Electromechanical-assisted training for walking after stroke

Stroke is a sudden, non-convulsive loss of neurological function due to an ischaemic or hemorrhagic intracranial vascular event (cerebrovascular accident). It is considered the second-highest cause of death globally and a leading cause of disability. Sensorimotor impairments are common in people affected by stroke.  Approximately three months after a stroke, 20% of people remain wheelchair-bound, and up to 70% showed a lower gait velocity and capacity. In this scenario, rehabilitation aims to enhance the functional independence of activities of daily living. Particularly, gait training plays a main role in the recovery of walking ability and is highly relevant for people who are unable to walk independently (non-ambulatory). Moreover, modern concepts of rehabilitation favour higher intensity, repetitive, task-specific practice to achieve better outcomes. Robotic (programmed to move and perform certain tasks automatically) and electromechanical (electrically operated mechanical) devices have been developed as gait-training tools that facilitate rehabilitation and intensive walking practice without the therapist’s consistent support. For example, automated electromechanical gait orthosis (i.e., Lokomat, Exowalk) and robot-driven foot plate exoskeleton (Gait Trainer GT I) enable the repetitive practice of complex gait cycles (with and without partial body weight support).

This review investigated whether these large electromechanical devices are helpful and safe to improve walking compared to physiotherapy or usual care and is important for people with post-stroke walking difficulties, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.

This is an update of Cochrane Systematic Reviews (CSRs) published in 2007 and 2017. The outcomes analysed were walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase. The CSR included 62 trials published and/or registered up to 6 January 2020, with 2,440 adult participants. Results showed that electromechanical-assisted devices for gait training in combination with physiotherapy increased walking independence. Moreover, these devices may improve walking velocity and probably will not improve mean walking capacity. Greater benefits are reached by non-ambulatory people and, in general, by those for whom the intervention was applied early post-stroke.

These results must be interpreted with caution because some trials (i) included ambulatory patients, (ii) considered different device-use duration and frequency of treatment, and (iii) included devices with electrical stimulation. Electromechanical-assisted gait training did not increase the risk of dropout from the study during intervention or the risk of death (from all causes).

People after stroke who receive electromechanical-assisted gait training in combination with physiotherapy may improve walking function more than those who receive gait training without these devices.

Comment by Sunita Gudwani