71
Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Effectiveness of Gait Exercise Assist Robot (GEAR) for stroke
patients with hemiplegia
Satoshi Hirano, MD, DMSc,1 Hitoshi Kagaya, MD, DMSc,1 Eiichi Saitoh, MD, DMSc,1
Shigeru Sonoda, MD, DMSc,2 Shigeo Tanabe, RPT, PhD,3 Masaki Katoh, RPT,4
Junya Yamada, RPT,4 Genichi Tanino, RPT, PhD,5 Akira Suzuki, RPT,5 Norihide Itoh, RPT, PhD6
Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
Department of Rehabilitation Medicine II, School of Medicine, Fujita Health University, Tsu, Mie, Japan
3
Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan
4
Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan
5
Department of Rehabilitation, Fujita Health University Nanakuri Memorial Hospital, Tsu, Mie, Japan6
Department of Advanced Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural
University of Medicine, Kamigyo-ku, Kyoto, Japan1
2

ABSTRACTHirano S, Kagaya H, Saitoh E, Sonoda S, Tanabe S,
Katoh M, Yamada J, Tanino G, Suzuki A, Itoh N.
Effectiveness of Gait Exercise Assist Robot (GEAR)
for stroke patients with hemiplegia. Jpn J Compr
Rehabil Sci 2017; 8: 71-76.
Objective: This study examined whether subacutestroke patients with hemiplegia who receive gait
training using the Gait Exercise Assist Robot (GEAR)
show early improvement in gait independence comparedto patients who receive orthosis-assisted gait training.
Methods: Six patients who satisfied the following
criteria were included in the study: patients withhemiplegia caused by primary supratentorial intracerebral
hemorrhage or cerebral infarction, within 60 days after
onset, aged 20 to 75 years, Functional Independence
Measure (FIM) walking score ≤ 3, Stroke Impairment
Assessment Set (SIAS) lower extremity total score ≤ 6,
and use of a knee-ankle-foot orthosis. Rehabilitation was
conducted for a maximum of 3 h a day, including 40 minof gait training using GEAR. A historical control groupwas selected from among patients admitted to the ward
for intensive inpatient rehabilitation at Nanakuri
Memorial Hospital. One control patient matching thecriteria of each subject was selected, with a total of six inthe control group. The primary outcome measure was theCorrespondence: Satoshi Hirano, MD, DMSc
Department of Rehabilitation Medicine I, School of
Medicine, Fujita Health University, 1-98 Dengakugakubo,
Kutsukake-cho, Toyoake, Aichi 470-1192, Japan.
E-mail: hirano0820@gmail.com
Accepted: April 10, 2017.
The department received a research grant and the robot
from Toyota Motor Corporation in this study.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.71

improvement in efficiency of FIM-walk, defined as thegain in FIM walking score from the baseline to supervised
walking divided by the number of weeks required.
Results: The mean improvement in efficiency of FIMwalk was 1.0 in the GEAR group and 0.54 in thecontrol group, and was significantly higher in the
GEAR group (p = 0.042).
Conclusion: Gait training using GEAR may facilitate
early improvement in gait independence.
Key words: stroke, hemiplegia, gait training, robot,
assistIntroduction
For stroke patients with hemiplegia, gait training isconventionally practiced using a lower extremity
orthosis [1-3]. By limiting the degree of freedom of
the lower extremity joints and simplifying the motions,the use of a lower extremity orthosis stabilizes the gaiteven for patients with paralysis. In the case of severe
paralysis, a more limited degree of freedom isnecessary [4]. The orthoses used by stroke patientswith hemiplegia are broadly divided into knee-anklefoot orthosis and ankle-foot orthosis. In a patient withmild hemiplegia, an ankle-foot orthosis that limits theankle joint motion is often used. On the other hand,when a patient with severe hemiplegia uses an anklefoot orthosis at the early stage of gait training, there isa high risk of the knee giving way. Therefore, the useof a knee-ankle-foot orthosis is desirable [5]. However,this presents several issues. (1) Since the patient has
difficulty launching the foot by him/herself, theamount of assistance during the swing phase isincreased. (2) Because the foot is launched with theknee remaining in extension, compensatory motion
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Hirano S et al.: Effectiveness of Gait Exercise Assist Robot (GEAR) for stroke patients with hemiplegia

