Instrumental-assisted vs overground gait training: What is the best way to improve gait in neurological patients? A systematic review and meta-analysis

Abstract

Gait disorders represent one of the most disabling features for people affected by neurological disease and recovery of walking function is one of the main goals of gait rehabilitation. However, to date, there is a lack of agreement on which is the most beneficial type of gait training in neurological subjects. International guidelines offer conflicting recommendations on instrumental gait rehabilitation: some recommend the use of instrumental methods [1,2], some advice against them [3,4], while others recommend instrumentation only for research purposes or for non-ambulatory persons [5,6]. Our aim was to compare the outcomes of instrumental-assisted vs overground gait training in patients with neurological disorders. The research was performed through several databases (PubMed, Scopus, Embase, Central). Eligibility criteria were studies of adults with neurologic disorders performing instrumental vs overground gait training. Outcomes were measures of gait, balance and independence in daily activities. We included randomized controlled trials in which intervention protocols included gait training performed with treadmill or Lokomat, while control group was trained by overground walking for the same experimental group’s amount of time. Quality of the included trials was evaluated with the Cochrane Collaboration’s tool for assessing risk of bias. Of the 1059 records identified, only 25 studies were included in this systematic review. Studies included 1075 patients in total, of whom 530 were trained by instrumental-assisted walking training and 545 by overground walking. 747 subjects (69.4%) had sequaele of stroke; 174 (16.2%) multiple sclerosis; 104 (9.7%) Parkinson’s disease; 30 (2.8%) with spinal cord injury; 20 (1.9%) with traumatic brain injury. The overall weighted mean age was 60 (range, 31-74) yrs in the instrumental group and 61 (range, 32-73) yrs in the overground one. Results showed that instrumental and overground gait training similarly improved comfortable gait speed, walking distance, balance and independence in daily activities (Table 1). However, biases assessment showed high or unclear risk of bias in more than 50% of the studies. Due to the current quality of the literature, it was not possible to achieve firm conclusions about the most effective type of gait training. Indeed, the instrumental rehabilitation did not reveal more benefits compared to overground walking training in any of the analysed outcomes. Therefore, higher-quality RCTs with larger sample sizes in different populations are needed for stronger conclusions.