Chad Swank Ph.D.

Swank, C., M. Trammell, M. Bennett, C. Ochoa, L. Callender, S. Sikka and S. Driver (2020). “The utilization of an overground robotic exoskeleton for gait training during inpatient rehabilitation-single-center retrospective findings.” Int J Rehabil Res Apr 8. [Epub ahead of print].

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Overground robotic exoskeleton gait training is increasingly utilized during inpatient rehabilitation yet without clear guidelines. We describe clinical characteristics associated with robotic exoskeleton gait training and examine outcomes of people with spinal cord injury and stroke who completed usual rehabilitation care with or without robotic exoskeleton gait training. Retrospective review of medical records over a 36 months period. Inpatients with spinal cord injury or stroke and >/=1 robotic exoskeleton gait training session were included. After obtaining a complete list of robotic exoskeleton gait training participants, medical records were reviewed for comparable matches as determined by gait functional independence measure score <4, age 18-100 years, meeting exoskeleton manufacturer eligibility criteria, and participating in usual care only. Functional independence measure was collected on all patients. For spinal cord injury, we collected the walking index for spinal cord injury II. For stroke, we collected the Stroke Rehabilitation Assessment of Movement Measure. Fifty-nine people with spinal cord injury (n = 31 robotic exoskeleton gait training; n = 28 usual care) and 96 people post-stroke (n = 44 robotic exoskeleton gait training; n = 52 usual care) comprised the medical record review. Fifty-eight percent of patients with spinal cord injury and 56% of patients post-stroke completed 5+ robotic exoskeleton gait training sessions and were included in analyses. Robotic exoskeleton gait training dosage varied between our patients with spinal cord injury and patients post-stroke. Robotic exoskeleton gait training utilization during inpatient rehabilitation required consideration of unique patient characteristics impacting functional outcomes. Application of robotic exoskeleton gait training across diagnoses may require different approaches during inpatient rehabilitation.

Swank, C., M. Trammell, L. Callender, M. Bennett, K. Patterson, J. Gillespie, P. Kapoor and S. Driver (2020). “The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation-a randomized controlled trial.” Clin Rehabil 34(4): 504-514.

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OBJECTIVE: Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge. DESIGN: Randomized control trial. SETTING: Inpatient rehabilitation facility. SUBJECTS: Patients admitted to inpatient rehabilitation post stroke. INTERVENTIONS: Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day. MAIN MEASURES: Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up. RESULTS: Seventy-three patients (PDAP (n = 37); control (n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 +/- 16.5 sessions (10.7 +/- 8.5 upper extremity; 12.4 +/- 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 +/- 655.82, control = 396.17 +/- 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 +/- 11.4, control = 80.8 +/- 16.7; P = 0.049), communication (PDAP = 93.6 +/- 8.3, control = 89.6 +/- 12.4; P = 0.042), mobility (PDAP = 62.2 +/- 22.5, control = 53.8 +/- 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 +/- 19.1, control = 52.2 +/- 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP (n = 11) completed significantly greater physical activity (P = 0.014; 3586.5 +/- 3468.5 steps/day) compared to control (n = 10; 1760.9 +/- 2346.3 steps/day). CONCLUSION: Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Swank, C., S. Almutairi, S. Wang-Price and F. Gao (2020). “Immediate kinematic and muscle activity changes after a single robotic exoskeleton walking session post-stroke.” Top Stroke Rehabil Feb 20:1-13. [Epub ahead of print].

