Science
Cochrane update: electromechanical gait training
Do electronic or robot-assisted gait training devices help people walk better after stroke?
Jakob Tiebel
Health Business Consultant
Rationale
Gait disorders are common after a stroke. In rehabilitation, electromechanical and robot-assisted gait training devices can help to improve walking ability. As the evidence base and the certainty of previous findings may have evolved since the last update in 2020, the researchers aimed to update the scientific data on the benefits and acceptance of these technologies in order to reassess their role in stroke rehabilitation.
Objectives of the review
Primary objective
The review investigated whether electromechanical and robot-assisted gait training improves walking ability in adults after stroke compared to physiotherapy (or standard care).
Secondary objectives
An investigation was also conducted to examine whether this therapeutic approach, when compared to physiotherapy (or standard care) after a stroke, influences walking speed, walking distance, treatment acceptance and overall mortality through to the end of the intervention phase.
The review investigated whether electromechanical and robot-assisted gait training improves walking ability in adults after stroke compared to physiotherapy (or standard care).
Secondary objectives
An investigation was also conducted to examine whether this therapeutic approach, when compared to physiotherapy (or standard care) after a stroke, influences walking speed, walking distance, treatment acceptance and overall mortality through to the end of the intervention phase.
Search methodology
The investigators searched various databases, including CENTRAL, MEDLINE and Embase, as well as seven other databases. In addition, relevant conference proceedings were searched, study and research registers were considered, reference lists were examined, and study authors were contacted to identify further published, unpublished and ongoing studies. The last search date was December 2023.
Inclusion criteria
All randomised controlled trials as well as randomised crossover studies in persons aged 18 years and over with a stroke of any severity and at any stage and care setting were included in the review. The use of electromechanical and robot-assisted gait training devices was compared with physiotherapy (or standard care).
Primary endpoints
The primary endpoint was the ability to walk independently, measured using the Functional Ambulation Category (FAC). An FAC score of 4 or 5 indicated that the affected individuals could walk independently over a distance of 15 metres – using medical aids such as walking sticks. An FAC score below 4 indicated dependence in walking (requiring supervision or assistance when walking).
Additional endpoints included walking speed, walking distance (6-minute walk test) and the number of study discontinuations.
Additional endpoints included walking speed, walking distance (6-minute walk test) and the number of study discontinuations.
People particularly benefit in the first three months after the stroke – but also afterwards.
Assessment of risk of bias
To assess the risk of bias, the researchers used the Cochrane Risk of Bias Tool version 1 (RoB 1). This tool was developed by the Cochrane Collaboration and is used to systematically assess the quality and trustworthiness of clinical studies. In doing so, it considers various potential sources of bias, such as randomisation, the blinding of participants and study personnel, as well as the handling of incomplete data. Each category is assessed separately to provide the clearest possible picture of how susceptible the examined studies are to bias.
Evaluation methodology
Two reviewers independently selected the studies for analysis, assessed their methodological quality and risk of bias, and extracted the relevant data.
The authors used random effects models for the meta-analysis. These models take into account that the included studies may differ in terms of their results and general conditions. This assumes that the true effects vary from study to study, allowing for a more realistic estimate of the overall effect when heterogeneity exists between studies.
The certainty in evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). This internationally recognised system evaluates the trustworthiness of the overall evidence based on several criteria such as study quality, inconsistency of results, indirect evidence, imprecision and pub-
lication bias. The result is a classification of the evidence into four levels: high, moderate, low or very low.
The authors used random effects models for the meta-analysis. These models take into account that the included studies may differ in terms of their results and general conditions. This assumes that the true effects vary from study to study, allowing for a more realistic estimate of the overall effect when heterogeneity exists between studies.
The certainty in evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). This internationally recognised system evaluates the trustworthiness of the overall evidence based on several criteria such as study quality, inconsistency of results, indirect evidence, imprecision and pub-
lication bias. The result is a classification of the evidence into four levels: high, moderate, low or very low.
Studies included
The updated review included a total of 101 studies (comprising 39 new studies and 62 from previous versions). In total, data from 4,224 people after stroke were analysed.
Results of the analysis
The results of the meta-analysis suggest that electromechanical-assisted gait training in combination with physiotherapy probably improves walking ability after stroke. Studies showed that patients receiving this therapy were more likely to regain independent walking ability than patients without this form of training (odds ratio 1.65).
The 95% confidence interval ranges from 1.21 to 2.25, which means that the true effect is highly likely to lie within this range. The p-value of 0.001 shows a statistically significant superiority of the intervention. The heterogeneity between studies was moderate (I² = 31%), indicating relatively good comparability across study results. In total, these results are based on 51 studies with a total of 2,148 participants. The evidence was classified as moderately certain according to GRADE, which means that further research is needed, but the results are overall very reliable.
With regard to walking speed, there was no clinically significant difference between the groups. Although a statistically significant difference was shown with a mean difference (MD) of 0.05 metres per second in favour of electromechanical-assisted gait therapy (95% confidence interval 0.02 to 0.08; p < 0.001; I² = 58%; 73 studies with a total of 3,043 participants), this increase in speed is rather small and is unlikely to represent a noticeable improvement in walking function in daily life for most patients. The evidence was assessed as moderately certain.
