By Joan Stilling, MD, MSc
Synopsis: An intensive real-life walking protocol, started as soon as possible after acute stroke, resulted in improved overall walking endurance, mobility, balance, and quality of life.
Source: 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.
Despite widespread guideline recommendations promoting high-repetition walking practice after stroke, implementation in real-world inpatient rehabilitation remains limited.1-5 The recently published Walk ’n Watch trial bridges this gap by evaluating a structured, progressive walking protocol delivered by physical therapists within inpatient rehabilitation settings across Canada. The study provides compelling evidence for the safety, feasibility, and effectiveness of embedding high-intensity gait training into standard care, with meaningful implications for stroke rehabilitation in both Canadian and U.S. systems.
The Walk ’n Watch trial was a Phase III, multisite, pragmatic, stepped-wedge cluster-randomized controlled trial (SW-RCT) conducted across 12 Canadian inpatient stroke rehabilitation units. Their pragmatic approach tested how well the gait training protocol works in routine clinical practice, not just under ideal, controlled conditions. A total of 306 adults with subacute stroke (mean time since stroke: 29 days) participated, with 162 participants receiving standard care and 144 receiving an individualized, progressive intensity walking intervention. Sites transitioned from usual care to the Walk ’n Watch intervention in a staggered, randomized sequence. The intervention consisted of at least 30 minutes of walking-related activities per session, five days per week, guided by step counters and heart rate monitors, with intensity individualized based on the six-minute walk test (6MWT). The main goal was to increase the number of participant steps at a target of 40% to 60% heart rate (HR) reserve (HRmax-HRrest).
The primary outcome was a change in 6MWT distance at four weeks. Secondary outcomes included resting HR and blood pressure, balance and mobility (Short Physical Performance Battery [SPPB]), gait speed, functional independence/disability (modified Rankin scale [mRS]), global cognition (Montreal Cognitive Assessment [MoCA]), depression (Patient Health Questionnaire-9 [PHQ-9]), quality of life (EuroQol-5 Dimensions [EQ-5D]), and safety events, including falls and hospitalizations. Masked assessors were used at baseline and post-intervention. Key findings from the trial included changes in walking endurance, mobility, balance, and quality of life, and evidence of safety of the intervention. Walking endurance, as evaluated by the 6MWT, improved by 133.6 m in the Walk ’n Watch group vs. 86.6 m in the usual care group. There was a between-group difference of 43.6 m (95% confidence interval [CI], 12.7 to 76.1), exceeding minimal clinically important difference (MCID) thresholds reported in stroke and cardiovascular literature.6,7 A per-protocol analysis (excluding three sites with low protocol fidelity) demonstrated an even greater improvement in 6MWT (52.6 m) in the Walk ’n Watch group, highlighting a dose-response relationship between walking intensity and functional gains.
For mobility and balance, the intervention group showed greater improvements in SPPB (1.15 points) and gait speed (0.13 m/s), both within MCID ranges.8,9 Quality of life, measured by the EQ-5D Visual Analogue Scale, improved by 8.0 points over usual care, exceeding the MCID of 6.4 seen in other chronic populations, but was slightly less than what is considered clinically significant in chronic stroke.10,11 No serious adverse events occurred during any Walk ’n Watch therapy sessions. Fall rates were similar between the two groups and mostly unrelated to therapy. Subgroup analysis suggested a much smaller treatment effect in women, possibly the result of baseline differences. Future research should explore tailoring the protocol to individual factors such as sex, frailty, and depression. Variability in fidelity across sites suggests a need for more comprehensive staff training, electronic medical record integration, and real-time feedback. Twelve-month follow-up data will elucidate the intervention’s long-term functional effect.
