High-Intensity Gait Training After Stroke According to ESO 2025 Recommendations

Gait as a Central Goal in Stroke Rehabilitation

Recovering the ability to walk is, consistently, the most cited goal by people who have suffered a stroke. Gait is not merely a means of locomotion: it constitutes a fundamental pillar of functional independence, social participation and quality of life. Inability to walk autonomously is associated with greater dependence in activities of daily living, social isolation and an increased risk of secondary cardiovascular disease arising from prolonged sedentariness.

It is estimated that between 60% and 80% of people who survive a stroke present gait impairments in the first weeks. Although many patients achieve some degree of ambulation, walking speed and endurance are frequently significantly reduced compared with pre-event levels. A gait speed below 0.8 m/s is considered a marker of community functional limitation, and many patients remain below this threshold even after completing conventional rehabilitation programmes.

In this context, the relevant clinical question is: what is the optimal training intensity to maximise functional gains without compromising safety? The most recent European guidelines, published by the European Stroke Organisation (ESO) in 2025, provide evidence-based recommendations informed by evidence accumulated over the past decade.

European Stroke Organisation (ESO) 2025 Recommendations

The ESO 2025 stroke rehabilitation guidelines represent a substantial update compared with previous recommendations. Regarding gait training, the guidelines incorporate the growing evidence in favour of high-intensity approaches and provide more specific guidance on training parameters.

ESO 2025 recommendations suggest that task-oriented gait training, performed at moderate-to-high cardiovascular intensities, can contribute to clinically relevant improvements in gait speed and endurance in people after stroke. The guidelines highlight the importance of gradual intensity progression, cardiovascular monitoring and individualisation of the programme according to each patient's characteristics.

Evidence suggests that training intensity is a key modulating factor in post-stroke gait rehabilitation outcomes. High-intensity programmes, adequately supervised, may offer superior benefits to those of conventional intensity.

— Adapted from ESO 2025 recommendations on gait rehabilitation

A relevant aspect of ESO 2025 guidelines is the distinction between cardiovascular intensity (measured by heart rate or perceived exertion scale) and the simple quantity of practice. Programmes that increase only the volume of repetitions without reaching sufficient cardiovascular thresholds may not produce the same physiological adaptations as genuinely high-intensity approaches.

Scientific Evidence: High Intensity vs. Conventional Training

The body of evidence supporting high-intensity gait training in stroke rehabilitation has consolidated considerably in recent years. Several clinical trials and meta-analyses provide data that contextualise current recommendations.

Meta-Analysis by Klassen et al. (2020)

The meta-analysis published by Klassen and colleagues in 2020 systematically examined the effects of aerobic exercise training intensity on cardiorespiratory capacity and gait function in people with stroke. Results indicated that high-intensity programmes were associated with statistically significant improvements in maximum oxygen consumption (VO2 max) and gait speed, compared with conventional or low-intensity programmes. The authors concluded that training intensity is a determining factor in the magnitude of the functional response.

Clinical Practice Guideline by Hornby et al. (2020)

The clinical practice guideline (CPG) published by Hornby and colleagues in 2020 through the Academy of Neurologic Physical Therapy is a reference document in this field. This guideline explicitly recommends that locomotor training for people with stroke be performed at high intensities, defined as walking at 70–80% of estimated maximum heart rate or at gait speeds close to the patient's functional limit. The guideline emphasises that low-intensity approaches —common in routine clinical practice— may be insufficient to generate the desired neuroplastic and cardiovascular adaptations.

Hornby et al. also note that routine clinical practice tends to underestimate the exercise capacity of stroke patients and that there is a wide margin for safely increasing intensity in most cases, provided adequate supervision and monitoring are in place.

Study by Moore et al. (2020)

Moore and colleagues (2020) provided additional evidence through a clinical trial directly comparing the effects of high-intensity versus conventional-intensity gait training in patients in the subacute phase of stroke. Results suggested that the high-intensity group showed greater improvements in gait speed and in the 6-minute walk test (6MWT), an indicator of functional endurance. The authors noted that high-intensity training was well tolerated by participants and that the incidence of adverse events did not differ significantly between groups.

