Return to Run After Stroke: A Case Series

Return to Run After Stroke: A Case Series

Michael James, SPT

 

Background

While in PT school, I enjoyed learning about the numerous specialty opportunities within physical therapy. The meaningful hands-on experiences that I had confirmed neurology as an interest of mine. It was specifically my inpatient rotation at UNC Lenoir in Kinston that my desire to treat the neurologic population was made ultimately clear. Stroke accounted for 60% of the caseload and I was afforded ample opportunity to practice neuro-specific clinical skills. I reflect on one of my most memorable patients, a woman who was able to regain the ability to walk after a neurological event just in time to attend her family’s annual beach vacation. Upon returning from her family event, she stopped by the hospital to share how grateful she was for the time, effort, and care that I provided her. She went on to say that she was able to participate in all the activities she had hoped for. She admitted that she was afraid that these activities would no longer be possible for her. As I reflect upon this experience, I knew that also understanding a patient’s goal in their recovery is paramount to their success. There was one last thing to do prior to her discharge, make sure she had the tools to navigate her trip successfully. I was able to help facilitate a beach wheelchair rental that allowed her to navigate sand by the water which is where her family usually spends most of the vacation. She shared that she was able to climb stairs to access the beach house, use a walker within the house and most importantly, engage in conversation and family celebrations. This patient experience highlights what I enjoy most about working with neurologic populations: functional gains translate into meaningful and memorable life experiences. I am proud to say that the culmination of interventions led to a successful beach trip for this patient, and I am excited to make an impact like this in my future patients’ lives. I am driven and inspired by stories like these!

After this experience, I considered the potential impact that a return to higher level activity may have for the neurologic patient. I reached out to Dr. Mike Lewek to inquire about research opportunities, and he suggested leading his pilot study about return to running after stroke. I was immediately interested, especially considering my personal interest in running and the opportunity to marry that with my PT passion. Being a runner myself and experiencing an injury that prevented me from participating in running provided a brief perspective of what these patients go through. Over the past year, I participated in a research experience where I developed a return to run framework and applied it to three individuals with stroke. Over the past semester, I’ve analyzed the data and written a manuscript that we hope to introduce into publication. It will provide clinical insight on how to treat a stroke survivor who desires to return to run. While this project will come to a close when I graduate, I will further explore my passion for working with neurologic populations as a UNC neurologic resident starting in the fall.

 

Statement of Need

Stroke is a disease that has traditionally been considered to affect older adults (aged 65 and older). However, recent trends have shown that stroke is becoming more prevalent in younger populations.^1,2 Individuals following stroke are typically discharged from physical therapy once they are independent with activities of daily living. Thus, they are not afforded the rehabilitation opportunity to return to higher level activity. Previous research has documented successful return to running in individuals after a neurological event (such as brain injury or spinal cord injury),^3-5 but there is limited research in return to running after stroke. Running is a recreational activity that provides a return to normalcy after a traumatic neurological event. Additionally, running is a component of many team-based sports. Regaining the ability to run post stroke can help to connect the individual with the community by fostering recreational and social opportunities. Running has many health-related benefits that can reduce future healthcare costs by improving cardiovascular fitness, injury prevention through regular tissue loading, weight management and mental health.

References:

1. Yahya T, Jilani MH, Khan SU, et al. Stroke in young adults: Current trends, opportunities for prevention and pathways forward. American Journal of Preventive Cardiology. 2020;3:100085. doi:10.1016/j.ajpc.2020.100085
2. Jackson G, Chari K. National hospital care survey demonstration projects: stroke inpatient hospitalizations. Natl Health Stat Report. 2019;(132):1-11.
3. Moriello G, Haller M, Ra A, Cable L, Stone K, Ingegni A. Running outcomes following an intensive exercise program in those with brain injury. Clin Kinesiol. 2013;67(4).
4. Moriello G, Frear M, Seaburg K. The recovery of running ability in an adolescent male after traumatic brain injury: a case study. J Neurol Phys Ther. 2009;33(2):111-120. doi:10.1097/NPT.0b013e3181a6ab6b
5. Gardner M, Holden M, Leikauskas J, Richard R. Partial body weight support with treadmill locomotion to improve gait after incomplete spinal cord injury: a single-subject experimental design. Phys Ther. 1998;78(4):361-374.

 

Purpose Statement:

We sought to investigate if running is possible after stroke. We identified impairments that limit running after stroke by using gait analysis, joint kinetics and the High Level Mobility Assessment Tool (HiMAT). We hypothesized that interventions used to improve walking ability, such as high intensity interval training and impairment specific exercises with a focus on power generation, would result in improved running ability as measured by speed and quality.