such as vaulting is necessary, with a risk of acquiring
a gait pattern different from the final gait. (3) Gait witha high degree of compensation and requiring a highlevel of assistance has a slow speed and hence low
training intensity. (4) The patient feels that “walking isdifficult,” which diminishes motivation.
In recent years, various types of robot-assisted gait
training systems have been developed. The Lokomat
is the main exoskeleton-type robot used for gait
training [6]. The exoskeleton worn over both lower
extremities directly controls the left and right hip andknee joints, and gait training takes place on a treadmill
with partial body weight support if necessary. On theother hand, the Gait Trainer is the main end-effector
robot [7]. The feet are held in place on foot plates, andthe robot directly drives the feet under partial bodyweight support.
The effectiveness of robot-assisted gait training
remains a matter of debate. Several studies haveshown significant improvement of gait independence
when gait training using the Lokomat or Gait Trainer
was combined with conventional physiotherapy,
compared to physiotherapy alone conducted for thesame duration [8-10]. In contrast, other studies foundno significant difference [11,12]. In these reports, thefrequency and the type of orthosis used were notclearly defined, which may be a factor that affected theresults.

In the present study, we compared a robot-assisted
plus physiotherapy group and a regular physiotherapy
group, while standardizing the type of orthosis used in
the two groups. The Gait Exercise Assist Robot(GEAR) [13] that we developed in collaboration with
Toyota Motor Corporation was used as the gait training
assist system. In patients with severe paralysis and gait
disturbance requiring the use of a knee-ankle-footorthosis, gait training using GEAR combined withconventional physiotherapy was compared withphysiotherapy alone. The results are presented in thisreport.
Methods
1. Mechanism of the Gait Exercise Assist Robot
The components of the GEAR system include aknee-ankle-foot robot, a low floor treadmill, a safetysuspending device (can be used as for body weightsupport), a robot weight support device, a monitor forpatient use, and a control panel (Figure 1). The kneeankle-foot robot with a motor attached to the knee
joint weighs approximately 5.7 kg, and is worn only
on the hemiplegic limb. Since the weight is canceledby the robot weight support device, the patient does
not feel the weight. The plantar region of the robot
is equipped with a pressure sensor. The systemdetermines the gait cycle from the pressure sensor andFigure 1. The Gait Exercise Assist Robot (GEAR).
The components of the GEAR system include a knee-ankle-foot robot, alow floor treadmill, a safety suspending device (can be used as for bodyweight support), a robot weight support device, a monitor for patient use,
and a control panel. The system determines the gait cycle from the pressure
sensor on the plantar region of the robot and the knee joint angle, andexecutes flexion and extension of the knee joint at the appropriate timing.
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Hirano S et al.: Effectiveness of Gait Exercise Assist Robot (GEAR) for stroke patients with hemiplegia73

