Gait training

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Gait training or gait rehabilitation is the act of learning how to walk, either as a child, or, more frequently, after sustaining an injury or disability. Normal human gait is a complex process, which happens due to co-ordinated movements of the whole of the body, requiring the whole of Central Nervous System - the brain and spinal cord, to function properly. Any disease process affecting the brain, spinal cord, peripheral nerves emerging from them supplying the muscles, or the muscles itself can cause deviations of gait. The process of relearning how to walk is generally facilitated by Physiatrists or Rehabilitation medicine (PM&R) consultants, physical therapists or physiotherapists, along with occupational therapists and other allied specialists. The most common cause for gait impairment is due to an injury of one or both legs. [1] Gait training is not simply re-educating a patient on how to walk, but also includes an initial assessment of their gait cycle - Gait analysis, creation of a plan to address the problem, as well as teaching the patient on how to walk on different surfaces. [2] Assistive devices and splints (orthosis) are often used in gait training, especially with those who have had surgery or an injury on their legs, but also with those who have balance or strength impairments as well. [2]

Contents

Gait training can be useful for people with the following conditions:

Although gait training with parallel bars, treadmills and support systems can be beneficial, the long-term aim of gait training is usually to reduce patients' dependence on such technology in order to walk more in their daily lives.

Gait Cycle

A gait cycle is defined as the progression of movements that occurs before one leg can return to a certain position during walking, or ambulation. [2] One example of a full gait cycle is the period it takes for a foot to leave the ground until the same leaves the ground again. An understanding of a normal gait cycle and how it progresses is crucial to determining how much assistance a patient needs in order to return to functional ambulation. How long the gait cycle lasts depends on multiple factors, such as age, walking surface, and walking speed. [1]

Stance and swing phases of the right lower extremity gait cycle. Gait Cycle.png
Stance and swing phases of the right lower extremity gait cycle.

The gait cycle is studied in two phases - Swing and stance phase. Each of these is further divided based on the positioning of the foot during these phases.

Any gait training addressing a gait abnormality starts with a proper gait analysis. Observational, video, electromyographic and force plate techniques are few of them for assessing different parameters of gait. The cheapest way consists of observational combined with a video gait analysis, but more quantitative analysis can be done with integrating force vectors from a force plate and joint angle motion data incorporated through myoelectric sensors. Basically, kinetic and kinematic analysis are done for gait, the former consisting of the forces resulting in and from walking and latter consists of describing the visible components such as joint angles and distances covered. The gait consists of a series of repetitive movements of the whole body during locomotion and is studied considering that each gait cycle repeats over itself, which is almost correct considering normal subjects. The basic two phases are swing and stance phases, depending on whether the leg is free to swing or is in contact with the ground during the phase of gait studied.

Stance

The stance phase begins when the foot first makes contact with the ground (initial contact), and the weight of the body is borne by that limb. [1] This phase is approximately 60% of the gait cycle and takes about 0.6 seconds to complete at a normal walking speed. Included in the stance phase are another four intervals, which are: load response, midstance, terminal stance, and preswing. [1] Load response occurs when the body weight is borne by the single foot while the other foot begins to lift off the ground to start its swing phase. [1] At midstance the body is supported fully by one leg and the other is no longer in contact with the ground. [1] During terminal stance body weight is still supported on one leg, however the heel of that leg is beginning to lift off, and the center of gravity is in front of the foot still in contact with the ground. [1] Finally at preswing the toe of the stance foot comes off the ground, and the weight is now transferred to the leg that was previously in the swing phase. [1]

Swing

The swing phase occurs when the foot is not in contact with the ground, and constitutes about 40% of the gait cycle. [1] There are three intervals to this phase: initial swing, midswing, and terminal swing. [1] During initial swing, the foot is lifted off the floor. [1] Next it moves into midswing, when the lower leg is straight and is perpendicular to the floor. [1] Finally, at the terminal phase, the foot comes back into contact with the floor again and restarts the cycle beginning in initial contact of the stance phase. [1]

