The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Clinical Practice Guidelines for Gait Training
Treadmill training and body-weight support (BWS) combined with physiotherapy versus treadmill training alone, level I (randomized controlled trial [RCT]): Grade C+ for gait speed at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait speed at follow-up, 4 months (no benefit demonstrated). Patients with post-acute and chronic stroke.
Treadmill training and BWS versus aggressive bracing-assisted walking, level I (RCT): Grade C+ for gait endurance and length of stay at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait speed at end of treatment, 2 weeks (no benefit demonstrated). Patients with subacute stroke.
Treadmill training versus standard customary exercises, level II (controlled clinical trial [CCT]): Grade B for mobility at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C+ for gait speed and stride length at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance). Patients with subacute stroke.
High-speed treadmill training versus lowspeed treadmill training, level I (RCT): Grade A for fastest comfortable gait speed at end of treatment, 4 weeks, and gait cadence at end of treatment, 2 weeks (clinically important benefit demonstrated); grade C+ for stride length at end of treatment, 2 and 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait speed, percent body weight support (%BWS) and upper extremity support at end of treatment, 2 and 4 weeks (no benefit demonstrated). Patients with chronic stroke.
Low-speed treadmill training versus standard gait training, level I (RCT): Grade C+ for fastest comfortable gait speed, gait cadence, and mobility at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for stride length at end of treatment, 2 and 4 weeks, and gait speed and gait cadence at end of treatment, 2 weeks (no benefit demonstrated). Patients with chronic stroke.
High-speed treadmill training versus standard gait training, level I (RCT): Grade A for fastest comfortable gait speed and stride length at end of treatment, 4 weeks, and gait cadence at end of treatment, 2 and 4 weeks (clinically important benefit demonstrated). Patients with chronic stroke.
Treadmill training combined with overground ambulation versus control, level I (RCT): Grade A for step length (affected side) at end of treatment, 4 weeks, and follow-up, 3 months (clinically important benefit demonstrated); grade C+ for gait speed at end of treatment, 4 weeks, and follow-up, 3 months, walking distance and step length (nonaffected side) at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for step width at end of treatment, 4 weeks, and follow-up, 3 months, quality of life and walking distance at follow-up, 3 months (no benefit demonstrated); grade D for gait cadence at end of treatment 4 weeks, and follow-up, 3 months, and quality of life at end of treatment, 4 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Electrogoniometric feedback training versus control, level I (RCT): Grade C+ for change in gait speed and maximum knee range of motion (ROM) (decrease of hyperextension) at end of treatment, 4 weeks, and follow-up, 4 weeks (clinically important benefit demonstrated without statistical significance). Patients with post-acute stroke.
Functional electrical stimulation (FES) of the ankle dorsiflexors versus control for gait training, level I (RCT): Grade C+ for functional status and level of walking independence at end of treatment, 4 weeks, and follow-up, 4 weeks (clinically important benefit demonstrated without statistical significance); grade D for motor function at end of treatment, 4 weeks, and follow-up, 4 weeks (no benefit demonstrated but favoring control). Patients with post-acute stroke.
FES of the ankle dorsiflexors versus control for gait training, level I (RCT): Grade A for stride length at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C+ for gait cadence and gait speed at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function at end of treatment, 3 weeks (no benefit demonstrated). Patients with chronic stroke.
FES of the ankle dorsiflexors and/or gastrocnemius versus control for gait training, level I (RCT): Grade A for physiological cost index (PCI) with FES (orthosis on) and decrease of spasticity (area beneath curve) at end of treatment, 12 weeks (clinically important benefit demonstrated); grade C+ for gait cycle time at end of treatment, 6 weeks, physiological cost index with FES (orthosis on) at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait speed with FES (orthosis on), physiological cost index without FES (orthosis off), and decrease of spasticity (relaxation index) at end of treatment, 4 and 12 weeks, decrease of spasticity (area beneath curve) at end of treatment, 4 weeks (no benefit demonstrated); grade D for stride length and ankle and knee angle at end of treatment, 6 weeks, gait speed without FES at end of treatment, 4 and 12 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Biofeedback (BFB) followed by FES versus control for gait training, level I (RCT): Grade A for gait cycle time at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C for stride length and knee angle at end of treatment, 6 weeks (no benefit demonstrated); grade D for ankle angle at end of treatment, 6 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Rhythmic auditory facilitation training versus control for gait training, level I (RCT): Grade A for gait speed and stride length at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C+ for gait symmetry at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait cadence at end of treatment, 6 weeks (no benefit demonstrated). Patients with post-acute stroke.
