Robot-Assisted Gait Rehabilitation in Stroke Patients - A Descriptive Retrospective Cohort Study

Keywords Gait, Rehabilitation, Stroke, Stroke rehabilitation, Patient discharge ALL Metrics - Views Downloads How to cite this article Tuliniemi K, Tuominen V, Herse F et al. Robot-Assisted Gait Rehabilitation in Stroke Patients - A Descriptive Retrospective Cohort Study [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:428 (https://doi.org/10.12688/f1000research.168911.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Research Article [version 1; peer review: 1 approved with reservations] Katja Tuliniemi1, Ville Tuominen2, Fredrik Herse3, [...] Katja Nolvi3, Mari Lahelma3, Anniina Cansel https://orcid.org/0000-0002-8903-2361 3, Hannu Kokki4Katja Tuliniemi1, Ville Tuominen2, [...] Fredrik Herse3, Katja Nolvi3, Mari Lahelma3, Anniina Cansel https://orcid.org/0000-0002-8903-2361 3, Hannu Kokki4 PUBLISHED 23 Mar 2026 Author details Author details 1 Wellbeing Services County of Central Ostrobothnia (Soite), Kokkola, Finland 2 Fysioline Oy, Tampere, Finland 3 Nordic Healthcare Group, Helsinki, Finland 4 School of Medicine, University of Eastern Finland, Kuopio, Finland 2 Fysioline Oy, Tampere, Finland 3 Nordic Healthcare Group, Helsinki, Finland 4 School of Medicine, University of Eastern Finland, Kuopio, Finland Katja Tuliniemi Roles: Conceptualization, Investigation, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing Roles: Conceptualization, Investigation, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing Ville Tuominen Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Fredrik Herse Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Katja Nolvi Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Mari Lahelma Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Anniina Cansel Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Hannu Kokki Roles: Conceptualization, Supervision, Writing – Review & Editing Roles: Conceptualization, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS This article is included in the Health Services gateway. Gait deficits are common after stroke and can cause severe physical limitations and high costs. Robot-assisted gait rehabilitation has been used for the last decades but there is a lack of real-world data on the effectiveness of walking therapy. This was evaluated in the present study. Observational retrospective registry-based study in Finland. Thirty-one acute stroke patients between late 2018 and 2022. Descriptive analysis was used to describe the characteristics of the patient population, the administration of the robot-assisted gait training, and the Functional Independence Measure. We analysed the changes over time in the robot rehabilitation parameters (steps, duration, average body weight support) with simple linear regression with rehabilitation parameter as a dependent variable and number of sessions as an independent variable, and significance of slope with t-test. The mean step count increased during 16 robot-assisted gait rehabilitation sessions from 563 steps to 1534 steps, the walking distance from 305 to 783 meters, and the Functional Independence Measure score from 54 to 94 points. Twenty-one (68%) patients were discharged from hospital to home. The real-life evidence of functional improvements during robot-assisted gait rehabilitation advocates for further research and incorporation of it in stroke rehabilitation. Gait, Rehabilitation, Stroke, Stroke rehabilitation, Patient discharge Corresponding Author(s) Anniina Cansel ([email protected]) Grant information: The study was funded by Fysioline Finland Oy, Tampere, Finland. AC, FH, KN, and ML are employees of Nordic Healthcare Group, which received funding from Fysioline Finland Oy in connection with the development of this manuscript. HK is a paid consultant for Fysioline Finland Oy. The funders were involved in shaping the study's design and contributing to the preparation of the manuscript. The funders had no role in data collection or analyses. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Tuliniemi K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Tuliniemi K, Tuominen V, Herse F et al. Robot-Assisted Gait Rehabilitation in Stroke Patients - A Descriptive Retrospective Cohort Study [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:428 (https://doi.org/10.12688/f1000research.168911.1) First published: 23 Mar 2026, 15:428 (https://doi.org/10.12688/f1000research.168911.1) Latest published: 23 Mar 2026, 15:428 (https://doi.org/10.12688/f1000research.168911.1) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Stroke is a major global health concern, ranking as the second leading cause of death and the third leading cause of death and disability combined (as expressed by disability-adjusted life-years [DALYs] lost) in the world. The burden of stroke has increased by 70% in the last three decades, with a global incidence of 13.8 million and an annual death toll of 5.5 million.1,2 In 2019, stroke accounted for 5.7% of the global disease burden.1 In Finland, stroke is the fourth leading cause of DALYs, with an incidence of 182 per 100,000 people and a prevalence of 1686 per 100,000 people in 2019.3 The economic burden of stroke is substantial, amounting to €745 billion globally (1.12% of the global gross domestic product, GDP). In Finland, the healthcare cost of stroke in 2017 was €640 million (3.1% of total healthcare costs), with a total DALYs cost of €1.1 milliard (0.5% of the GDP).4 These costs include immediate medical care, hospitalization, medications, and rehabilitation