The effect of tilt-table robot-assisted training on functional outcomes in people with stroke and sarcopenia: a retrospective cohort study

The effect of tilt-table robot-assisted training on functional outcomes in people with stroke and sarcopenia: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of tilt-table robot-assisted training on functional outcomes in people with stroke and sarcopenia: a retrospective cohort study JunHo Seo, ChiBok Park, Soyeong Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6468495/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background This study aimed to compare rehabilitation outcomes between people with stroke who have sarcopenia and those without, stroke following tilt-table robot-assisted training. By analyzing differences in physical function between these groups, this study sought to identify the impact of sarcopenia on the effectiveness of rehabilitation. These findings are expected to offer clinical insights into the need for personalized rehabilitation strategies to optimize functional recovery in people with stroke and sarcopenia. Methods A total of 74 people with stroke who received tilt-table robot-assisted training at Gwangju G Rehabilitation Hospital between July 2022 and June 2024 were included. The participants were classified into two groups on the basis of the 2019 criteria established by the Asian Working Group for Sarcopenia (AWGS): those with sarcopenia (SRG) and those without sarcopenia (NSRG). All participants underwent a 4-week recovery-phase rehabilitation program that included tilt-table robot-assisted training (R-BOT+, CoTras, Republic of Korea), conducted five times a week for 30 minutes per session. Functional outcomes—including muscle strength (Manual Muscle Testing, MMT), balance (Berg Balance Scale, BBS), gait function (Functional Ambulation Categories, FAC), and activities of daily living (Korean version of the Modified Barthel Index, K-MBI)—were assessed before and after the intervention. The Wilcoxon signed-rank test was used for within-group comparisons, and the Mann–Whitney U test was used for between-group comparisons. Statistical significance was set at p < .05. Results Both groups showed significant improvements in muscle strength, balance, gait, and activities of daily living after the intervention (p < .05). However, between-group comparisons revealed significantly greater improvements in balance and activities of daily living in the group without sarcopenia (p .05). Conclusion Tilt-table robot-assisted training effectively improved muscle strength, balance, gait, and activities of daily living in people with stroke, regardless of sarcopenia status. However, individuals with both stroke and sarcopenia showed less improvement in balance and activities of daily living, underscoring the need for tailored rehabilitation strategies for this population. Trial registration: This trial was approved by the Public Institutional Review Board of the Ministry of Health and Welfare (P01–202411–01–011) and registered in the Clinical Research Information Service of Korea (KCT0010038). Robot-assisted training Sarcopenia Stroke Functional recovery Figures Figure 1 Introduction Stroke is a major global health concern, ranking as the second leading cause of death and the third leading cause of disability worldwide [ 1 ]. Although age-standardized incidence rates have declined, both the prevalence and incidence among individuals under the age of 70 have increased by 22% and 15%, respectively, underscoring the growing public health burden of stroke even in younger populations [ 2 ]. In particular, early-onset stroke—defined as stroke occurring before the age of 45—reduces productive life expectancy and often leads to long-term complications and residual impairments. These sequelae not only diminish the quality of life for people who experience a stroke but also impose considerable social and financial burdens on families and healthcare systems [ 3 ]. Accordingly, early diagnosis and timely rehabilitation interventions are essential for addressing these challenges. People with stroke commonly experience a range of functional impairments resulting from neuromuscular damage. In particular, muscle weakness and compromised balance can significantly limit independent ambulation and performance in activities of daily living (ADL) [ 4 , 5 ]. These impairments may persist beyond the acute phase, extending into the subacute and chronic stages, which highlights the importance of continuous rehabilitation efforts to support long-term functional recovery. In recent years, various therapeutic approaches have been explored to improve outcomes, and robot-assisted training has emerged as a promising and effective method [ 6 , 7 ]. Sarcopenia, first defined by Rosenberg in 1989, refers to the progressive loss of skeletal muscle mass and strength [ 8 ]. It is associated with an increased risk of falls, fractures, physical limitations, hospitalization, and mortality [ 9 ]. Diagnosis typically involves assessments of muscle mass, muscle strength, and physical performance [ 10 ]. Age-related muscle loss accelerates beginning in middle age, with skeletal muscle mass decreasing by approximately 6% per decade. This decline is driven by factors such as neurodegeneration, mitochondrial dysfunction, inflammation, and hormonal changes, all of which may contribute to reduced functional capacity and adverse health outcomes [ 11 – 13 ]. Among individuals with chronic health conditions, sarcopenia is widely recognized as a major risk factor. Its prevalence among people with stroke has been reported to range from 14–54% [ 11 ]. Stroke-related sarcopenia is particularly associated with poor rehabilitation outcomes and may hinder gains in ambulation and ADL performance [ 12 ]. Early identification of sarcopenia and implementation of tailored rehabilitation programs are therefore essential to support optimal recovery in this population. Robot-assisted therapy has gained increasing attention as a means to improve motor function in people with stroke. Among the available technologies, the tilt-table robot is designed to facilitate upright positioning, standing, and early gait training in individuals who are unable to stand independently. This device supports neuromuscular stimulation and promotes the activation of postural and lower limb muscles, thereby contributing to balance control [ 13 , 14 ]. Additionally, the interactive features and virtual reality environments incorporated into tilt-table robots may enhance participant motivation and engagement, further supporting functional recovery [ 13 ]. Compared with traditional rehabilitation approaches, tilt-table robots offer the added advantages of early upright positioning and consistent weight-bearing activities, which are essential for neuromuscular re-education. However, the effectiveness of tilt-table robot-assisted training in people with stroke who also have sarcopenia remains unclear. While some studies have demonstrated functional improvements following robot-assisted interventions in individuals with stroke, these benefits may be limited to those with impaired muscle function due to sarcopenia [ 15 ]. Given that sarcopenia is closely linked to functional decline and may influence rehabilitation outcomes, it is important to examine how this condition affects responses to robotic training. Despite growing interest in personalized rehabilitation, few studies have systematically assessed the differential outcomes of tilt-table robot-assisted therapy in people with and without sarcopenia. Individuals with sarcopenia may require modified or more intensive therapeutic strategies to achieve meaningful functional gains. Thus, there is a clear need to explore individualized approaches and determine whether rehabilitation outcomes vary depending on sarcopenia status. The purpose of this study was to examine the impact of sarcopenia on functional outcomes in people with stroke by comparing rehabilitation effects following tilt-table robot-assisted training between those with and without sarcopenia. The results provide clinical evidence to guide early, individualized rehabilitation strategies for optimizing recovery in people with stroke and sarcopenia. METHODS Study Procedure This retrospective study included data collected from 74 individuals with stroke who received