Use of a Focused, Intensive Repeated Stepping Training (FIRST) Program of Inpatient Rehabilitation

Indiana University
Shirley Ryan AbilityLab and 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, Chris Henderson, Linda Lovell, Elliot Roth, Roberta Virva, and John Butzer


This project has two knowledge translation (KT) activities. The first is to test how well a gait and balance assessments battery works. This “battery” is a measure to assess how a person changes in function (that is, improves or declines) related to walking. The second is to use a high-intensity walking training program, titled Focused, Intensive Repeated Stepping Training (FIRST). The program will be used at the Mary Free Bed Rehabilitation Hospital. The project will compare standard care with high intensity gait training on short- and long-term mobility outcomes, health, and community participation in adults who have had a stroke.


Being able to walk again soon after a stroke, spinal cord injury, or acquired brain injury is a primary goal of patients and their families. The ability to walk again depends largely on the location and extent of the injury. Most patients who have had a stroke or acquired brain injury can recover some ability to walk (80% to 95%)1,2,3. One quarter of patients (25%) with a spinal cord injury walk independently. For those patients who do recover, most walk slowly and for limited distances. They also often walk with assistive devices, such as canes or walkers, for safety. How well someone can walk often predicts where he or she goes after receiving rehabilitation, 4, 5, later health status6, and participation in the community.7, 8 Even walking slightly slower after a stroke or injury is associated with significant increases in healthcare use such as increasing medical or surgical visits or longer hospital visits. Patients may not increase their ability to walk because of a lack of accessibility to current evidence, lack of access to adequate training equipment, and therapists’ adherence to traditional interventions that are not as effective as evidence-based interventions.9

This project has two primary components. The first is a KT project that aims to use gait and balance assessments in Years 1 and 2. In Year 3 of the project, the aim is to carry out a high-intensity walking training program. Using data collected in this project, we will compare outcomes of conventional care to the outcomes achieved on patients who received the FIRST program. Specifically, we will determine the short- and long-term ability to walk, health, and community participation outcomes in adults who have had a stroke.

Previously, we were able to successfully use the gait and balance assessments and the FIRST program10, 11 in inpatient rehabilitation stroke programs. This resulted in five to six times greater amounts of walking than typically achieved, but the results varied substantially between patients with different levels of stroke severity.12, 13 As a result of the program, patients’ improvements in walking and nonwalking tasks (that is, standing up, moving from a bed to a chair, etc.) were greater than the outcomes identified in previous research.11, 14, 15

Understanding the effectiveness of these high-intensity walking interventions to improve health, mobility, and community participation used in the clinical setting may be of extraordinary value to the multiple stakeholders, such as patients, families, and healthcare professionals, involved in the rehabilitation of these patients.

KT Strategies

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

The KTA Implementation Plan (Years 1–2)

We conducted online surveys annually among hospital clinicians to identify the beliefs, barriers, and facilitators toward use of assessments and intensive gait training, as well as organizational readiness to change. To select the evidence to use, we reviewed the measurement recommendations and current guidelines that recommended reliable and valid walking and balance measures for patients with stroke. Based on recommendations in published guidelines, we selected the 10 meter walk test (10MWT),1,2 the 6 minute walk test (6MWT),1,2 and the Berg Balance Scale (BBS)1-3 for the gait and balance assessments battery. To adapt the knowledge locally, we made recommendations for assessment standardization procedures, timing, and documentation at Mary Free Bed Rehabilitation Hospital.

The barriers identified during the first survey provided information about how to better support clinicians in administering the assessments. We selected and used KT interventions to overcome barriers during the first 6 months of the project until therapists followed the procedures to assess patients at least 85% of the time. We categorized the barriers into knowledge and skills, social influences, and environmental context and resources using the Theoretical Domains Framework.16,17 These barriers guided the selection of a multicomponent KT intervention that included education, mentoring, development of knowledge tools, leadership support, chart audit and feedback, rewards, and environmental modifications.

To monitor use of the gait and balance assessments, we audited the medical charts. After using the additional KT strategies, including chart audit and feedback, reminders, and mentoring, use of the gait and balance assessments increased to as high as 100%. Therapists have followed the procedures for the gait and balance assessments at least 85% of the time for more than 26 months. After 15 months, we continued to monitor use of the gait and balance assessments but discontinued the feedback (that is, we stopped the KT intervention of feedback).

