Introduction:
Though clinical practice guidelines support high repetitions of walking after stroke, practice is slow to change with low levels of walking activity in stroke rehabilitation units. We undertook an implementation trial to change practice; we enabled entire stroke units to use the Walk ‘n Watch protocol and determined the effect of implementation on the 6 Minute Walk Test (6MWT) at hospital discharge.
Methods:
This 12-site clinical trial across 7 Canadian provinces used a stepped-wedge cluster design to randomize when each site switched from Usual Care to the Walk ‘n Watch protocol. At the start of the Walk ‘n Watch phase, we trained all front-line physical therapists on the unit with training workshops, manuals, hands-on practice, and videos. Each site was provided onboarding materials to address staff changes so therapists who did not attend the initial training could adopt the protocol. Each site also identified a ‘protocol champion’ to facilitate initial weekly huddles with therapists to discuss barriers to implementation. Therapists were trained to complete safety screening and to determine eligibility. The Walk ‘n Watch protocol focused on completing a minimum of 30-minutes of daily weight-bearing, walking-related activities that progressively increased in intensity informed by activity trackers measuring heart rate and step number. Blinded assessors completed the outcomes at baseline and 4-weeks later (near discharge). Primary analysis used a linear mixed-effects model adjusted for stratum, date of enrollment, age, sex and baseline 6MWT.
Results:
The total number of participants was 306 (162 Usual Care, 144 Walk ‘n Watch, 188 males/118 females) with a mean(SD) age of 68(13), 29(17) days since stroke, and a baseline 6MWT of 152(106) m. The improvement on the 6MWT was 43.6m (95%CI 12.7, 76.1) greater in the Walk ‘n Watch group compared to the Usual Care group. Further, the Walk ‘n Watch group improved quality of life (EQ5D), balance and mobility (Short Physical Performance Battery) and gait speed.
Conclusions:
The implementation trial design enabled the protocol to be tested under real-world conditions, involving all therapists on each unit to deliver the protocol. The trial had a deliberate aim to facilitate changes in practice that resulted in clinically meaningful improvements in walking and quality of life.
