For walking exercise in patients with chronic stroke, what is the optimal intensity (vigorous vs moderate) and minimum duration (4, 8, or 12 weeks) to maximize immediate improvement in walking capacity?
In this randomized clinical trial that enrolled 55 stroke survivors, 6-minute walk test gains after 12 weeks of training were 71 m with vigorous training intensity vs 27 m with moderate training intensity, a significant difference. Within the vigorous intensity group, walking capacity significantly increased after each 4-week training block.
The findings suggest that optimal dosing for walking exercise for patients with chronic stroke may include at least 12 weeks of training at vigorous intensity.
For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization.
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.
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.
Of 55 participants (mean [SD] age, 63  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.
ClinicalTrials.gov Identifier: NCT03760016
Boyne P, Billinger SA, Reisman DS, et al. Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial. JAMA Neurol. 2023;80(4):342–351. doi:10.1001/jamaneurol.2023.0033
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