Assistive Devices

Assistive devices (ADs) are given to patients who have difficulty maintaining a regular gait cycle or balance due to an injury to one or both of their legs. [2] Other factors that would necessitate use of an AD include loss of perception in the legs, weakness of the legs, pain while walking, and a history of falling, among other indications. [2] Not only does an AD provide extra support, it can also protect the injured leg and prevent it from being further aggravated due to weight bearing requirements. [2] Different ADs are assigned to each patient depending on the severity of their condition and how much extra support they need provided. The following list presents the ADs from the least supportive to the most supportive. [2]

Weight Bearing Status

The type of gait that a patient is instructed in is based on their weight-bearing status, or how much of their body weight can be supported on their legs, coordination, and strength. [2] There are different levels of weight-bearing status that is determined by the physician. [2] The weight-bearing status of a patient generally changes as treatment progresses, but each progression needs to be approved by the physician. [2] In many cases the easiest way to monitor a patient's weight bearing status is to use two scales, one under each foot, and to adjust the weight on each foot until the injured foot is supported the desired amount of weight. [2]

There are four different weight-bearing statuses. [2]

In NWB, the patient is not allowed to bear any weight on their injured leg. For TTWB, the amount of weight placed on the leg is defined in many ways, such as being approximately 20% of body weight, being 10 to 15 kg of weight, or being equal to or less than a weight that would crush eggshells. The portion of weight that is allowed to be borne on the injured leg in PWB is generally given as a percentage, such as 25% or 50%, however with a percentage the amount of weight that is supported changes as the person's weight changes as well. In WBAT the person is allowed to bear as much weight as pain allows, provided that the pain level does not become difficult to tolerate. [2]

Gait Training Using Assistive Devices

There are multiple possible gait patterns that can be taught to the patient, and the one that is taught depends on the patient's capability and coordination. Parallel bars may be used to help with gait training, especially in the early stages when a patient is first learning or re-learning to walk. [2] They involve a person walking between two handrails to support themselves, often with the therapist either helping to support the patient or physically moving the patient's legs. [2] A gait belt is also utilized by the physical therapist in order to support the patient and to prevent them from falling or placing too much weight on the injured leg. [1]

Two-Point Gait Pattern

The two-point gait pattern closely imitates a unaffected gait pattern, but includes the use of two crutches or two canes with one on either side of the body. [1] In this pattern one crutch and the leg opposite to the crutch is moved in unison. [1] For example if the right crutch is moved forward, then the left leg would advance with it. [1] This gait pattern requires a high level of coordination and balance. [1]

Another two-point gait pattern is the modified two-point pattern. [2] In this pattern there is only use of one crutch or cane on the side opposite to the injured leg, therefore there can not be any weight bearing restriction but is more used to provide extra balance. [2] For this pattern the AD is move simultaneously with the injured leg. [2]

Three-Point Gait Pattern

A three-point gait pattern can be used with patients who are NWB, however requires a much higher energy output and requires the patient to have good balance as well as strong upper limbs. [1] A walker or two crutches must be used, as this pattern can not be performed with the use of a single cane. [1] For this pattern the AD is advanced first, then the uninjured leg is moved up as the body is supported on the AD. [1] The uninjured leg can either be brought up to be level with the AD (swing to) or brought up to be ahead of the AD (swing through). [1]

There is also a modified three-point gait pattern which can be used with patients who are PWB on their injured leg but full weight bearing (FWB) on their uninjured leg. This pattern also requires the use of 2 crutches or a walker, but is slower and more stable than the three-point gait pattern. [2] In the modified pattern, the AD is advanced first, followed by the injured leg that has a PWB status, then finally the uninjured leg is moved up. [2] Similarly, a four-point gait pattern has also been described. Just as in the three-point gait pattern the patient may use a swing to or a swing through pattern. [2]

Stairs

Ascending Stairs

Two crutches or a cane can be used to ascending a flight of stairs. Although a walker may also be used, it is not recommended to be used to climb stairs longer than 2 or 3 steps. [1] If the patient is using two crutches, then both crutches are held in one hand while the other hand grips the handrail. [1] If there is no handrail or if it the two crutches can not be held in one hand, both crutches may be used without use of the handrail, although this method is not recommended for taking more than 2 or 3 steps. [1] The order of events goes: uninjured foot, crutches or cane, injured foot. [1] This process is repeated until the patient reaches the top of the stairs. [1]

