Journal of Rehabilitation Medicine 51-2 | Page 4

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 1 J Rehabil Med 51, 2019