Science

A comparison of the best end-effector gait trainers

There are various ways to relearn how to walk following a stroke using robotics devices. In everyday clinical practice, exoskeleton-supported (e.g. Lokomat) and end-effector-based gait trainers (e.g. THERA-Trainer lyra) are mainly used. Treadmills are used with and without weight relief in the later phase. But which therapy is the most effective for improving walking?

To answer this question, researchers conducted a systematic review of randomised controlled trials with network meta-analysis. Indirect comparisons and network meta-analyses represent a key evolution of traditional meta-analyses. The primary endpoint was walking speed, while the secondary endpoints were walking ability, gait endurance and gait stability. No gait training or conventional gait training served as the reference category. This was contrasted with treadmill training with or without bodyweight relief, treadmill training with and without a speed paradigm, and electromechanically-assisted gait training with end-effector and exoskeleton devices. The systematic search resulted in 40,567 hits. The evaluation included 95 randomised controlled trials with a total of 4,458 patients after a stroke. For the primary endpoint of walking speed, significant improvements were achieved through gait training with end-effector-assisted devices (MD = 0.16 m/s; 95% CI = 0.04–0.28). None of the other interventions improved walking speed significantly. For the secondary endpoint of gait endurance, end-effector-assisted gait training and treadmill training with bodyweight relief showed a significant improvement (MD = 47 m, CI: 4-90 and MD = 38 m, CI 4-72, respectively). No network meta-analysis was performed for the secondary endpoint of walking ability due to significant inconsistencies. No difference was identified between the safety of the individual interventions.

The researchers come to the conclusion that, compared to conventional gait rehabilitation, end-effector-assisted gait training in particular significantly and clinically improves gait speed and gait endurance following a stroke.

Compared to conventional gait rehabilitation, treadmill therapy with partial bodyweight relief achieves significant and clinically significant improvements in gait endurance compared to conventional therapy.

Comments

A highly interesting study with unexpected results! The title of the publication was later criticised as being misleading.

Walking speed had been chosen as the primary endpoint. The title is “The Improvement of Walking Ability Following Stroke”. Actually, the parameters of walking ability, walking speed, walking distance and steadiness have to be differentiated. Whether this was an oversight remains unclear.

But it changes nothing about the quality and significance of the results. The end effector also remains the method of choice for regaining walking ability, as demonstrated by current meta-analyses and guidelines.

Literature:
Mehrholz J, Pohl M, Kugler J, Elsner B. (2018). The Improvement of Walking Ability Following Stroke. Deutsches Ärzteblatt International, 28 September 2018; 115(39):639-645. doi: 10.3238/arztebl.2018.0639. PubMed PMID: 30375325; PubMed Central PMCID: PMC6224539.

Jakob Tiebel
studied Applied Psychology with a focus on Healthcare Managementand has gained clinical expertise through previous therapeutic work in neurorehabilitation. He researches and publishes on theory-practice transfer in neurorehabilitation and is the owner of Native.Health, a digital health marketing agency.