services, emphasizing the importance of post-stroke rehabilitation in achieving better functional outcomes and reducing long-term disability. Motor impairment of the lower extremities is one of the most important determinants of long-term disability.5 Conventional rehabilitation of stroke includes physical therapy among speech and occupational therapies. Part of physical therapy is gait rehabilitation with the guidance of physiotherapists and sometimes the use of a treadmill. Compared to conventional rehabilitation recent literature highlights the positive impact of robot-assisted gait training (RAGT) on functional outcomes in patients with severe stroke.6 RAGT has demonstrated effectiveness in improving gait parameters, including walking speed, step length, and symmetry.7 Furthermore, this technology provides the therapist with objective measures of the patient’s performance during the therapy and enables targeted intensive, task-specific training in a controlled environment to individual patient needs. RAGT is a more effective mode of rehabilitation for certain patient groups, e.g., individuals with severe to moderate impairments in walking abilities and functional mobility than conventional approaches.4,6 However, other studies, including the LEAPS trial by Duncan et al. and meta-analyses by Merholz et al. and Yamamoto et al., have questioned the superiority of RAGT compared to conventional training.8–10 These mixed findings highlight the need to understand better which patient groups may benefit most from RAGT. Therefore, more research is needed to define the effectivity of RAGT.11 Although RAGT therapy is used increasingly, there is still a knowledge gap between RAGT's efficacy, i.e., performance under ideal and controlled circumstances and its effectiveness, i.e., how well it works in normal clinical settings. These data are important as the economic costs for post-stroke care are substantial.4 Real-world data (RWD) generates additional evidence to that found in clinical research settings. Robust RWD can bridge the gap between research and clinical practice to better understand the clinical profile of patients as well as the value of using different treatment options. With this study, the aim was to increase understanding of RAGT for stroke patients based on retrospectively collected RWD from Soite, one of the 21 wellbeing services counties of Finland. The secondary aim was to describe how RAGT was administered in a real-world hospital-based setting as well as to extrapolate the potential benefits of rehabilitation robots in broader healthcare contexts in Soite. This observational retrospective study was conducted in Finland in the Wellbeing Services County of Central Ostrobothnia (Soite). The structured data was collected from patients who had a stroke between 2017 and 2022 and were treated in Soite’s hospital, focusing on the time of RAGT from late 2018 to 2022 (Table 1). Patients were excluded if their clinical condition rendered robotic therapy unsafe or unbeneficial. Otherwise, all patients meeting the inclusion criteria were eligible. Additionally, information from the patient’s medical history was collected from the system from 2010 onwards. Due to the registry-based nature of the study, informed consent was not required from the subjects (Act on the Secondary Use of Health and Social Data (552/2019)). The study was granted a research permit approved by the Wellbeing Services County of Central Ostrobothnia on 9.1.2023. This study was not preregistered. Data were gathered in the spring of 2023 retrospectively from electronic medical record (EMR) systems (Lifecare®, Tietoevry Oy, Espoo, Finland), Functional Independence Measure (FIM) score registry (FIM®-järjestelmä, FCG, Finnish Consulting Group Oy, Helsinki, Finland), and from the rehabilitation robot (Lokomat®, Hocoma AG, Volketswil, Switzerland) that was used at the Kokkola Central Hospital located in the Soite wellbeing services county. The structured EMR data included data on inpatient days, procedures, emergency department (ED) visits, physician, nurse, physiotherapist and other healthcare professional visits and consultations over the phone, diagnostics as well as sex, age, height, weight, and municipality of residence. The severity of the stroke was evaluated from the first recorded measurement, baseline, of the FIM score after the stroke had occurred. The patients were grouped into two groups (mild to moderate, and severe) according to the FIM score severity of the symptoms caused by the stroke, the FIM score can range between 18 = complete dependence/total assistance, and 126 = complete independence. Mild to moderate group scores were 65 or above and severe group scores were below 65. The patient data measured by the robot, and extracted from it, included distance in meters and number of steps, duration of the session, walking speed, body weight support, and guidance force. Body weight support is decreasing the amount of weight the patient needs to support with their lower extremities, and guidance force is the extent to which the patient’s movements are guided by the orthoses of the robot while walking.12 EMR data, the patient data extracted from the robot, and the FIM-score registry had been registered with the patient's unique identity code. The data were pseudonymized. The gathering, linking, and pseudonymising of data were done by Soite´s internal IT service. The study includes adult patients who experienced their first stroke between January 1, 2017, and December 31, 2022. Specifically, the study focuses on individuals who received