patients had 7 to 10 years of clinical experience; they must have had some criteria, explicit or implicit, for making their clinical decisions. I urge them to share these insights with the reader. They recorded or noted many interesting observations, but did not report them.

Case reports should provide the reader with enough detail in procedure to be useful for clinicians who want to use the proposed treatment program. What were the criteria for progressing the mode and intensity of exercise? The authors reported that they progressed patients depending on the "degree of disablement." Were the criteria based on impairments or function? When the authors did share some of their criteria (eg, "As soon as a patient was able to stand and take a few steps. . . . "), we were uncertain about the level of assistance required. Another example is the statement that "velocity was progressively increased according to individual capacity." Would the authors be willing to share the observations that enabled them to determine capacity? Was this determination made based on cardiovascular response or functional capabilities?

Case reports should not confuse case report methodology with clinical trial methodology. Case reports should report within-subject variance rather than across-subject variance. When assessing the patients' tolerance or their compliance with this program, a more useful presentation of the data in Table 3 would be within-subject variance over the 5 weeks rather than mean compliance and across-subject variance over the 5 weeks. In attempting to present data for a group of patients, it appears the authors have used clinical trial methodology rather than case report methodology.

What were the procedures for Kinetron and treadmill training? The authors report the work-rest interval for each exercise, but not the absolute time for each part of the treatment. They report the total time, the time for special gait-related training (SGT). They report that the frequency of physical therapy sessions was twice daily, with SGT only once a day. We do not know, however, how the components of treatment were distributed. Could patients tolerate Kinetron and treadmill training in the same session, or were these types of training separated? How was each portion of the treatment progressed with intensity or with time? The distribution of activity may in itself affect the patients' tolerance to such an aggressive program, and we believe that reporting more specific descriptive data would provide worthwhile facts for clinicians.

From the ranges presented, it appears that the exercise times were quite variable among patients. We are curious about how the authors decided upon a 1:1 (minute) and 2:1 (minute) work-rest ratio. This may be an appropriate approach for patients in the early recovery period, but what was the rationale? Did the authors try other intervals, and did this one work best? What happened when they worked at longer intervals? Did patients fatigue, stumble, or become short of breath? Why did the authors decide to increase training with the same work-rest interval and not try to increase the work-rest ratio? The criteria for progression are important, especially because this is an early intervention program initiated only 1 week after stroke. Many clinicians are reluctant to start intensive training early. If the authors want to convince the reader that the program can be tolerated, then they must provide the reader with some more information about tolerance, not just the number of treatments and treatment time.

The authors state that the amount of therapy provided to patients in their program was twice as much as that usually given in an institution. The references supporting this statement are more than 10 years old and do not reflect current practice. Current reimbursement standards in the United States require that inpatient rehabilitation clients receive a minimum of 3 hours of therapy a day (this obviously includes therapies other than physical therapy).

A practical consideration for clinical therapists wanting to try treadmill training with patients who have had a stroke is the treadmill speed required. Many treadmills will not run below 0.4 m/s, let alone at 0.045 or 0.09 m/s. If therapists want to use the treadmill for this patient population, they need to check the specifications carefully before purchasing a treadmill for their clinic. Those treadmills currently used in cardiac rehabilitation may not be appropriate for patients requiring very slow walking speeds. Another practical concern is that this training required three therapists to treat one patient. Beyond efficacy is a concern for efficiency and cost-containment. Any future study to examine the efficacy of this training program must consider the patient benefit and cost in terms of therapist time.

From a conceptual point of view, the authors' rationale for this program is based on the motor learning principle of task specificity. The motor relearning program for stroke proposed by Carr and Shepherd[11] suggests treadmill walking as a way of improving rhythm and timing of walking. They also suggest it as a useful method of increasing cardiopulmonary efficiency and endurance and of measuring these variables as a guide to progress.[11]

Although we believe that bicycle, Kinetron, and treadmill exercise may improve walking overground, we are not convinced that the program described is task-specific training. We are well aware that although these tasks have similarities to overground walking, they have different task demands and characteristics.[12-14] In spite of the differences, we believe that these treatments may be useful for improving strength, coordination, and balance. According to Schmidt,[15] Winstein,[16] and Gentile,[17] using these devices would not be considered task-specific training. There appear to be different postural demands, sources of resistance to limb movement, sources of sensory stimuli during limb movement, and directions of external forces interacting with internal segmental and muscle forces among overground walking, treadmill locomotion, and Kinetron exercise.

We cannot assume the similarities of these tasks until we test them. it would be valuable to know whether patients are using the same kinematic, kinetic, and electromyographic patterns. We just do not know. We do believe, however, that these tasks are more similar to overground walking than are isolated mat exercises or isolated joint exercises in concentric, eccentric, or isometric modes on an isokinetic device. It is also quite possible that exercise on these devices does improve the capacity and the abilities required for overground walking. Some limited clinical evidence and several reports from controlled animal studies support the concept of using bicycling and treadmill exercise to improve walking patterns. We only disagree with the idea that exercise on these devices is task-specific in the sense expressed in this report.