the knee joint angle, and executes flexion and extensionof the knee joint at the appropriate timing. With thismechanism, even patients with severe hemiplegia canpractice a multi-step gait resembling the final gait
pattern without excessive compensatory motion, withminimal assistance from the early stage of gait training.
The torque for assisting knee extension and the force
for assisting swing-out of the paralyzed lower limb
with robot weight support can be regulated from thecontrol panel. By gradually reducing the level ofassistance according to the patient’s walking capability,
it is possible to constantly maximize the effort of thepatient.
2. Subjects
This study was conducted after obtaining approval
from the ethics committee of our university. The inclusion
criteria were as follows: patients with hemiplegia caused
by primary supratentorial intracerebral hemorrhage or
cerebral infarction; within 60 days after onset; aged 20 to
75 years; Functional Independence Measure (FIM) [14]walking score ≤ 3; total score of the hip flexion test, knee
extension test and foot tap test in the Stroke Impairment
Assessment Set (SIAS) [15, 16] (lower extremity motor
function score) ≤ 6; SIAS verticality score ≥ 2; FIM
comprehension score ≥ 2; FIM memory score ≥ 3; FIM
social interaction score ≥ 3; and requirement of kneeankle-foot orthosis in gait training. Exclusion criteria
were: training restriction due to reduced cardiac function
or respiratory dysfunction; inadequate control ofhypertension (resting systolic blood pressure ≥ 160
mmHg or diastolic blood pressure ≥ 100 Hg); severe
joint contracture or limb deformity; visual orauditory impairment hindering training; and a history oforthopedic or neurological disease that affects gait. Six
patients admitted to the Department of Rehabilitation
at Fujita Health University Hospital between February
2013 and February 2015, who satisfied the above
criteria, gave written consent to participate in the study.
A historical control group (a group that practiced
gait training using a lower extremity orthosis; hereafter“orthosis group”) was selected from the database ofpatients who received inpatient treatment at the ward
for intensive inpatient rehabilitation at Fujita Health
University Nanakuri Memorial Hospital. Among thepatients who were admitted from April 2006 anddischarged up to March 2014, 222 patients satisfied
the following criteria: hemiplegia caused by primarysupratentorial intracerebral hemorrhage or cerebral
infarction; within 60 days after onset; aged 20 to 75
years; FIM walking score ≤ 3; SIAS lower extremity
motor function score ≤ 6; SIAS verticality score ≥ 2;
FIM comprehension score ≥ 2; FIM memory score ≥3; FIM social interaction score ≥ 3; receiving gait
training using a knee-ankle-foot orthosis; and no
discontinuation of rehabilitation due to any
complications during hospitalization. From thesepatients, one matching patient for each subject interms of the following criteria was selected:
・FIM walking score and SIAS lower extremity motor
function score at the beginning of gait training were
the same as those of the subject.
・The disease (intracerebral hemorrhage or cerebral
infarction) was the same as the subject.
・The duration from onset to first evaluation after
admission was closest to the duration from onset tofirst evaluation of the subject.
The six control patients identified were included in
the orthosis group.
3. Gait training protocol
The GEAR group received gait training using
GEAR (hereafter “GEAR training”) for 40 min a day,
5 times a week. During GEAR training, the level ofrobot assistance was set as low as possible, as long as
the gait pattern did not deteriorate excessively. The
necessity of using feedback and the type of feedback
were determined by the attending physician or thetherapist in charge. GEAR was used in principle until
the patient was capable of overground gait using anankle-foot orthosis at the supervision level. However,prolongation of the duration was allowed at thediscretion of the attending physician or the therapist in
charge. For the whole rehabilitation program, training(physiotherapy, occupational therapy, and speechlanguage-hearing therapy) including using GEAR was
performed for a maximum of 3 h a day, 6 days a week.
The content of training other than GEAR wasdetermined by the attending physician and the therapist
in charge. There were no restrictions regarding training
content.
The orthosis group received training (physiotherapy,
occupational therapy, and speech-language-hearing
therapy) for a maximum of 3 h a day, 7 days a week.
The type of orthosis used, training content, andtraining intensity were determined by the attending
physician and the therapist in charge.
4. Outcome measures
The FIM walking score, individual scores and total
score for SIAS lower extremity motor function, and 10
m walking speed were evaluated.
In the GEAR group, once participation in the study
was agreed and the day of initiating GEAR training was
decided, the baseline evaluation was done as early as
possible. Subsequent evaluation was conducted once aweek until discharge. GEAR training was started within
1 to 3 days of the baseline evaluation. In the orthosis
group, the baseline evaluation was conducted
immediately after admission (day of admission or thefollowing day), and subsequent evaluation was done
once every 2 weeks until discharge.
The primary outcome measure was the improvementin efficiency of FIM-walk, defined by the following
formula:Jpn J Compr Rehabil Sci Vol 8, 2017

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Hirano S et al.: Effectiveness of Gait Exercise Assist Robot (GEAR) for stroke patients with hemiplegia

efficiency of FIM-walk improvement, FIM walking
score at discharge, and SIAS lower extremity motor
function score at discharge. p Values less than 0.05
were considered to be significant.

