Overground gait training v Robotic gait training to improve walking in people with SCI and motor function in the lower limbs | SCI Physiotherapy Clinical Practice Guidelines

	Overground gait training v Robotic gait training to improve walking in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.		Weak opinion statement FOR Overground gait training may be provided (in favour of robotic gait training)to improve walking in people with SCI. Clinical note: Robotic gait training includes the use of devices such as the Lokomat (with and without electrical stimulation) and exoskeletons.
I	Overground gait training
C	Robotic gait training	Consensus-based opinion statement Weak for (85%)
O	Ability to walk	Consensus-based opinion statement Weak for (85%)
	SUMMARY	3 RCTs (see references)		Mean difference (95% CI): Walking ability: WISCI points 3 (-1 to 7) Favours robotic gait training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Very serious	Imprecision Serious	Indirectness No serious	Publication bias Serious

OVERGROUND GAIT TRAINING V ROBOTIC GAIT TRAINING ON WALKING: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours Robotic training	Favours the I	Don't know
RESOURCES REQUIRED	Large costs Robotic training	Moderate costs	Negligible costs and savings of overground walking training	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact for overground walking training	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes for overground walking training		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes for overground walking training		Don't know

OVERGROUND GAIT TRAINING V ROBOTIC GAIT TRAINING ON WALKING: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
ALCOBENDAS-MAESTRO 2012	Overground gait training V Robotic Gait training	Intervention: 40 sessions of overground gait training Comparison: 40 sessions of lokomat	C2 to T12 AIS C and D SCI	37/38	Walking Index for SCI	Some Concerns of Risk of Bias PEDro = 8/10
ESCLARIN-RUZ 2014	Overground gait training V Robotic Gait training	Intervention: Overground training 60 minute, 5 days/week for 8 weeks Comparison: Lokomat 60 minutes 5 days/week for 8 weeks	AIS C or D SCI	41/42	Walking Index For SCI	Some Concerns of Risk of Bias PEDro = 8/10
HORNBY 2005	Overground gait training V Robotic Gait training	Intervention: Overground gait training 3 x 30mins per week for 8 weeks Comparison: Robotic gait training 3 x 30 mins per week for 8 weeks	T10 to L4 AIS B,C,D SCI	10/10	Walking index for SCI	Some Concerns of Risk of Bias PEDro = 3/10

The Australian and NZ SCI Physiotherapy guideline committee recommends overground gait training in favour of robotic gait training to improve walking in people with SCI.

This is a consensus-based opinion statement supported by the opinions of the experts even though there is one randomised controlled trial related to this topic. However, the result of this randomised controlled trial is inconclusive preventing an evidence recommendation. The guideline states:

Overground gait training may be provided (in favour of robotic gait training) to improve walking in people with SCI.

This statement was formed by considering the opinions of the experts alongside other factors. The other factors that were considered were benefits and harms, values and preferences, resource use, equity, accessibility, and feasibility. The results of one randomised controlled trial was also taken into consideration. This is a consensus-based opinion statement. Consensus-based opinion statements are less robust than evidence-based recommendations. They can be strong or weak.

This is a strong consensus-based opinion statement which means that the guideline panel is confident they can probably recommend overground gait training in favour of robotic gait training to improve walking in people with SCI based on opinion.

To learn more about the research related to this intervention go to the research summary.

Alcobendas-Maestro M E-RAC-LRMM-GAP-MGG-VEMJL. Lokomat robotic-assisted versus overground training within 3 to 6 months of incomplete spinal cord lesion: randomized controlled trial. Neurorehabilitation and neural repair 2012; 26: 1058.
Esclarin-Ruz A A-MMC-LRP-MGF-SMAG-VEMJL. A comparison of robotic walking therapy and conventional walking therapy in individuals with upper versus lower motor neuron lesions: a randomized controlled trial. Archives of physical medicine and rehabilitation 2014; 95: 1023.
Hornby TG, Campbell DD, Zemon DH, et al. Clinical and quantitative evaluation of robotic-assisted treadmill walking to retrain ambulation after spinal cord injury. Topics in Spinal Cord Injury Rehabilitation 2005 Fall;11(2):1-17.