tilt-table robot-assisted training at G Rehabilitation Hospital in Gwangju between July 1, 2022, and June 30, 2024, out of a total of 577 individuals who underwent rehabilitation during that period. Participants were classified into two groups based on the 2019 criteria of the Asian Working Group for Sarcopenia (AWGS), using skeletal muscle mass index (SMI) and handgrip strength: those with sarcopenia (SRG) and those without sarcopenia (NSRG). A total of 45 participants were assigned to the SRG and 29 to the NSRG. Both groups received the same recovery-phase rehabilitation program, which included tilt-table robot-assisted training. Participants The participants were individuals who were diagnosed with hemiplegia due to stroke, which was confirmed by Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging, and who received tilt-table robot-assisted training within six months of stroke onset. The exclusion criteria were as follows: (1) individuals who experienced recurrent hemorrhage or infarction after the initial diagnosis; (2) those with severe orthopedic conditions, such as multiple fractures; (3) those with vestibular, visual, or auditory impairments that could affect balance or gait; and (4) cases in which data collection was likely to significantly influence study outcomes. Intervention All the participants received tilt-table robot-assisted training via the R-BOT+ (R-BOT+, CoTras, Republic of Korea) for four weeks, five sessions per week, with each session lasting 30 minutes. The system offers multiple training modes passive, active, active-assisted, and resistance and provides partial body weight support via a harness and fixation device. Unlike conventional tilt- tables, the robotic system supports an upright posture and enables repetitive stepping and alternating leg movements through knee flexion and extension. A monitor displays visual cues, such as foot movements, to stimulate engagement and provide real-time feedback during training. The robot is equipped with a functional electrical stimulation (FES) system synchronized with robotic movements. This system includes eight channels delivering stimulation to the bilateral rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius muscles. The participants were categorized into two groups on the basis of the presence or absence of sarcopenia, as defined by the 2019 criteria of the AWGS [ 9 ]. Sarcopenia was diagnosed when both the SMI and handgrip strength fell below established thresholds: SMI < 7.0 kg/m² for men and < 5.7 kg/m² for women; and handgrip strength < 28 kg for men and < 18 kg for women. SMI was measured via bioelectrical impedance analysis (BIA) with a BWA 2.0 device (InBody, Seoul, Republic of Korea), which was conducted in either the supine or standing position depending on the participant’s condition. Handgrip strength was assessed by an occupational therapist via a Jamar hydraulic hand dynamometer (B&L Engineering, Santa Ana, CA, USA). When both hands could be evaluated, the higher value was recorded; otherwise, the single available measurement was used. The final diagnosis of sarcopenia was confirmed by a rehabilitation medicine specialist. Outcome Measure Muscle Manual Test (MMT) Muscle strength was evaluated for 12 bilateral muscle groups of the upper and lower extremities: shoulder flexion and abduction, elbow flexion and extension, wrist flexion and extension, hip flexion and extension, knee flexion and extension, and ankle dorsiflexion and plantar flexion. Each muscle group was graded from 1 point (grade 0) to 6 points (grade 5), yielding a maximum possible score of 144 [ 16 ]. Berg balance scale (BBS) Balance ability was assessed by evaluating the participant’s stability while sitting, standing, and performing position transitions. The maximum score was 56, with higher scores reflecting better balance performance [ 17 ]. Functional ambulation category (FAC) Gait function was measured on the basis of the level of assistance required for ambulation, regardless of the use of assistive devices. Gait independence was rated on a seven-point scale, with scores ranging from 0 to 6 points [ 18 ]. Korean modified bathel index (K-MBI) ADL function was assessed via a scale consisting of 10 subtasks, each scored from 0 to 5 on the basis of the level of assistance needed. The total possible score was 100, with higher scores indicating greater independence in daily activities [ 19 ]. Statistical anaiysis The sample size was calculated via G*Power 3.1 software with a significance level (α) of 0.05, effect size (d) of 0.8, and power (1-β) of 0.8, resulting in a minimum requirement of 26 participants per group (total n = 52). To account for a 10% dropout rate, 28 participants were included in each group (total n = 56). Statistical analyses were performed via SPSS version 27 for Windows. As the data did not meet the assumption of normality, nonparametric tests were employed. The Kruskal-Wallis test was used for between-group comparisons, and the Wilcoxon signed-rank test was used for within-group comparisons. The significance level was set at p < 0.05 for all analyses. RESULTS General characteristics of the participants A total of 74 participants were included in the study, with 45 assigned to the SRG and 29 assigned to the NSRG. The general characteristics of the participants are presented in Table 1 . Table 1 General characteristics of the subjects Total (74) SRG (45) NSRG (29) Sex (Male : Female) 35:39 19:26 16:13 Age (yr) 67.53 ± 13.62 a 70.42 ± 12.53 63.03 ± 14.23 Height (cm) 162.26 ± 8.99 161.64 ± 8.37 163.21 ± 9.91 Body weight (kg) 60.77 ± 12.06 56.20 ± 10.36 67.87 ± 11.17 Cause of lesion (Infarction : hemorrhage) 35:39 23:22 12:17 K-MMSE (Score) 11.24 ± 7.85 10.56 ± 7.95 12.31 ± 7.71 SMI(kg/m 2 ) 6.70 ± 4.82 6.40 ± 6.16 7.15 ± 1.06 Phase angle(°) 4.48 ± 1.57 3.93 ± 1.13 5.32 ± 1.80 a Mean±SD, SRG : Participants diagnosed with stroke and sarcopenia undergoing tilt table robot-assisted training, NSRG : Participants with stroke and no sarcopenia undergoing tilt table robot assisted training, K-MMSE : Korean Mini Mental State Examination, SMI : Skeletal muscle mass Changes in muscle strength Both the SRG and NSRG demonstrated significant within-group improvements in muscle strength following the intervention (p 0.05). Changes in balance Significant within-group improvements in balance were observed in both groups (p < 0.05). In addition, a significant between-group difference was found, favoring the NSRG (p < 0.05). Changes in gait Both groups showed significant within-group improvements in gait function (p 0.05). Changes in activities of daily living Significant within-group improvements in ADL performance were observed in both the SRG and NSRG (p < 0.05). Moreover, a significant between-group difference was identified (p < 0.05), with the NSRG demonstrating greater improvement. Table 2 Comparison of Pre- and Post intervention Outcomes between the SRG and NSRG Variable Group Pre Post Change P P MMT (Score) SRG 86.89 ± 18.34 92.40 ± 17.60 5.51 ± 8.39 0.001* 0.061 NSRG 90.34 ± 12.38 98.90 ± 13.75 8.55 ± 9.12 0.001* BBS (Score) SRG 3.07 ± 4.94 7.80 ± 10.61 4.73 ± 8.79 0.001* 0.005 + NSRG 2.07 ± 2.35 13.90 ± 14.03 11.83 ± 14.05 0.001* FAC (Score) SRG 0.11 ± 0.31 0.47 ± 0.75 0.36 ± 0.74 0.002* 0.113 NSRG 0.07 ± 0.25 0.69 ± 0.85 0.62 ± 0.86 0.002* K-MBI (Score) SRG 12.00 ± 10.68 20.64 ± 15.07 8.64 ± 10.61 0.001* 0.008 + NSRG 10.59 ± 9.59 28.97 ± 18.42 18.38 ± 16.66 0.001* a Mean±SD, SRG : Participants diagnosed with stroke and sarcopenia undergoing tilt table robot-assisted training, NSRG : Participants with stroke and no sarcopenia undergoing tilt table robot assisted training, MMT : muscle manual test, BBS : Berg balance scale, FAC : Functional ambulation category, K-MBI : Korean modified bathel index, Wilcoxon signed-rank test * p < .05, Mann–Whitney U test + p < .05 DISCUSSION This study evaluated the effects of tilt-table robot-assisted training on physical function in individuals with stroke, comparing those with and without sarcopenia. The findings revealed significant improvements in muscle strength, balance, gait, and ADL in both groups. These results suggest that tilt-table robot-assisted training is effective for enhancing early functional recovery regardless of sarcopenia status. Muscle strength improved significantly in both the SRG and the NSRG, with no