Dr Ray O’Connor concludes his review of recent clinical papers on stroke, and takes a look at the various methods of rehabilitation
Orthotics and balance training
Stroke-induced hemiplegia is a major cause of long-term disability, often leading to lower limb deformities and abnormal gait. Ankle-foot orthoses (AFO) have shown effectiveness in improving these conditions, but limited research explores the benefits of combining AFO therapy with balance training.
This randomised controlled trial1 aimed to explore the effects of combining balance training exercises with orthotic intervention on various gait characteristics in stroke patients with lower limb paralysis.
Dr Ray O’Connor
The trial involved 32 patients, 12–18 weeks post-stroke, randomized into two groups: balance training only (n = 16) and balance training with orthotics (n = 16). Gait performance was evaluated at baseline and post intervention using the Timed Up and Go Test (TUG) and 10-Meter Walk Tests. Results showed that the combination therapy group showed significant improvements in gait parameters. For the 10-Meter Walk Test, the mean pre-intervention speed was 0.31 ± 0.03 m/s, and post-intervention speed was 0.40 ± 0.03 m/s.
In the TUG test, mean pre-intervention time was 27.04 ± 2.04 s, and postintervention time was 20.55 ± 2.30 s (p < 0.05). These improvements were greater than those observed in the balance-only group. The authors’ conclusion was that the combination of balance training and AFO therapy significantly improves gait in chronic hemiplegic stroke patients. This approach offers a promising rehabilitation strategy to enhance functional mobility and quality of life in stroke survivors.
Robotic Assisted Gait Training
Robotic-assisted gait training (RAGT) is a promising adjunct to conventional rehabilitation for stroke survivors. However, its additive benefit over standard therapy remains to be fully clarified. This systematic review and meta-analysis2 evaluated the effectiveness of combining RAGT with conventional rehabilitation in improving gait-related outcomes among individuals with stroke.
The authors searched PubMed, Embase, CINAHL, and Cochrane CENTRAL through September 2024 for randomized controlled trials (RCTs) comparing combined RAGT and conventional rehabilitation versus conventional rehabilitation alone in adults post-stroke. Twenty-three RCTs (n = 907) were included. The combined intervention significantly improved gait function (SMD = 0.51, p = 0.001), gait speed (SMD = 0.47, p = 0.010), balance (MD = 4.58, p < 0.001), and ADL performance (SMD = 0.35, p = 0.001). Subgroup analyses revealed that end-effector robotic systems yielded superior outcomes compared to exoskeletons, particularly in subacute stroke patients.
The most pronounced benefits were seen in gait velocity and dynamic balance, especially with ≤15 training sessions. The authors concluded that integrating RAGT with conventional rehabilitation enhances motor recovery and functional performance in stroke survivors. End-effector devices appear most effective in subacute phases, supporting individualized RAGT application based on patient and device characteristics.
Virtual reality applications
Virtual reality (VR) applications have emerged as a treatment approach in stroke rehabilitation, with the first randomised trial published in 2004. A wide range of applications have been tested in research studies and adopted in clinical practice, from non-immersive, non-customised, interactive game-based applications to immersive applications specifically designed for rehabilitation settings.
This is an update of a Cochrane review3 first published in 2011 and then again in 2015 and 2017. The primary objective was to assess the effects of VR compared with an alternative intervention or no intervention for upper limb function and activity in people after stroke. The secondary objectives were to assess the effects of VR compared with an alternative intervention or no intervention on gait and balance, global motor function, cognitive function, activity limitation, participation restriction and quality of life, and adverse events in people after stroke. The critical outcome of interest was upper limb function and activity.
Important outcomes included mobility outcomes (gait speed, balance), global cognitive function, activity limitation, participation restriction and quality of life, and adverse events. The authors included 190 trials involving a total of 7,188 participants, of which 119 studies are newly included in the current update. They found that the majority of studies were small, with only 36 (19 per cent) studies involving more than 50 participants, and the largest study recruiting 152 participants. Interventions varied in terms of both the goals of treatment and the VR applications used.