Commentary
The Walk ’n Watch study significantly advances the field of stroke rehabilitation in several domains. Improvements using the high-intensity intervention exceeded MCIDs in walking endurance, mobility, and balance, reinforcing the functional relevance of this approach and its potential to reduce post-stroke complications, such as deconditioning. Unlike prior trials delivered by research staff, Walk ’n Watch was embedded in routine clinical workflows and delivered by 85 primary physical therapists across diverse hospital settings. This pragmatic design demonstrates real-world implementation and enhances generalizability, supporting clinical uptake. It provides a structured and feasible method to enact guideline recommendations for high-repetition gait training in inpatient rehab, where dose intensity often is insufficient. Lastly, the protocol replaces electrocardiogram-monitored stress testing (as used in the earlier DOSE trial) with a simple therapist-administered 6MWT, minimizing resource burden.4 Step targets were individualized and easily tracked using commercially available wearables, demonstrating the potential for scalability in low-resource settings.
Although the Canadian inpatient rehabilitation model allows for longer inpatient stays (often extending to four or more weeks), U.S. inpatient rehabilitation facilities (IRFs) typically discharge patients within one to three weeks post-stroke, often before day 30.12 Despite this compressed timeline, the Walk ’n Watch protocol aligns well with the structure and goals of U.S. IRFs. The protocol fits within 30- to 60-minute physical therapy blocks and can be incorporated into existing three-hour per day therapy schedules required by Medicare. In addition, its adaptable protocol can be compressed for delivery over two weeks in IRFs or extended into subacute rehabilitation (SAR)/skilled nursing facilities, outpatient, or home health settings to maintain continuity post-discharge. With demonstrated improvements in mobility and quality of life, and with minimal added cost, it is compatible with value-based payment models (e.g., bundled payments for care improvement [BPCI], a Medicare payment model, or accountable care organization [ACO]-based rehabilitation networks), which focus on interventions that are cost-effective, and improve quality of care and patient outcomes. Finally, the use of the 6MWT for progression and wearables for monitoring creates a model that can be carried out across care transitions. The Walk ’n Watch protocol offers a high-value, scalable approach that may drive functional gains across the post-stroke care continuum, addressing a critical need in stroke care delivery across settings in the United States.
Joan Stilling, MD, MSc, is Assistant Professor of Clinical Rehabilitation Medicine at Weill Cornell.
References
- Ada L, Dean CM, Morris ME, et al. Randomized trial of treadmill walking with body weight support to establish walking in subacute stroke: The MOBILISE trial. Stroke. 2010;41(6):1237-1242.
- Duncan PW, Sullivan KJ, Behrman AL, et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med. 2011;364(21):2026-2036.
- Nave AH, Rackoll T, Grittner U, et al. Physical fitness training in patients with subacute stroke (PHYS-STROKE): Multicentre, randomised controlled, endpoint blinded trial. BMJ. 2019;366:l5101.
- Klassen TD, Dukelow SP, Bayley MT, et al. Higher doses improve walking recovery during stroke inpatient rehabilitation. Stroke. 2020;51(9):2639-2648.
- Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98-e169.
- Bohannon RW, Crouch R. Minimal clinically important difference for change in 6-minute walk test distance of adults with pathology: A systematic review. J Eval Clin Pract. 2017;23(2):377-381.
- Fulk GD, He Y. Minimal clinically important difference of the 6-minute walk test in people with stroke. J Neurol Phys Ther. 2018;42(4):235-240.
- Bohannon RW, Glenney SS. Minimal clinically important difference for change in comfortable gait speed of adults with pathology: A systematic review. J Eval Clin Pract. 2014;20(4):295-300.
- Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54(5):743-749.
- Chen P, Lin KC, Liing RJ, et al. Validity, responsiveness, and minimal clinically important difference of EQ-5D-5L in stroke patients undergoing rehabilitation. Qual Life Res. 2016;25(6):1585-1596.
- Cheng LJ, Chen LA, Cheng JY, et al. Systematic review reveals that EQ-5D minimally important differences vary with treatment type and may decrease with increasing baseline score. J Clin Epidemiol. 2024;174:111487.
- Camicia M, Wang H, DiVita M, et al. Length of stay at inpatient rehabilitation facility and stroke patient outcomes. Rehabil Nurs. 2016;41(2):78-90.
An intensive real-life walking protocol, started as soon as possible after acute stroke, resulted in improved overall walking endurance, mobility, balance, and quality of life
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