Automated training devices for improving walking after stroke

Review question

Do machine- and robot-assisted walking training devices improve walking after stroke?

Background

Many people who have had a stroke have difficulties walking, and improving walking is one of the main goals of rehabilitation. Automated training devices assist walking practice.

Search date

The review is current to August 2016.

Study characteristics

We included 36 studies involving a total of 1472 participants over the age of 18 years with acute, postacute, or chronic ischaemic or haemorrhagic stroke. The mean age in the included studies ranged from 48 years to 76 years. The majority of studies were conducted in an inpatient setting.

Key results

We found moderate-quality evidence that electromechanical-assisted gait training combined with physiotherapy when compared with physiotherapy alone may improve recovery of independent walking in people after stroke.

We determined that for every seven patients treated with electromechanical- and robotic-assisted gait training devices, just one prevention of dependency in walking occurs.

Specifically, people in the first three months after stroke and those who are not able to walk appear to benefit most from this type of intervention. The importance of the type of device is still not clear. Further research should address what frequency or duration of walking training might be most effective and how long the benefit lasts. It also remains unclear how such devices should be used in routine rehabilitation.

Quality of the evidence

The quality of the evidence for automated electromechanical- and robotic-assisted gait-training devices for improving walking after stroke was moderate. The quality of evidence was low for walking speed, very low for walking capacity, and low for adverse events and people discontinuing treatment.

Authors' conclusions: 

People who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices. We concluded that seven patients need to be treated to prevent one dependency in walking. Specifically, people in the first three months after stroke and those who are not able to walk seem to benefit most from this type of intervention. The role of the type of device is still not clear. Further research should consist of large definitive pragmatic phase III trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training as well as how long any benefit may last.

Read the full abstract...
Background: 

Electromechanical- and robotic-assisted gait-training devices are used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane Review first published in 2007.

Objectives: 

To investigate the effects of automated electromechanical- and robotic-assisted gait-training devices for improving walking after stroke.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last searched 9 August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 8), MEDLINE in Ovid (1950 to 15 August 2016), Embase (1980 to 15 August 2016), CINAHL (1982 to 15 August 2016), AMED (1985 to 15 August 2016), Web of Science (1899 to 16 August 2016), SPORTDiscus (1949 to 15 September 2012), the Physiotherapy Evidence Database (PEDro) (searched 16 August 2016), and the engineering databases COMPENDEX (1972 to 16 November 2012) and Inspec (1969 to 26 August 2016). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted authors in an effort to identify further published, unpublished, and ongoing trials.

Selection criteria: 

We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robotic-assisted gait training versus normal care.

Data collection and analysis: 

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted the data. The primary outcome was the proportion of participants walking independently at follow-up.

Main results: 

We included 36 trials involving 1472 participants in this review update. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (random effects) 1.94, 95% confidence interval (CI) 1.39 to 2.71; P < 0.001; I² = 8%; moderate-quality evidence) but did not significantly increase walking velocity (mean difference (MD) 0.04 m/s, 95% CI 0.00 to 0.09; P = 0.08; I² = 65%; low-quality evidence) or walking capacity (MD 5.84 metres walked in 6 minutes, 95% CI -16.73 to 28.40; P = 0.61; I² = 53%; very low-quality evidence). The results must be interpreted with caution because 1) some trials investigated people who were independent in walking at the start of the study, 2) we found variations between the trials with respect to devices used and duration and frequency of treatment, and 3) some trials included devices with functional electrical stimulation. Our planned subgroup analysis suggested that people in the acute phase may benefit, but people in the chronic phase may not benefit from electromechanical-assisted gait training. Post hoc analysis showed that people who are non-ambulatory at intervention onset may benefit, but ambulatory people may not benefit from this type of training. Post hoc analysis showed no differences between the types of devices used in studies regarding ability to walk, but significant differences were found between devices in terms of walking velocity.

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