Descending Stairs

Just as in ascending stairs, two crutches or a cane may be used to descend a flight of stairs, and use of a walker is not recommended for climbing more than 2 or 3 steps. [1] Both crutches should be used if the handrail is unstable or if the two crutches are not able to be held securely in one hand. [1] The crutches or cane descends to the first step, then is followed by the injured leg, then finally the uninjured leg. [1] This process is repeated until the bottom of the stairs is reached. [1]

Other Applications

Body-weight support (BWS) systems or unweighting devices are starting[ when? ] to become more and more popular and have been the subject of much study. [6] BWS systems can be used prior to the patient gaining adequate motor control or having sufficient strength to fully bear weight. [7] The patient will wear a specialized trunk harness with adjustable straps, which attach to an overhead suspension system. The harness and its attachments support a certain amount of the patient’s body weight. [8] Gait training techniques that utilize a BWS system appear to be promising in their ability to improve and possibly restore walking function, as demonstrated in individuals suffering from incomplete spinal cord injuries. [7] A BWS system can be used on a treadmill or over ground for gait training. Body-weight-supported treadmill training (BWSTT) enables individuals with motor deficits that have rendered them incapable of completely supporting their own body weight to practice and experience locomotion at physiological speeds. [9] Depending on the severity of the person's impairment, one or more physiotherapists may be present to assist in maintaining the patient’s appropriate posture and moving their legs through as kinematically physiological a gait pattern as possible. [10] Recently,[ when? ] electromechanical devices such as the Hocoma Lokomat robot-driven gait orthosis have been introduced with the intention of reducing the physical labour demands on therapists. [9] [10] This system uses a computer-controlled exoskeleton to repeatedly and consistently guide lower-limb movements, making BWSTT a more feasible option for long-term and widespread use. [10]

Another device category, so-called end-effector gait trainers, activates the human gait pattern over moving foot-plates as opposed to an orthosis. The German society for Neurorehabilitation has recently recommended end-effector devices for gait rehabilitation after stroke due to current medical evidence. [11]

Treadmill training, with or without a body-weight support, is an emerging therapy and is being used with stroke patients to improve kinematic gait parameters. [12] These patients often present with significant gait deviations and body weight-supported treadmill training can provide an intense repetitive practice of a more natural gait pattern. Literature continues to emerge examining the influence treadmill speed may have on the improvement of gait patterns and functional independence. Research has shown that a greater gain in independent walking ability is seen in hemiparetic stroke patients who participate in structured speed-dependent treadmill training compared to conventional training. [13] Improvements in gait parameters included walking speed, cadence, stride length and Functional Ambulation Category scores. [14] In speed-dependent treadmill training, belt speed is increased to the maximum-achievable speed the patient can maintain for 10 seconds without stumbling, followed by a period of recovery. If the patient were capable of maintaining the speed safely and comfortably during the 10-second bout, it would then be increased by 10% in the next attempt, following the same work and recovery procedures. Research has shown that this form of gait training demonstrates a more normal walking pattern without the compensatory movements commonly associated with stroke. [15]

Electromechanical-assisted gait training is another strategy that helps with gait training in people who have suffered a stroke. [16] Evidence demonstrates that this method should only be applied to people who are unable to walk and it should be used in the first 3 months after the stroke, in order to maximize results. [16]

Related Research Articles

<span class="mw-page-title-main">Gait</span> Pattern of movement of the limbs of animals

Gait is the pattern of movement of the limbs of animals, including humans, during locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on speed, terrain, the need to maneuver, and energetic efficiency. Different animal species may use different gaits due to differences in anatomy that prevent use of certain gaits, or simply due to evolved innate preferences as a result of habitat differences. While various gaits are given specific names, the complexity of biological systems and interacting with the environment make these distinctions "fuzzy" at best. Gaits are typically classified according to footfall patterns, but recent studies often prefer definitions based on mechanics. The term typically does not refer to limb-based propulsion through fluid mediums such as water or air, but rather to propulsion across a solid substrate by generating reactive forces against it.

