(1) Objective: The objective was two-fold: (a) test a protocol of combined interventions; (b) administer this combined protocol within the framework of a six-month, intensive, long-duration program. The array of interventions was designed to target the treatment-resistant impairments underlying persistent mobility dysfunction: weakness, balance deficit, limb movement dyscoordination, and gait dyscoordination. (2) Methods: A convenience sample of eight chronic stroke survivors (>4 months post stroke) was enrolled. Treatment was 5 days/week, 1–2.5 h/day for 6 months, as follows: strengthening exercise, balance training, limb/gait coordination training, and aerobic exercise. Outcome measures: Berg Balance Scale (BBS), Fugl-Meyer Lower Limb Coordination (FM), gait speed, 6 Minute Walk Test (6MWT), Timed up and Go (TUG), Functional Independence Measure (FIM), Craig Handicap Assessment Rating Tool (CHART), and personal milestones. Pre-/post-treatment comparisons were conducted using the Permutation Test, suitable for ordinal measures and small sample size. (3) Results: For the group, there was a statistically (p ≤ 0.04) significant improvement in balance, limb movement coordination (FM), gait speed, functional mobility (TUG), and functional activities (FIM). There were measurable differences (minimum detectible change: MDC) in BBS, FM, gait speed, 6MWT, and TUG. There were clinically significant milestones achieved for selected subjects according to clinical benchmarks for the BBS, 6MWT, gait speed, and TUG, as well as achievement of personal milestones of life role participation. Effect sizes (Cohen’s D) ranged from 0.5 to 1.0 (with the exception of the (6MWT)). After six months of treatment, the above array of gains were beyond that reported by other published studies of chronic stroke survivor interventions. Personal milestones included: walking to mailbox, gardening/yardwork, walking a distance to neighbors, return to driving, membership at a fitness center, vacation trip to the beach, swimming at local pool, returning to work, housework, cooking meals. (4) Conclusions: Stroke survivors with mobility dysfunction were able to participate in the long-duration, intensive program, with the intervention array targeted to address impairments underlying mobility dysfunction. There were either clinically or statistically significant improvements in an array of measures of impairment, functional mobility, and personal milestone achievements.

BACKGROUND: Gait deficits and functional disability are persistent problems for many stroke survivors, even after standard neurorehabilitation. There is little quantified information regarding the trajectories of response to a long-dose, 12-month intervention. OBJECTIVE: We quantified treatment response to an intensive neurorehabilitation mobility and fitness program. METHODS: The 12-month neurorehabilitation program targeted impairments in balance, limb coordination, gait coordination, and functional mobility, for five chronic stroke survivors. We obtained measures of those variables every two months. RESULTS: We found statistically and clinically significant group improvement in measures of impairment and function. There was high variation across individuals in terms of the timing and the gains exhibited. CONCLUSIONS: Long-duration neurorehabilitation (12 months) for mobility/fitness produced clinically and/or statistically significant gains in impairment and function. There was unique pattern of change for each individual. Gains exhibited late in the treatment support a 12-month intervention. Some measures for some subjects did not reach a plateau at 12 months, justifying further investigation of a longer program (>12 months) of rehabilitation and/or maintenance care for stroke survivors.

Purpose: Depression is prevalent among stroke survivors and is associated with a number of adverse health outcomes. However, for those with severe depression after chronic stroke, there is little to no information regarding response of depression to exercise addressing persistent physical impairments and dysfunction or response to exercise therapy for those who are severely depressed. Methods:We enrolled a male stroke survivor at 1.75 years post stroke, with severe depression. Measures collected at pre-and post-treatment were as follows: Beck Depression (mood); Fugl-Meyer (FM joint movement coordination); Berg Balance Scale (BBS); Timed Up and Go (TUG; mobility); Functional Independence Measure (FIM; subscales of Self-Care, Transfer, Locomotion); Craig Handicap Assessment and Reporting Technique (CHART; quality of life assessment of how patients with disabilities function in the community and at home); 36-Item Short Form Survey (SF36; quality of life measure); and the Stroke Impact Scale (SIS; stroke-specific quality of life measure). Exercise was scheduled as follows: 6mo therapy, five times/wk (1-2.5hrs/session); and additional 6mo, 2-3times\wk, and included aerobic exercise and coordination/strength training for balance and gait. The treatment protocol included exercises for balance and coordination of the lower limb, strengthening, gait coordination, and aerobics exercise on a stationary cycle.Results: Depression improved from severe to mild. The initial presence of severe depression did not preclude significant improvement in mobility and life role participation. Clinically significant gains were exhibited, not only in depression, but also in balance, mobility, and activities of daily living. Moreover, his quantified changes included clinically significant progression to categories of 'low fall risk' and 'functionally independent'. He achieved important clinical and functional goals, as reflected by improved scores in measures of life role participation and personal milestones. Conclusion:Though this is a case study, it is reasonable to consider that a long-duration exercise program can be of great benefit in terms of functional and quality of life gains, regardless of the initial presence of severe depression.

Purpose: This case study provides quantitative evidence of the feasibility and benefit of a long-dose, 10-month neurorehabilitation program for a chronic stroke survivor who, in the midst of the neurorehabilitation program, underwent surgery and radiation treatment for breast cancer. Methods:The patient was age 60 years, and 6 years post-stroke (left middle cerebral artery stroke), exhibiting impairments in balance, strength, and gait coordination, as well as deficits in functional mobility, and compromised quality of life. Her comprehensive mobility/fitness neurorehabilitation program included aerobics, strength and coordination training, and balance and gait coordination training. Treatment was 1.5 -2 hours per day, 5 days/week for 6 months, followed by an additional 4 months of treatment 3 days/week. Outcome measures were acquired at entry into the neurorehabilitation program, and at months 2, 4, 6, 8 and 10. Measures included the following: modified Ashworth (mASH, spasticity); Fugl-Meyer (FM; isolated limb joint coordination); 6-minute walk test (6MWT; walking endurance); gait speed; Berg Balance Scale (BBS; static and dynamic balance); Timed Up and Go (TUG; mobility); 10 Meter Walk Test (10MWT; short distance, self-selected and fast walking speed); Functional Gait Assessment (FGA; dynamic balance and postural stability during gait); Functional Independence Measure (FIM; assessment of functional status and disability); Craig Handicap Assessment and Reporting Technique (CHART; quality of life assessment of how patients with disabilities function in the community and at home); 36-Item Short Form Survey (SF36; quality of life measure); and the Stroke Impact Scale (SIS; stroke-specific quality of life measure). Fatigue level was queried during and following radiation therapy.Results: From baseline through month 4, the patient demonstrated improvements in most outcome measures. For example, she improved from 3 minutes of cycling endurance to 45 minutes, and balance improvement reached the threshold for functional independence. At month 5, she was diagnosed with breast cancer and underwent a partial mastectomy. She underwent radiation treatment, which concluded in month 7. Prior, during, and after the cancer treatment, she continued participation in the neurorehabilitation program.Following the partial mastectomy, she exhibited continued improvement in BBS, 10MWT-normal speed, FGA, CHART, SF-36, and SIS. Notably, the TUG continued to improve significantly by 4.73sec. She showed some decline in values for the 6MWT, gait speed, and 10MWT-fast walking speed.Four weeks following the end of the course of radiation therapy, most measures showed a small decline. But in contrast, by 12 weeks after the end of radiation (which coincided with 10 months of participation in the neurorehabilitation program), the following measures showed a revival in improvement: Fugl-Myer (limb coordination); 6MWT (walking endurance); gait speed; BBS (balance); FIM (functional tasks); subdomains of the CHART quality of life measure (p...