The concepts of task specificity and task transfer are important to physical therapists. The authors reference Winstein et al,[18] who suggested that training patients with hemiparesis at a task in one context (weight-shifting standing) does not necessarily transfer to another context (walking). According to the specificity-of-learning hypothesis, the results reported by Winstein et al should not be surprising. This general hypothesis is that we should attempt, whenever possible, to match those conditions in acquisition practice with those expected in the criterion performance.[19] Stemming from Henry's work[20] is the view that because skills are very specific, changing the conditions under which a task is performed will require a substantial shift in the underlying abilities. Because practicing a task under one set of conditions and then performing the task under different conditions would require a shift in abilities, the conditions in practice and "test" should be equated whenever possible. Treadmill walking, Kinetron training, and overground walking each have different task demands.

The strongest variable in learning is practice, and the amount of variability in a practice trial is another important factor affecting learning.[19] The treadmill and the Kinetron permit the patient to practice walking activity at a variety of speeds, inclines (position), and resistance (Kinetron). This allows variable practice that may increase the patient's capacity to vary speed and effort, and hopefully carry this capacity to overground walking. Just as healthy people can adjust to different walking speeds, this should be the goal for patients who have had a stroke. An important part of learning open skills, such as walking, is acquiring the capability to cope with novel situations. By having patients walk on the treadmill and step on the Kinetron at variable speeds, therapists may better prepare patients for the demands of the

environment. However, we do not know enough about task transfer or learning motor skill in a disabled population to be sure.

We believe the rationale for using a treadmill or Kinetron training for stroke rehabilitation is not just task specificity. We believe the rationale can be justified from several perspectives: (1) specificity of practice, (2) variability of practice, (3) timing (interlimb coordination), (4) improved capacity for walking (balance and strength), and (5) cardiovascular training.

The journal has encouraged clinicians to submit case reports. Case reports are a valuable source of information for physical therapy practice. They provide a forum to share ideas for evaluation and treatment that is not possible in a research format. Although case reports are not research studies, they do require objective documentation of patient characteristics, procedures, and patient responses that should reflect the standards of clinical practice in physical therapy. We thank the authors for their willingness to share their ideas and experiences. We hope this report stimulates some thinking and questioning about our fears of early intensive treatment for patients who have had a stroke and generates ideas for clinical studies. (*) Cybex, Div of Lumex Inc, 2100 Smithtown Ave, Ronkonkoma, NY 11779.

References

[1] Glasser L. Effects of isokinetic training on the rate of movement during ambulation in hemiparetic patients. Phys Ther. 1986;66:673-676. [2] Waagfjord JW, Levangie PK, Certo CME. Effects of treadmill training on gait in a hemiparetic patient. Phys Ther. 1990;70:549-560, [3] Brown DA, DeBacher GA Bicycle ergometer and electromyographic feedback for treatment of muscle imbalance in patients with spastic hemiparesis: suggestion from the field. Phys Ther. 1987;67:1715-1719. [4] Giuliani CA. Adult hemiplegic gait. In: Smidt G, ed. Gait in Rehabilitation. New York, NY: Churchill Livingstone Inc; 1990:253-266. [5] Hall CD, Light KI. Heavy resistive exercise effect on reciprocal movement coordination of closed-head injured subjects with spasticity. Neurology Report. 1990;14:19. [6] Hunter M, Tomberlin J, Kirkikis C, Kuna ST. Progressive exercise testing in closed head-injured subjects: comparison of exercise apparatus in assessment of a physical conditioning program. Phys Ther. 1990;70:363-371. [7] Jankowski LW, Sullivan J. Aerobic and neuromuscular training: effect on the capacity, efficiency, and fatigability of patients with traumatic brain injury. Arch Phys Med Rehabil. 1990;71:500-504. [8] Rothstein J. Measurement and clinical practice: theory and application. In: Rothstein JM, ed. Measurement in Physical Therapy. New York, NY: Churchill Livingstone Inc; 1985:1-46. [9] Hertzer NR, Young JR, Beren EG, et al. Coronary angiography in 506 patients with extracranial cerebrovascular disease. Arch Intern Med 1985;145:849-852. [10] Rokey R, Rolak LA, Harati Y, et al. Coronary artery disease in patients with cerebrovascular disease: a prospective study. Ann Neurol. 1984; 16:50-53. [11] Carr JH, Shepherd RB. A Motor Relearning Programme for Stroke. 2nd ed. Rockville, Md: Aspen Systems Corp; 1987. [12] Strathy GM, Chao EY, Laughman RK. Changes in knee function associated with treadmill ambulation. J Biomech. 1983;16:517-522. [13] Murray MP, Spurr GB, Sepic SB, et al. Treadmill vs floor walking: kinematics, electromyogram, and heart rate. J Appl Phsiol. 1985; 69:87-91. [14] Arsenault AB, Winter DA, Marteniuk RG. Treadmill versus walkway locomotion in humans: an EMG study. Ergonomics. 1986;29: 665-676. [15] Schmidt RA. Motor learning principles for physical therapy. In: Lister MJ, ed. II Step: Contemporary Management of Motor Control Problems Washington, DC: Foundation for Physical Therapy Inc; 1991:49-63. [16] Winstein CJ. Designing practice for motor learning: clinical implications. In: Lister MJ, ed. II Step: Contemporary Management of Motor Control Problem Washington, DC: Foundation for Physical Therapy Inc; 1991:65-76. [17] Gentile AM. Skill acquisition: action, movement and neuromuscular process. In: Carr JH, Shepherd RB, Gordon J, et al, eds. Movement Science Foundations for Physical Therapy in Rehabilitation. Rockville, md: Aspen Publishers Inc; 1987:93-154. [18] Winstein CJ, Gardner ER, McNeal DR, et al. Standing balance training: effects on balance and locomotion in hemiparetic adults. Arch Phys Med Rehabil. 1989;70:755-762. [19] Schmidt RA. Motor Control and Learning. 2nd ed. Champaign, Ill: Human Kinetics Publishers Inc; 1988. [20] Henry FM. Specificity versus generality in learning motor skill. In: Brown RL, Kenyon GS, eds. Classical Studies on Physical Activity. Englewood Cliffs, NJ: Prentice-hall; 1968:331-340.