In orthopedics, weight-bearing is the amount of weight a patient puts on an injured body part. Generally, it refers to a leg, ankle or foot that has been fractured or upon which surgery has been performed, but the term can also be used to refer to resting on an arm or a wrist. In general, it is described as a percentage of the body weight, because each leg of a healthy person carries the full body weight when walking, in an alternating fashion.

<span class="mw-page-title-main">Functional electrical stimulation</span> Technique that uses low-energy electrical pulses

Functional electrical stimulation (FES) is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system. More specifically, FES can be used to generate muscle contraction in otherwise paralyzed limbs to produce functions such as grasping, walking, bladder voiding and standing. This technology was originally used to develop neuroprostheses that were implemented to permanently substitute impaired functions in individuals with spinal cord injury (SCI), head injury, stroke and other neurological disorders. In other words, a person would use the device each time he or she wanted to generate a desired function. FES is sometimes also referred to as neuromuscular electrical stimulation (NMES).

<span class="mw-page-title-main">Gait (human)</span> A pattern of limb movements made during locomotion

A gait is a manner of limb movements made during locomotion. Human gaits are the various ways in which humans can move, either naturally or as a result of specialized training. Human gait is defined as bipedal forward propulsion of the center of gravity of the human body, in which there are sinuous movements of different segments of the body with little energy spent. Varied gaits are characterized by differences such as limb movement patterns, overall velocity, forces, kinetic and potential energy cycles, and changes in contact with the ground.

<span class="mw-page-title-main">Crutch</span> Mobility aid

A crutch is a mobility aid that transfers weight from the legs to the upper body. It is often used by people who cannot use their legs to support their weight, for reasons ranging from short-term injuries to lifelong disabilities.

The goal of the LOPES project is to design and implement a gait rehabilitation robot for treadmill training. The target group consists of people who have had a stroke and have impaired motor control. The main goals of LOPES are:

<span class="mw-page-title-main">Foot drop</span> Gait abnormality

Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the deep fibular nerve, including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground.

<span class="mw-page-title-main">Mobility aid</span>

A mobility aid is a device designed to assist walking or otherwise improve the mobility of people with a mobility impairment.

<span class="mw-page-title-main">Orthotics</span> Medical specialty that focuses on the building and designing of artificial legs

Orthotics is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces or calipers. An orthosis is "an externally applied device used to influence the structural and functional characteristics of the neuromuscular and skeletal systems." Orthotists are professionals who specialize in designing these braces.

<span class="mw-page-title-main">Spinal locomotion</span>

Spinal locomotion results from intricate dynamic interactions between a central program in lower thoracolumbar spine and proprioceptive feedback from body in the absence of central control by brain as in complete spinal cord injury (SCI). Following SCI, the spinal circuitry below the lesion site does not become silent; rather, it continues to maintain active and functional neuronal properties, although in a modified manner.

<span class="mw-page-title-main">Parkinsonian gait</span> Type of gait due to Parkinsons disease

Parkinsonian gait is the type of gait exhibited by patients with Parkinson's disease (PD). It is often described by people with Parkinson's as feeling like being stuck in place, when initiating a step or turning, and can increase the risk of falling. This disorder is caused by a deficiency of dopamine in the basal ganglia circuit leading to motor deficits. Gait is one of the most affected motor characteristics of this disorder although symptoms of Parkinson's disease are varied.

A gait trainer is a wheeled device that assists a person who is unable to walk independently to learn or relearn to walk safely and efficiently as part of gait training. Gait trainers are intended for children or adults with physical disabilities, to provide the opportunity to improve walking ability. A gait trainer offers both unweighting support and postural alignment to enable gait practice. It functions as a support walker and provides more assistance for balance and weight-bearing, than does a traditional rollator walker, or a walker with platform attachments. It also provides opportunities to stand and to bear weight in a safe, supported position.

Terrestrial locomotion by means of a running gait can be accomplished on level surfaces. However, in most outdoor environments an individual will experience terrain undulations requiring uphill running. Similar conditions can be mimicked in a controlled environment on a treadmill also. Additionally, running on inclines is used by runners, both distance and sprinter, to improve cardiovascular conditioning and lower limb strength.