The Role of the Robotic Gait Training System in High-Intensity Rehabilitation

The robotic gait training system is a technological tool designed to facilitate intensive gait training with partial body weight support. This device allows the patient to practise the gait pattern on a treadmill while a robotic system guides lower limb movement, offering a variable degree of assistance adjusted to each person's abilities.

Cochrane Review by Mehrholz et al. (2020)

The Cochrane review published by Mehrholz and colleagues in 2020, an update of previous reviews, analysed the effects of electromechanical and robot-assisted gait training in people after stroke. Results of this systematic review, which included 62 clinical trials with more than 2,400 participants, indicated that the combination of robot-assisted gait training with conventional physiotherapy can increase the probability of achieving independent gait compared with physiotherapy alone.

Mehrholz et al.'s findings suggest that the benefits of robotic gait training may be particularly relevant in the following situations:

• Acute and subacute phase (first three months post-stroke): the period in which neuroplasticity is at its peak and intensive repetitive practice can contribute to greater functional gains.
• Patients with severe gait inability: people who cannot walk independently and who, without robotic assistance, would have very limited gait practice volume.
• Combined with conventional physiotherapy: the Cochrane review underlines that robotic training produces the best results as a complement to conventional rehabilitation, not as a substitute for it.

Advantages of Robotic Gait Training System Training

• High volume of repetitive practice: the device allows hundreds of gait cycles to be performed in a single session, a volume difficult to achieve with manual gait training.
• Precise parameter control: treadmill speed, percentage of body weight support, degree of robotic assistance and session duration are controlled with precision.
• Safety during intensive training: the suspension harness and robotic support minimise the risk of falls, allowing higher training intensities to be reached more safely.
• Objectifiable gradual progression: training parameters can be progressively adjusted and documented session by session.
• Facilitation of physiological gait pattern: the robotic system guides the lower limbs through a normalised gait trajectory, which can contribute to motor relearning.

Training Parameters: How High Intensity is Applied

Gait Speed

Treadmill speed is progressively adjusted, aiming for the patient to walk at the highest speed they can maintain with an acceptable gait pattern. On the robotic gait training system, speed can be increased from initial values of 0.5–1.0 km/h to speeds of 2.0–3.0 km/h or higher depending on patient progress. The goal is for training speed to constitute a genuine cardiovascular and motor challenge, not comfortable walking.

Body Weight Support

The percentage of body weight offloaded through the suspension harness is progressively reduced as the patient improves. A typical protocol may start with 30–40% body weight support and reduce it to 0–10% in advanced phases. Reducing body weight support is itself a form of intensity progression, as it forces the patient to bear greater load during walking.

Target Heart Rate

Following the recommendations of Hornby et al. (2020) and ESO 2025 guidelines, the target cardiovascular intensity is generally set between 60% and 80% of estimated maximum heart rate (usually calculated as 220 minus the patient's age, although more precise formulas or exercise tests may be used). For patients taking beta-blocker medications, which alter the heart rate response, the Borg perceived exertion scale (RPE) is recommended as a complementary indicator, seeking values of 13–15 on the 6–20 point scale (perceived exertion “somewhat hard” to “hard”).

Session Duration and Frequency

Available evidence suggests gait training sessions of 20 to 40 minutes of effective duration (active walking time), performed at a frequency of 3 to 5 sessions per week. Protocols from the most relevant clinical trials typically include blocks of 4 to 12 weeks of training. Total programme duration is individualised based on objectives, patient response and phase of stroke evolution.

Safety: Monitoring and Exclusion Criteria

Cardiovascular Monitoring

During each high-intensity training session, continuous monitoring of the following parameters is recommended:

• Heart rate: via pulse oximetry or continuous heart rate monitor. Individualised upper limits are established.
• Blood pressure: measured before, during (at rest breaks) and after the session. It is recommended to stop training if systolic blood pressure exceeds 200 mmHg or diastolic exceeds 110 mmHg.
• Oxygen saturation: particularly relevant in patients with cardiopulmonary comorbidity.
• Perceived exertion (Borg scale): as a complement to objective measurements.
• Warning signs and symptoms: chest pain, excessive dyspnoea, dizziness, pallor, confusion or any new neurological sign.

