Robot-Aided Gait Training in PLS — Lokomat-Pro Case Report 2021
No data existed on robot-aided rehabilitation in PLS before this 2021 case report. A 54-year-old woman with PLS and significant spastic paraparesis underwent a structured rehabilitation protocol combining conventional physiotherapy with robot-aided gait training using the Lokomat-Pro exoskeleton. Conventional physiotherapy alone produced no meaningful functional gains. The combined approach — adding the Lokomat — produced measurable improvements in spasticity, walking function, balance, and lower limb muscle strength. One patient is not a clinical trial, but this is the first published evidence that robotic gait training is feasible and potentially beneficial in PLS.
Background: why rehabilitation evidence matters in PLS
PLS has no disease-modifying treatment. The management of PLS is entirely symptomatic and functional — which means that rehabilitation therapy is not a supplement to pharmacological treatment but a central component of care in its own right. Despite this, the research base for physical therapy in PLS is thin. Most of what informs rehabilitation decisions in PLS is extrapolated from ALS and other neurodegenerative conditions, where the evidence is also limited.
Robot-aided rehabilitation is theoretically well-suited to PLS because it allows highly controlled, repetitive, task-oriented motor training at intensities that would be difficult to achieve through conventional physiotherapy alone. The principle underlying robotic rehabilitation is motor relearning through neuroplasticity — intensive, repetitive movement can help restore or maintain neural connectivity in ways that passive therapy cannot. This principle has been applied in stroke rehabilitation with documented benefit, and has been explored in ALS with some positive signals. PLS had no published data at all before this report.
What they did
The patient was a 54-year-old woman who had been diagnosed with PLS five years before admission. She presented with gait difficulties secondary to spastic paraparesis and was admitted to the IRCCS Centro Neurolesi in Messina, Italy, for intensive rehabilitation.
The study used a sequential design: first, the patient underwent a period of conventional physiotherapy alone. Then she underwent a combined protocol adding robot-aided gait training with the Lokomat-Pro exoskeleton system to the conventional physiotherapy. Clinical assessments were conducted at baseline, after the conventional PT phase, and after the combined phase. Outcome measures included validated clinical scales for spasticity (Modified Ashworth Scale), walking function, balance, and lower limb strength.
The Lokomat-Pro is a driven gait orthosis — a robotic exoskeleton that supports and guides the lower extremities through the walking cycle while the patient is on a treadmill, providing precisely controlled, repetitive gait training with adjustable levels of active patient participation. It allows training at intensities and step volumes not achievable through manual-assisted walking.
What they found
After the conventional physiotherapy phase, no significant functional improvement was observed on any of the outcome measures. This is consistent with the general clinical experience in PLS, where maintenance of function rather than improvement is typically the realistic goal of standard physiotherapy.
After the combined robot-aided plus conventional physiotherapy phase, the patient showed significant improvement in: spasticity severity on the Modified Ashworth Scale; walking function (including walking speed and gait quality); balance; and lower limb muscle strength. The authors describe the improvements as clinically meaningful on the scales used, not merely statistical noise.
No adverse events related to the Lokomat-Pro training were reported. The patient tolerated the combined protocol well. The authors concluded that combined robot-aided and conventional rehabilitation could be a promising approach to reduce the PLS disability burden.
Why it matters
One patient cannot tell you that Lokomat training works for PLS in general. The honest interpretation of a single case report is proof of concept: the approach was feasible, it was tolerated, and in this patient it appeared to produce functional gains. That is useful but limited evidence.
What makes this report significant beyond its size is what it represents for PLS research. Before 2021, there was literally nothing published on robot-aided rehabilitation in PLS. This report opens the door. It gives rehabilitation specialists a basis for designing trials, for justifying clinical use in PLS patients, and for funding applications. It is a starting point, not a conclusion — and it is described honestly that way in the paper itself.
For someone with PLS who is exploring rehabilitation options, this report is worth knowing about. Robotic gait training programs exist at academic rehabilitation centers, and some insurance coverage for Lokomat-style therapy exists for neurological conditions. A conversation with a rehabilitation specialist about whether this approach is appropriate for your specific situation, current functional level, and disease stage is a reasonable next step. The evidence base is very early, but the signals are positive and the risk profile from this case appears low.
Limitations
A single case report cannot establish efficacy or generalizability. The sequential design (conventional PT then combined PT plus Lokomat) does not control for time, learning effects, or natural variation in symptoms. The improvements observed after the combined phase could reflect cumulative therapy, patient motivation, or simple clinical variability rather than a specific effect of the robotic component. Larger, controlled studies are needed before conclusions can be drawn about Lokomat-Pro therapy for PLS as a population.
How this connects
This case report is unique among the spasticity studies in that it addresses non-pharmacological management of spasticity — specifically the potential for intensive rehabilitation to improve spasticity and gait in PLS. It connects to the broader Spasticity Research hub, which covers both pharmacological and non-pharmacological approaches. The practical context for rehabilitation in PLS — what to expect from physiotherapy, when to consider more intensive approaches — is addressed on the Spasticity management page. For the pharmacological side of spasticity management, including when to consider escalation to intrathecal baclofen, see the ITB Utility in PLS report.
Citation
Portaro S, Ciatto L, Raciti L, Aliberti E, Aliberti R, Naro A, Calabrò RS. A case report on robot-aided gait training in primary lateral sclerosis rehabilitation: rationale, feasibility and potential effectiveness of a novel rehabilitation approach. Innovations in Clinical Neuroscience. 2021;18(4–6).