Implementation of a Focused, Intensive Repeated Stepping Program of Inpatient Rehabilitation

Indiana University, Shirley Ryan AbilityLab, Mary Free Bed Rehabilitation Hospital
RRTC on Developing Optimal Strategies in Exercise and Survival Skills to increase Health and Function
Submitted by Jenni Moore, T. George Hornby, Linda Lovell, Elliot Roth, Roberta Virva and John Butzer


The objective of this project is to evaluate feasibility and effectiveness of a high-intensity walking training program, titled Focused, Intensive Repeated Stepping Training (FIRST), which will be implemented into clinical inpatient rehabilitation at two separate sites. The participating inpatient rehabilitation facilities include the Rehabilitation Institute of Chicago (RIC) in Chicago, Illinois, and Mary Free Bed (MFB) in Grand Rapids, Michigan. This project has two primary components. The first is a KT project that aims to implement a gait outcome measurement (OM) battery (Years 1 and 2) and a high-intensity walking training program (Years 3 and 5) at MFB. In the second project, we will examine the effectiveness of the gait training program on short- and long-term mobility outcomes, health, and community participation in adults with stroke.


Recovery of walking early following stroke, spinal cord injury (SCI), or acquired brain injury (ABI) is a primary goal of patients and their families, although return of independent locomotion depends largely on the magnitude and location of the injury. Most patients with stroke or ABI can recover some gait function (80% to 95%)Footnote 1,Footnote 2,Footnote 3, but only 25% of those with SCI (50% motor incompleteFootnote 4, Footnote 5) walk independently. For those who do recover, most walk at slow speeds and for limited distances, with devices often required for safety. The extent of walking ability is often a primary predictor of discharge destination following rehabilitationFootnote 6, Footnote 7, subsequent health statusFootnote 8, and community participation status.Footnote 9, Footnote 10 Studies suggest that even small decreases in gait speed from baseline are associated with significant increases in health care utilization (e.g., number of medical/surgical visits, hospitalization duration) with costs approaching ~$1200/year.Footnote 11

Reasons that patients do not achieve greater stepping practice include lack of accessibility to current evidence, availability of adequate equipment, and therapists' adherence to traditional interventions.Footnote 26 Few studies have attempted to implement focused stepping interventions during inpatient rehabilitation to examine their feasibility and effectiveness on long-term outcomes.

At RIC, we were able to successfully implement a gait OM battery and the FIRST programFootnote 27, Footnote 28 in inpatient rehabilitation stroke programs. This program resulted in average amounts of stepping that were five to six times greater than typically achieved, but that varied substantially with the severity of initial or discharge impairments.Footnote 25, Footnote 29 As a result of the program, patients demonstrated substantial improvements in walking and nonwalking tasks that were greater than the outcomes identified in previous retrospective analyses at RICFootnote 28 or published improvements in walkingFootnote 30 and balance.Footnote 31

Understanding the effectiveness of these focused stepping interventions to improve health, mobility, and community participation implemented in the clinical setting may be of extraordinary value to the multiple stakeholders (patients/families, health care professionals) involved in the rehabilitation of these patients.

KT Strategies

This project will evaluate the effectiveness of the KT strategies used to implement the gait OM battery and the FIRST program at MFB. The study will evaluate the effectiveness of the KT interventions on clinician behavior and patient outcomes. We will utilize the Knowledge-to-Action (KTA) framework as a step-by-step process for implementation, which is briefly described next.

Identify the problem related to use of outcomes and evidence in clinical practice (Years 1–5)

Online surveys will be administered annually to identify the beliefs, barriers, and facilitators toward use of OMs and intensive gait training to stakeholders at RIC and MFB (clinicians, administrators, patients).32 Specific measures are being collected to identify organization and clinic staff values, beliefs, and readiness to change. We will also use information gained from these surveys to identify appropriate strategies to implement the gait OM battery and the FIRST intervention.

Implement standardized outcome measures (Years 1–5)

A gait OM battery was implemented at MFB during the first year of the grant. The KT strategies used to implement the OMs included an educational session, mentoring, engaging participation from leadership, monthly chart audit and feedback, and weekly reminders. We also recruited a local champion from MFB to advocate for the project. In addition, adapted guidelines that describe recommended use of the standard OM battery were provided to MFB. The OMs are collected on admission, weekly, and at discharge by staff physical therapists.

Delivery of the FIRST program in the clinical inpatient setting (ongoing data collection at RIC Years 1–5; implemented at MFB Years 3, 4, 5)

The FIRST project is an ongoing project on stroke units at RIC; therefore, fidelity and outcome data will be collected throughout the grant period.28 During implementation of the FIRST project at MFB, we will provide online and live education courses, mentoring, leadership support, chart audit and feedback, and regular reminders about the program. Furthermore, we will regularly discuss the project, including its barriers and facilitators, with stakeholders at MFB to determine whether additional KT strategies are required. Methods for alleviating barriers to the FIRST program will be tailored to meet the clinicians’ needs.