robotic rehabilitation with the Lokomat® rehabilitation robot at Kokkola Central Hospital from late 2018 onwards, encompassing the years 2019–2022. The study population inclusion criteria were as follows: 1) stroke diagnosis [International Classification of Diseases 10th Revision (ICD-10) diagnostic codes I60-I68] recorded for the first time between January 1, 2017 and December 31, 2022, 2) acute hospitalisation (less than 90 days from stroke onset) in Soite’s hospital, 3) at least one RAGT session during the acute hospitalisation, and 4) municipality of residence in the Soite wellbeing services county. RAGT sessions were started according to the evaluation of the physiotherapists based on the patient’s general condition and the attending physician permission to start rehabilitation. The Lokomat® is a technologically advanced RAGT device used in neurological rehabilitation centres to complement conventional therapies. Over two decades ago, it was developed to enhance the rehabilitation of people with spinal cord injuries but nowadays it is used in numerous other conditions including stroke.13 Lokomat® rehabilitation robot is used to automate motor activities. It consists of a dynamic body weight supporting system used in conjunction with integrated exoskeleton robotic orthosis and treadmill which replicates the lower limb biomechanics of walking on the ground. Lokomat® measures and records information during the therapy sessions and that information was utilised in the study. Walking speed and guidance force were initially determined by physiotherapists based on each patient's clinical presentation. Adjustments were made dynamically across sessions to match improvements in strength, coordination, and tolerance. Speed was gradually increased, and guidance force was asymmetrically tailored to support the hemiplegic side. In addition to the aforementioned parameters, the Lokomat® measures and records biofeedback from the hip and knee in the stance and swing phases of the gait. Data were entered and analysed with R (version 4.3.0, R Core Team (2022). URL (https://www.R-project.org/). Normality was tested using Shapiro-Wilk’s normality test. Data are expressed as mean (SD) and median (IQRs) for continuous normally and non-normally distributed variables, respectively, and frequencies along with the number of cases (percentage) for categorical variables. The change over time in robot rehabilitation parameters (steps, duration, average body weight support %-average) was analysed using simple linear regression with the rehabilitation parameter as a dependent variable and the number of sessions as an independent variable. Progression of parameters was shown with regression lines for individual patients (with thin lines) and for all the patients with a 95% confidence interval (CI) (with thick lines). The significance of the slope was tested using a t-test. A two-sided p-value <0.05 was considered statistically significant. The results entail a description of patient characteristics (Table 2), information on RAGT administration (Table 3), development during the RAGT rehabilitation period in gait characteristics (Figure 1) and FIM scores, and data on where the patients were discharged from the hospitalisation period. | Patient characteristics | All | Mild to moderate, baseline FIM score ≥ 65 | Severe, baseline FIM score < 65 | Baseline FIM score not available | |---|---|---|---|---| | Number of patients | 31 | 7 | 17 | 7 | | Gender | |||| | Female | 12 (39 %) | <5 | 9 (53 %) | <5 | | Male | 19 (61 %) | ≥5 | 8 (47 %) | ≥5 | | Age, years | 70 (62–80) | 62 (56–74) | 73 (63–80) | 69 (60–75) | | Diagnosis group | |||| | I63, Cerebral infarction | 22 (71 %) | ≥5 | 12 (71 %) | ≥5 | | Other | 9 (29 %) | <5 | 5 (29 %) | 1 | 8 (26 %) | <5 | 6 (35 %) | <5 | | Number of RAGT sessions, sessions/patient | 7 (3–15) | 3 (2–15) | 9 (3–14) | 3 (2–13) | | Frequency of RAGT sessions, sessions/week/patient | 2.0 (1.1–2.7) | 2.5 (1.3–4.4) | 1.8 (1.1–2.3) | 2.0 (1.5–2.7) | A total of 31 patients met all the inclusion criteria. Variations in the number of patients analysed per parameter are due to incomplete data or early therapy termination. Twenty-four (77%) of the 31 patients had been through FIM evaluation at the beginning and at the end of their RAGT period and were assigned into groups according to the severity. One in three (eight patients, 33%) of the patients who had been through FIM evaluation used wheelchair as their main aid for locomotion before the rehabilitation. The progression of step count, walking distance and body weight support %-average over the course of rehabilitation of the patients is shown in Figure 1 for all the patients (thick line with 95% CI) and individual patients (thin lines). Step count increased significantly during RAGT sessions from 563 steps (95% CI 466–661) in the first session to 1534 steps (95% CI 1435–1633) in the 16th session (Figure 1). Consequently, the walking distance increased from 305 meters (95% CI 252–357) in the first session to 783 meters (95% CI 725–842) in the 16th session (P<0.0001). Body weight support %-average decreased during RAGT sessions from 67%-average (95% CI 65–69) in the first session to 56%-average (95% CI 54–57) in the 16th session. Twenty-four (77%) of the 31 patients who received RAGT had their FIM evaluation at the beginning of their rehabilitation and at the end of their rehabilitation. The total scores improved by median of 39 (IQR 26–50) points. The cognitive scores improved by 2 (IQR 0–6) points and the motor scores by 35 (IQR 27–48) points. The total FIM scores at