Repetitive gait training early after stroke
rehabilitation and improved outcome (19, 20). This
emphasizes the need to develop a rehabilitative ap-
proach designed to take advantage of this time-window.
Such an approach should include high-dose training
initiated within the first weeks aiming at the recovery
of normal function (15). This is in great contrast with
how rehabilitation is provided in current practice (21,
22). Therefore, this review aims to detect therapeutic
strategies allowing such intensive therapy in the early
phase when patients usually have severe weakness
and are unable to walk. It is hypothesized that highly-
repetitive gait training has the potential to improve
long-term outcome when temporally matching the
critical time-window.
However, there are concerns that application of
rehabilitation too early might slow recovery (23, 24)
or even induce infarct-expansion (25). In addition,
clinicians might limit the patient’s effort to engage in
exercise, since this can lead to short-term increases in
spasticity (26) and an increased risk of falling (27). To
clarify these aspects, all trials on early repetitive gait
training will be collected to investigate feasibility as
well as effectiveness.
• Which strategies providing repetitive walking practi-
ce to non-ambulatory patients early post-stroke have
already been investigated in the scientific literature?
• Is early-initiated repetitive gait training feasible in
terms of safety and patients’ acceptance?
• Is repetitive gait training early after stroke more ef-
fective than conventional physiotherapy in terms of
gait recovery and do these effects persist?
METHODS
The current review was developed in adherence to the guideli-
nes of Preferred Reporting Items for Systematic Reviews and
Meta-analysis (PRISMA) (28).
Definitions
According to the World Health Organization (WHO), stroke is
defined as rapidly developing signs of disturbance of cerebral
functions lasting > 24 h (unless interrupted by surgery/death),
with no apparent non-vascular cause (29).
The focus here is on the early rehabilitation phase, defined
as the first 3 months post-stroke, i.e. the period during which
most gait recovery gains are observed (5, 16). Studies initiating
gait training within a mean of at most 31 days post-stroke were
included, to guarantee that the investigated population was
exposed to the intervention within this time-window.
Furthermore, participants included in this review were non-
ambulatory (Functional Ambulation Classification (FAC) ≤3, or
equivalent) (30) as we aim to report interventions which can be
provided to patients who are dependent in walking.
The intervention was considered repetitive gait training if
an “active motor sequence was performed repetitively within
a single training session, and the practice was aimed towards
a clear functional goal” (31). In this case, the motor sequence
79
was defined as whole, complex gait cycles and the functional
goal as independent walking. The training might be provided
with the assistance of therapists or with (electro-)mechanical
devices. Trials were excluded if training is combined with an-
other intervention (e.g. electrical stimulation) and the effects
could not be isolated.
A study was identified as a randomized controlled trial
(RCT) if the participants were assigned prospectively to 1 of
2 (or more) alternative forms of intervention using random al-
location. In included trials all groups spend an equal amount
of time on therapy.
Literature search
In October 2017, the following databases were searched for
trials published between January 2000 and October 2017: Pub-
Med, Web of Science, the Cochrane Library, PEDro and Rehab
Data. Indexing terms and free-text words of the following key
terms and synonyms were used: (Participants) “stroke” and “
(sub-)acute” or “inpatient”; (Intervention) “exercise therapy” or
“task-specific training”; (Outcome) “gait” or “walking”; (Study
design) “RCT”. A detailed search strategy used in PubMed can
be found in supplemental material (see Table SI 1 ). A search
revision was scheduled while finalizing the manuscript to avoid
missing recently published studies.
Search records were saved in EndNote X8. Duplicates were
identified and removed. Afterwards, different screening phases
based on abstracts and full-texts were conducted. Disagreement
between 2 reviewers (JS, WS) performing study selection
independently were discussed with a third reviewer (ST) to
reach consensus.
Studies were included when: (i) patients had been diagnosed
with stroke, (ii) the mean stroke interval (time between stroke
onset and randomization) was at most 31 days, (iii) patients
were non-ambulant (FAC ≤ 3), (iv) effects of repetitive gait
training were investigated and (v) compared with conventional
physiotherapy, (vi) the study used an RCT design, and (vii) the
article was written in English, German or Dutch.
Methodological quality
The Physiotherapy Evidence Database Scale (PEDro), an 11-
item scale, was used to assess methodological quality of inclu-
ded RCTs. All scores were obtained from the PEDro database.
The first item, eligibility criteria, does not account for the total
score and blinding of patients (item 5) and therapists (item 6) is
impossible due to the nature of the intervention. Therefore, the
maximum score is considered to be 8 and the following classifi-
cation is used: a study with a PEDro score of 7–8 is considered
good quality, while a score of 5–6 indicates moderate quality.
To guarantee high-quality reporting, trials with a high risk of
bias, i.e. a PEDro score of ≤ 4, were excluded.
Outcomes
The following data were extracted from selected studies: sample
size, stroke interval, baseline impairment, type of experimental
intervention and characteristics, between-group differences in
the occurrence of adverse events and drop-outs, and effects on
gait-specific outcomes. In case of missing data or inadequate
documentation, the corresponding author was contacted.
http://www.medicaljournals.se/jrm/content/?doi = 10.2340/16501977-2505
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J Rehabil Med 51, 2019