Does robotic walking training work?

What is robotic or electromechanical gait training?

Robotic gait training uses devices that support body weight and guide or assist leg movements during walking. Examples include exoskeletons attached to the legs while walking on a treadmill, end-effector devices that move the feet on footplates, and wearable exoskeletons for overground walking.

These devices allow people who cannot walk, or who walk with difficulty, to practise many walking steps in a session with less physical effort from therapists.

Does it help people walk after a stroke?

A Cochrane review of 62 trials with 2,440 people after stroke found that electromechanical-assisted gait training combined with physiotherapy increased the odds of becoming independent in walking (odds ratio 2.01, high-quality evidence). The authors estimated that eight patients need to be treated to prevent one person from remaining dependent in walking 1.

Walking speed increased by an average of 0.06 metres per second, based on low-quality evidence, but walking capacity, measured by distance walked in six minutes, did not improve significantly 1.

Who benefits most after a stroke?

According to the review, people in the first three months after stroke and those who are unable to walk at the start of training seem to benefit most 1. Post hoc analysis suggested that people who can already walk may not benefit 1.

The role of the type of device remains unclear, and the ideal frequency and duration of training are still being studied 1.

What about spinal cord injury?

A Cochrane review of locomotor training for walking after spinal cord injury included five randomised trials with 309 people 2. It found no statistically significant advantage of any locomotor training approach over other forms of physical rehabilitation. In one study of 74 people, those receiving robotic-assisted training had lower walking capacity than those receiving other interventions 2.

The review concluded that the effects of robotic-assisted locomotor training in spinal cord injury are not clear and that larger trials are needed 2. For people with incomplete injuries, robotic devices may be one option within a broader walking programme.

Is robotic training better than therapist-led walking practice?

Robotic training is used together with physiotherapy rather than as a replacement. It can increase the amount of practice, particularly for people who need a lot of physical support. Therapist-led overground walking practice, balance training and strengthening remain essential for transferring skills to real-life walking.

Decisions about robotic training are based on the person's walking ability, time since injury, goals and access to devices.

What does a robotic gait training session involve?

A session usually starts with fitting a harness to support part of the body weight and adjusting the device to the person's leg length and body size. The therapist sets the speed, amount of body weight support and level of assistance.

As walking improves, support and assistance are reduced so that the person does more of the work. Sessions are usually combined with other therapy, such as balance, strengthening and overground walking practice.

How do I know if robotic training is right for me?

The rehabilitation team considers walking ability, time since stroke or injury, the ability to stand and bear weight, cardiovascular fitness, skin condition and personal goals. People who cannot yet walk independently are often the main group considered.

Access to devices varies between centres. If robotic training is not available, intensive therapist-led walking practice, treadmill training and other approaches are still effective ways to practise walking.

Are there any risks?

In the stroke review, electromechanical-assisted gait training did not increase the risk of dropping out or death 1. Possible issues include skin irritation or pressure from harnesses and straps, fatigue and, rarely, joint discomfort.

Devices require careful fitting and supervision by trained staff, and some people with severe spasticity, joint contractures or bone fragility may not be suitable.

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