the beginning of the rehabilitation were median of 53 (IQR 37–70) points, while cognitive scores were 30 (IQR 20–33) and motor scores 26 (IQR 19–37). At the end of rehabilitation, the total FIM scores were median of 94 (IQR 74–110) points meanwhile cognitive scores were 31 (IQR 26–33) points and motor scores 68 (IQR 45–77) points. Twenty-one (68%) of the 31 patients who received RAGT were discharged from the hospital to home, and ten to assisted living facilities. The majority (76%, n = 16) of those discharged home was discharged independently (or with the support of family members) without the assistance of home care. Half (53%, n = 9) of the 17 severe stroke patients were discharged to home, and six (67%) of them did not need the assistance of home care. In the past two decades, robot-assisted rehabilitation after stroke has been studied as a promising approach associated with improved functional outcomes and quality of life for individuals recovering from stroke. Our study undertook a thorough evaluation of the effectiveness of RAGT by integrating multiple key findings. Firstly, step count and walking distance increased over the course of rehabilitation, while body weight support decreased, suggesting improvements in mobility and ambulation among patients receiving RAGT. This tangible progress is particularly significant in the context of stroke recovery, where the restoration of ambulatory function is a pivotal goal. This finding is consistent with previous research that has shown that RAGT rehabilitation can improve substantially walking ability in people with stroke.14,15 Stroke survivors prefer improvements in their walking distance rather than their walking speed.16 In consistent to our data, a recent study has shown that intensive walking therapy can increase the step count during physical therapy substantially. In Klassen et al. study, the mean step count in the conventional rehabilitation was 580 steps per session, whereas in the intensive therapy group mean step count was over three-fold higher. Moreover, walking endurance benefits achieved were retained over the first year poststroke.17 Especially, RAGT in combination with conventional rehabilitation has shown better results than conventional rehabilitation on its own.14,18 FIM scores improved clinically significantly during the rehabilitation period in patients receiving RAGT. According to the literature the minimal clinically important difference (MCID) for FIM score is 22 (total FIM), 17 (motor FIM), and 3 (cognitive FIM).19 The improvements observed in this study, 39 points for the total FIM score and 35 points for the motor FIM score, were two-fold compared to the MCID. The cognitive FIM change was a little less than the proposed MCID. This is most likely due to higher cognitive scores at the baseline measurement which can be a reason for changes that are below MCID.19 Sufficient motor and cognitive functions are important measures of functional independence, and our findings suggest that RAGT may be associated with substantially improved ability to perform activities of daily living. Other studies have also found that RAGT is effective in improving e.g., FIM and other scores that measure gait independence.20,21 Consistent with our data, Peters et al. found that the high-intensity gait training may improve participants’ cognitive function modestly more effectively than the usual care.22 We found that guidance forces were applied asymmetrically between limbs, often providing more support to the hemiplegic side. This was an intentional clinical strategy to encourage symmetry and assist the impaired side while minimizing compensatory reliance on the unaffected side. This is supported by the data indicating that stroke is more common in the left hemisphere, and thus, more guidance force is needed for the right lower limb.23–25 This is likely because the left hemisphere is responsible for motor control, and damage to the left hemisphere can lead to more severe walking impairments. van Vliet et al have highlighted the importance of targeting rehabilitation interventions more specifically to individual stroke patients.26 RAGT is a preferred model as it allows this kind of rehabilitation tailored to the individual needs. Notably, a large proportion of patients with severe stroke receiving RAGT were discharged from hospital to home rather than to assisted living facilities. This outcome may reflect a potential cost-effectiveness of RAGT and the association between RAGT and increased patient independence and self-sufficiency, although causal inference cannot be drawn due to the study design. One study has found that of all stroke patients 78% were discharged to home and 22% to assisted living facilities.27 That study had included also patients with mild strokes and therefore the likelihood of being discharged to assisted living facilities was even lower compared to our study.27 In future more research, especially from randomized clinical trials, is needed to define the effectivity of RAGT. Robust RWD can bridge the gap between research and clinical practice to better understand the clinical profile of patients as well as the value of using different treatment options. Future research should investigate the long-term effects of RAGT on walking ability and function in people with stroke. Additionally, it is recommended that future real-world evidence research should include a bigger patient population to investigate the effectiveness of RAGT compared to other rehabilitation methods for stroke patients. A larger and more diverse patient population