Sustainability plan

To ensure ongoing implementation of the project, a sustainability plan will be developed and executed in Years 4 and 5. The plan will include ongoing compliance feedback to clinicians and managers, the inclusion of OMs and gait training intervention reports during team conferences, and clinician incentives for using OMs and the FIRST program in clinical practice.


To date, we have implemented the OM battery at MFB and have been monitoring the treatment fidelity of the program at RIC. At MFB, clinician compliance with administration of the gait OM battery averaged 46% during the first month after implementation. After using the additional KT strategies, including chart audit and feedback, reminders, and mentoring, compliance increased to as high as 100%. Although the recent audit produced these perfect results, the average compliance, not including the first month, is ~86%.

Future plans for evaluation will include the determination of the impact of the FIRST project on clinicians’ behavior related to use of the gait training protocol, impact of the FIRST program on short- and long-term patient outcomes, and an evaluation of the cost effectiveness of implementation of the program.

Lessons Learned or Learning

Throughout implementation of this program, we have encountered ongoing barriers that have been addressed. Implementation requires a sustained effort with ongoing stakeholder feedback to determine barriers, facilitators, and ways in which we can support successful KT.


Footnote 1

Wade, D. T., Skilbeck, C. E., & Hewer, R. L. (1983). Predicting Barthel ADL score at 6 months after an acute stroke. Archives of Physical Medicine and Rehabilitation, 64(1):24–8.

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Footnote 2

Skilbeck, C. E., Wade, D. T., Hewer, R. L., & Wood, V. A. (1983). Recovery after stroke. Journal of Neurology, Neurosurgery & Psychiatry, 46(1):5–8.

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Footnote 3

Katz, D. I., Polyak, M., Coughlan, D., Nichols, M., & Roche, A. (2009). Natural history of recovery from brain injury after prolonged disorders of consciousness: Outcome of patients admitted to inpatient rehabilitation with 1–4 year follow-up. Progress in Brain Research, 177:73–88.

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Footnote 4

National Spinal Cord Injury Statistical Center. (2004). The 2004 annual statistical report for the model spinal cord injury care systems. Birmingham, AL: Author.

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Footnote 5

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Footnote 6

Joy, J. E., Altevogt, B. M., Liverman, C. T., & Johnson, R. T. (Eds.). (2005). Spinal cord injury: Progress, promise, and priorities. Washington, DC: National Academies Press

Return to footnote 6 referrer

Footnote 7

West, T., Churilov, L., Bernhardt, J. (2013). Early physical activity and discharge destination after stroke: A comparison of acute and comprehensive stroke unit care. Rehabilitation Research and Practice, 2013. Article ID 498014. doi:10.1155/2013/498014.

Return to footnote 7 referrer

Footnote 8

West, T., & Bernhardt, J. (2013). Physical activity patterns of acute stroke patients managed in a rehabilitation focused stroke unit. BioMed Research International, 2013. Article ID 438679. doi:10.1155/2013/438679.

Return to footnote 8 referrer

Footnote 9

Ryan, A. S., Dobrovolny, C. L., Silver, K. H., Smith, G. V., & Macko, R. F. (2000). Cardiovascular fitness after stroke: Role of muscle mass and gait deficit severity. Journal of Stroke and Cerebrovascular Diseases, 9(4):185–91.

Return to footnote 9 referrer

Footnote 10

Lord, S. E., & Rochester, L. (2005). Measurement of community ambulation after stroke: Current status and future developments. Stroke, 36(7):1457–61.

Return to footnote 10 referrer

Footnote 11

Moore, J. L., Roth, E. J., Killian, C., & Hornby, T. G. (2010). Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a "plateau" in recovery. Stroke, 41(1):129–35.

Return to footnote 11 referrer

Footnote 12

Purser, J. L., Weinberger, M., Cohen, H. J., Pieper, C. F., Morey, M. C., Li, T., et al. (2005). Walking speed predicts health status and hospital costs for frail elderly male veterans. Journal of Rehabilitation Research and Development, 42(4):535–46.

Return to footnote 12 referrer

Footnote 13

Holleran, C. L., Straube, D. S., Kinnaird, C. R., Leddy, A. L., Hennessy, P. W., & Hornby, T. G. (2014). Feasibility and potential efficacy of high intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabilitation and Neural Repair, 7:643–51.

Return to footnote 13 referrer

Footnote 14

Macko, R. F., Ivey, F. M., Forrester, L.W., Hanley, D., Sorkin, J. D., Katzel, L. I., et al. (2005). Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled trial. Stroke, 36(10):2206–11.

Return to footnote 14 referrer

Footnote 15

Outermans, J. C., van Peppen, R. P., Wittink, H., Takken, T., & Kwakkel, G. (2010). Effects of a high-intensity task-oriented training on gait performance early after stroke: A pilot study. Clinical Rehabilitation, 24(11):979–87.

