LEAPS: Locomotor training not superior to home-based therapy post-stroke

International Stroke Conference 2011

Results from the LEAPS trial have indicated that a locomotor training program featuring body weight-supported treadmill training did not produce superior outcomes in patients post-stroke when compared with a rigorous home-based physical therapy, although both did produce improvements in mobility at 1 year.

“The important message [of this study] is that patients do change and they improve over time. What we found is that the more high-tech intervention didn’t help them walk any better [and that] the home-based exercise program works as well,” Pamela W. Duncan, PhD, professor and research fellow at Duke University School of Medicine, Durham, North Carolina, and investigator on the trial, said in an interview with Cardiology Today.

The Multi-site Phase III Randomized Trial of Physical Therapy Interventions to Improve Walking Recovery Post-stroke (LEAPS) was the largest randomized controlled trial performed in rehab, including 408 patients following stroke. The patients were randomly assigned to three groups: early locomotor training program (LTP; n=139) at two months post-stroke, late LTP (n=143) at 6 months post-stroke and home-based therapy (n=126) 2 months post-stroke.

At 1 year following stroke, the researchers found that functional outcome did not differ significantly between groups, with improved functional walking ability reported in 50.4% of the early-LTP group, 53.8% of the late-LTP group and 51.6% of the home-based therapy arm. Additionally, those in the early LTP group did not have improved change in comfortable walking speed at 1 year when compared with the late-LTP group (0.23 ± 0.20 m/s vs. 0.24 ± 0.23 m/s).

In the study’s secondary outcome, Duncan and fellow colleagues found that when compared to usual care at 6 months, those who received more structured, progressive interventions recovered twice as well.

“So, in stroke as in heart disease, exercise and maintaining your strength and mobility is extremely important and we have to figure out ways to do this more effectively,” Duncan said. – by Brian Ellis

For more information:

Duncan PW. LB 11. Presented at: International Stroke Conference 2011. Feb. 9-11, 2011; Los Angeles.

We know that recovery and rehabilitation post-stroke is very important. We are looking for new approaches to improve outcomes in our stroke survivors. Walking and mobility are two of the biggest things that affect quality of life in a stroke survivor.

Although [the LEAPS researchers] hoped that this innovative approach to improving walking would be beneficial they weren’t able to show that. However, they were able to show that if you do home-based physical therapy at 2 months post the usual time period for rehab you had some very important recovery in terms of walking and mobility at 6 months and a year. This is important to us because sometimes the early acute rehab period passes and both patients and physicians neglect the longer-term importance of physical therapy and rehab. I try to emphasize it to my patients but sometimes insurance doesn’t cover it and other things kick in. I think this implies that home-based physical therapy started two months after stroke could still be very important for improving long-term outcomes.

So I think this shows us that sometimes the more innovative, possibly more costly approach isn’t always better than old-fashioned home-based physical therapy which I think that this trial shows is a very important rehabilitation opportunity for us to improve outcomes.

– Ralph Sacco, MD
President, American Heart Association
Miller Professor of Neurology, Epidemiology and Human Genetics, Miller School of Medicine, University of Miami

I think the LEAPS result is a transformative result. It shows us that intensive and prolonged therapy to improve gait is better than our usual care of only short and modest intensity therapy. It didn’t really matter which way we delivered the intensive and prolonged therapy, whether it was home-based physical therapy or a sophisticated locomotor weight elevation program. But we didn’t know for the lower extremity and for gait whether intensive therapy was better than standard care. We knew that for upper extremity before and this means that we need to change the way we’re taking care of patients. We need to have them engage much more often in prolonged therapy so that they can gain all the benefit they can while their brain is plastic and responsive to change after a stroke.

– Jeffrey L. Saver, MD
Director, UCLA Stroke Center, Los Angeles

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