should be considered to thoroughly evaluate the comparative effectiveness of RAGT in contrast to alternative rehabilitation methods for individuals recovering from stroke. Additionally, future research employing a randomized controlled trial with a control group is necessary to confirm the observed trends and establish definitive causal relationships. It is essential to acknowledge certain limitations inherent in our study. Firstly, the number of patients with stroke receiving RAGT was notably small, which may impact the generalizability of our findings to a broader population. Additionally, due to retrospective data limitations, stroke subtype (ischemic vs haemorrhagic), NIHSS scores, cognitive assessments, and comorbidities were not consistently recorded or able to be retrieved from the EMR systems. Future studies should aim to include this information to better characterize treatment response and subgroup differences. The average session duration in this study was shorter than the 45–60 minutes commonly recommended in the literature. This reflects real-world clinical constraints, such as patient fatigue, scheduling limitations, and availability of trained staff. Furthermore, patients in the subacute phase may tolerate only shorter durations in body weight support level exceeded 50%, which is above the typically recommended threshold. This was necessary due to the severity of motor impairment and early stage of recovery in many patients. Although higher support levels may reduce active muscle effort, they were essential to ensure patient safety and facilitate consistent stepping patterns early in therapy. Furthermore, our study exclusively draws data from one wellbeing services county in Finland, potentially limiting the broader applicability of our results to a more diverse range of settings or regions. We also observed substantial variability in the number of RAGT sessions per patient (ranging from 2 to 15). This likely reflects clinical judgment, individual tolerance, and recovery trajectory. Future research could examine whether greater session frequency correlates with improved outcomes in a dose-response model. To thoroughly assess the effectiveness of RAGT, it would be valuable to compare outcomes with a control group or baseline measures to isolate the impact of the robotic intervention beyond typical recovery. Additionally, analysing patient characteristics and concurrent interventions can offer deeper insights into how RAGT influences post-stroke rehabilitation outcomes. These factors should be considered when interpreting and applying the implications of our study findings. Additionally, session parameters such as speed, body weight support, and guidance force were determined dynamically by the therapist rather than a fixed algorithm. While this approach enhances patient individualization, it may limit reproducibility and generalizability of the findings. In conclusion, our study has several important implications for the treatment of stroke patients. It suggests that early RAGT after stroke can improve walking ability, function, and discharge to home. These findings collectively advocate for the incorporation of RAGT into comprehensive stroke rehabilitation programs, paving the way for improved patient outcomes and post-stroke recovery trajectories. According to Finnish legislation, registry-base studies require a research permit from the health authority who owns the registry (Act on the Secondary Use of Health and Social Data; 552/2019, Finland). Ethical approval from ethics committee is needed only for interventional studies (Medical Research Act; 488/1999, Finland). Therefore, ethical approval was not required for the study. The study was granted a research permit approved by the Wellbeing Services County of Central Ostrobothnia on 9.1.2023. They also waived the need for ethical approval and informed consent, given the retrospective register-based study design. We confirm that all methods were carried out in accordance with relevant guidelines and regulations. The data underlying the results of this study are not publicly available because they comprise individual-level Finnish registry data containing personal (potentially identifiable) information. Under Finnish and EU data protection legislation (including GDPR) and the terms of the registry data permit(s) and confidentiality agreements, these data cannot be shared openly under an open licence. In this study, no separate ethics committee approval was required (explained below in the part of Ethical Approval). Data access is governed by the registry data owner & controller/permit authority Wellbeing Services County of Central Ostrobothnia, and may be granted only for specific, approved research purposes following a formal application and subject to data protection and security requirements. How to apply: Requests should be submitted to Wellbeing Services County of Central Ostrobothnia via [email protected]. The corresponding author can provide guidance on the application route and required documentation: [email protected] [corresponding author email]. Zenodo. STROBE checklist for RAGT Manuscript. https://doi.org/10.5281/zenodo.16740633.28 This project contains the following underlying data: Data is available under the terms of Creative Commons Attribution 4.0 International license. We would like to thank the physiotherapists Jenni Kujala and Jenny Wiklund, occupational therapist Johanna Jämsä as well as the head of informational services Kalle Tornberg and statistical designer Sirpa Lastikka for their contributions to the research. - 1. Feigin VL, Stark BA, Johnson CO, et al.: Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021; 20(10): 795–820. PubMed Abstract | Publisher Full Text | Free Full Text - 2. Saini V, Guada L, Yavagal DR: Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions. Neurology. 