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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non-ambulatory patients early after stroke: a systematic review

L Ada, CM Dean, J Vargas, and S Ennis.

Review published: 2010.

Link to full article: [Journal publisher]

CRD summary

This generally well-conducted review concluded that mechanically assisted walking with body weight support appeared more effective than overground walking in increasing independent walking in patients who could not walk within one month after stroke. Given the differences between included trials and paucity of data (particularly for longer term outcomes), the authors' conclusions should be interpreted with some caution.

Authors' objectives

To determine whether mechanically assisted walking with body weight support results in more independent walking in comparison with assisted overground walking, in non-ambulatory patients early after stroke.

Searching

MEDLINE, CINAHL, EMBASE and PEDro were searched up to August 2009 for studies in any language. Search terms were reported. Authors of ongoing trials were contacted and reference lists of retrieved studies were screened for further references.

Study selection

Randomised controlled trials (RCTs) or quasi-RCTs that compared mechanically assisted walking with body weight support to assisted overground walking (over a period longer than 15 minutes) were eligible for inclusion in the review. Trials had to report on independent walking, Eligible participants were adults (over 18 years old) who had a stroke (>24 hours) or were subacute (stroke less than three months prior to the trial) and were undergoing inpatient stroke rehabilitation. Participants also had to be non-ambulatory as measured by the Functional Ambulatory Category (FAC<3), the Motor Arm Scale (MAS<3) or the Functional Independence Measure (FIM<5); if populations included mixed ambulatory and non-ambulatory patients, trials had to report separate data for non-ambulatory patients. Further information specifying types of eligible interventions and outcomes (primary and secondary) were reported in the review.

Included trials compared mechanically assisted walking (using treadmill with a harness, or robotic device and harness, or electro-mechanical gait trainer with harness). In most trials, the intervention group also received some degree of overground assisted walking. The control group in all of the trials received overground walking assisted by therapists. Training lasted from 20 to 80 minutes per day, from three to five days per week for four to six weeks, or until discharge from inpatient rehabilitation.

The mean age of included patients ranged from 57 to 73 years; the average time post-stroke was up to one month. All but one of the trials defined non-ambulatory as FAC<3; the remaining trial defined non-ambulatory as MAS<2. Details of the included outcome measures were also reported in the review.

Two reviewers independently assessed the studies for inclusion; discrepancies were resolved by consensus after discussion with a third reviewer.

Assessment of study quality

Two reviewers independently assessed the methodological quality of each included trial using the PEDro scale. Criteria assessed included: random allocation; concealment of allocation; similarity of groups at baseline; participant, assessor and therapist blinding; over 15% drop-out; intention-to-treat analysis; between group difference reported; and point estimate with variability reported. Each trial was awarded a score between zero and 10. Trials had to score over 4 points to be included in the review. Discrepancies were resolved by a third reviewer.

Data extraction

Four-week and six-month data were extracted by one reviewer and checked by a second reviewer. Dichotomous data were extracted and used to calculate risk differences (RD) for number of independent patients walking with 95% confidence intervals (CIs); means with standard deviations (SDs) were reported for continuous outcomes (walking speed and walking capacity in patients able to walk independently). Trial authors were contacted where necessary for further clarification.

Methods of synthesis

Trials were grouped by outcome and time point. Pooled risk differences and mean differences (MDs), with 95% confidence intervals, were calculated using a fixed-effect model. Statistical heterogeneity was assessed using I2. Where there was evidence of significant heterogeneity (I2 over 25%), data were pooled using a random-effects model.

Results of the review

Six RCTs (n=549 patients; range 35 to 155) were included in the review. The mean PEDro score was 6.7 (range 5 to 8).

Mechanically assisted walking with body weight support significantly increased in the number of patients who achieved independent walking at four weeks (RD 0.23, 95% CI 0.15 to 0.30; fixed-effect model; six RCTs) and at six months (RD 0.23, 95% CI 0.07 to 0.39; random-effects model; three RCTs) compared with overground walking.

Patients with mechanically assisted walking also had a significantly increased walking speed at six months (MD 0.12m/s, 95% CI 0.02 to 0.21; five RCTs) and walked further at six months (MD 55m, 95% CI 15 to 96; two RCTs).

Authors' conclusions

Mechanically assisted walking with body weight support appeared to be more effective than overground walking in increasing independent walking in non-ambulatory patients within the first month of a stroke. This was without detriment to walking speed and capacity at four weeks up to six months.

CRD commentary

The review answered a clearly defined research question. Attempts were made to reduce language and publication bias by searching for published and unpublished ongoing studies in any language. The authors also sought to reduce reviewer error and bias at each stage of the review process.

The quality of the included trials was assessed using appropriate criteria; the trials were reported to be of moderate to good quality. There was some evidence of both statistical and clinical heterogeneity, which was acknowledged as a potential limitation of the review. The trials appeared to have some limitations in their methodology and provided little long term data.

Overall, this was a generally well-conducted review, but the differences between trials and paucity of data (particularly for longer term outcomes) suggest that the conclusions should be interpreted with some degree of caution.

Implications of the review for practice and research

Practice: The authors stated that this review agreed with previous reviews in suggesting that it is worthwhile to use some form of mechanical assistance to improve walking after stroke.

Research: The authors did not state any implications for research.

Funding

Not stated.

Bibliographic details

Ada L, Dean CM, Vargas J, Ennis S. Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non-ambulatory patients early after stroke: a systematic review. Journal of Physiotherapy 2010; 56(3): 153-161. [PubMed: 20795921]

Indexing Status

Subject indexing assigned by NLM

MeSH

Body Weight /physiology; Exercise Test; Humans; Outcome Assessment (Health Care); Physical Therapy Modalities /instrumentation; Robotics; Stroke /physiopathology /therapy; Walking /physiology; Weight-Bearing /physiology

AccessionNumber

12010007227

Database entry date

14/09/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 20795921

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