Control groups usually received the same amount of an alternative form of therapy. In many studies risk of bias was unclear due to poor reporting. The findings were that there was moderate- to low-certainty evidence that the use of virtual reality and interactive video gaming is slightly more beneficial than alternative therapy approaches in improving upper limb function, balance, and activity limitation. Furthermore, greater benefits were seen for upper limb function when VR was used in addition to usual care (to increase overall therapy time).
There was mixed evidence on the effects on mobility outcomes including gait speed, and insufficient evidence to reach any conclusions about the effect of VR and interactive video gaming on participation restriction and quality of life.
The next paper was a randomized controlled single-blind study4 that looked at the synergistic effects of combining task-oriented circuit training (TOCT) and VR on improving upper extremity function in stroke patients.
This study investigated the impact on upper limb functions and quality of life (QoL) in subacute stroke patients. Stroke patients were recruited and allocated to a control group (CG) or an experimental group (EG). Patients in CG received 40-minute VR, while those in EG underwent 20-minute VR and 20-minute TOCT.
Additionally, all patients received 40 minutes of traditional rehabilitation therapy five times per week for a total of four weeks. The study included 64 ischemic and haemorrhagic stroke patients, with no significant differences in demographics or baseline scores between the two groups. After intervention, both groups demonstrated significant improvements in upper limb motor function, activities of daily living, and QoL (P < .001).
The authors concluded that the combination of VR with TOCT can significantly enhance upper limb function and QoL in subacute stroke patients, with superior outcomes compared to TOCT alone. VR serves as a safe, efficient, and cost-effective adjunctive therapy, showing promise for clinical application in stroke rehabilitation.
Vagus Nerve stimulation
The purpose of this report5 was to determine the long-term effects of vagus nerve stimulation paired with rehabilitation on impairment, activity, and participation in people with upper extremity (UE) impairment after ischemic stroke. The study was a post hoc analysis of data from the VNS-REHAB (A Pivotal Randomized Study Assessing Vagus Nerve Stimulation [VNS] During Rehabilitation for Improved Upper Limb Motor Function After Stroke) randomized clinical trial. Initially, 108 participants across 19 sites with chronic ischemic stroke and moderate-to-severe UE impairment were enrolled in VNS-REHAB.
Participants received 18 sessions of in-clinic intensive task-specific rehabilitation and 3 months of self-initiated home-based exercise with either real (active) or sham (control) vagus nerve stimulation. Thereafter, control participants crossed over to receive in-clinic therapy paired with active stimulation. All participants performed home-based exercises paired with self-initiated active stimulation for 1 year. The Fugl-Meyer Assessment UE, Wolf Motor Function Test, and participation outcomes were assessed through 12 months.
Seventy-four participants (69 per cent; 51 male; mean age 59 years) completed one-year follow-up and provided pooled data through one year. At one year, compared with baseline, there were improvements in impairment, activity and patient-reported outcomes. The authors concluded that paired vagus nerve stimulation maintained improvements in UE impairment, activity, participation, and quality-of-life measures at 1 year. Paired vagus nerve stimulation is a Food and Drug Administration–approved, beneficial treatment option for long-term benefit in individuals with chronic UE limitations after ischemic stroke.
References:
- Tariq S et al. Evaluation of balance and orthotic gait training techniques for rehabilitation in hemiplegic stroke patients. Scientific Reports (2025) 15:15059. https://doi.org/10.1038/s41598-025-98227-1.
- Lee JH et al. Effectiveness of Robot-Assisted Gait Training in Stroke Rehabilitation: A Systematic Review and Meta-Analysis. J. Clin. Med. 2025, 14, 4809. https://doi.org/10.3390/jcm14134809.
- Laver KE et al. Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2025, Issue 6. Art. No.: CD008349. DOI: 10.1002/14651858.CD008349.pub5.
- Liu Y et al. Virtual reality combined with task-oriented circuit training for upper limb rehabilitation in subacute stroke patients A randomized controlled trial. Medicine 2025;104:31(e43505). http://dx.doi.org/10.1097/MD.0000000000043505.
- Kimberley T et al. Long-Term Outcomes of Vagus Nerve Stimulation Paired With Upper Extremity Rehabilitation After Stroke. Stroke. 2025;56:2255–2265. DOI: 10.1161/STROKEAHA.124.050479.