Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS). Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients: a randomized crossover study. The effectiveness of locomotor therapy using robotic-assisted gait training in subacute stroke patients: a randomized controlled trial. Effectiveness of gait training using an electromechanical gait trainer, with and without functional electric stimulation, in subacute stroke: a randomized controlled trial. Electromyographic feedback in the remobilization of stroke patients: a controlled trial. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. Biofeedback and functional electric stimulation in stroke rehabilitation. Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground. Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: a randomized controlled pilot study. Rehabilitation of walking with electromyographic biofeedback in foot-drop after stroke. Comparison of partial body weight-supported treadmill gait training versus aggressive bracing assisted walking post stroke.
To evaluate the effect of repetitive locomotor training on an electromechanical gait trainer plus physiotherapy in subacute stroke patients.
                Randomized controlled trial.
                Four German neurological rehabilitation centres.
                One hundred and fifty-five non-ambulatory patients (first-time stroke <60 days).
                Group A received 20 min locomotor training and 25 min physiotherapy; group B had 45 min physiotherapy every week day for four weeks.
                Primary variables were gait ability (Functional Ambulation Category, 0-5) and the Barthel Index (0-100), blindly assessed at study onset, end, and six months later for follow-up. Responders to the therapy had to become ambulatory (Functional Ambulation Category 4 or 5) or reach a Barthel Index of > or = 75. Secondary variables were walking velocity, endurance, mobility and leg power.
                The intention-to-treat analysis revealed that significantly greater number of patients in group A could walk independently: 41 of 77 versus 17 of 78 in group B (P B < 0.0001) at treatment end. Also, significantly more group A patients had reached a Barthel Index > or = 75: 44 of 77 versus 21 of 78 (P B < 0.0001). At six-month follow-up, the superior gait ability in group A persisted (54 of 77 versus 28 of 78, P B < 0.0001), while the Barthel Index responder rate did not differ. For all secondary variables, group A patients had improved significantly more (P B < 0.0001) during the treatment period, but not during follow-up.
                Intensive locomotor training plus physiotherapy resulted in a significantly better gait ability and daily living competence in subacute stroke patients compared with physiotherapy alone. The purpose of this study was to compare treadmill and electromechanical gait trainer therapy in subacute, nonambulatory stroke survivors. The gait trainer was designed to provide nonambulatory subjects the repetitive practice of a gait-like movement without overexerting therapists.
                This was a randomized, controlled study with a crossover design following an A-B-A versus a B-A-B pattern. A consisted of 2 weeks of gait trainer therapy, and B consisted of 2 weeks of treadmill therapy. Thirty nonambulatory hemiparetic patients, 4 to 12 weeks after stroke, were randomly assigned to 1 of the 2 groups receiving locomotor therapy every workday for 15 to 20 minutes for 6 weeks. Weekly gait ability (functional ambulation category [FAC]), gait velocity, and the required physical assistance during both kinds of locomotor therapy were the primary outcome measures, and other motor functions (Rivermead motor assessment score) and ankle spasticity (modified Ashworth score) were the secondary outcome measures. Follow-up occurred 6 months later.
                The groups did not differ at study onset with respect to the clinical characteristics and effector variables. During treatment, the FAC, gait velocity, and Rivermead scores improved in both groups, and ankle spasticity did not change. Median FAC level was 4 (3 to 4) in group A compared with 3 (2 to 3) in group B at the end of treatment (P=0.018), but the difference at 6-month follow up was not significant. The therapeutic effort was less on the gait trainer, with 1 instead of 2 therapists assisting the patient at study onset. All but seven patients preferred the gait trainer.
                The newly developed gait trainer was at least as effective as treadmill therapy with partial body weight support while requiring less input from the therapist. Further studies are warranted. To evaluate the effectiveness of early and prolonged locomotor treatment with the use of a robotic-assisted gait training (RAGT) device (Lokomat; Hocoma Inc., Zurich, Switzerland) on the functional outcomes of patients after subacute stroke.
                A nonblinded prospective, randomized, controlled study.
                Rehabilitation department in tertiary university medical center.
                Sixty-seven patients in the first 3 months after subacute stroke were randomized into 2 groups as follows. Thirty-seven patients were treated with RAGT, and 30 were treated with regular physiotherapy. Inclusion criteria were first stroke, independent ambulation before the stroke, and neurological severity between 6 and 20 according to the National Institutes of Health Stroke Scale (NIHSS).
                RAGT treatment was administered 3 times a week for 30 minutes, combined with regular physiotherapy for 6 weeks. Control patients received the equivalent additional time of regular physiotherapy.
                The primary outcome was the ability to walk independently, as assessed by use of the functional ambulatory capacity scale. The secondary outcomes included the neurological status according to the NIHSS; functional motor assessment (determined by use of the stroke activity scale); and gait parameters, including gait velocity, endurance, and number of climbed stairs.
                In the intention-to-treat analysis, subjects in the RAGT group exhibited greater gains than the control group in their ability to walk independently, as expressed by a greater functional ambulatory capacity score (P < .01), and in their neurological status according to NIHSS (P < .01). Among those who achieved independent walking, nonsignificant differences between groups were noted according to secondary outcome measures of gait parameters except from step climbing.