2021; 97(20): S6–S16. Publisher Full Text - 3. Finnish Brain Association: Infograph.2020 [cited 2024 Jan 19]. Reference Source - 4. Luengo-Fernandez R, Violato M, Candio P, et al.: Economic burden of stroke across Europe: A population-based cost analysis. Eur. Stroke J. 2020; 5(1): 17–25. Publisher Full Text - 5. 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Publisher Full Text Author details Author details 1 Wellbeing Services County of Central Ostrobothnia (Soite), Kokkola, Finland 2 Fysioline Oy, Tampere, Finland 3 Nordic Healthcare Group, Helsinki, Finland 4 School of Medicine, University of Eastern Finland, Kuopio, Finland 2 Fysioline Oy, Tampere, Finland 3 Nordic Healthcare Group, Helsinki, Finland 4 School of Medicine, University of Eastern Finland, Kuopio, Finland Katja Tuliniemi Roles: Conceptualization, Investigation, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing Roles: Conceptualization, Investigation, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing Ville Tuominen Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Fredrik Herse Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Katja Nolvi Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Mari Lahelma Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Anniina Cansel Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Hannu Kokki Roles: Conceptualization, Supervision, Writing – Review & Editing Roles: Conceptualization, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The study was funded by Fysioline Finland Oy, Tampere, Finland. AC, FH, KN, and ML are employees of Nordic Healthcare Group, which received funding from Fysioline Finland Oy in connection with the development of this manuscript. HK is a paid consultant for Fysioline Finland Oy. The funders were involved in shaping the study's design and contributing to the preparation of the manuscript. The funders had no role in data collection or analyses. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright © 2026 Tuliniemi K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics | Views | Downloads | | |---|---|---| | F1000Research | - | - | | PubMed Central Data from PMC are received and updated monthly. | - | - | Citations CITE how to cite this article Tuliniemi K, Tuominen V, Herse F et al. Robot-Assisted Gait Rehabilitation in Stroke Patients - A Descriptive Retrospective Cohort Study [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:428 (https://doi.org/10.12688/f1000research.168911.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 23 Mar 2026 Views 0 How to cite this report: Ahmed U. Reviewer Report For: Robot-Assisted Gait Rehabilitation in Stroke Patients - A Descriptive Retrospective Cohort Study [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:428 (https://doi.org/10.5256/f1000research.186133.r473155) The direct URL for this report is: https://f1000research.com/articles/15-428/v1#referee-response-473155 https://f1000research.com/articles/15-428/v1#referee-response-473155 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 25 Apr 2026 Umair Ahmed, University Institute of Physical Therapy, University of Lahore, Lahore, Pakistan Approved with Reservations VIEWS 0 Manuscript: Robot-Assisted Gait Rehabilitation in Stroke Patients – A Descriptive Retrospective Cohort Study Overall recommendation: Major revision required before approval This manuscript addresses an important clinical topic: the use of robot-assisted gait training (RAGT) in real-world stroke rehabilitation. ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close Overall recommendation: Major revision required before approval This manuscript addresses an important clinical topic: the use of robot-assisted gait training (RAGT) in real-world stroke rehabilitation. ... Continue reading Manuscript: Robot-Assisted Gait Rehabilitation in Stroke Patients – A Descriptive Retrospective Cohort Study Overall recommendation: Major revision required before approval This manuscript addresses an important clinical topic: the use of robot-assisted gait training (RAGT) in real-world stroke rehabilitation. The study provides useful descriptive data from a hospital-based Finnish cohort and reports improvements in step count, walking distance, body-weight support, FIM scores, and discharge outcomes. However, several methodological, analytical, and reporting issues limit the strength of the conclusions and should be addressed before the findings can be interpreted confidently. 1. The funding disclosure contains inconsistent information. One statement indicates that the funders were involved in shaping the study design and manuscript preparation, while another states that the funders had no role in study design, data analysis, publication decision, or manuscript preparation. This contradiction is important because it affects readers’ ability to judge the risk of reporting or interpretation bias. The authors should provide a clear phase-by-phase description of funder involvement in study conception, design, data collection, analysis, interpretation, manuscript writing, and publication decision-making. 