significant between-group differences. These findings indicate that tilt-table robot-assisted training can effectively increase muscle strength irrespective of sarcopenia status. Muscle weakness is a common consequence of stroke due to neuromuscular impairment; however, the repetitive and structured standing and weight-bearing movements facilitated by this robotic intervention may support neuromuscular adaptation and strength recovery [ 20 , 21 ]. In particular, the environmental feedback provided in the upright position and training protocols that stimulate neuroplasticity may further enhance muscle performance [ 22 , 23 ]. The fact that strength gains were also observed in individuals with sarcopenia suggests that this approach may be beneficial for promoting neuromuscular activation and mitigating muscle dysfunction in this population. Balance significantly improved within both groups, but a notable between-group difference was observed, with individuals without sarcopenia showing greater gains. Sarcopenia is associated with impaired balance and an increased risk of falls, largely due to reduced muscle mass and strength [ 24 , 25 ]. These physical limitations may have attenuated the extent of balance improvement in the SRG [ 26 ]. While tilt-table robot-assisted training enhances postural control by facilitating repetitive practice of upright standing and weight shifting, individuals with sarcopenia may benefit from additional targeted interventions—such as resistance training or proprioceptive exercises—to address their specific deficits [ 27 , 28 ]. Gait function also improved significantly in both groups, with no significant differences between them. These findings suggest that the intervention was equally effective in improving gait, regardless of sarcopenia status. The body weight-supported environment of the tilt-table robot enables safe and effective practice of coordinated stepping movements [ 29 ]. This repetitive gait training, combined with neuromuscular stimulation, may contribute to cortical reorganization and improved locomotor function [ 30 , 31 ]. These findings highlight the potential of tilt-table robot-assisted training as a valuable tool in early gait rehabilitation for individuals with stroke, including those at risk for sarcopenia. ADL performance significantly improved in both groups, and a significant difference between groups was identified. Improvements in ADL are closely linked to enhancements in balance and gait function [ 32 ]. However, individuals with sarcopenia may face persistent challenges in daily activities due to muscle fatigue and reduced endurance [ 33 , 34 ]. Although the intervention contributed to greater independence, the relatively smaller gains observed in the SRG suggest that individualized strategies may be necessary to fully support functional recovery in this population. Tailored rehabilitation programs incorporating endurance and functional strength training may be particularly beneficial. Overall, the findings of this study indicate that tilt-table robot-assisted training is effective in improving physical function in individuals with stroke, including those with sarcopenia. While the intervention yielded benefits across all functional domains, the relatively smaller improvements in balance and ADL among participants with sarcopenia underscore the need for individualized rehabilitation strategies to optimize outcomes. This study has several limitations. This was a retrospective, single-center study with a limited sample size and short intervention duration. Additionally, variability in sarcopenia diagnostic criteria and assessment tools across studies may limit the generalizability of the findings. Future research should involve larger, multicenter trials with long-term follow-up to examine the sustained effects of tilt-table robot-assisted training. Further exploration of tailored rehabilitation strategies may contribute to more effective early interventions and improved physical independence for individuals with stroke and sarcopenia. CONCLUSION This study compared the effects of tilt-table robot-assisted training on physical function in individuals with stroke, with and without sarcopenia. The findings revealed significant improvements in muscle strength, balance, gait, and ADL across both groups, indicating the overall effectiveness of the intervention regardless of sarcopenia status. However, individuals at risk for sarcopenia exhibited relatively smaller gains in balance and ADL performance. These results highlight the importance of developing individualized rehabilitation strategies to address the specific needs of this population and to further promote physical independence and quality of life during stroke recovery. Abbreviations AWGS Asian working group for sarcopenia BIA Bioelectrical impedance analysis SMI Skeletal muscle mass index K-MMSE Korean mini mental state exam SRG Participants diagnosed with stroke and sarcopenia undergoing tilt table robot-assisted training NSRG Participants with stroke and no sarcopenia undergoing tilt table robot assisted training ADL activities of daily living MMT muscle manual test BBS Berg balance scale FAC Functional ambulation category K-MBI Korean modified bathel index FES Functional electrical stimulation MRI Magnetic Resonance Imaging CT Computed Tomography Declarations Acknowledgment Not applicable. Authors' contributions This study was conceptualized and designed by J.-H. S. and S.-Y. K. The methodology was also developed by J.-H. S. and S.-Y. K. Software development, validation, formal analysis, data curation, and resource management were conducted by C.-B. P. The investigation was carried out by J.-H. S. The original draft of the manuscript was written by J.-H. S. and S.-Y. K., who also reviewed and edited the final version. Tables 1 and 2 were created by J.-H. S. and S.-Y. K., while Figure 1 was prepared by C.-B. P. The overall supervision and project administration were managed by S.-Y. K. All authors have read and approved the final version of the manuscript for publication. Funding No funding was received for this study. Availability of data and materials The data are not publicly available owing to institutional policies and privacy restrictions but are available from the corresponding author upon reasonable request. Ethics approval and consent to participate This study was approved by the Public Institutional Review Board of the Ministry of Health and Welfare (Approval No. P01-202411-01-011) and registered with the Clinical Research Information Service of Korea (Registration No. KCT0010038). In addition, a waiver of informed consent was granted by the ethics committee. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1 Department of Physical Therapy, Graduate School, Nambu University, Gwangju, Korea. ² Gwangju 365 Rehablitation Hospital, Gwangju, Korea. 3 Department of Physical Therapy, Nambu University, Gwangju, Korea. References GBD 2019 Stroke Collaborators. 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. Béjot Y, Delpont B, Giroud M. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6468495","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":457439903,"identity":"c4dfa8bb-94a1-498e-80cd-b25b54960236","order_by":0,"name":"JunHo Seo","email":"","orcid":"","institution":"Gwangju 365 Rehabilitation Hospital","correspondingAuthor":false,"prefix":"","firstName":"JunHo","middleName":"","lastName":"Seo","suffix":""},{"id":457439904,"identity":"03ab9a8f-5a96-4340-8a21-793fa665c897","order_by":1,"name":"ChiBok Park","email":"","orcid":"","institution":"Nambu University","correspondingAuthor":false,"prefix":"","firstName":"ChiBok","middleName":"","lastName":"Park","suffix":""},{"id":457439905,"identity":"26146951-4bd3-43f9-adf3-f30ab6a3d4d1","order_by":2,"name":"Soyeong Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBACAwbmxgMgBhsz8wFitTA2gJXysbMlkKhFjp/HgDgt5uyNDQc+ttkktjHzfHvws80mn4H98NEN+LRY9hxsODizLQ2ohXe7YW9bmmUDT1raDbwOu5HYcJi37TBIyzYJnjOHDRgkeMzwa7n/sOHwX7AWnmeSf878J0LLDcaGw4wQLWzSPBUHCGux7ElsONhzLs24jZnNTFqmItmAjZBfzNkPH3zwo8xGdn7/4WeSbwzsDPjZDx/DqwUMGNmQOGw4laGAP8QpGwWjYBSMghEKAIGnSyMcm+lsAAAAAElFTkSuQmCC","orcid":"","institution":"Gwangju 365 Rehabilitation Hospital","correspondingAuthor":true,"prefix":"","firstName":"Soyeong","middleName":"","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2025-04-17 06:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6468495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6468495/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83040836,"identity":"c6c1c274-2487-4906-899a-7daef5cabb3d","added_by":"auto","created_at":"2025-05-19 10:41:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":180795,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Procedure\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6468495/v1/d2ded80fe65d269be2698a4b.png"},{"id":83041576,"identity":"e74b1d11-4559-4cc3-a0fd-66792242e49b","added_by":"auto","created_at":"2025-05-19 10:49:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":897924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6468495/v1/6cda83e2-4e56-456f-8b41-0d0de1cefe84.