Comparative efficacy of different gait-training modalities on walking and functional outcomes in stroke rehabilitation: a Bayesian network meta-analysis

Gait impairment is a major contributor to persistent disability after stroke. Several land-based and aquatic gait-training modalities are used in rehabilitation, but their comparative effects on walking capacity, balance, and functional mobility remain uncertain. To compare the efficacy of different gait-training modalities on walking and functional outcomes in adults after stroke using a Bayesian network meta-analysis. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched from inception to January 22, 2026. Randomized controlled trials evaluating overground walking (OGW), land-based treadmill training (LTT), aquatic overground walking (AOW), aquatic treadmill training (ATT), or control interventions were included. The primary outcomes were walking endurance assessed using the 6-Minute Walk Test (6MWT) and walking speed assessed using the 10-Meter Walk Test. Secondary outcomes included the Berg Balance Scale (BBS), Timed Up and Go Test (TUG), cadence, and Fugl-Meyer Assessment of the Lower Extremity. Bayesian random-effects network meta-analyses were conducted for the 6MWT, walking speed, BBS, and TUG, and treatment rankings were summarized using the surface under the cumulative ranking curve. Cadence and lower-extremity motor function were summarized narratively because of sparse evidence. Twenty-six randomized controlled trials involving 1,111 participants were included. For the 6MWT, OGW had the highest ranking and was associated with a greater walking distance than control (MD 57.04 m, 95% CrI 29.22–89.14), as was LTT (MD 43.80 m, 95% CrI 18.25–75.23). AOW was not significantly different from control, and no clear differences were found among the active interventions. For walking speed, ATT ranked highest, but only OGW was significantly superior to control (MD 0.143 m/s, 95% CrI 0.047–0.242). For BBS, AOW ranked highest, and all four active gait-training modalities were associated with higher scores than control. For TUG, ATT ranked highest, although no pairwise comparison reached statistical significance. Leave-one-out analyses indicated that the 6MWT ranking was comparatively stable, whereas the rankings for walking speed and BBS were more sensitive to individual studies. The certainty of evidence ranged from low to very low. OGW and LTT were associated with improved walking endurance compared with control, while OGW was also associated with greater short-distance walking speed. All four active gait-training modalities were associated with better balance scores than control, but the evidence did not establish clear differences among the active interventions or significant benefits for functional mobility measured using TUG. Treatment rankings should therefore be interpreted cautiously in light of sparse evidence, imprecise comparisons, sensitivity to individual studies, and low to very low certainty of evidence.