Return to footnote 15 referrer

Footnote 16

Horn, S. D., DeJong, G., Smout, R. J., Gassaway, J., James, R., & Conroy B. (2005). Stroke rehabilitation patients, practice, and outcomes: Is earlier and more aggressive therapy better? Archives of Physical Medicine and Rehabilitation, 86(12):S101–14.

Return to footnote 16 referrer

Footnote 17

Hornby, T. G., Straube, D. S., Kinnaird, C. R., Holleran, C. L., Echauz, A. J., Rodriguez, K. S., et al. (2011). Importance of specificity, amount, and intensity of locomotor training to improve ambulatory function in patients poststroke. Topics in Stroke Rehabilitation, 18(4):293–307.

Return to footnote 17 referrer

Footnote 18

Katch, V. L., McArdle, W. D., & Katch, F. I. (2011). Essentials of exercise physiology. Baltimore, MD: Lippincott Williams & Wilkins.

Return to footnote 18 referrer

Footnote 19

Schmidt, R., & Lee, T. (1999). Motor control and learning: A behavioral emphasis (3rd ed.). Champaign, IL: Human Kinetics Inc.

Return to footnote 19 referrer

Footnote 20

Mehrholz, J., Elsner, B., Werner, C., Kugler, J., & Pohl, M. (2013). Electromechanical-assisted training for walking after stroke: Updated evidence. Stroke, 44(10):127–8.

Return to footnote 20 referrer

Footnote 21

Mehrholz, J., Elsner, B., Werner, C., Kugler, J., & Pohl, M. (2013). Electromechanical-assisted training for walking after stroke. The Cochrane Database of Systematic Reviews, 7. Article ID CD006185.

Return to footnote 21 referrer

Footnote 22

Mehrholz, J., Pohl, M., & Elsner, B. (2014). Treadmill training and body weight support for walking after stroke. The Cochrane Database of Systematic Reviews, 1. Article ID CD002840.

Return to footnote 22 referrer

Footnote 23

Kleim, J.A., & Jones, T.A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech Language and Hearing Research, 51(1):S225–39.

Return to footnote 23 referrer

Footnote 24

Krakauer, J. W., Carmichael, S. T., Corbett, D., & Wittenberg, G. F. (2012). Getting neurorehabilitation right: What can be learned from animal models? Neurorehabilitation and Neural Repair, 26(8):923–31.

Return to footnote 24 referrer

Footnote 25

Lang, C. E., Macdonald, J. R., Reisman, D. S., Boyd, L., Jacobson Kimberley, T, Schindler-Ivens, S. M., et al. (2009). Observation of amounts of movement practice provided during stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 90(10):1692–8.

Return to footnote 25 referrer

Footnote 26

Scrivener, K., Sherrington, C., & Schurr, K. (2012). Exercise dose and mobility outcome in a comprehensive stroke unit: Description and prediction from a prospective cohort study. Journal of Rehabilitation Medicine, 44(10):824–9.

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Footnote 27

Bobath, B. (1990). Adult hemiplegia: Evaluation and treatment (3rd ed.). Oxford: Butterworth-Heinemann.

Return to footnote 27 referrer

Footnote 28

Moore, J. L., Pickering, L., Mathur, G., Van Der Laan, K., & Hornby, T. G. (2014). The battery of rehabilitation assessments and interventions: A case of successful knowledge translation. Proceedings of the American Physical Therapy Association, combined sections meeting, Las Vegas, NV.

Return to footnote 28 referrer

Footnote 29

Hennessy, P. W., & Hornby, T. G. (2014). High repetitions of intensive stepping practice delivered in the inpatient rehab setting. Proceedings of the American Physical Therapy Association, combined sections meeting, Las Vegas, NV

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Footnote 30

Lang, C., Macdonald, J., & Gnip, C. (2007). Counting repetitions: An observational study of outpatient therapy for people with hemiparesis post-stroke. Journal of Neurologic Physical Therapy, 31(1):3–11.

Return to footnote 30 referrer

Footnote 31

Pohl, M., Werner, C., Holzgraefe, M., Kroczek, G., Mehrholz, J., Wingendorf, I., et al. (2007). Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: A single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS). Clinical Rehabilitation, 21(1):17–27.

Return to footnote 31 referrer

Footnote 32

Rose, D., Paris, T., Crews, E., Wu, S. S., Sun, A., Behrman, A. L., et al. (2011). Feasibility and effectiveness of circuit training in acute stroke rehabilitation. Neurorehabilitation and Neural Repair, 25(2):140–8.

Return to footnote 32 referrer

Footnote 33

Shaneyfelt, T., Baum, K. D., Bell, D., Feldstein, D., Houston, T. K., Kaatz, S., et al. (2006). Instruments for evaluating education in evidence-based practice: A systematic review. Journal of the American Medical Association, 296(9):1116–27.

Return to footnote 33 referrer