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of tilt-table robot-assisted training on functional outcomes in people with stroke and sarcopenia: a retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is a major global health concern, ranking as the second leading cause of death and the third leading cause of disability worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although age-standardized incidence rates have declined, both the prevalence and incidence among individuals under the age of 70 have increased by 22% and 15%, respectively, underscoring the growing public health burden of stroke even in younger populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In particular, early-onset stroke\u0026mdash;defined as stroke occurring before the age of 45\u0026mdash;reduces productive life expectancy and often leads to long-term complications and residual impairments. These sequelae not only diminish the quality of life for people who experience a stroke but also impose considerable social and financial burdens on families and healthcare systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Accordingly, early diagnosis and timely rehabilitation interventions are essential for addressing these challenges.\u003c/p\u003e \u003cp\u003ePeople with stroke commonly experience a range of functional impairments resulting from neuromuscular damage. In particular, muscle weakness and compromised balance can significantly limit independent ambulation and performance in activities of daily living (ADL) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These impairments may persist beyond the acute phase, extending into the subacute and chronic stages, which highlights the importance of continuous rehabilitation efforts to support long-term functional recovery. In recent years, various therapeutic approaches have been explored to improve outcomes, and robot-assisted training has emerged as a promising and effective method [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSarcopenia, first defined by Rosenberg in 1989, refers to the progressive loss of skeletal muscle mass and strength [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is associated with an increased risk of falls, fractures, physical limitations, hospitalization, and mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Diagnosis typically involves assessments of muscle mass, muscle strength, and physical performance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Age-related muscle loss accelerates beginning in middle age, with skeletal muscle mass decreasing by approximately 6% per decade. This decline is driven by factors such as neurodegeneration, mitochondrial dysfunction, inflammation, and hormonal changes, all of which may contribute to reduced functional capacity and adverse health outcomes [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong individuals with chronic health conditions, sarcopenia is widely recognized as a major risk factor. Its prevalence among people with stroke has been reported to range from 14\u0026ndash;54% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Stroke-related sarcopenia is particularly associated with poor rehabilitation outcomes and may hinder gains in ambulation and ADL performance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Early identification of sarcopenia and implementation of tailored rehabilitation programs are therefore essential to support optimal recovery in this population.\u003c/p\u003e \u003cp\u003eRobot-assisted therapy has gained increasing attention as a means to improve motor function in people with stroke. Among the available technologies, the tilt-table robot is designed to facilitate upright positioning, standing, and early gait training in individuals who are unable to stand independently. This device supports neuromuscular stimulation and promotes the activation of postural and lower limb muscles, thereby contributing to balance control [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, the interactive features and virtual reality environments incorporated into tilt-table robots may enhance participant motivation and engagement, further supporting functional recovery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Compared with traditional rehabilitation approaches, tilt-table robots offer the added advantages of early upright positioning and consistent weight-bearing activities, which are essential for neuromuscular re-education.\u003c/p\u003e \u003cp\u003eHowever, the effectiveness of tilt-table robot-assisted training in people with stroke who also have sarcopenia remains unclear. While some studies have demonstrated functional improvements following robot-assisted interventions in individuals with stroke, these benefits may be limited to those with impaired muscle function due to sarcopenia [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Given that sarcopenia is closely linked to functional decline and may influence rehabilitation outcomes, it is important to examine how this condition affects responses to robotic training.\u003c/p\u003e \u003cp\u003eDespite growing interest in personalized rehabilitation, few studies have systematically assessed the differential outcomes of tilt-table robot-assisted therapy in people with and without sarcopenia. Individuals with sarcopenia may require modified or more intensive therapeutic strategies to achieve meaningful functional gains. Thus, there is a clear need to explore individualized approaches and determine whether rehabilitation outcomes vary depending on sarcopenia status.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to examine the impact of sarcopenia on functional outcomes in people with stroke by comparing rehabilitation effects following tilt-table robot-assisted training between those with and without sarcopenia. The results provide clinical evidence to guide early, individualized rehabilitation strategies for optimizing recovery in people with stroke and sarcopenia.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Procedure\u003c/h2\u003e \u003cp\u003eThis retrospective study included data collected from 74 individuals with stroke who received tilt-table robot-assisted training at G Rehabilitation Hospital in Gwangju between July 1, 2022, and June 30, 2024, out of a total of 577 individuals who underwent rehabilitation during that period. Participants were classified into two groups based on the 2019 criteria of the Asian Working Group for Sarcopenia (AWGS), using skeletal muscle mass index (SMI) and handgrip strength: those with sarcopenia (SRG) and those without sarcopenia (NSRG). A total of 45 participants were assigned to the SRG and 29 to the NSRG. Both groups received the same recovery-phase rehabilitation program, which included tilt-table robot-assisted training.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe participants were individuals who were diagnosed with hemiplegia due to stroke, which was confirmed by Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) imaging, and who received tilt-table robot-assisted training within six months of stroke onset. The exclusion criteria were as follows: (1) individuals who experienced recurrent hemorrhage or infarction after the initial diagnosis; (2) those with severe orthopedic conditions, such as multiple fractures; (3) those with vestibular, visual, or auditory impairments that could affect balance or gait; and (4) cases in which data collection was likely to significantly influence study outcomes.