2. Although Figure 1 presents individual patient regression lines, the manuscript does not clearly specify the unit of analysis used for the inferential slope test and 95% confidence interval of the group-level trend. The authors should clarify whether the reported regression and p-values were based on pooled session-level observations, patient-level slopes, or session-level summary values. If repeated session-level observations were pooled across patients, the analysis should account for within-patient clustering, for example using a linear mixed-effects model with patient as a random effect or a GEE approach. 3. The current conclusion implies that early RAGT can improve walking ability, function, and discharge home. This wording suggests a causal effect, which is not supported by the single-arm retrospective observational design. The discussion itself acknowledges that causal inference cannot be drawn. The conclusion should therefore be revised to use descriptive or associative language, such as “patients receiving RAGT showed improvements” or “RAGT was associated with functional gains.” The authors should also acknowledge that some observed improvements may reflect natural neurological recovery, concurrent rehabilitation, or patient selection rather than the effect of RAGT alone. 4. The manuscript classifies patients into mild-to-moderate and severe groups using a FIM cut-point of ≥65 and <65. However, no citation or clinical rationale is provided for this threshold. Since this classification is used in the descriptive tables and interpretation of severity groups, the authors should either cite a validated source for this cut-point or explain why this threshold was chosen in the present clinical context. 5. The manuscript does not adequately describe other rehabilitation therapies received alongside RAGT, such as conventional physiotherapy, occupational therapy, or speech therapy. This is clinically important because improvements in FIM and gait outcomes may be influenced by the total rehabilitation package rather than RAGT alone. The authors should provide a descriptive summary of concurrent rehabilitation, including type, frequency, and duration where available. 6. The baseline FIM is described as the first recorded FIM measurement after stroke, but the interval from stroke onset to baseline FIM and from stroke onset to first RAGT session is not reported. This information is important because early spontaneous recovery after stroke may contribute to observed functional improvements. The authors should report median time from stroke onset to first FIM assessment and to first RAGT session. 7. The manuscript states that patients were excluded if robotic therapy was unsafe or unbeneficial, but this criterion is not operationally defined. The authors should clarify how many patients were excluded for this reason, what clinical criteria were used, whether a standardized screening process existed, and whether these decisions were documented in the medical record. 8. Session duration is reported as an aggregate value, with a median duration of 21 minutes, but its progression across sessions is not shown. Since training duration is directly related to rehabilitation dose and neuroplastic adaptation, the authors should present session duration over time, similar to the figures for step count, walking distance, and body-weight support. This would help readers determine whether patients tolerated longer sessions over time or whether short sessions were consistent throughout treatment. 9. The authors reasonably explain that individual-level registry data cannot be made publicly available because of data protection restrictions. However, the R analysis code does not contain identifiable patient data and could be shared openly. Depositing the code on Zenodo or a similar repository would improve transparency, reproducibility, and confidence in the reported analyses. 10. The discussion links asymmetric guidance force to the idea that left-hemisphere stroke is more common and therefore more right-limb guidance force may be needed. This interpretation should be presented more cautiously. Guidance force was dynamically adjusted by physiotherapists according to individual clinical presentation, so the observed asymmetry may reflect patient-specific motor impairment rather than hemispheric lateralization alone. The authors should acknowledge this uncertainty and avoid presenting lateralization as a definitive explanation. Overall recommendation: Major revision required before approval This manuscript addresses an important clinical topic: the use of robot-assisted gait training (RAGT) in real-world stroke rehabilitation. The study provides useful descriptive data from a hospital-based Finnish cohort and reports improvements in step count, walking distance, body-weight support, FIM scores, and discharge outcomes. However, several methodological, analytical, and reporting issues limit the strength of the conclusions and should be addressed before the findings can be interpreted confidently. 1. The funding disclosure contains inconsistent information. One statement indicates that the funders were involved in shaping the study design and manuscript preparation, while another states that the funders had no role in study design, data analysis, publication decision, or manuscript preparation. This contradiction is important because it affects readers’ ability to judge the risk of reporting or interpretation bias. The authors should provide a clear phase-by-phase description of funder involvement in study conception, design, data collection, analysis, interpretation, manuscript writing, and publication decision-making. 