APTA guidelines debut to mixed reviews
Clinical practice guidelines released by the American Physical Therapy Association (APTA) in 2020 continue to stir debate among clinicians about the best gait training interventions for stroke patients, according to Richard L. Harvey, MD, professor of Physical Medicine and Rehabilitation at Northwestern University’s Feinberg School of Medicine in Chicago. The APTA’s recommendations focus on two primary interventions — moderate to high, intensity walking training and the use of virtual reality technology — as well as several other interventions.
“Not surprisingly, a lot of clinicians raised concerns about the interventions recommended in the guidelines,” said Dr. Harvey who is also clinical chair of the Brain Innovation Center at the Shirley Ryan AbilityLab and the Wesley and Suzanne Dixon Stroke Chair of Stroke Rehabilitation Research.
Specifically, the new guidelines on gait training are for patients who are beyond the six-month mark following an acute stroke. In addition to the high-intensity walking training and use of virtual reality technology recommendations, the APTA indicated strength training, cycling at aerobic intensities and circuit training have a strong body of evidence for improvement of walking speed and distance.
Conversely, the APTA concluded that balance training, body-weight supported treadmill training and robotic-assisted walking training were less effective.
According to Dr. Harvey, stroke patients experience long-term locomotor deficits, which result in a decrease in walking speed and distance.
Dr. Harvey said opposition to proposed interventions include the argument that high-intensity gait training can jeopardize the health of patients with heart disease. However, he noted that while a patient’s heart rate and blood pressure must be closely monitored, his lab has never had a negative patient outcome from the high-intensity gait training. As for the use of virtual reality technology, Dr. Harvey said most clinicians who oppose it do so on the basis of the expense to the facility as well as the extra time and complexity of setting up these systems for therapy.
Also, there are gaps in identifying other interventions to speed recovery in patients who have had a stroke. According to Dr. Harvey, many physicians believe physical therapy is an important intervention after stroke but have little knowledge of the different approaches of PT available.
He also said there are knowledge gaps in improving the gait of stroke patients, noting the need to explore a better understanding of how the spinal cord changes after stroke and the associated neuroplastic physiology.
“We know some changes happen in the spinal cord. If we understood these changes a little better, we could come up with better physiologically appropriate interventions,” Dr. Harvey said. “For example, there is currently research being done in animal models involving circuitry. That research has only recently begun to translate to human studies.”
