Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial.

Autor:	Boyne P; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Billinger SA; Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City.; Department of Cell Biology and Integrative Physiology, School of Medicine, University of Kansas Medical Center, Kansas City.; University of Kansas Alzheimer's Research Disease Center, Fairway.; Department of Physical Medicine and Rehabilitation, School of Medicine, University of Kansas Medical Center, Kansas City., Reisman DS; Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark., Awosika OO; Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio., Buckley S; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Burson J; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Carl D; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., DeLange M; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Doren S; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Earnest M; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Gerson M; Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.; Department of Cardiology, College of Medicine, University of Cincinnati, Cincinnati, Ohio., Henry M; Department of Physical Therapy, Rehabilitation Sciences, and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City., Horning A; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Khoury JC; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio., Kissela BM; Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio., Laughlin A; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., McCartney K; Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark., McQuaid T; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Miller A; Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark., Moores A; Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City., Palmer JA; Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City., Sucharew H; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio., Thompson ED; Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark., Wagner E; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Ward J; Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City., Wasik EP; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio., Whitaker AA; Department of Physical Therapy, Rehabilitation Sciences, and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City., Wright H; Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark., Dunning K; Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio.
Jazyk:	angličtina
Zdroj:	JAMA neurology [JAMA Neurol] 2023 Apr 01; Vol. 80 (4), pp. 342-351.
DOI:	10.1001/jamaneurol.2023.0033
Abstrakt:	Importance: For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization. Objective: To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke. Design, Setting, and Participants: This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled. Interventions: Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated. Main Outcomes and Measures: The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training. Results: Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, -9 to 33 m]; mean difference, 15 m [95% CI, -13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue. Conclusions and Relevance: These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains. Trial Registration: ClinicalTrials.gov Identifier: NCT03760016.
Databáze:	MEDLINE
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