Improvement in efficiency of FIM-walk=

5 - baseline FIM walking score

Number of weeks to reach FIM walking score of 5

Improvement in efficiency of FIM-walk was calculated
every 2 weeks in the GEAR group, in order to match theorthosis group.
Secondary outcome measures were FIM walking
score at discharge, SIAS lower extremity motor
function score at discharge, 10 m walking speed atdischarge, and duration from onset to discharge (days).
Statistical analyses were performed using IBM
SPSS Statistics 20.0.0 (SPSS Inc., Chicago, IL, USA).
The paired t-test was used to analyze the duration fromonset to baseline evaluation, age, 10 m walking speed
at discharge, and duration from onset to discharge.
Wilcoxon rank sum test was used to analyze theResults
Table 1 shows the characteristics of the patients in
the GEAR group and orthosis group. Baseline FIM
walking scores and baseline SIAS lower extremity
motor function scores were identical in the two groups.
The results of evaluations are shown in Table 2. The
improvement in efficiency of FIM-walk was significantly
higher in the GEAR group (p = 0.042). No significant
differences between the two groups were observed for
the FIM walking score, SIAS lower extremity motor
function score, and 10 m walking speed at discharge. The
mean duration from onset to discharge was 112.5 days in

Table 1. Patient characteristics.

Case
A
B
C
D
E
F
MedianMean±SDp Value

Baseline
FIM-walk
GEAR Orthosis
group group
2
2
2
2
2
2
2

Baseline
SIAS-LEGEAR Orthosis
group group

2
2
2
2
2
2
2

3
6
1
0
1
2
2.5

3
6
1
0
1
2
2.5

Onset to baseline
evaluation (days)
GEAR Orthosis
group group
25
29
33
17
16
14

Hemiplegic side

Age

GEAR Orthosis
group group

GEAR Orthosis
group group

22
21
30
20
14
14

L
L
R
L
R
R

L
L
L
R
L
L

22±8
20±6
0.206

62
65
46
72
70
50

50
69
40
69
51
44

61±11 54±120.081

FIM-walk, Functional Independence Measure walking score; SIAS-LE, Stroke Impairment Assessment Set lower
extremity score.
Table 2. Results of evaluations.

Case

Efficiency of
FIM-walk
improvement
GEAR
group

A
B
C
D
E
F
MedianMean±SDp Value

Orthosis
group

0.75
0.75
1.50
0.75
0.75
0.25
0.75
0.21
1.50
0.75
0.75
0.50
0.75
0.63
1.00±0.39 0.54±0.25
0.042*

SIAS-LE atdischarge

10 m walking
speed atdischarge (km/h)

Onset to discharge(days)GEAR Orthosis GEAR Orthosis
group group
group group

GEAR Orthosis
group group

GEAR
group

Orthosisgroup

Durationof GEARexercise(weeks)
GEAR
group

6
5
5
6
5
6
5.5

2.5
0.9
1.0
3.5
1.5
1.9

104
115
161
95
115
85

104
132
178
129
111
96

3
3
5
4
4
4

FIM-walk atdischarge

0.180

7
6
6
5
6
6
6

10
8
6
9
8
11
8.5

12
11
4
5
6
6
6

0.276

3.2
1.2
1.7
0.6
2.4
3.0

1.9±1.0 2.0±1.0
0.814

112.5±26.5 125.0±29.5
0.075

3.8±0.8

FIM-walk, Functional Independence Measure walking score; SIAS-LE, Stroke Impairment Assessment Set lower
extremity score.
*p < 0.05, Wilcoxon rank sum test.
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Hirano S et al.: Effectiveness of Gait Exercise Assist Robot (GEAR) for stroke patients with hemiplegia75

