Effectiveness of treadmill gait training on gait symmetry in unilateral transtibial amputees post-prosthetic fitting: A systematic review

Abstract

Gait asymmetry is a common issue in individuals with unilateral transtibial amputation following prosthetic fitting, often leading to reduced functional mobility and an increased risk of secondary musculoskeletal complications. This systematic review aimed to evaluate the effectiveness of split-belt treadmill training based on error-augmentation training (EAT) principles in improving gait symmetry in this population, while also synthesising current evidence, analysing variations in intervention protocols, and identifying research gaps to support evidence-based clinical decision-making in prosthetic rehabilitation. A comprehensive literature search was conducted using MEDLINE, CINAHL Plus, and AMED databases to identify relevant studies involving adults with unilateral transtibial amputation undergoing split-belt treadmill training based on EAT principles. Five studies met the inclusion criteria, including four quasi-experimental studies and one randomised controlled trial protocol. Data were extracted on study characteristics, intervention parameters, and gait symmetry outcomes, and methodological quality was assessed using the JBI and CASP critical appraisal tools. The findings demonstrated short-term improvements in gait symmetry, particularly in step length symmetry, commonly assessed using indices such as the Asymmetry Index (AI) and Normalised Symmetry Index (NSI). Three studies reported moderate to large effect sizes (Cohen’s d = 0.53–3.71), while two demonstrated statistically significant improvements. However, these benefits were not consistently maintained over time, particularly following single-session interventions. Common methodological limitations included small sample sizes, lack of control groups, and short follow-up durations. Overall, split-belt treadmill training based on EAT principles appears to be a promising intervention for improving short-term gait symmetry in individuals with unilateral transtibial amputation; however, further high-quality trials with standardised protocols and extended follow-up are required to establish long-term effectiveness.