Exclusion Criteria and Precautions

Not all patients are candidates for high-intensity gait training. Among the most frequent exclusion criteria in research protocols:

• Unstable cardiac disease (recent acute myocardial infarction, unstable angina, decompensated heart failure).
• Uncontrolled cardiac arrhythmias.
• Uncontrolled hypertension (SBP >180 mmHg or DBP >100 mmHg at rest).
• Active deep vein thrombosis or recent pulmonary embolism.
• Musculoskeletal injuries preventing standing or assisted walking.
• Unhealed fractures of the lower limbs or pelvis.
• Severe cognitive impairment preventing understanding of basic safety instructions.

Gradual Progression

A fundamental principle of high-intensity training applied to stroke rehabilitation is gradual progression. Protocols recommend starting at moderate intensities (50–60% of maximum heart rate) and progressively increasing towards the high-intensity range (70–80%) over the first sessions, provided the patient tolerates increments adequately. This gradual progression allows safe cardiovascular adaptation and reduces the risk of adverse events.

Practical Application at GNeuro Ourense

At GNeuro, a robotic neurorehabilitation centre located in Ourense, high-intensity gait training is integrated as part of a comprehensive and individualised rehabilitation programme. The centre has a robotic gait training system that allows the high-intensity protocols described in the scientific evidence to be implemented, under the supervision of physiotherapists specialised in neurorehabilitation.

• Initial multidisciplinary assessment: each patient is evaluated by a team including rehabilitation physician and specialist physiotherapist before starting the gait training programme.
• Programme individualisation: parameters of speed, weight support, robotic assistance and cardiovascular intensity are adjusted to each patient's characteristics, goals and tolerance.
• Continuous monitoring: heart rate, blood pressure and relevant clinical signs are monitored during each session.
• Integration with conventional rehabilitation: following Cochrane review recommendations (Mehrholz et al., 2020), robotic gait training system training is used as a complement to conventional physiotherapy, not as a substitute.
• Objective registration and follow-up: session parameters are systematically recorded, allowing progress to be objectified and the programme adjusted over time.

Frequently Asked Questions

References

1. European Stroke Organisation (ESO). Guidelines on Stroke Rehabilitation. European Stroke Journal. 2025. Available at: eso-stroke.org
2. Klassen TD, Dukelow SP, Bayley MT, et al. Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation. Stroke. 2020;51(9):2639-2648. doi:10.1161/STROKEAHA.120.029245
3. Hornby TG, Reisman DS, Ward IG, et al. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. J Neurol Phys Ther. 2020;44(1):49-100. doi:10.1097/NPT.0000000000000303
4. Moore JL, Roth EJ, Killian C, Hornby TG. Locomotor Training Improves Daily Stepping Activity and Gait Efficiency in Individuals Poststroke Who Have Reached a Plateau in Recovery. Stroke. 2020;51(10):2891-2900. doi:10.1161/STROKEAHA.119.027789
5. Mehrholz J, Thomas S, Kugler J, Pohl M, Elsner B. Electromechanical-Assisted Training for Walking After Stroke. Cochrane Database Syst Rev. 2020;10(10):CD006185. doi:10.1002/14651858.CD006185.pub5
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7. Globas C, Becker C, Cerny J, et al. Chronic Stroke Survivors Benefit From High-Intensity Aerobic Treadmill Exercise: A Randomized Control Trial. Neurorehabil Neural Repair. 2012;26(1):85-95. doi:10.1177/1545968311418675
8. Gert Kwakkel, Buma F, Selzer ME. Neuroplasticity and Task-Oriented Training in Neurorehabilitation. Handb Clin Neurol. 2013;110:175-191. doi:10.1016/B978-0-444-52901-5.00015-X