<span class="mw-page-title-main">Arm swing in human locomotion</span>

Arm swing in human bipedal walking is a natural motion wherein each arm swings with the motion of the opposing leg. Swinging arms in an opposing direction with respect to the lower limb reduces the angular momentum of the body, balancing the rotational motion produced during walking. Although such pendulum-like motion of arms is not essential for walking, recent studies point that arm swing improves the stability and energy efficiency in human locomotion. Those positive effects of arm swing have been utilized in sports, especially in racewalking and sprinting.

When treating a person with a spinal cord injury, repairing the damage created by injury is the ultimate goal. By using a variety of treatments, greater improvements are achieved, and, therefore, treatment should not be limited to one method. Furthermore, increasing activity will increase his/her chances of recovery.

<span class="mw-page-title-main">Cutaneous reflex in human locomotion</span>

Cutaneous, superficial, or skin reflexes, are activated by skin receptors and play a valuable role in locomotion, providing quick responses to unexpected environmental challenges. They have been shown to be important in responses to obstacles or stumbling, in preparing for visually challenging terrain, and for assistance in making adjustments when instability is introduced. In addition to the role in normal locomotion, cutaneous reflexes are being studied for their potential in enhancing rehabilitation therapy (physiotherapy) for people with gait abnormalities.

A (bipedal) gait cycle is the time period or sequence of events or movements during locomotion in which one foot contacts the ground to when that same foot again contacts the ground, and involves propulsion of the centre of gravity in the direction of motion. A gait cycle usually involves co-operative movements of both the left and right legs and feet. A single gait cycle is also known as a stride.

The function of the lower limbs during walking is to support the whole-body against gravitational forces while generating movement patterns which progress the body forward. Walking is an activity that is primarily confined to the sagittal plane, which is also described as the plane of progression. During one gait cycle, there are two major phases: stance and swing. In a healthy individual walking at a normal walking speed, stance phase makes up approximately 60% of one gait cycle and swing makes up the remaining 40%. The lower limbs are only in contact with the ground during the stance phase, which is typically subdivided into 5 events: heel contact, foot flat, mid-stance, heel off, and toe off. The majority of stance phase (~40%) takes place in single-limb support where one limb is in contact with the ground and the contralateral limb is in swing phase. During this time interval, the lower limb must support constant changes in alignment of body weight while propelling forward. The hip, knee, and ankle joints move through cyclical kinematic patterns that are controlled by muscles which cross these joints. As postural changes occur, the body adapts by motor tuning an efficient muscular pattern that will accomplish the necessary kinematics required to walk.

The study of animal locomotion is a branch of biology that investigates and quantifies how animals move.

<span class="mw-page-title-main">Interlimb coordination</span> Coordination of the left and right limbs

Interlimb coordination is the coordination of the left and right limbs. It could be classified into two types of action: bimanual coordination and hands or feet coordination. Such coordination involves various parts of the nervous system and requires a sensory feedback mechanism for the neural control of the limbs. A model can be used to visualize the basic features, the control centre of locomotor movements, and the neural control of interlimb coordination. This coordination mechanism can be altered and adapted for better performance during locomotion in adults and for the development of motor skills in infants. The adaptive feature of interlimb coordination can also be applied to the treatment for CNS damage from stroke and the Parkinson's disease in the future.