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eAll the participants received tilt-table robot-assisted training via the R-BOT+ (R-BOT+, CoTras, Republic of Korea) for four weeks, five sessions per week, with each session lasting 30 minutes. The system offers multiple training modes passive, active, active-assisted, and resistance and provides partial body weight support via a harness and fixation device. Unlike conventional tilt- tables, the robotic system supports an upright posture and enables repetitive stepping and alternating leg movements through knee flexion and extension. A monitor displays visual cues, such as foot movements, to stimulate engagement and provide real-time feedback during training.\u003c/p\u003e \u003cp\u003eThe robot is equipped with a functional electrical stimulation (FES) system synchronized with robotic movements. This system includes eight channels delivering stimulation to the bilateral rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius muscles.\u003c/p\u003e \u003cp\u003eThe participants were categorized into two groups on the basis of the presence or absence of sarcopenia, as defined by the 2019 criteria of the AWGS [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Sarcopenia was diagnosed when both the SMI and handgrip strength fell below established thresholds: SMI\u0026thinsp;\u0026lt;\u0026thinsp;7.0 kg/m\u0026sup2; for men and \u0026lt;\u0026thinsp;5.7 kg/m\u0026sup2; for women; and handgrip strength\u0026thinsp;\u0026lt;\u0026thinsp;28 kg for men and \u0026lt;\u0026thinsp;18 kg for women. SMI was measured via bioelectrical impedance analysis (BIA) with a BWA 2.0 device (InBody, Seoul, Republic of Korea), which was conducted in either the supine or standing position depending on the participant\u0026rsquo;s condition. Handgrip strength was assessed by an occupational therapist via a Jamar hydraulic hand dynamometer (B\u0026amp;L Engineering, Santa Ana, CA, USA). When both hands could be evaluated, the higher value was recorded; otherwise, the single available measurement was used. The final diagnosis of sarcopenia was confirmed by a rehabilitation medicine specialist.\u003c/p\u003e\n\u003ch3\u003eOutcome Measure\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eMuscle Manual Test (MMT)\u003c/h2\u003e \u003cp\u003eMuscle strength was evaluated for 12 bilateral muscle groups of the upper and lower extremities: shoulder flexion and abduction, elbow flexion and extension, wrist flexion and extension, hip flexion and extension, knee flexion and extension, and ankle dorsiflexion and plantar flexion. Each muscle group was graded from 1 point (grade 0) to 6 points (grade 5), yielding a maximum possible score of 144 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBerg balance scale (BBS)\u003c/h2\u003e \u003cp\u003eBalance ability was assessed by evaluating the participant\u0026rsquo;s stability while sitting, standing, and performing position transitions. The maximum score was 56, with higher scores reflecting better balance performance [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFunctional ambulation category (FAC)\u003c/h3\u003e\n\u003cp\u003eGait function was measured on the basis of the level of assistance required for ambulation, regardless of the use of assistive devices. Gait independence was rated on a seven-point scale, with scores ranging from 0 to 6 points [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eKorean modified bathel index (K-MBI)\u003c/h3\u003e\n\u003cp\u003eADL function was assessed via a scale consisting of 10 subtasks, each scored from 0 to 5 on the basis of the level of assistance needed. The total possible score was 100, with higher scores indicating greater independence in daily activities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical anaiysis\u003c/h2\u003e \u003cp\u003e The sample size was calculated via G*Power 3.1 software with a significance level (α) of 0.05, effect size (d) of 0.8, and power (1-β) of 0.8, resulting in a minimum requirement of 26 participants per group (total n\u0026thinsp;=\u0026thinsp;52). To account for a 10% dropout rate, 28 participants were included in each group (total n\u0026thinsp;=\u0026thinsp;56). Statistical analyses were performed via SPSS version 27 for Windows. As the data did not meet the assumption of normality, nonparametric tests were employed. The Kruskal-Wallis test was used for between-group comparisons, and the Wilcoxon signed-rank test was used for within-group comparisons. The significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eGeneral characteristics of the participants\u003c/h2\u003e \u003cp\u003eA total of 74 participants were included in the study, with 45 assigned to the SRG and 29 assigned to the NSRG. The general characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral characteristics of the subjects\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(74)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003cp\u003e(45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNSRG\u003c/p\u003e \u003cp\u003e(29)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (Male : Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35:39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19:26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16:13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (yr)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.53\u0026thinsp;\u0026plusmn;\u0026thinsp;13.62\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.42\u0026thinsp;\u0026plusmn;\u0026thinsp;12.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.03\u0026thinsp;\u0026plusmn;\u0026thinsp;14.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162.26\u0026thinsp;\u0026plusmn;\u0026thinsp;8.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161.64\u0026thinsp;\u0026plusmn;\u0026thinsp;8.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e163.21\u0026thinsp;\u0026plusmn;\u0026thinsp;9.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody weight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.77\u0026thinsp;\u0026plusmn;\u0026thinsp;12.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.20\u0026thinsp;\u0026plusmn;\u0026thinsp;10.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause of lesion\u003c/p\u003e \u003cp\u003e(Infarction : hemorrhage)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35:39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23:22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12:17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK-MMSE (Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.24\u0026thinsp;\u0026plusmn;\u0026thinsp;7.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMI(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase angle(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eMean\u0026plusmn;SD, \u003cem\u003eSRG\u003c/em\u003e: Participants diagnosed with stroke and sarcopenia undergoing tilt table robot-assisted training, \u003cem\u003eNSRG\u003c/em\u003e: Participants with stroke and no sarcopenia undergoing tilt table robot assisted training, \u003cem\u003eK-MMSE\u003c/em\u003e: Korean Mini Mental State Examination, \u003cem\u003eSMI\u003c/em\u003e: Skeletal muscle mass\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eChanges in muscle strength\u003c/h2\u003e \u003cp\u003eBoth the SRG and NSRG demonstrated significant within-group improvements in muscle strength following the intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, no significant between-group differences were detected (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eChanges in balance\u003c/h2\u003e \u003cp\u003eSignificant within-group improvements in balance were observed in both groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In addition, a significant between-group difference was found, favoring the NSRG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eChanges in gait\u003c/h2\u003e \u003cp\u003eBoth groups showed significant within-group improvements in gait function (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there was no significant difference between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eChanges in activities of daily living\u003c/h2\u003e \u003cp\u003eSignificant within-group improvements in ADL performance were observed in both the SRG and NSRG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Moreover, a significant between-group difference was identified (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with the NSRG demonstrating greater improvement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Pre- and Post intervention Outcomes between the SRG and NSRG\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMMT (Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.89\u0026thinsp;\u0026plusmn;\u0026thinsp;18.