Author Response

The commentary by Giuliani and Duncan emphasizes the importance of early and effective physical therapy for the promotion of recovery after stroke, while raising methodological and theoretical issues about our report. We agree with the commentary that the format of the report is not that of a classical case report. The physical therapy program described in the report was but one of three programs administered to patients who had sustained an acute stroke and who were participating in a pilot randomized control trial (RCT). This RCT, designed to study the effectiveness of the task-oriented gait training program, found the task-oriented gait training program to be more effective than conventional neurodevelopmental physical therapy for promoting improved gait velocity[1,2] in patients following an acute stroke. The main purposes of the report were to describe the task-oriented gait training program that we developed for this RCT and to demonstrate the feasibility of initiating the program early in patients after a stroke.

As stated in the report, the patients who were included in the study had to be free of any clinical problems that could interfere with this physical therapy program. The program, therefore, excluded patients with an unstable cardiac status or other medical conditions that presented a health risk. Heart rate and blood pressure were not monitored, nor was an exertion scale used, although such measures were discussed in the planning stage. Instead, the patients' tolerance to therapy, from which the progression was decided, was based on simple and sound clinical judgment developed over the years by experienced physical therapists. A patient can tire more easily one day because of mood swings or lack of sleep or because the exercise is too demanding physiologically. Therapists base daily decisions on physiological as well as psychological factors, and it was not our intent to list these factors. Although the therapists took note of each patient's reaction to therapy, they used this information mainly to guide them from day to day in progressing the therapy. In the report, we chose to estimate the patients' ability to comply with the therapy by measuring the time dedicated to each modality. The lack of individual results, mentioned in the commentary, is the consequence of the review process that led us to reduce the "Results" and "Discussion" sections.

The report was written to provide general guidelines that could be used by therapists to develop their own progressive treatment program, each patient being unique. We agree that methods of progressing training regimens that use the Kinetron(*) or the treadmill are poorly understood. One has to keep in mind, however, that all questions cannot be answered in one report. Moreover, a case report is not a platform for developing concepts at length; we are therefore grateful that the commentary has elaborated on task specificity. There is one point, however, that we want to make clear. The gait training program presented in this report was inspired by the task-specificity concept; therefore, task-oriented (and not task-specific) activities were devised as preparatory exercises in view of initiating gait training as early as possible.

The commentary has raised many important questions and helped put our work into perspective. We appreciate the in-depth analysis made of our report and the opportunity to respond.

References

[1] Malouin F, Richards CL, Wood-Dauphinee S, Williams JI. Effects of an intense task-oriented gait training program in acute stroke patients: a pilot study. In: Woollacott M, Horak F, eds. Posture and Gait. Control Mechanism Portland, Ore: University of Oregon Books; 1992;2: 407-410. [2] Richards CL, Malouin F, Wood-Dauphinee S, et al. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil in press.

F Malouin, PhD, PT, is Professor, Physiotherapy Department, Faculty of Medicine, Laval University, and Neurobiology Research Center, Hopital de l'Enfant-Jesus, 1401, 18e Rue, Quebec City, Quebec, Canada G1j 1Z4. Address correspondence to Dr Malouin at the Neurobiology Research Center.

M Potvin, PT, is Physical Therapist, Department of Physical Therapy, Hopital de l'Enfant-Jesus.

J Prevost, PT, is Physical Therapist, Department of Physical Therapy, Hopital de l'Enfant-Jesus.

CL Richards, PhD, PT, is Professor and Director, Physiotherapy Department, Faculty of Medicine, Laval University, and Neurobiology Research Center, Hopital de l'Enfant-Jesus.

S Wood-Dauphinee, PhD, PT, is Associate Professor and Director, School of Physical and Occupationa Therapy, McGill University, Montreal, Quebec, Canada H3G 1Y5.