Towards Evidence-based Practice of Technology-based Gait Rehabilitation after Stroke.

The future of neurorehabilitation after stroke could be full of technologies. But, maybe and first of all, we should look back. Already in 1986, Melvin Kranzberg formulated six laws of technology with for instance Kranzberg’s law #1 that says ‘Technology is neither good nor bad; nor is it neutral. ’(Kranzberg, 1986) This could mean for physiotherapists that the introduction of technologies is not neutral, because it can and will change the application of physiotherapy in terms of intensity and duration of therapy. Perhaps we should consider a new seventh law of technology: ‘Physiotherapists should know all the available options of technology, and all physiotherapists should know the scientific evidence when using technology in physiotherapy for individual patients. ’ Please consider this as a very first draft. But what are key examples of evidence of technology for stroke physiotherapy? For instance to improve walking function after stroke, practice provided by therapists should be activity-specific and functional and should be progressively more difficult, challenging, of sufficient intensity, frequency and duration (Winstein et al., 2016). We have now scientific evidence for the effectiveness of task-specific practice coming from several Cochrane reviews: for the more severely affected non-ambulatory patients after stroke, even people who cannot stand or sit alone, electromechanical-assisted gait training can improve the ability to walk, and for already ambulatory people after stroke treadmill training can increase walking speed and distance (Mehrholz, Elsner, & Pohl, 2014). If we dig a bit deeper in the huge list of trials about treadmill training after stroke, we recognize that so called (gait) speed protocols that are progressively more difficult, highly challenging, of sufficient intensity, frequency, and duration are highly effective to improve gait speed after stroke (Mehrholz et al., 2014; Pohl, Mehrholz, Ritschel, & Ruckriem, 2002). But how does the right information needed for clinical practice ends up on the desk of the physiotherapist? It will be just a big task for the future to implement the appropriate information into practice. As cited and mentioned earlier, technology is all but not neutral. Let me give another example: a relatively new technology for people after stroke is the so called powered robotic exoskeleton (Louie & Eng, 2016; Wall, Borg, & Palmcrantz, 2015). These electromechanical-assisted ‘mobile’ solutions for gait training principally offer the potential to increase repetitive walking practice. In clinics in Germany, therapists are asked at the moment what they ‘think’ about these new devices and are asked to test them. Besides the glossy brochures and friendly representatives, research-based recommendations for the use of ‘mobile’ robotic exoskeletons for gait rehabilitation after stroke, however, are still lacking. One recent review found that ‘mobile’ powered exoskeletons are ‘feasible’ if used for gait training in patients with lower extremity paresis in a clinical setting (Wall et al., 2015): ‘feasible’ is sometimes a soft/smart description of no apparent studies and evidence, and the review stated that data is too sparse to allow any insightful conclusions (Wall et al., 2015). A newly published scoping review identified 11 studies in the field, which where all published within the last 5 years, involving 216 participants (Louie & Eng, 2016). Only three of the included studies, however, were performed with a randomized controlled trial design but included a low number of participants (i.e. between 3 and 16 people). Additionally, these studies also observed that these powered robotic exoskeletons can be used relatively safely (what might sound even dangerous to clinicians) for gait training after stroke (Louie & Eng, 2016). In summary, we are far away to recommend on an evidence-based level ‘mobile’ powered exoskeletons for clinical routine. Eventually, despite future and maybe sometimes dazzling technologies, we should retain our skepticism