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.40\u0026thinsp;\u0026plusmn;\u0026thinsp;17.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.51\u0026thinsp;\u0026plusmn;\u0026thinsp;8.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.34\u0026thinsp;\u0026plusmn;\u0026thinsp;12.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98.90\u0026thinsp;\u0026plusmn;\u0026thinsp;13.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.55\u0026thinsp;\u0026plusmn;\u0026thinsp;9.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBBS (Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.80\u0026thinsp;\u0026plusmn;\u0026thinsp;10.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;8.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003e0.005\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.90\u0026thinsp;\u0026plusmn;\u0026thinsp;14.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.83\u0026thinsp;\u0026plusmn;\u0026thinsp;14.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFAC (Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eK-MBI (Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.64\u0026thinsp;\u0026plusmn;\u0026thinsp;15.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.64\u0026thinsp;\u0026plusmn;\u0026thinsp;10.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003e0.008\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNSRG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.59\u0026thinsp;\u0026plusmn;\u0026thinsp;9.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.97\u0026thinsp;\u0026plusmn;\u0026thinsp;18.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eMean\u0026plusmn;SD, \u003cem\u003eSRG\u003c/em\u003e: Participants diagnosed with stroke and sarcopenia undergoing tilt table robot-assisted training, \u003cem\u003eNSRG\u003c/em\u003e: Participants with stroke and no sarcopenia undergoing tilt table robot assisted training, \u003cem\u003eMMT\u003c/em\u003e: muscle manual test, \u003cem\u003eBBS\u003c/em\u003e: Berg balance scale, \u003cem\u003eFAC\u003c/em\u003e: Functional ambulation category, \u003cem\u003eK-MBI\u003c/em\u003e: Korean modified bathel index, Wilcoxon signed-rank test \u003csup\u003e*\u003c/sup\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.05, Mann\u0026ndash;Whitney U test\u003csup\u003e+\u003c/sup\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study evaluated the effects of tilt-table robot-assisted training on physical function in individuals with stroke, comparing those with and without sarcopenia. The findings revealed significant improvements in muscle strength, balance, gait, and ADL in both groups. These results suggest that tilt-table robot-assisted training is effective for enhancing early functional recovery regardless of sarcopenia status.\u003c/p\u003e \u003cp\u003eMuscle strength improved significantly in both the SRG and the NSRG, with no significant between-group differences. These findings indicate that tilt-table robot-assisted training can effectively increase muscle strength irrespective of sarcopenia status. Muscle weakness is a common consequence of stroke due to neuromuscular impairment; however, the repetitive and structured standing and weight-bearing movements facilitated by this robotic intervention may support neuromuscular adaptation and strength recovery [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In particular, the environmental feedback provided in the upright position and training protocols that stimulate neuroplasticity may further enhance muscle performance [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The fact that strength gains were also observed in individuals with sarcopenia suggests that this approach may be beneficial for promoting neuromuscular activation and mitigating muscle dysfunction in this population.\u003c/p\u003e \u003cp\u003eBalance significantly improved within both groups, but a notable between-group difference was observed, with individuals without sarcopenia showing greater gains. Sarcopenia is associated with impaired balance and an increased risk of falls, largely due to reduced muscle mass and strength [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These physical limitations may have attenuated the extent of balance improvement in the SRG [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. While tilt-table robot-assisted training enhances postural control by facilitating repetitive practice of upright standing and weight shifting, individuals with sarcopenia may benefit from additional targeted interventions\u0026mdash;such as resistance training or proprioceptive exercises\u0026mdash;to address their specific deficits [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGait function also improved significantly in both groups, with no significant differences between them. These findings suggest that the intervention was equally effective in improving gait, regardless of sarcopenia status. The body weight-supported environment of the tilt-table robot enables safe and effective practice of coordinated stepping movements [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This repetitive gait training, combined with neuromuscular stimulation, may contribute to cortical reorganization and improved locomotor function [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These findings highlight the potential of tilt-table robot-assisted training as a valuable tool in early gait rehabilitation for individuals with stroke, including those at risk for sarcopenia.\u003c/p\u003e \u003cp\u003eADL performance significantly improved in both groups, and a significant difference between groups was identified. Improvements in ADL are closely linked to enhancements in balance and gait function [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, individuals with sarcopenia may face persistent challenges in daily activities due to muscle fatigue and reduced endurance [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Although the intervention contributed to greater independence, the relatively smaller gains observed in the SRG suggest that individualized strategies may be necessary to fully support functional recovery in this population. Tailored rehabilitation programs incorporating endurance and functional strength training may be particularly beneficial.\u003c/p\u003e \u003cp\u003eOverall, the findings of this study indicate that tilt-table robot-assisted training is effective in improving physical function in individuals with stroke, including those with sarcopenia. While the intervention yielded benefits across all functional domains, the relatively smaller improvements in balance and ADL among participants with sarcopenia underscore the need for individualized rehabilitation strategies to optimize outcomes.\u003c/p\u003e \u003cp\u003eThis study has several limitations. This was a retrospective, single-center study with a limited sample size and short intervention duration. Additionally, variability in sarcopenia diagnostic criteria and assessment tools across studies may limit the generalizability of the findings. Future research should involve larger, multicenter trials with long-term follow-up to examine the sustained effects of tilt-table robot-assisted training. Further exploration of tailored rehabilitation strategies may contribute to more effective early interventions and improved physical independence for individuals with stroke and sarcopenia.