                This controlled study showed, at the end of a 6-week trial, that locomotor therapy with the use of RAGT combined with regular physiotherapy produced promising effects on functional and motor outcomes in patients after subacute stroke as compared with regular physiotherapy alone. To compare the therapeutic effects of conventional gait training (CGT), gait training using an electromechanical gait trainer (EGT), and gait training using an electromechanical gait trainer with functional electric stimulation (EGT-FES) in people with subacute stroke.
                Nonblinded randomized controlled trial.
                Rehabilitation hospital for adults.
                Fifty patients were recruited within 6 weeks after stroke onset; 46 of these completed the 4-week training period.
                Participants were randomly assigned to 1 of 3 gait intervention groups: CGT, EGT, or EGT-FES. The experimental intervention was a 20-minute session per day, 5 days a week (weekdays) for 4 weeks. In addition, all participants received their 40-minute sessions of regular physical therapy every weekday as part of their treatment by the hospital.
                Five-meter walking speed test, Elderly Mobility Scale (EMS), Berg Balance Scale, Functional Ambulatory Category (FAC), Motricity Index leg subscale, FIM instrument score, and Barthel Index.
                The EGT and EGT-FES groups had statistically significantly more improvement than the CGT group in the 5-m walking speed test (CGT vs EGT, P=.011; CGT vs EGT-FES, P=.001), Motricity Index (CGT vs EGT-FES, P=.011), EMS (CGT vs EGT, P=.006; CGT vs EGT-FES, P=.009), and FAC (CGT vs EGT, P=.005; CGT vs EGT-FES, P=.002) after the 4 weeks of training. No statistically significant differences were found between the EGT and EGT-FES groups in all outcome measures.
                In this sample with subacute stroke, participants who trained on the electromechanical gait trainer with body-weight support, with or without FES, had a faster gait, better mobility, and improvement in functional ambulation than participants who underwent conventional gait training. Future studies with assessor blinding and larger sample sizes are warranted. Electromyographic biofeedback was compared with simple exercise therapy as to its effectiveness in improving foot-drop in 22 stroke patients. The study was designed to be a rigorous trial of biofeedback and the patients tested were aged and had stroke of long duration. One group of 11 patients underwent 6 weeks of exercise therapy 2 sessions per week for 15 minutes per session; the 2nd group of 11 patients underwent similar therapy with EMG feedback. All therapy was conducted by a research assistant who was not a trained therapist. The groups were assessed blind before treatment, after treatment and a 6-week follow-up. The significantly greater improvements in the biofeedback group in terms of muscle strength at the end of treatment were maintained at follow-up. On the range of movement and gait analysis measures, both groups showed some improvement after treatment. However, at follow-up this improvement had relapsed for the exercise group while for the biofeedback group it had been maintained. It is argued that controlled trials are possible in biofeedback and that using patients as their own controls is not justified in view of the present findings and the previously reported literature. Experimental and control groups of 10 hemiparetic stroke patients each underwent a 6 week, twice daily gait training program. The control group participated in a conventional physical therapy gait program. The experimental group trained in the same basic program with the addition of rhythmic auditory stimulation (RAS). Patients entered the study as soon as they could complete 5 strides with hand-held assistance. The training program had to be completed within 3 months of the patients' stroke. In the experimental group RAS was used as a timekeeper to synchronize step patterns and gradually entrain higher stride frequencies. Study groups were equated by gender, lesion site, and age. Motor function was assessed at pretest using Barthel, Fugl-Meyer, and Berg Scales. Walking patterns were assessed during pre- and post-test without RAS present. Pre- vs post-test measures revealed a statistically significant (P<0.05) increase in velocity (164% vs 107%), stride length (88% vs 34%), and reduction in EMG amplitude variability of the gastrocnemius muscle (69% vs 33%) for the RAS-training group compared to the control group. The difference in stride symmetry improvement (32% in the RAS-group vs 16% in the control group) was statistically not significant. The data offer evidence that RAS is an efficient tool to enhance efforts in gait rehabilitation with acute stroke patients. The study examined the efficacy of functional electric stimulation (FES) and biofeedback (BFB) treatment of gait dysfunction in patients with hemiplegia after stroke. These two therapeutic modalities were tested alone and in combination in a prospective, controlled, randomized trial. The authors hypothesized that in concurrent use, these two modalities would complement one another. Thirty-six hemiplegic patients undergoing rehabilitation after stroke were accepted for study and randomized into four groups to receive either control, FES, BFB, or combined therapies. Each patient received 30 minutes of treatment three times per week for six weeks, in addition to their general rehabilitation program. Quantitative gait analysis was performed biweekly on each subject during the experimental therapy and for four weeks afterward. Thirty-two subjects completed the study. Combined therapy with BFB and FES resulted in improvements in both knee and ankle minimum flexion angles during swing phase that were statistically significant with p = 0.05 and p = 0.02, respectively. Velocity of gait, cycle time, and symmetry of stance phases also improved. The length of time elapsed since the stroke did not prove to be a significant factor. To compare the effect of walking training on a treadmill with body weight support (BWS) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke.
