Highlights
- The Walk ‘n Watch trial demonstrated a 43.6-meter greater improvement in the 6-minute walk test (6MWT) compared to usual care.
- The structured, progressive protocol was delivered safely by front-line physical therapists with no serious adverse events during exercise sessions.
- Pragmatic implementation at 12 sites across Canada suggests the protocol is feasible for real-world inpatient stroke rehabilitation.
- The intervention addresses the repetition gap by mandating at least 30 minutes of high-intensity walking per session.
Introduction: Addressing the Repetition Gap in Stroke Recovery
In the landscape of neurorehabilitation, the gap between clinical guidelines and bedside practice remains a significant hurdle. While evidence-based guidelines consistently advocate for high-repetition, high-intensity walking training to improve outcomes after stroke, observational studies often reveal a different reality. In many inpatient rehabilitation units, patients spend a limited amount of time engaged in active walking, often failing to reach the dosage required to drive neuroplasticity and functional recovery. This discrepancy, often termed the repetition gap, stems from various systemic barriers, including time constraints, lack of structured protocols, and concerns regarding patient safety during high-intensity exercise.
The Walk ‘n Watch trial, recently published in The Lancet Neurology, sought to bridge this gap. By evaluating a structured, progressive exercise protocol designed for delivery by front-line physical therapists, the study aimed to determine if a pragmatic implementation package could translate theoretical benefits into meaningful clinical gains within the subacute phase of stroke recovery.
Study Design: A Pragmatic, Multisite Approach
The Walk ‘n Watch study was a pragmatic, phase 3, stepped-wedge, cluster-randomised controlled trial. This design is particularly well-suited for implementation research as it allows all participating sites to eventually adopt the intervention while providing a robust control through the sequential transition of clusters. The trial involved 12 inpatient stroke rehabilitation units across seven Canadian provinces.
Participant Characteristics
The study enrolled 314 participants (306 included in the primary analysis) with a mean age of 68 years. On average, participants were 29 days post-stroke at the time of enrollment. Their baseline walking endurance, as measured by the 6-minute walk test (6MWT), was 152 meters, indicating significant mobility impairment. The diversity of the sites and the inclusion of typical inpatient populations enhance the external validity of the findings.
The Intervention: Walk ‘n Watch Protocol
Unlike traditional rehabilitation, which can be variable in intensity, the Walk ‘n Watch protocol required a minimum of 30 minutes of walking-related activities per session. The protocol was characterized by several key features:
1. Progression: Intensity was progressively increased based on objective data from heart rate and step count monitors.
2. Assessment-Driven: Progressions were prescribed based on a screening 6MWT conducted by the treating physical therapist.
3. Implementation Package: Front-line therapists received specific training, making the protocol part of the standard unit workflow rather than a specialized research-only activity.
The control group received usual care, which reflects the standard rehabilitation practices typically provided in Canadian stroke units.
Key Findings: Significant Gains in Functional Mobility
The results of the trial provide compelling evidence for the efficacy of structured walking protocols. The primary endpoint was the change in 6MWT distance at 4 weeks post-randomisation.
Primary Endpoint: Walking Endurance
Participants in the Walk ‘n Watch group showed a substantially greater improvement in walking endurance compared to those receiving usual care. Specifically:
1. The mean 6MWT distance in the Walk ‘n Watch group increased from 163.6 m at baseline to 297.2 m at 4 weeks.
2. The usual care group increased from 137.1 m to 223.6 m.
3. After adjusting for variables such as age, sex, and baseline performance, the Walk ‘n Watch group achieved a 43.6-meter (95% CI 12.7–76.1) greater improvement than the control group.
In the context of stroke rehabilitation, a 43.6-meter difference is considered clinically meaningful. It often represents the threshold between requiring physical assistance for mobility and achieving the level of endurance necessary for independent community ambulation.
Safety and Tolerability
Safety is a paramount concern when increasing exercise intensity in a subacute stroke population. The trial reported that no serious adverse events occurred during the Walk ‘n Watch sessions. While nine serious adverse events requiring acute care admission were reported during the study period, they were evenly distributed between the groups (four in usual care, five in Walk ‘n Watch) and were not directly attributed to the intervention. This suggests that the screening and monitoring components of the protocol effectively mitigated risks.
Expert Commentary: Clinical Implications
The Walk ‘n Watch trial is a landmark study for several reasons. First, it demonstrates that high-intensity walking is not only effective but also safe in the subacute phase of stroke. Second, it highlights the power of pragmatic trial designs in proving that complex interventions can be successfully implemented by existing staff within existing healthcare structures.
From a physiological perspective, the success of Walk ‘n Watch likely stems from the principles of task-specific training and intensity. By ensuring a minimum of 30 minutes of walking and using heart rate monitors to maintain intensity, the protocol targets both the neuromuscular and cardiovascular systems. This dual focus is essential for improving walking endurance, which is a composite of strength, coordination, and aerobic capacity.
However, some questions remain. While the overall results were positive, further research is needed to identify which patient subgroups benefit most. For instance, do patients with more severe initial deficits show the same relative gains as those with higher baseline function? Additionally, the long-term sustainability of these gains after discharge from the inpatient setting warrants further investigation.
Conclusion: Moving Evidence into Action
The Walk ‘n Watch protocol offers a scalable, safe, and effective solution for improving walking outcomes in stroke rehabilitation. By providing physical therapists with a structured framework for progression and monitoring, the protocol removes much of the guesswork and inconsistency associated with usual care. For health policy experts and clinical leads, these findings suggest that adopting such structured protocols could significantly enhance the efficiency of inpatient rehabilitation units and improve the functional independence of stroke survivors.
Funding and Trial Registration
This research was supported by the Canadian Institutes of Health Research, Canada Brain Research Fund, Michael Smith Health Research BC, Fonds de recherche du Québec-Santé, Canada Research Program, and the Heart and Stroke Foundation of Canada. The trial is registered with ClinicalTrials.gov, NCT04238260.
References
1. Peters S, Hung SH, Bayley MT, et al. Safety and effectiveness of the Walk ‘n Watch structured, progressive exercise protocol delivered by physical therapists for inpatient stroke rehabilitation in Canada: a phase 3, multisite, pragmatic, stepped-wedge, cluster-randomised controlled trial. Lancet Neurol. 2025;24(8):643-655.
2. Bernhardt J, Hayward KS, Kwakkel G, et al. Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce. Neurorehabil Neural Repair. 2017;31(9):793-799.
3. Lang CE, Macdonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil. 2009;90(10):1692-1698.
4. Duncan PW, Sullivan KJ, Behrman AL, et al. Body-weight-supported treadmills and walking facilities for patients with stroke. N Engl J Med. 2011;364(21):2026-2036.
