Improving walking is one of the main goals of rehabilitation after stroke. Electromechanical or robotic devices allow people with stroke with impaired walking to participate in intensive, high repetition, walking practice. This systematic review aimed to estimate the effects of electromechanical- or robot-assisted gait training and normal care compared to normal care alone on the ability to walk independently in people with stroke.
Guided by a protocol, sensitive searches were conducted in 11 databases (including Cochrane CENTRAL, Medline, Embase and PEDro) and two trial registers to identify randomised controlled trials in adults with stroke evaluating electromechanical- or robot-assisted gait training. Stroke could be clinically diagnosed and of any severity, stage or setting. Trials could evaluate any electromechanical or robotic device that enable repetitive walking practice. These are broadly classified into end-effector (where the participants feet are placed on footplates that are moved to simulate walking) or exoskeleton (where a frame is attached to the body segments which move the knees and hips to simulate walking). The Gait Trainer GT and Haptic Walker are examples of end-effector devices. The Lokomat is an example of an exoskeleton device. The comparison for all trials was electromechanical- or robotic-assisted training plus normal care versus normal care alone. Normal care involved over-ground gait training and exercise with a physiotherapist. The primary outcome was the proportion of participants walking independently. Walking independence could be assessed using the Functional Ambulation Category (score 4 or 5), Barthel Index ambulation item (score 3), Functional Independence Measure walking item (score 6 or 7) or Rivermead Mobility Index (‘walking inside, with an aid if necessary’ or ‘walking on uneven ground’ item score ‘yes’). We decided to report one secondary outcome, walking speed, in this summary because we think it is of interest to people with stroke and clinicians. Two reviewers independently selected trials for inclusion, extracted data and evaluated trial quality. Disagreements were resolved by discussion or arbitration from a third reviewer. Trial methodology was evaluated using the Cochrane risk of bias tool and certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was used to calculate the odds ratio and its 95% confidence interval (CI) for the ability to walk independently.
62 trials (2,440 participants) were included in the meta-analyses. Participants were aged 47 to 76 years, on average, and about 65% were men. Electromechanical- or robotic-assisted training commonly involved sessions of 30 to 60 minutes in duration on 3 to 5 days/week for 3 to 4 weeks. 24 trials recruited people 3 months or less and 16 recruited people > 3 months post stroke. 40 trials recruited only independent walkers, 18 recruited only dependent walkers, and 4 a mix of independent and dependent walkers. 41 trials used an exoskeleton device and 14 an end-effector device (7 trials could not be categorised as exoskeleton or end-effector).
Electromechanical- or robot-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking by 2.14 (95% CI 1.57 to 2.92; 38 trials; 1,567 participants; high-certainty evidence) and increased walking speed by a mean of 0.06 m/sec (95% CI 0.02 to 0.10; 42 trials; 1,600 participants; low certainty evidence) compared to physiotherapy alone at the end of the intervention phase.
Electromechanical- or robotic-assisted training in combination with physiotherapy increases the chance of regaining independent walking ability after stroke. If 100 people with stroke who could not walk independently received electromechanical- or robotic-assisted training and physiotherapy, about 62 would be able to walk independently at the end of the intervention period compared to 45 in the group receiving physiotherapy alone.
Mehrholz J, et al. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev 2020;Issue 10