                Randomized controlled experimental study.
                Multicentre design; three departments of rehabilitation medicine.
                Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were randomized into a treatment group and a control group.
                The treatment group received walking training on a treadmill with BWS for 30 minutes, 5 days a week. The control group received walking training according to the Motor Relearning Programme (MRP) on the ground for 30 minutes 5 days a week, not including treadmill training. During the time in the rehabilitation department (about two months), all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups.
                Functional Independence Measure (FIM), walking velocity for 10 m, Functional Ambulation Classification (FAC), Fugl-Meyer Stroke Assessment and Berg's Balance Scale. The assessments were performed at admission, at discharge and at 10-month follow-up.
                There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM, walking velocity, FAC, Fugl-Meyer Stroke Assessment, and Berg's Balance Scale. Patients in both groups improved in these variables from admission to the 10-month follow-up.
                Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground. To investigate gait outcomes with supported treadmill ambulation training (STAT) associated with regular rehabilitation in acute stroke survivors.
                Randomized controlled trial, pilot study.
                Rehabilitation medicine service at a Veterans Affairs medical center.
                Seven acute stroke survivors assigned to regular intervention group and 6 patients assigned to STAT intervention.
                Regular intervention consisted of 3 hours daily of physical therapy, kinesiotherapy, and occupational therapy. STAT group received regular rehabilitation with STAT substituted for usual gait training. Participants were tested at baseline, treated for an average of 3 weeks, and retested on discharge. The analysis of covariance procedure was used to test for differences between the 2 approaches.
                Functional Ambulation Category Scale, gait speed, walking distance, gait energy expenditure, and gait energy cost.
                The small sample size did not generate enough power to detect significant differences in any variable. However, medium to large effect sizes of 0.7 and 1.16 standard deviation units were observed for gait energy cost and walk distance, respectively.
                This pilot study indicated that STAT is a safe, feasible, and promising intervention for acute stroke survivors. A larger trial is warranted for statistical relevance. Alterations of gait cycle and foot-drop on the paretic limb are characteristic of stroke patients. Electromyographic biofeedback treatment has been used in rehabilitation of walking, but results are controversial. We performed gait analysis to evaluate the efficacy of electromyographic biofeedback compared with physical therapy.
                Sixteen patients with ischemic stroke were enrolled in the study. The experimental group (4 men, 4 women) received electromyographic biofeedback treatment together with physical therapy. The control group (5 men, 3 women) was treated with physical therapy only. Clinical and functional evaluations before and after treatment were performed using Canadian Neurological, Adams, Ashworth, Basmajian, and Barthel Index scales. Computerized gait analysis was performed in all patients.
                Electromyographic biofeedback patients showed significantly increased scores on the Adams scale (P < .05) and Basmajian scale (P < .01). Gait analysis in this group showed a recovery of foot-drop in the swing phase (P < .02) after training.
                Our data confirm that the electromyographic biofeedback technique increases muscle strength and improves recovery of functional locomotion in patients with hemiparesis and foot-drop after cerebral ischemia. To test the hypothesis that partial body weight-supported treadmill training (PBWSTT) provides more effective gait training than an equally supportive but less physiologic aggressive bracing assisted walking (ABAW) program.
                Following informed consent, patients participating in an inpatient rehabilitation program with significant leg weakness and need for at least moderate assistance for walking, without orthostatic hypotension, symptomatic dyspnea, or angina pectoris were randomized to receive PBWSTT vs. ABAW. PBWSTT was provided by a commercially available, overhead motorized hoist attached to a parachute-type body harness, which provided partial support of the patient's weight over a treadmill. Therapists assisted with weight shifting, leg advancement, and foot placement as needed. ABAW included aggressive early therapist-assisted ambulation using knee-ankle combination bracing and hemi-bar if needed. Treatment sessions of up to 45 minutes per day, five days per week were given as tolerated for the duration of the inpatient stay or until patients could walk over-ground unassisted. All patients had an additional 45-minute session of functionally oriented physical therapy each day with or without bracing as judged appropriate by the patient's individual therapist.
                Fifty-six patients a mean age of 71 +/- 1 SEM were enrolled 40 +/- 3 days post stroke. Although the outcome of the two groups as a whole did not differ, a subgroup with major hemispheric stroke defined by the presence of hemiparesis, hemianopic visual deficit, and hemihypesthesia who received more than 12 treatment sessions showed significantly better over-ground endurance (90 +/- 34 vs. 44 +/- 10 meters) and speed scores (12 +/- 4 vs. 8 +/- 2 meters/minute) for PBWSTT vs. ABAW, respectively.
                PBWSTT and ABAW are equally effective gait training techniques except for a subset of patients with major hemispheric stroke who are difficult to mobilize using ABAW alone.
Patients who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than patients receiving gait training without these devices. However, further research should address specific questions, for example what frequency or duration of electromechanical-assisted gait training might be most effective and at what time after stroke. Follow-up studies are also needed to find out how long the benefit lasts.