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study compared the effects of tilt-table robot-assisted training on physical function in individuals with stroke, with and without sarcopenia. The findings revealed significant improvements in muscle strength, balance, gait, and ADL across both groups, indicating the overall effectiveness of the intervention regardless of sarcopenia status. However, individuals at risk for sarcopenia exhibited relatively smaller gains in balance and ADL performance. These results highlight the importance of developing individualized rehabilitation strategies to address the specific needs of this population and to further promote physical independence and quality of life during stroke recovery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eAWGS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cp\u003eAsian working group for sarcopenia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eBIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cp\u003eBioelectrical impedance analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eSMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cp\u003eSkeletal muscle mass index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eK-MMSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eKorean mini mental state exam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eSRG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eParticipants diagnosed with stroke and sarcopenia undergoing tilt table robot-assisted training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNSRG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eParticipants with stroke and no sarcopenia undergoing tilt table robot assisted training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eactivities of daily living\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eMMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003emuscle manual test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eBBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eBerg balance scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eFunctional ambulation category\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eK-MBI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eKorean modified bathel index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eFunctional electrical stimulation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eMagnetic Resonance Imaging\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eComputed Tomography\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conceptualized and designed by J.-H. S. and S.-Y. K. The methodology was also developed by J.-H. S. and S.-Y. K. Software development, validation, formal analysis, data curation, and resource management were conducted by C.-B. P. The investigation was carried out by J.-H. S. The original draft of the manuscript was written by J.-H. S. and S.-Y. K., who also reviewed and edited the final version. \u003cstrong\u003eTables 1 and 2 were created by J.-H. S. and S.-Y. K., while Figure 1 was prepared by C.-B. P.\u003c/strong\u003e The overall supervision and project administration were managed by S.-Y. K. All authors have read and approved the final version of the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are not publicly available owing to institutional policies and privacy restrictions but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Public Institutional Review Board of the Ministry of Health and Welfare (Approval No. P01-202411-01-011) and registered with the Clinical Research Information Service of Korea (Registration No. KCT0010038). In addition, a waiver of informed consent was granted by the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003eDepartment of Physical Therapy, Graduate School, Nambu University, Gwangju, Korea. ² Gwangju 365 Rehablitation Hospital, Gwangju, Korea. \u003csup\u003e3\u003c/sup\u003eDepartment of Physical Therapy, Nambu University, Gwangju, Korea.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGBD 2019 Stroke Collaborators. 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. \u003c/li\u003e\n\u003cli\u003eB\u0026eacute;jot Y, Delpont B, Giroud M. Rising stroke incidence in young adults: more epidemiological evidence, more questions to be answered. J Am Heart Assoc. 2016;5:e003661.\u003c/li\u003e\n\u003cli\u003eYousufuddin M, Young N. Aging and ischemic stroke. Aging (Albany NY). 2019;11(9):2542-44. \u003c/li\u003e\n\u003cli\u003eGhika-Schmid F, Ghika J, Regli F, Bogousslavsky J. Hyperkinetic movement disorders during and after acute stroke: the lausanne stroke registry. J Neurol Sci. 1997;146(2):109-16.\u003c/li\u003e\n\u003cli\u003eKim JS. Delayed onset mixed involuntary movements after thalamic stroke: clinical, radiological and pathophysiological findings. Brain. 2001;124(Pt 2):299-309.\u003c/li\u003e\n\u003cli\u003eTater P, Pandey S. Post stroke movement disorders: clinical spectrum, pathogenesis, and management. Neurol India. 2021;69(2):272-83.\u003c/li\u003e\n\u003cli\u003eGalv\u0026atilde;o ACJ, Dias C, Miranda AL, Moura D, Palhares CVT, Oliveira Leopoldino A, Polese JC. Stroke related sarcopenia in individuals with different physical activity levels: a cross-sectional study. Physiother Res Int. 2024 Apr;29(2):e2084.\u003c/li\u003e\n\u003cli\u003eCruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruy\u0026egrave;re O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing group for the european working group on sarcopenia in older people 2 (EWGSOP2), and the extended group for EWGSOP2. Sarcopenia: revised european consensus on definition and diagnosis. Age Aging. 2019;48(1):16\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eChen, L. K., Woo, J., Assantachai, P., Auyeung, T. W., Chou, M. Y., Iijima, K., Jang, H. C., Kang, L., Kim, M., Kim, S., Kojima, T., Kuzuya, M., Lee, J. S. W., Lee, S. Y., Lee, W. J., Lee, Y., Liang, C. K., Lim, J. Y., Lim, W. S., Peng, L. N., \u0026hellip; Arai, H. Asian working group for sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21(3):300-7.e2.\u003c/li\u003e\n\u003cli\u003eAbe T, Iwata K, Yoshimura Y, Shinoda T, Inagaki Y, Ohya S, Yamada K, Oyanagi K, Maekawa Y, Honda A, Kohara N, Tsubaki A. Low muscle mass is associated with walking function in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis. 2020;29(11):105259.\u003c/li\u003e\n\u003cli\u003eMas MF, Gonz\u0026aacute;lez J, Frontera WR. Stroke and sarcopenia. Curr Phys Med Rehabil Rep. 2020;8(4):452-60.\u003c/li\u003e\n\u003cli\u003eYoshimura Y, Wakabayashi H, Bise T, Nagano F, Shimazu S, Shiraishi A, Yamaga M, Koga H. Sarcopenia is associated with worse recovery of physical function and dysphagia and a lower rate of home discharge in japanese hospitalized adults undergoing convalescent rehabilitation. Nutrition. 2019;61:111\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKwon SC, Shin WS. Comparison of robotic tilt-table training and body weight support treadmill training on lower extremity strength, balance, gait, and satisfaction with rehabilitation, in patients with subacute stroke. J Korean Soc Phys Med. 2020;15(4):163\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eKim SY, Kim BG, Cho WS, Park CB. Effects of gait training using a robot for balance in total hip arthroplasty patients after bilateral avascular necrosis: a case study. J Korean Phys Ther. 2021;33(5):231\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eYoo SD, Lee HH. The effect of robot-assisted training on arm function, walking, balance, and activities of daily living after stroke: a systematic review and meta-analysis. Brain Neurorehabil. 2023;16(3):e24.\u003c/li\u003e\n\u003cli\u003eKim SY, Cho WS, Park CB, Kim BG. Effect of sarcopenia on functional recovery in acute stroke patients admitted for standard rehabilitation program. Medicina (Kaunas). 2024;60(10):1716.\u003c/li\u003e\n\u003cli\u003eBlum L, Korner-Bitensky N. Usefulness of the berg balance scale in stroke rehabilitation: a systematic review. Phys Ther. 2008;88(5):559-66.\u003c/li\u003e\n\u003cli\u003eMehrholz J, Wagner K, Rutte K, Meissner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007;88(10):1314-9.\u003c/li\u003e\n\u003cli\u003eOhura T, Hase K, Nakajima Y, Nakayama T. Validity and reliability of a performance evaluation tool based on the modified barthel index for stroke patients. BMC Med Res Methodol. 2017;17(1):131.\u003c/li\u003e\n\u003cli\u003eHyun SJ, Lee J, Lee BH. The effects of sit to stand training combined with real time visual feedback on strength, balance, gait ability, and quality of life in patients with stroke: a randomized controlled trial. Int J Environ Res Public Health. 2021;18(22):12229.\u003c/li\u003e\n\u003cli\u003eGil-Castillo J, Barria P, Aguilar C\u0026aacute;rdenas R, Baleta Abarza K, Andrade Gallardo A, Biskupovic Mancilla A, Azor\u0026iacute;n JM, Moreno JC. A robot-assisted therapy to increase muscle strength in hemiplegic gait rehabilitation. Front Neurorobot. 