 

Learning Objectives:

1. The student will successfully submit an IRB application as measured by IRB approval for the research project.
2. The student will conduct background research on return to running after neurological event including selections on running biomechanics as measured by consumption of two research articles per week. The student will keep a journal of themes and ideas as a reflection for each paper.
3. The student will conduct all onsite evaluation and treatment sessions for all participants in the study group.
4. Learn to conduct suitable outcome measures (e.g., 6MWT, mini-BESTest, etc) to evaluate pre-post changes following running intervention.
5. Student will gain experience with running training for people post-stroke.
6. Demonstrate appropriate inter-personal skills while working with research subjects and grow professional communication abilities.
7. Student will gain experience in scientific writing and will produce a case series for journal submission by the end of the semester.
8. Produce and present research findings to an audience of PTs in Kinston, NC where primary treatment population is stroke.

 

Products:

Capstone Running Case Series

• Last semester (Fall 2022) I completed a research project under the supervision of Dr. Mike Lewek, PT, PhD and PhD candidate Chelsea J. (CJ) Parker, DPT, PT. After its completion, we analyzed the data with the intent of producing a manuscript. The creation of the manuscript was a multiple-month process that included weekly meetings with Dr. Mike Lewek to create, revise and produce a paper for publication. The committee has reviewed the manuscript but the version linked here does not incorporate any proposed edits.

Capstone Running Presentation

• A presentation discussing research and clinical implications was held at UNC Lenoir Hospital on 4/27/23 for physical therapists and physical therapist assistants.

 

Health Literacy:

Dr. Mike Lewek and I discussed presentation considerations given that the presentation audience was physical therapists and physical therapist assistants. While I did not have to consider health literacy given my audience, I did tailor the presentation to be clinically focused with an emphasis on how the framework could be employed in the clinic. The presentation included many videos and focused on a thorough description of the high intensity interval training protocol, exercise progression/regressions, cueing strategies and general intervention approach. This captivated the audience and led to a successful presentation per survey feedback.

 

Evaluation:

• Dr. Mike Lewek and I met frequently throughout the course of the research experience and manuscript generation. During the initial stages, I was responsible for the Institutional Review Board (IRB) application which required review from Dr. Mike Lewek before submission. I was also responsible for reading background literature and proposing components of intake/outtake evaluation including outcome measures and any other variables we would measure. Dr. Mike Lewek and I met frequently during the intervention period to discuss intervention strategy. We continued our weekly meetings during the last semester where he frequently evaluated and edited both the manuscript and presentation. Dr. Chelsea (CJ) Parker and Dr. Sarah McAuliffe reviewed the manuscript for the final evaluation where they provided edits and feedback.
• Additionally, I created a google survey that was used for evaluation of effectiveness and clarity of the presentation at UNC Lenoir.

 

Self Reflection:

• This research experience was incredibly fulfilling mainly because of the results and the impact that I had on the participants involved in the study. I had to be creative in my intervention approach as there is only one case study guiding clinicians on return to run after stroke. I am glad to contribute this case series which will hopefully translate into future randomized controlled trials that investigate return to run after stroke. I am also excited to submit an abstract to the combined section meeting (CSM) in 2024.
• The most challenging component of this process was the scientific writing. I encountered many writing blocks during the manuscript production and my toughest breakthroughs happened while running in the Linville Gorge Wilderness area. During these times, I felt incredibly grateful for my ability to run and explore beautiful places. Perhaps these writing breakthroughs happened here because I fully embraced what running means to me and I want to share these experiences with others. Regardless, I have learned that even when things are difficult, remain persistent and never give up.
• Overall, I am incredibly proud of the project that I have created. Through this experience, I have developed a passion for returning neurologic patients to high level activity. This experience will undoubtedly arm me with the tools to battle complex cases and develop creative interventions during the neurologic residency next year. I am also excited to open a clinic with a neuro-specific focus on returning individuals to higher level activity in the future.

 

Acknowledgments:

• Michael Lewek, PT, PhD, I know that I’ve told you before but I am incredibly grateful for your wisdom and experience as I could not have produced this manuscript without you. You have a unique way of probing your students, directing them towards the light when they feel lost. Your words are encouraging and I consider myself lucky to have been a part of your lab group. I have learned so much from you and I will certainly miss our Monday meetings. I look forward to working with you in the future both for CSM and PT Rounds presentations in the next academic year.
• Chelsea (CJ) Parker, PT, DPT, thank you for lending your expertise on this project and your thorough editing of the manuscript. You were an incredible support, providing supervision for every treatment session that I conducted during the intervention period of this study (so many hours that you gave)! I wish you nothing but success as you move through the remainder of your PhD!
• Sarah McAuliffe, PT, DPT, OCS, FAAOMPT, thank you so much for reviewing the manuscript and consulting with Dr. Mike Lewek and I at the midpoint of the intervention period. You provided many intervention ideas, including the triple flexion/extension drill. I look forward to working along side you at the Hillsborough clinic next year!