Key messages
• Electronic and robotic devices plus physiotherapy probably help people walk independently again after a stroke. They may particularly benefit people in the first three months after a stroke.
• We need more research to find out how often, and for how long, these devices should be used.
What is a stroke?
A stroke happens when the flow of blood to part of the brain is cut off, blocking the supply of oxygen and nutrients to brain cells. This causes a sudden attack of weakness that usually affects one side of the body. If the supply of blood to the brain is stopped, brain cells begin to die. This can lead to brain injury, disability, and even death.
People who survive a stroke are often left with long-term problems caused by the injury to their brain. They may find physical activities, such as walking, difficult because of weakened leg muscles on one or both sides of their body, stiff joints, or lack of co-ordination. People may need a long period of rehabilitation, including physiotherapy, before they can recover their former independence. Physiotherapy includes exercise, massage, skills training, and electrical treatment to help people regain movement.
Walking after a stroke
One of the most important goals after a stroke is to help people walk again. Robotic devices (programmed to move and perform certain tasks automatically) and electrically powered mechanical (electromechanical) devices have been developed to help people practise walking. People who have trouble walking after a stroke need a lot of practice to get better. It is unclear if these walking machines are effective.
What did we want to find out?
We wanted to find out if gait-training devices combined with physiotherapy can help people improve their walking after a stroke compared to not using such devices.
What did we do?
We searched for studies that looked at the use of gait-training devices to help people learn to walk again after a stroke. We were interested in:
• how many people could walk independently;
• how fast people could walk;
• how far they could walk in 6 minutes;
• how many people dropped out of the study; and
• how many people died.
We looked for studies in which people were assigned to treatment groups at random. This type of study usually gives the most reliable evidence about the effects of a treatment.
What did we find?
We found 101 studies involving 4224 adults (average age 47 to 76 years) who had had a stroke and were learning to walk again. The studies compared the effects of physiotherapy plus electromechanical and robotic devices for gait training with the effects of physiotherapy alone or usual care. In most studies, the training period lasted three to four weeks; the shortest time was 10 days, and the longest was eight weeks.
At the end of training, compared with physiotherapy or usual care, using a gait‑training device plus physiotherapy:
• probably helps more people walk independently (51 studies; 2148 people);
• probably does not increase people's average walking velocity (73 studies; 3043 people);
• does not increase the distance people could walk in 6 minutes (42 studies; 1966 people); and
• does not increase or decrease how many people dropped out of the study, or how many people died (deaths were rare) (101 studies; 4224 people).
For every nine people treated with a device plus physiotherapy, probably one extra person walks independently by the end of treatment.
At follow-up, using a gait‑training device plus physiotherapy may not help more people walk independently, and probably does not increase people's average walking velocity or the distance people could walk in 6 minutes, compared with physiotherapy or usual care.
What are the limitations of the evidence?
We have low to high confidence in our results. Many studies were of low or poor quality with small sample sizes. Therefore, some studies may have made the benefits of these devices seem greater than they are.
How up-to-date is this evidence?
The evidence is current to December 2023.
Moderate-certainty evidence shows that people who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are probably more likely to achieve independent walking than people who receive gait training without these devices. We concluded that nine patients need to be treated to prevent one dependency in walking.
Further research should consist of large, definitive pragmatic phase 3 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. Future trials should consider time poststroke in their trial design.
Electromechanical- and robot-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 and previously updated in 2017.
Primary
• To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) improves walking in adults after stroke.
Secondary
• To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase.
We searched CENTRAL, MEDLINE, Embase, and seven other databases. We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors to identify further published, unpublished, and ongoing trials. The date of the latest search was December 2023.
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 robot-assisted gait training versus normal care.
Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We assessed the quality of evidence using the GRADE approach. The primary outcome was the proportion of participants walking independently at follow-up.
We included in this review update 62 trials involving 2440 participants. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (random effects) 2.01, 95% confidence interval (CI) 1.51 to 2.69; 38 studies, 1567 participants; P < 0.00001; I² = 0%; high-quality evidence) and increased mean walking velocity (mean difference (MD) 0.06 m/s, 95% CI 0.02 to 0.10; 42 studies, 1600 participants; P = 0.004; I² = 60%; low-quality evidence) but did not improve mean walking capacity (MD 10.9 metres walked in 6 minutes, 95% CI -5.7 to 27.4; 24 studies, 983 participants; P = 0.2; I² = 42%; moderate-quality evidence). Electromechanical-assisted gait training did not increase the risk of loss to the study during intervention nor the risk of death from all causes. 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 variation between trials with respect to devices used and duration and frequency of treatment, and (3) some trials included devices with functional electrical stimulation. Post hoc analysis showed that people who are non-ambulatory at the start of the intervention 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 revealed differences between devices in terms of walking velocity and capacity.
This Cochrane review had no dedicated funding.
Protocol (2006): doi:10.1002/14651858.CD006185
Original review (2007): doi:10.1002/14651858.CD006185.pub2
Review update (2013): doi:10.1002/14651858.CD006185.pub3
Review update (2017): doi:10.1002/14651858.CD006185.pub4
Review update (2020): doi:10.1002/14651858.CD006185.pub5