2022;16:837494.\u003c/li\u003e\n\u003cli\u003ePollock A, Gray C, Culham E, Durward BR, Langhorne P. Interventions for improving sit-to-stand ability following stroke. Cochrane Database Syst Rev. 2014;2014(5):CD007232.\u003c/li\u003e\n\u003cli\u003eJames E, Nichols S, Goodall S, Hicks KM, O\u0026apos;Doherty AF. The influence of resistance training on neuromuscular function in middle-aged and older adults: a systematic review and meta-analysis of randomised controlled trials. Exp Gerontol. 2021;149:111320.\u003c/li\u003e\n\u003cli\u003eS\u0026aacute;nchez-Rodr\u0026iacute;guez D, Marco E, Miralles R, et al. Sarcopenia, physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit. Arch Gerontol Geriatr. 2014;59(1):39-43.\u003c/li\u003e\n\u003cli\u003eGadelha AB, Neri SGR, Oliveira RJ, et al. Severity of sarcopenia is associated with postural balance and risk of falls in community-dwelling older women. Exp Aging Res. 2018;44(3):258-69.\u003c/li\u003e\n\u003cli\u003eFhon JRS, Silva ARF, Lima EFC, et al. Association between Sarcopenia, falls, and cognitive impairment in older people: a systematic review with meta-analysis. Int J Environ Res Public Health. 2023;20(5):4156.\u003c/li\u003e\n\u003cli\u003eKim CY, Lee JS, Kim HD, Kim J, Lee IH. Lower extremity muscle activation and function in progressive task-oriented training on the supplementary tilt table during stepping-like movements in patients with acute stroke hemiparesis. J Electromyogr Kinesiol. 2015;25(3):522-30.\u003c/li\u003e\n\u003cli\u003eOzaki K, Kondo I, Hirano S, et al. Training with a balance exercise assist robot is more effective than conventional training for frail older adults. Geriatr Gerontol Int. 2017;17(11):1982-90. \u003c/li\u003e\n\u003cli\u003eKuznetsov AN, Rybalko NV, Daminov VD, Luft AR. Early poststroke rehabilitation using a robotic tilt-table stepper and functional electrical stimulation. Stroke Res Treat. 2013;2013:946056.\u003c/li\u003e\n\u003cli\u003eHesse S, Malezic M, Schaffrin A, Mauritz KH. Restoration of gait by combined treadmill training and multichannel electrical stimulation in nonambulatory hemiparetic patients. Scand J Rehabil Med. 1995;27(4):199-204.\u003c/li\u003e\n\u003cli\u003eHe R, Dong Y, Li Y, et al. Therapeutic and orthotic effects of an adaptive functional electrical stimulation system on gait biomechanics in participants with stroke. J Neuroeng Rehabil. 2025;22(1):62.\u003c/li\u003e\n\u003cli\u003eShen Y, Shi Q, Nong K, et al. Exercise for sarcopenia in older people: a systematic review and network meta-analysis. J Cachexia Sarcopenia Muscle. 2023;14(3):1199-211.\u003c/li\u003e\n\u003cli\u003eYoshimura Y, Wakabayashi H, Bise T, Tanoue M. Prevalence of sarcopenia and its association with activities of daily living and dysphagia in convalescent rehabilitation ward inpatients. Clin Nutr. 2018;37(6 Pt A):2022-8.\u003c/li\u003e\n\u003cli\u003eLandi F, Calvani R, Cesari M, et al. Sarcopenia as the biological substrate of physical frailty. Clin Geriatr Med. 2015;31(3):367-74.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuroengineering-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jner","sideBox":"Learn more about [Journal of NeuroEngineering and Rehabilitation](http://jneuroengrehab.biomedcentral.com/)","snPcode":"12984","submissionUrl":"https://submission.nature.com/new-submission/12984/3","title":"Journal of NeuroEngineering and Rehabilitation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Robot-assisted training, Sarcopenia, Stroke, Functional recovery","lastPublishedDoi":"10.21203/rs.3.rs-6468495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6468495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to compare rehabilitation outcomes between people with stroke who have sarcopenia and those without, stroke following tilt-table robot-assisted training. By analyzing differences in physical function between these groups, this study sought to identify the impact of sarcopenia on the effectiveness of rehabilitation. These findings are expected to offer clinical insights into the need for personalized rehabilitation strategies to optimize functional recovery in people with stroke and sarcopenia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 74 people with stroke who received tilt-table robot-assisted training at Gwangju G Rehabilitation Hospital between July 2022 and June 2024 were included. The participants were classified into two groups on the basis of the 2019 criteria established by the Asian Working Group for Sarcopenia (AWGS): those with sarcopenia (SRG) and those without sarcopenia (NSRG). All participants underwent a 4-week recovery-phase rehabilitation program that included tilt-table robot-assisted training (R-BOT+, CoTras, Republic of Korea), conducted five times a week for 30 minutes per session. Functional outcomes\u0026mdash;including muscle strength (Manual Muscle Testing, MMT), balance (Berg Balance Scale, BBS), gait function (Functional Ambulation Categories, FAC), and activities of daily living (Korean version of the Modified Barthel Index, K-MBI)\u0026mdash;were assessed before and after the intervention. The Wilcoxon signed-rank test was used for within-group comparisons, and the Mann\u0026ndash;Whitney U test was used for between-group comparisons. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBoth groups showed significant improvements in muscle strength, balance, gait, and activities of daily living after the intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;.05). However, between-group comparisons revealed significantly greater improvements in balance and activities of daily living in the group without sarcopenia (p\u0026thinsp;\u0026lt;\u0026thinsp;.05). No significant differences in muscle strength or gait function were detected between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTilt-table robot-assisted training effectively improved muscle strength, balance, gait, and activities of daily living in people with stroke, regardless of sarcopenia status. However, individuals with both stroke and sarcopenia showed less improvement in balance and activities of daily living, underscoring the need for tailored rehabilitation strategies for this population.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003e This trial was approved by the Public Institutional Review Board of the Ministry of Health and Welfare (P01\u0026ndash;202411\u0026ndash;01\u0026ndash;011) and registered in the Clinical Research Information Service of Korea (KCT0010038).\u003c/p\u003e","manuscriptTitle":"The effect of tilt-table robot-assisted training on functional outcomes in people with stroke and sarcopenia: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 10:40:59","doi":"10.21203/rs.3.rs-6468495/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-04T14:04:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-06T04:22:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T06:42:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26187801074863430402138068382842243886","date":"2025-05-20T08:39:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212342512017371853830869010591979071010","date":"2025-05-16T06:40:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-14T18:20:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T17:40:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-29T07:52:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of NeuroEngineering and Rehabilitation","date":"2025-04-17T06:07:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuroengineering-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jner","sideBox":"Learn more about [Journal of NeuroEngineering and Rehabilitation](http://jneuroengrehab.biomedcentral.com/)","snPcode":"12984","submissionUrl":"https://submission.nature.com/new-submission/12984/3","title":"Journal of NeuroEngineering and Rehabilitation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92508f3c-882a-4179-913b-78b816829db6","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-19T11:08:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 10:40:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6468495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6468495","identity":"rs-6468495","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}