the GEAR group and 125 days in the orthosis group.
Although the duration tended to be shorter in the GEAR
group, no significant difference was observed. In the
GEAR group, GEAR training was conducted for an
average of 3.8 weeks.
Discussion
In the present study, gait training using GEAR instroke patients with hemiplegia significantly improved
the efficiency of FIM-walk improvement, compared topatients who practiced gait training using only a lower
extremity orthosis. The results of this study suggestthat GEAR training promotes the recovery of walking
ability. Because the use of GEAR in gait training
maximizes the residual capability of the patient, we set
the level of robot assistance at the minimum level aslong as the gait pattern did not deteriorate excessively.
Therefore, as the patient’s gait capability improves,
the level of robot assistance is gradually reduced.
Animal experiments have suggested that the functionimproving effect of training for motor paralysis ishigher with an assist-as-needed approach than with afixed-assist approach [17]. In addition, Krishnan et al.
[18] reported that in stroke patients with hemiplegia,
creating opportunities for the patient to actively
control the extremities by using a robot that provides
minimum assist matching the patient’s ability may
contribute to functional improvement, compared totraining by passively repeating the gait pattern. Task
specificity, training procedure, repetitive intensity,
enhanced sensory feedback, and sustained motivation
are important elements for the recovery of motor
function [19]. In gait training using GEAR, the featureof minimizing robot assistance may increase theopportunity of active training by the patient, leading to
improvement in walking ability. Furthermore, both theadvantages of ankle-foot orthosis during the swing
phase and knee-ankle-foot orthosis during the stancephase can be exploited by using GEAR, which may be
one of the reasons for obtaining significant favorable
results in the present study.
Various types of robot-assisted gait training systems
have been developed, and an increasing number are
being introduced into clinical practice. All thesesystems control both lower extremities. In one study,
when subacute stroke patients received robot-assisted
gait training in addition to regular physiotherapy, theproportion of patients walking independently increased
significantly compared to those receiving physiotherapy
alone, although there was no significant difference inwalking speed [20]. However, other reports showed nodifference when robot-assisted training was used in
combination with physiotherapy compared to regularphysiotherapy alone [11, 12]. Possible reasons for thisdiscrepancy are the differences in the time of treatment
initiation, treatment duration, treatment frequency, andpatient status [8]. In addition, previous studies did not

provide clear descriptions of the regular physiotherapy
and orthosis used. Unless this information is clearly
available, it is not possible to discuss the usefulness ofrobot-assisted gait training systems.
In this study, there was no significant difference in the
duration from onset to discharge between the two groups.
The duration to discharge is determined not only by
walking ability and motor function, but is influenced by amultitude of factors including sensory impairment, visual
field impairment, excretory function, and family
background [21, 22]. Since the mean number of days todischarge was approximately 10% shorter in the GEAR
group, a significant difference might be observed byincreasing the number of cases in a future study.
This study has some limitations. We examined a small
series of only six cases, and the GEAR group and theorthosis group were recruited or selected from different
facilities. Also, although the duration of GEAR training
was fixed at 40 min a day, there was no restriction on thecontent of regular physiotherapy except for the use of aknee-ankle-foot orthosis at the initiation phase of gait
training. Future studies are necessary to address theselimitations.
The Gait Exercise Assist Robot (GEAR), which isa one-limb type gait training assist system, was used in
gait training for subacute stroke patients with hemiplegia,
and achieved early improvement of gait independencecompared to patients who received gait training using an
orthosis. This result suggests the usefulness of GEAR in
gait training for stroke patients with hemiplegia. Further
studies on a larger number of cases are warranted toconfirm the effectiveness of GEAR.
Acknowledgements
The authors would like to express their appreciation
to staff members of Toyota Motor Corporation for
their cooperation in robot development. This study
was supported in part by JSPS KAKENHI Grant
Number 16K01476.
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