2. Although Figure 1 presents individual patient regression lines, the manuscript does not clearly specify the unit of analysis used for the inferential slope test and 95% confidence interval of the group-level trend. The authors should clarify whether the reported regression and p-values were based on pooled session-level observations, patient-level slopes, or session-level summary values. If repeated session-level observations were pooled across patients, the analysis should account for within-patient clustering, for example using a linear mixed-effects model with patient as a random effect or a GEE approach. 3. The current conclusion implies that early RAGT can improve walking ability, function, and discharge home. This wording suggests a causal effect, which is not supported by the single-arm retrospective observational design. The discussion itself acknowledges that causal inference cannot be drawn. The conclusion should therefore be revised to use descriptive or associative language, such as “patients receiving RAGT showed improvements” or “RAGT was associated with functional gains.” The authors should also acknowledge that some observed improvements may reflect natural neurological recovery, concurrent rehabilitation, or patient selection rather than the effect of RAGT alone. 4. The manuscript classifies patients into mild-to-moderate and severe groups using a FIM cut-point of ≥65 and <65. However, no citation or clinical rationale is provided for this threshold. Since this classification is used in the descriptive tables and interpretation of severity groups, the authors should either cite a validated source for this cut-point or explain why this threshold was chosen in the present clinical context. 5. The manuscript does not adequately describe other rehabilitation therapies received alongside RAGT, such as conventional physiotherapy, occupational therapy, or speech therapy. This is clinically important because improvements in FIM and gait outcomes may be influenced by the total rehabilitation package rather than RAGT alone. The authors should provide a descriptive summary of concurrent rehabilitation, including type, frequency, and duration where available. 6. The baseline FIM is described as the first recorded FIM measurement after stroke, but the interval from stroke onset to baseline FIM and from stroke onset to first RAGT session is not reported. This information is important because early spontaneous recovery after stroke may contribute to observed functional improvements. The authors should report median time from stroke onset to first FIM assessment and to first RAGT session. 7. The manuscript states that patients were excluded if robotic therapy was unsafe or unbeneficial, but this criterion is not operationally defined. The authors should clarify how many patients were excluded for this reason, what clinical criteria were used, whether a standardized screening process existed, and whether these decisions were documented in the medical record. 8. Session duration is reported as an aggregate value, with a median duration of 21 minutes, but its progression across sessions is not shown. Since training duration is directly related to rehabilitation dose and neuroplastic adaptation, the authors should present session duration over time, similar to the figures for step count, walking distance, and body-weight support. This would help readers determine whether patients tolerated longer sessions over time or whether short sessions were consistent throughout treatment. 9. The authors reasonably explain that individual-level registry data cannot be made publicly available because of data protection restrictions. However, the R analysis code does not contain identifiable patient data and could be shared openly. Depositing the code on Zenodo or a similar repository would improve transparency, reproducibility, and confidence in the reported analyses. 10. The discussion links asymmetric guidance force to the idea that left-hemisphere stroke is more common and therefore more right-limb guidance force may be needed. This interpretation should be presented more cautiously. Guidance force was dynamically adjusted by physiotherapists according to individual clinical presentation, so the observed asymmetry may reflect patient-specific motor impairment rather than hemispheric lateralization alone. The authors should acknowledge this uncertainty and avoid presenting lateralization as a definitive explanation. - Is the work clearly and accurately presented and does it cite the current literature? Partly - Is the study design appropriate and is the work technically sound? Partly - Are sufficient details of methods and analysis provided to allow replication by others? Partly - If applicable, is the statistical analysis and its interpretation appropriate? Partly - Are all the source data underlying the results available to ensure full reproducibility? No source data required - Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Neurological Rehabilitation CITE HOW TO CITE THIS REPORT Ahmed U. Reviewer Report For: Robot-Assisted Gait Rehabilitation in Stroke Patients - A Descriptive Retrospective Cohort Study [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:428 (https://doi.org/10.5256/f1000research.186133.r473155) The direct URL for this report is: https://f1000research.com/articles/15-428/v1#referee-response-473155 https://f1000research.com/articles/15-428/v1#referee-response-473155 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | | |---|---| | 1 | | | Version 1 23 Mar 26 | read | - Umair Ahmed, University of Lahore, Lahore, Pakistan Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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