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Background: Robotic Exoskeletons (EKSO) are novel technology for retraining common gait dysfunction in people post-stroke. EKSO’s capability to influence gait characteristics post-stroke is unknown.Objectives: To compare temporospatial, kinematic, and muscle activity gait characteristics before and after a single EKSO session and examine kinematic symmetry between involved and uninvolved limbs.Methods: Participants post-stroke walked under two conditions: pre-EKSO, and immediately post-EKSO. A 10-camera motion capture system synchronized with 6 force plates was used to obtain temporospatial and kinematic gait characteristics from 5 walking trials of 9 meters at a self-selected speed. Surface EMG activity was obtained from bilateral gluteus medius, rectus femoris, medial hamstrings, tibialis anterior, and soleus muscles. Wilcoxon Signed Rank tests were used to analyze differences pre- and post-EKSO. Single EKSO session consisted of 22.3+/-6.8 minutes total time (walk time=7.2+/-1.5 minutes) with 250+/-40 steps.Results: Six ambulatory (Functional Ambulation Category, range=4-5) adults (3 female; 44.7+/-14.6 years) with chronic stroke (4.5+/-1.9 years post-stroke) participated. No significant differences were observed for temporospatial gait characteristics. Muscle activity was significantly less post-EKSO in the involved leg rectus femoris during swing phase (p=0.028). Ankle dorsiflexion range of motion on the involved leg post-EKSO was significantly less during stance phase (p=0.046). Differences between involved and uninvolved joint range of motion symmetry were found pre-EKSO but not post-EKSO in swing phase hip flexion and stance phase knee flexion and knee extension.Conclusions: EKSO training appears capable of altering gait in people with chronic stroke and a viable intervention to reduce gait dysfunction post-stroke.

Swank, C., M. Trammell, L. Callender, M. Bennett, K. Patterson, J. Gillespie, P. Kapoor and S. Driver (2020). “The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation-a randomized controlled trial.” Clin Rehabil Jan 15. [Epub ahead of print].

Full text of this article.

OBJECTIVE: Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge. DESIGN: Randomized control trial. SETTING: Inpatient rehabilitation facility. SUBJECTS: Patients admitted to inpatient rehabilitation post stroke. INTERVENTIONS: Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day. MAIN MEASURES: Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up. RESULTS: Seventy-three patients (PDAP (n = 37); control (n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 +/- 16.5 sessions (10.7 +/- 8.5 upper extremity; 12.4 +/- 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 +/- 655.82, control = 396.17 +/- 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 +/- 11.4, control = 80.8 +/- 16.7; P = 0.049), communication (PDAP = 93.6 +/- 8.3, control = 89.6 +/- 12.4; P = 0.042), mobility (PDAP = 62.2 +/- 22.5, control = 53.8 +/- 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 +/- 19.1, control = 52.2 +/- 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP (n = 11) completed significantly greater physical activity (P = 0.014; 3586.5 +/- 3468.5 steps/day) compared to control (n = 10; 1760.9 +/- 2346.3 steps/day). CONCLUSION: Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Driver, S., C. Swank, K. Froehlich-Grobe, E. McShan, S. Calhoun and M. Bennett (2019). “Weight Loss After Stroke Through an Intensive Lifestyle Intervention (Group Lifestyle Balance-Cerebrovascular Accident): Protocol for a Randomized Controlled Trial.” JMIR Res Protoc 8(10): e14338. [Epub October 18]

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BACKGROUND: Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), because of impaired mobility, behavioral and emotional disorders, and sensory losses. Weight gain increases the patient’s risk of recurrent stroke and chronic diseases, such as diabetes, metabolic syndrome, and pulmonary and heart disease. Approaches to weight loss in this population are lacking, although necessary because of the unique physiological and cognitive needs of persons after a stroke. Evidence shows that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight loss. The Group Lifestyle Balance (GLB) intervention is a 12-month, evidence-based weight loss program that has been used extensively with the general population; this program was modified to meet the needs of people who have had a stroke (GLB-CVA). OBJECTIVE: This randomized controlled trial (RCT) aims to examine the efficacy of the GLB-CVA on weight and secondary outcomes, compared with that of a waitlist control group. METHODS: This RCT will enroll and randomize 64 patients over an 18-month period. RESULTS: Currently, 51 people are waitlisted, with 23 out of 51 screened and 16 out of 23 eligible. CONCLUSIONS: It is anticipated that the findings from this RCT will contribute to the evidence base regarding weight loss strategies for people living with stroke. CLINICAL TRIAL: ClinicalTrials.gov NCT03873467.