The distance walked in the 6-minute walk test also showed no relevant clinical difference. The mean additional distance covered was 11 metres (MD 11 metres; 95% confidence interval 1.8 to 20.3 metres; p = 0.02; I² = 43%; 42 studies with 1,966 participants). Although this difference was statistically significant, the actual gain here also remains at a level that will likely mean little or no noticeable improvement in practical daily life of those affected. The evidence for this was classified with high certainty.
Regarding therapy adherence and safety, it was shown that electromechanical-assisted gait therapy neither altered the likelihood of study discontinuation nor the risk of a fatal outcome compared to physiotherapy or standard care. For these endpoints, there was high certainty of evidence.
The 95% confidence interval ranges from 1.21 to 2.25, which means that the true effect is highly likely to lie within this range. The p-value of 0.001 shows a statistically significant superiority of the intervention. The heterogeneity between studies was moderate (I² = 31%), indicating relatively good comparability across study results. In total, these results are based on 51 studies with a total of 2,148 participants. The evidence was classified as moderately certain according to GRADE, which means that further research is needed, but the results are overall very reliable.
With regard to walking speed, there was no clinically significant difference between the groups. Although a statistically significant difference was shown with a mean difference (MD) of 0.05 metres per second in favour of electromechanical-assisted gait therapy (95% confidence interval 0.02 to 0.08; p < 0.001; I² = 58%; 73 studies with a total of 3,043 participants), this increase in speed is rather small and is unlikely to represent a noticeable improvement in walking function in daily life for most patients. The evidence was assessed as moderately certain.
The distance walked in the 6-minute walk test also showed no relevant clinical difference. The mean additional distance covered was 11 metres (MD 11 metres; 95% confidence interval 1.8 to 20.3 metres; p = 0.02; I² = 43%; 42 studies with 1,966 participants). Although this difference was statistically significant, the actual gain here also remains at a level that will likely mean little or no noticeable improvement in practical daily life of those affected. The evidence for this was classified with high certainty.
Regarding therapy adherence and safety, it was shown that electromechanical-assisted gait therapy neither altered the likelihood of study discontinuation nor the risk of a fatal outcome compared to physiotherapy or standard care. For these endpoints, there was high certainty of evidence.
Long-term effects following completion of the intervention
In the follow-up examinations after study completion, it was shown that electromechanical-assisted gait training in combination with physiotherapy possibly does not increase the chance of independent walking (OR 1.64; 95% CI 0.77 to 3.48; p = 0.20; I² = 69%; 8 studies; 569 participants; low certainty of evidence).
No significant differences were found for walking speed (MD 0.05 m/s; 95% CI −0.03 to 0.13; p = 0.22; I² = 66%; 17 studies; 857 participants; moderate certainty of evidence) and walking distance (MD 9.6 metres; 95% CI −14.6 to 33.7; p = 0.44; I² = 53%; 15 studies; 736 participants; moderate-certainty evidence).
The researchers point out that the results should be interpreted with caution. On the one hand, some studies also included people who were already able to walk independently at the start of the study. On the other hand, there were differences between the studies regarding the equipment used, the duration of treatment
and the frequency of therapy.
No significant differences were found for walking speed (MD 0.05 m/s; 95% CI −0.03 to 0.13; p = 0.22; I² = 66%; 17 studies; 857 participants; moderate certainty of evidence) and walking distance (MD 9.6 metres; 95% CI −14.6 to 33.7; p = 0.44; I² = 53%; 15 studies; 736 participants; moderate-certainty evidence).
The researchers point out that the results should be interpreted with caution. On the one hand, some studies also included people who were already able to walk independently at the start of the study. On the other hand, there were differences between the studies regarding the equipment used, the duration of treatment
and the frequency of therapy.
Further research is needed to determine how often and for how long these devices should be used.
Authors’ conclusions
The review concludes that electromechanical-assisted gait training in combination with phy-siotherapy following stroke may, with moderate certainty of evidence, help to restore independent walking ability. Based on the available data, it is estimated that approximately nine patients need to be treated in order to prevent sustained walking dependency in one patient (Number Needed to Treat = 9).
For future research, the authors recommend large-scale, practice-oriented Phase 3 studies to enable more targeted investigation of questions regarding optimal treatment frequency, therapy duration and the sustainability of the achieved effects. Furthermore, the timing of the intervention following the stroke should be given greater consideration in future studies.
For future research, the authors recommend large-scale, practice-oriented Phase 3 studies to enable more targeted investigation of questions regarding optimal treatment frequency, therapy duration and the sustainability of the achieved effects. Furthermore, the timing of the intervention following the stroke should be given greater consideration in future studies.
Ambulante Rehabilitation
Fachkreise
Gait
lyra
Science
Stationäre Rehabilitation
THERAPY
THERAPY 2025-II
THERAPY Magazine
Jakob Tiebel
Health Business Consultant
Jakob Tiebel is OT and studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of an agency for digital health marketing.
References:
- Mehrholz J, Kugler J, Pohl M, Elsner B. Electromechanical-assisted training for walking after stroke. Cochrane Database of Systematic Reviews 2025, Issue 5. Art. No.: CD006185. DOI: 10.1002/14651858.CD006185.pub6. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006185.pub6/full
You need to load content from reCAPTCHA to submit the form. Please note that doing so will share data with third-party providers.
More InformationYou are currently viewing a placeholder content from Turnstile. To access the actual content, click the button below. Please note that doing so will share data with third-party providers.
More Information