International studies analyze whether feedback about mobility and exercise improves walking outcomes among stroke patients

Stroke is the most common diagnosis for which individuals are admitted to hospital-based rehabilitation programs. Two recent multicenter international trials in which Mayo Clinic participated have examined the impact of providing feedback about walking performance to stroke patients admitted to inpatient rehabilitation units.

The Stroke Inpatient Rehabilitation Reinforcement of Walking Speed (SIRROWS) trial found that patients who received immediate verbal feedback about walking speed during inpatient rehabilitation showed clinically significant gains in walking speed. This single-blind, multicenter trial found that providing immediate feedback about walking speed during routine physical therapy helped patients increase walking speed by enough to permit unlimited, slow community ambulation at discharge from inpatient rehabilitation.

When the SIRROWS results were published, the authors suggested that the next phase of research should examine the impact of providing even more feedback to patients during inpatient care and increasing the feedback provided during the first three to six months of outpatient rehabilitation. That recommendation became the basis of the Stroke Inpatient Rehabilitation Reinforcement of ACTivity trial (SIRRACT).

SIRRACT participants were recruited from 12 international and four American rehabilitation centers, including Mayo Clinic. Inclusion criteria included:

  • Stroke within the past month requiring inpatient rehabilitation
  • Residual hemiparesis
  • The ability to walk at least five steps upon entering the study

Daily walking and other exercise were monitored by bilateral triaxial accelerometers on the ankles. Patient activity data were collected using a personal activity monitor (PAM). About the size of an average USB flash drive, the PAM contains a triaxial accelerometer that records data related to skills practice and provides outcome measures of daily activities and participation for analysis. This data also provides performance-related feedback to patients, which can boost their motivation to engage in activity. After inpatient sensor data were uploaded nightly to a central server, activity-recognition algorithms analyzed the data and returned a summary to the participants at each research site.

SIRRACT compares the effects of two different levels of feedback about physical activity and walking performance provided during inpatient rehabilitation for stroke in 150 subjects. Participants were randomized to receive one of two levels of activity feedback. Primary outcome measures were the daily duration of walking practice, derived from the sensors, and a timed 15-meter walk at discharge by a blinded observer.

The control group was told only how fast they walked in timed 10-meter walks on Monday, Wednesday and Friday. The experimental group received the same feedback as the control group, as well as information about distances walked, daily number of steps, time spent exercising and number of repetitions of leg movements.

According to Allen W. Brown, M.D., a physiatrist and director of brain rehabilitation research at Mayo Clinic, participating in international studies like SIRROWS and SIRRACT meshes well with Mayo Clinic's established clinical practice and research experience. Mayo's CARF-accredited inpatient rehabilitation program admits about 200 patients affected by stroke each year.

As researchers and clinicians await publication of the SIRRACT results, Dr. Brown observes that if a higher level of frequent, detailed feedback is shown to improve outcomes among stroke patients with disabilities, it might well change the way in which inpatient rehabilitation care for stroke is delivered.

"SIRRACT might provide us with strong evidence to support a broader role for the use of personal activity monitors, both during and after inpatient rehabilitation," says Dr. Brown. "As the cost of these activity monitors decreases, this technology might also help us treat patients in rural areas more effectively."

Points to remember

  • Two recent international multicenter trials in which Mayo Clinic participated have examined the impact of providing feedback about walking performance to stroke patients admitted to inpatient rehabilitation units.
  • The Stroke Inpatient Rehabilitation Reinforcement of Walking Speed (SIRROWS) trial found that patients who received immediate verbal feedback about walking speed during inpatient rehabilitation showed clinically significant gains in walking speed.
  • The recently concluded Stroke Inpatient Rehabilitation Reinforcement of ACTivity trial (SIRRACT) compares the effects of two different levels of feedback about physical activity and walking performance provided during inpatient rehabilitation in 150 subjects.
  • SIRRACT also illustrates a potentially significant role for the use of personal activity monitors in clinical research and in motivating patients to perform more exercise on their own and during formal therapy sessions.