Objective To investigate how much movement practice occurred during stroke rehabilitation, and what factors might influence doses of practice provided. Design Observational survey of stroke therapy sessions. Setting 7 inpatient and outpatient rehabilitation sites. Participants We observed a convenience sample of 312 physical and occupational therapy sessions for people with stroke. Intervention NA Main Outcome Measures We recorded numbers of repetitions in specific movement categories and data on potential modifying factors (patient age, side affected, time since stroke, Functional Independence Measure item scores, and years of therapist experience). Descriptive statistics were used to characterize amounts of practice. Correlation and regression analyses were used to determine if potential factors were related to the amount of practice in the two important categories of upper extremity functional movements and gait steps. Results Practice of task-specific, functional upper extremity movements occurred in 51% of the sessions that addressed upper limb rehabilitation and the average number of repetitions/session was 32 (95% CI = 20–44). Practice of gait occurred in 84% of sessions that addressed lower limb rehabilitation and the average number of gait steps/session was 357 (95% CI = 296–418). None of the potential factors listed above accounted for significant variance in the amount of practice in either of these two categories. Conclusions The amount of practice provided during post-stroke rehabilitation is small compared to animal models. It is possible that current doses of task-specific practice during rehabilitation are not adequate to drive the neural reorganization needed to optimally promote function post stroke.

Given the contemporary clinical belief that more practice is better, it is important to determine how much practice currently occurs during physical therapy (PT) and occupational therapy (OT). The purpose of this study was to examine the number of repetitions of various activities during PT and OT outpatient treatment sessions for people with hemiparesis post-stroke. We observed 36 treatment sessions and recorded the types of activities and the number of repetitions of each activity that were done. Observations were categorized and descriptive statistics were generated for each category and subcategory. Our results showed that treatment time averaged 36 minutes per session. In sessions addressing the upper extremity, the average number of repetitions per session were 39 for active-exercise movements, 34 for passive-exercise movements, and 12 for purposeful movements. In sessions addressing the lower extremity, the average number of repetitions per session were 33 for active-exercise movements, six for passive-exercise movements, and eight for purposeful movements. In sessions addressing gait, the average number of steps taken was 292. In sessions addressing transfers, the average number of repetitions per session was 11. For most categories, there was considerable variability in the number of repetitions observed. We conclude that the numbers of repetitions observed during PT and OT for people with hemiparesis post-stroke are relatively small, except for gait steps. The fact that the number of repetitions of upper extremity purposeful movements was smaller than the number of repetitions of upper extremity active- and passive-exercise movements was surprising. This finding is inconsistent with current teaching that practice of purposeful movements is an integral part of improving functional status.

Objective To determine whether providing a controlled resistance versus assistance to the paretic leg at the ankle during treadmill training will improve walking function in individuals poststroke. Design Repeated assessment of the same patients with parallel design and randomized controlled study between 2 groups. Setting Research units of rehabilitation hospitals. Participants Patients (N=30) with chronic stroke. Intervention Subjects were stratified based on self-selected walking speed and were randomly assigned to the resistance or assistance training group. For the resistance group, a controlled resistance load was applied to the paretic leg at the ankle to resist leg swing during treadmill walking. For the assistance group, a load that assists swing was applied. Main Outcome Measures Primary outcome measures were walking speed and 6-minute walking distance. Secondary measures included clinical assessments of balance, muscle tone, and quality of life. Outcome measures were evaluated before and after 6 weeks of training and at 8 weeks’ follow-up, and compared within group and between the 2 groups. Results After 6 weeks of robotic training, walking speed significantly increased for both groups, with no significant differences in walking speed gains observed between the 2 groups. In addition, 6-minute walking distance and balance significantly improved for the assistance group but not for the resistance group. Conclusions Applying a controlled resistance or an assistance load to the paretic leg during treadmill training may induce improvements in walking speed in individuals poststroke. Resistance training was not superior to assistance training in improving locomotor function in individuals poststroke.

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Abstract Background and Purpose European clinical practice guidelines recommend physical therapy for people with Parkinson disease (PD) soon after diagnosis to provide education, physical activity advice, and individualized interventions when needed. However, therapy is frequently not used until after gait and balance problems occur. The purpose of this administrative case study is to present the application of a proactive physical therapy (PAPT) approach at 1 rehabilitation center using implementation frameworks to support the (1) implementation process, (2) determinants of implementation success, and (3) implementation evaluation. Case Description The PAPT program targeted people with PD before the onset of significant mobility dysfunction. It was initiated in 1 outpatient neurological rehabilitation center. The program used shared decision-making to promote long-term maintenance of independent exercise. The Knowledge-to-Action Framework was used by champions to plan implementation processes. Implementation barriers were addressed using the Consolidated Framework for Implementation Research. The program was evaluated using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework with mixed methods. Outcomes In the program’s first year, 38 people were referred, 28 were evaluated, and 20 participated in the 6-month program evaluation. Following PAPT, the number of participants reporting regular participation in aerobic, strengthening, and flexibility exercise approximately doubled, while those engaging in balance activities increased from 1 to 8. They reported a median of 140 minutes of aerobic exercise per week. Implementation barriers included location, insurance coverage, and difficulty scheduling long-term follow-up visits. Participants reported physical and emotional benefits of the program. Discussion Implementation frameworks assisted with the implementation and evaluation of a PAPT delivery model that helped people with PD to increase and maintain independent exercise participation.