Step length biofeedback training versus control for gait training, level 1 (RCT): Grade C for step length at end of treatment, 4 weeks (no benefit demonstrated). Patients with post-acute stroke.
Musical motor feedback training versus control for gait training, level I (RCT): Grade C+ for gait speed, stride length, and gait symmetry at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait cadence and heel-on–toe-off distance at end of treatment, 3 weeks (no benefit demonstrated). Patients with post-acute stroke.
FES versus standard rehabilitation for gait training, level I (RCT): Grade A for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment, 2 and 3 weeks (clinically important benefit demonstrated); grade C+ for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment, 1 week, and follow-up, 5 weeks, and for spasticity at end of treatment, 1, 2, and 3 weeks, and follow-up, 5 weeks (clinically important benefit demonstrated without statistical significance); grade C for walking ability at follow-up, 5 weeks (no benefit demonstrated); grade D+ for walking ability at end of treatment, 1, 2, and 3 weeks (clinically important benefit favoring control without statistical significance). Patients with post-acute stroke.
FES versus placebo for gait training, level I (RCT): Grade A for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C+ for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment, 1 and 2 weeks, and follow-up, 5 weeks, and for spasticity at end of treatment, 1, 2, and 3 weeks, and follow-up, 5 weeks (clinically important benefit demonstrated without statistical significance); grade C for walking ability at follow-up, 5 weeks (no benefit demonstrated); grade D+ for walking ability at end of treatment, 1 week (clinically important benefit favoring control without statistical significance); grade D- for walking ability at end of treatment, 2 and 3 weeks (clinically important benefit favoring control). Patients with post-acute stroke.
Placebo FES versus control for gait training, level I (RCT): Grade A for walking ability at end of treatment, 3 weeks (clinically important benefit demonstrated);
grade C+ for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment, 1 and 2 weeks, and follow-up, 5 weeks, for spasticity at end of treatment, 2 and 3 weeks, and follow-up, 5 weeks, and for walking ability at end of treatment, 2 weeks, and follow-up, 5 weeks (clinically important benefit demonstrated without statistical significance); grade C for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment, 3 weeks, and for walking ability at end of treatment, 1 week (no benefit demonstrated); grade D+ for spasticity at end of treatment, 1 week (clinically important benefit favoring control without statistical significance). Patients with post-acute stroke.
Functional lower extremity training versus control, level I (RCT): Grade A for quality of life at end of treatment, 12 weeks, and follow-up, 6 and 18 weeks, functional status at follow-up, 6 weeks, quality of life at end of treatment, 12 weeks, comfortable gait speed and maximum gait speed at end of treatment, 12 and 20 weeks, and follow-up, 6 weeks (clinically important benefit demonstrated); grade C+ for comfortable gait speed and maximum gait speed at follow-up, 18 and 32 weeks, and quality of life at follow-up, 32 weeks (clinically important benefit demonstrated without statistical significance); grade C for mobility at end of treatment, 12 and 20 weeks, and follow-up, 26, 38, and 52 weeks, and functional status at follow-up, 32 weeks (no benefit demonstrated); grade D for functional status and quality of life at follow-up, 6, 18, and 32 weeks (no benefit demonstrated but favoring control). Patients with subacute stroke.
Treadmill training and BWS versus control, level I (RCT): Grade A for gait speed at end of treatment 2 to 3 weeks and follow-up, 3 months, balance at end of treatment, 6 weeks, gait distance at end of treatment, 2 to 3 weeks, motor recovery at end of treatment, 6 weeks, oxygen consumption at end of treatment, 2 to 3 weeks (clinically important benefit demonstrated); grade C+ for cardiovascular endurance at end of treatment, 2 to 3 weeks, gait endurance at end of treatment, 6 weeks, and follow-up, 3 months, and decrease in gait energy cost at end of treatment, 2 to 3 weeks, motor recovery at follow-up, 3 months (clinically important benefit demonstrated without statistical significance); grade C for mobility at end of treatment, 2, 3, and 10 weeks, and follow-up, 10 months, functional status and cognitive status at end of treatment, 10 weeks, and follow-up, 10 months, motor function at end of treatment, 10 weeks, and energy expenditure at end of treatment, 2 and 3 weeks (no benefit demonstrated); grade D for motor function at follow-up, 10 months (no benefit demonstrated but favoring control); grade D+ for functional independence measure (FIM) locomotion at end of treatment, 2 to 3 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with acute and post-acute stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100
