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footplates and therefore there is no foot clearance
during the swing phase.
• The exoskeleton Lokomat (38, 45, 49) is a robotic-
driven orthosis consisting of actuators applying
motion to the hip and knee joints of the patient to
guide locomotion in a pre-programmed kinematic
trajectory based on characteristics of a healthy sym-
metrical gait pattern.
There is an exception to this division. Ochi et al. (46)
investigated a treadmill-based system including robotic
arms, which guide the thighs and legs to reproduce a
physiological gait pattern. As this system resembles
the characteristics of before-mentioned exoskeletons
(i.e. precise control of kinematics in the hip and knee
joints), it will be accounted as such in the analysis.
These training modalities are compared with a
control group, which is provided with conventional
physiotherapy. This includes pre-gait exercises aiming
at paretic leg strengthening and sitting balance. If pos-
sible, manual-assisted over-ground balance and gait
training was provided. However, the exact content of
the control intervention throughout the included studies
is poorly described.
Few studies provided detailed information on the
therapy dose. Ada et al. (36) documented that partici-
pants were able to walk 129 m during the first session
of BWSTT compared with only 26 m in the control
group. Tong et al. (39) documented that participants
performed 500–1,000 steps during a session using an
end-effector robot and during conventional therapy
50–100 steps only. Pohl et al. (35) found that partici-
pants walked with the same device 851 to 1,076 steps,
similar to the results of Morone et al. (43). In addition,
Peurala et al. (48) found that, with robot assistance,
participants were able to initially walk 20 min without
needing resting breaks, while none in the control group
were able to. A similar documentation on exoskeletons
is lacking, but authors declared that the exoskeleton
allowed patients to practice walking at much higher
doses compared with the control condition (45, 49).
Overall therapy dose, as measured by the total augmen-
ted time spent walking in the experimental group, is
found to vary between 300 and 960 min. Most studies
provided additional 400 min of walking practice in 20
sessions over 4 weeks, meaning that 5 training sessions
were provided weekly (see Table II).
Descriptive analysis of the feasibility
In total, 53 patients dropped out of the experimental
group, while 55 dropped out of the control group (see
Table III). The great majority of drop-outs were unre-
lated to the intervention (e.g. scheduling interference).
In a single study, adverse events were reported without
any difference between experimental and control group
(43). In addition, few studies reported minor events
caused by training, such as discomfort due to the
harness (47), hypotension (43), pain (36, 43) or pres-
sure sores (45), which led to a temporal discontinuity
of the intervention. However, no study documented a
significant difference between groups in the occurrence
of such events (see Table III).
Quantitative analysis of the effectiveness
The following outcome measures on the comparative
effectiveness of repetitive gait training were detected
and classified according to the ICF.
Table III. Extracted data from included studies on feasibility and effectiveness on gait-specific outcomes, as documented in the published
article
Experimental/Control group Activity a (i.e. walking ability) Body function a
ID Adverse events Drop-outs Walking
Independence post-
intervention Walking Independence Walking Walking
follow-up
Speed Endurance Motor
control
Peurala et al. (48) 2009
Tong et al. (39) 2006 0 5/3 × × × 0 0/4 □ □ □ 4/3 12/9 □ * □ * × × Chua et al. (40) 2016 0 7/13 Pohl et al. (35) 2007
Chang et al. (38) 2012 0
0 5/6
1/3 Han et al. (49) 2016 0 0/4 Schwartz et al. (45) 2009
Ng et al. (42) 2008
Morone et al. (43) 2011
Morone et al. (44) 2012
0 4/2
Ochi et al. (46) 2015
0
Franceschini et al. (47) 2009 0
Ada et al. (36) 2010
0 0/0
9/3
4/2
Dean et al. (37) 2010
Nilsson et al. (41) 2001 4/3
0
×
□
×
□
×
×
□
×
×
□ *
×
×
×
×
×
×
□
×
□
□
Muscle
strength
□
×
×
×
×
×
×
×
×
×
×
×
*Indicates the low motricity group, i.e. the group with more motor impairments at baseline. The studies Tong et al. 2006 and Ng et al 2008, Morone et al. 2011
and Morone et al. 2012, and Ada et al. 2010 and Dean et al. 2010 are dependent as they investigated the same dataset. a Results for gait-specific outcome are
reported as stated in the original article. These might differ from results of the meta-analysis due to differences in statistical methodology: (x), neutral or uncertain
effect; ( □ ), beneficial effect or likely to be beneficial.
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