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J Rehabil Med 2019; 51: 78–88 REVIEW ARTICLE FEASIBILITY AND EFFECTIVENESS OF REPETITIVE GAIT TRAINING EARLY AFTER STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS Jonas SCHRÖDER, MSc 1,2 , Steven TRUIJEN, MSc, PhD 1,2 , Tamaya VAN CRIEKINGE, MSc 1,2 and Wim SAEYS, MSc, PhD 1–3 From the 1 Research group MOVANT (MOVement ANTwerp), Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Wilrijk, 2 Multidisciplinary Motor Centre Antwerp (M2OCEAN), University of Antwerp, and 3 Rehabilitation Hospital Revarte, Edegem, Belgium Background: Pre-clinical evidence suggests a period early after stroke during which the brain is most receptive to rehabilitation, if it is provided as high- dose motor training. Objective: To evaluate the feasibility of repetitive gait training within the first 3 months post-stroke and the effects on gait-specific outcomes. Methods: PubMed, Web of Science, Cochrane Libra- ry, Rehab Data and PEDro databases were searched systematically. Randomized controlled trials were included to descriptively analyse the feasibility and quantitatively investigate the effectiveness of re- petitive gait training compared with conventional therapy. Results: Fifteen randomized controlled trials were included. Repetitive training can safely be provided through body weight support and locomotor assis- tance from therapists or a robotic device. No dif- ference in drop-out rates was reported despite the demanding nature of the intervention. The meta- analysis yielded significant, but small, effects on walking independence and endurance. Training with end-effector robots appears most effective. Conclusion: Robots enable a substantial, yet fea- sible, increase in the quantity of walking practice early post-stroke, which might enhance functional recovery. However, the mechanisms underlying the- se effects remain poorly understood. Key words: humans; stroke; stroke rehabilitation; exercise therapy; robotics; walking; paresis. Accepted Oct 8, 2018; Epub ahead of print Dec 4, 2018 J Rehabil Med 2019; 51: 78–88 Correspondence address: Jonas Schröder, Research group MOVANT (MOVement ANTwerp), Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Wilrijk, Belgium. Email: jonas. [email protected] S troke is a leading cause of long-term disability worldwide and a dramatic increase in incidence is expected (1). The economic consequences are enormous (2), particularly regarding stroke survivors who remain dependent on continuous support (3). For social participation, regaining mobility is obligatory (4). However, more than 20% of stroke survivors do not reach independent walking (5, 6) and even if achieving independence, the great majority struggle to ambulate in the community (7). These persisting LAY ABSTRACT Animal models suggest that rehabilitation provided as repetitive motor training is most effective early after stroke. To investigate whether such a rehabilitation approach can enhance long-term walking recovery in human patients with stroke, this review gathered clini- cal studies on the effects of repetitive gait training. We found that robots, in particular, provide a substantial, yet feasible, increase in the amount of walking practice in those stroke patients who are unable to walk. This in- crease in rehabilitation dose improves walking ability in the long-term. However, these effects are inconsistent, rather small, and in contrast with neutral effects on mo- tor functions of the paretic leg. Therefore, the effects of repetitive training in the context of early stroke rehabi- litation remain poorly understood and further research is required. disabilities will aggravate physical inactivity, leading to deconditioning and poor long-term outcome (5, 8). If research fails to provide effective rehabilitation, the increasing incidence will inevitably lead to a growing dependent stroke population. Considering that no therapeutic approach, to date, has proven superior (9) and effect sizes in clinical research are, in general, low (10), it seems reasonable to reflect on basic research. Interesting pre-clinical evidence on timing of stroke rehabilitation has been published. In rodents, motor training loses effective- ness if provided delayed, i.e. 7 (11) and 30 days (12) post-stroke, respectively, compared with earlier expo- sure. This activity-induced recovery pattern matches the temporal pattern of increased gene expression important for neuronal growth and plasticity in the post-stroke brain (13, 14). Thus, it appears that a li- mited period of heightened plasticity is induced early after stroke, in which the brain is most receptive to rehabilitation (14). Since this period is time-dependent, it is best described as a critical time-window for stroke rehabilitation (15). In human stroke survivors, greatest gait recovery gains occur within the first 3 months post-stroke (5, 16) and rehabilitative interventions outside this period have rather modest effects (15, 17, 18). This time-dependent recovery profile corresponds highly to characteristics of a critical time-window, as mentioned above, which might be reflected in the association between earlier This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm doi: 10.2340/16501977-2505 Journal Compilation © 2019 Foundation of Rehabilitation Information. ISSN 1650-1977