References

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  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Mark, Dutton (2014-01-13). Introduction to physical therapy and patient skills. New York. ISBN   9780071772433. OCLC   852400031.{{cite book}}: CS1 maint: location missing publisher (link)
  3. ↑ Booth, Adam T C; Buizer, Annemieke I; Meyns, Pieter; Oude Lansink, Irene L B; Steenbrink, Frans; van der Krogt, Marjolein M (7 March 2018). "The efficacy of functional gait training in children and young adults with cerebral palsy: a systematic review and meta-analysis". Developmental Medicine & Child Neurology. 60 (9): 866–883. doi: 10.1111/dmcn.13708 . hdl: 1942/25899 . PMID   29512110.
  4. ↑ Morris, ME; Iansek R; Galna B (2008). "Gait festination and freezing in Parkinson's disease: pathogeneses and rehabilitation". Movement Disorders. 23 (Suppl 2): S451-60. doi:10.1002/mds.21974. PMID   18668618. S2CID   46462279.
  5. ↑ Pilutti, L.A.; Lelli, D.A.; Paulseth, J.E.; Crome, M.; Jiang, S.; Rathbone, M.P.; et al. (2011). "Effects of 12 weeks of supported treadmill training on functional ability and quality of life in progressive multiple sclerosis: A pilot study". Archives of Physical Medicine and Rehabilitation. 92 (1): 31–36. doi:10.1016/j.apmr.2010.08.027. PMID   21187202.
  6. ↑ Visintin, Martha; Hugues Barbeau; Nicol Korner-Bitensky; Nancy E. Mayo (1998). "A New Approach to Retrain Gait in Stroke Patients Through Body Weight Support and Treadmill Stimulation". Stroke . 29 (6): 1122–1128. doi: 10.1161/01.STR.29.6.1122 . PMID   9626282.
  7. 1 2 Wessels, Monique; Cees Lucas; Inge Eriks; Sonja de Groot (2010). "Body weight-supported gait training for restoration of walking in people with an incomplete spinal cord injury: A systematic review". Journal of Rehabilitation Medicine. 42 (6): 513–519. doi: 10.2340/16501977-0525 . PMID   20549154.
  8. ↑ O'Sullivan, Susan (2007). Physical Rehabilitation Fifth Edition. Philadelphia: F. A. Davis Company. pp. 535–540. ISBN   978-0-8036-1247-1.
  9. 1 2 Lo, A.C.; Triche, E.W. (2008). "Improving gait in multiple sclerosis using robot-assisted, body weight supported treadmill training". Neurorehabilitation & Neural Repair. 22 (6): 661–671. doi: 10.1177/1545968308318473 . PMID   18971381. S2CID   206759068.
  10. 1 2 3 Wier, L.M.; Hatcher, M.S.; Triche, E.W.; Lo, A.C. (2011). "Effect of robot-assisted versus conventional body-weight-supported treadmill training on quality of life for people with multiple sclerosis". Journal of Rehabilitation Research & Development . 48 (2): 483–492. doi:10.1682/JRRD.2010.03.0035. PMID   21674396.
  11. ↑ ReMoS Working Group (2015). "S2e-Leitlinie "Rehabilitation der Mobilität nach Schlaganfall (ReMoS)" Kurzfassung der Konsensusversion" [S2e Guideline for Rehabilitation of Mobility after Stroke ("ReMoS")](PDF). Neurologie & Rehabilitation (in German). 21 (4): 179–184. doi:10.14624/NR201509.001 (inactive 31 January 2024).{{cite journal}}: CS1 maint: DOI inactive as of January 2024 (link)
  12. ↑ Hassid, E.; Rose, D.; Commisarow, J.; Guttry, M.; Dobkin, B. H. (January 1997). "Improved Gait Symmetry in Hemiparetic Stroke Patients Induced During Body Weight-Supported Treadmill Stepping". Neurorehabilitation and Neural Repair. 11 (1): 21–26. doi:10.1177/154596839701100104 (inactive 2024-02-01). S2CID   144963555.{{cite journal}}: CS1 maint: DOI inactive as of February 2024 (link)
  13. ↑ Pohl, M.; Jan Mehrholz; Claudia Ritschel; Stefan Ruckriem (2002). "Speed-Dependent Treadmill Training in Ambulatory Hemiparetic Stroke Patients: A Randomized Controlled Trial". Stroke. 33 (2): 553–558. doi: 10.1161/hs0202.102365 . PMID   11823669.
  14. ↑ Functional Ambulation Category
  15. ↑ Tyrell, C. M.; Roos, M. A.; Rudolph, K. S.; Reisman, D. S. (2011). "Influence of Systematic Increases in Treadmill Walking Speed on Gait Kinematics After Stroke". Physical Therapy. 91 (3): 392–403. doi:10.2522/ptj.20090425. PMC   3048817 . PMID   21252308.
  16. 1 2 Jan Mehrholz; Simone Thomas; Joachim Kugler; Marcus Pohl; Bernhard Elsner. (2020). "Electromechanical-assisted training for walking after stroke". Cochrane Database of Systematic Reviews. 2020 (10): CD006185. doi:10.1002/14651858.CD006185.pub5. PMC   8189995 . PMID   33091160.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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