We started several activities to sustain the use of the gait and balance assessments at the hospital. The leadership team integrated the gait and balance assessments into the organizational goals and vision. To do this, the leaders determined the battery should be used throughout the organization. The leaders applied it using the same methods described here. Supervisors wrote performance appraisal goals for the physical therapists or physical therapy aides related to adhering to the use of the gait and balance assessments. Similarly, supervisors asked physical therapists or their aides to create performance appraisal goals related to using the gait and balance assessments. Human resources staff added the use of the gait and balance assessments into the physical therapist job descriptions. Routine clinical practices and processes incorporated the use of the gait and balance assessments. New-hire orientations also included a discussion of the gait and balance assessments and the importance of the procedure. Lastly, management is modifying the electronic medical record to accommodate gait and balance assessments data.

Delivery of the FIRST Program at the Hospital (Years 3–5)

In Year 3, we began to implement the gait training program. Using the same methods described earlier, we developed a multicomponent KT plan that was guided by the identification of barriers to using the program. Now in the fourth year of the program, we are continuing to develop KT interventions to improve fidelity of delivery of the FIRST program.


To date, we have used the gait and balance assessments at the hospital and have been monitoring their use for almost 3 years. Clinicians have been using the gait and balance assessments more than 85% of the time for over 2 years. The hospital has used the gait and balance assessments throughout the entire system. Now, the hospital uses it as a foundation for a learning health system. On a survey, all clinicians reported that using the gait and balance assessments increased use of outcome measures and guided their decisionmaking. Clinicians also reported discussing outcome measure results with colleagues. Clinicians reported an increased understanding of the value that these measures add to clinical practice. In addition, all clinicians reported that the culture within their department has shifted to one that is driven by data. They now have and use data rather than relying on subjective observations such as “The patient walks slowly” or “The patient has poor balance.”

Upon admission to the hospital, 71% of patients with stroke (n = 157) required physical assistance for at least one of the ambulatory outcome measures, and 32% required at least supervision for sitting. Almost of a third of participants (28%) had low assessment scores, indicating significant difficulties with walking and/or sitting. After 1 week, 53% of patients had detectable changes in the gait and balance assessments, and their gait continued to improve until they left the hospital. When investigating the gait and balance assessments to identify functional change not captured by the Functional Independence Measure (FIM) locomotion, a federally required measurement in inpatient rehabilitation, 34 of 95 participants (36%) with the necessary data demonstrated no change in week 1 FIM locomotion from admission, whereas 10 of 34 participants (29%) demonstrated clinically meaningful change for the 10MWT or 6MWT.

Once the data collection is finished, we will examine the impact of using the gait training program on short- and long-term patient outcomes. We will also evaluate the cost effectiveness of using the program.

Lessons Learned

Throughout this program, we have encountered ongoing barriers that have required an iterative process (that is, barrier assessment, KT interventions, and monitoring) to overcome. Using the program requires a sustained effort with clear and open communication among all members of the project team, end users, and stakeholders.

More Information

Free online educational modules have been developed for the high-intensity gait training program. For information about these modules or about the FIRST project, please contact Jenni Moore at

Contact Information

Shirley Ryan AbilityLab and Mary Free Bed Rehabilitation Hospital
RRTC on Developing Optimal Strategies in Exercise and Survival Skills to Increase Health and Function
Address: 355 East Erie
Chicago, IL 60611
Contact: Jenni Moore at


  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.
  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.
  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.
  4. 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
  5. 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.
  6. 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.
  7. 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.
  8. Lord, S. E., & Rochester, L. (2005). Measurement of community ambulation after stroke: Current status and future developments. Stroke, 36(7):1457–61.
  9. 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.
  10. Bobath, B. (1990). Adult hemiplegia: Evaluation and treatment (3rd ed.). Oxford: Butterworth-Heinemann.
  11. 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.
  12. 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.
  13. 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
  14. 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.
  15. 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.
  16. Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation science : IS. 2017;12(1):77.
  17. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology: An International Review. 2008;57(4):660-680.