Quadrupedal training approaches in post-stroke rehabilitation: a scoping review of evidence, mechanisms, and clinical applications.

Background: Persistent impairments in trunk control, balance, and mobility are frequently observed after stroke, even after standard task-specific rehabilitation. Quadrupedal-derived training (QT)-which involves four-point support, dynamic contralateral tasks, transitional kneeling, and crawling-has attracted clinical interest because it may activate bilateral and spinal sensorimotor networks. Nonetheless, the evidence supporting QT has not been thoroughly systematically mapped. Objective: To synthesize the extent, characteristics, mechanisms, and clinical applications of quadrupedal-derived training in adult post-stroke rehabilitation. Methods: A scoping review was conducted in accordance with the JBI Manual for Evidence Synthesis and the PRISMA-ScR guidelines. It involved searching five databases and additional sources from 2010 to 2025 to find studies on QT in stroke populations, along with mechanistic and translational evidence. The outcomes were pre-mapped to the International Classification of Functioning (ICF) domains. Data on intervention types, total dosage, supervision, progression criteria, safety, and feasibility were gathered. Stakeholder input from stroke survivors, clinicians, and researchers helped shape implementation considerations. Results: Eighteen studies met the inclusion criteria, including five randomized controlled trials and one case study involving stroke populations, as well as mechanistic and translational research. QT consistently improved trunk control and balance, with effects on functional mobility and certain gait parameters varying depending on the variant and dose. Kneeling-based QT showed greater balance benefits than treadmill-based training in subacute inpatient settings, while static and dynamic four-point variants were mainly used with chronic outpatient groups. No serious adverse events occurred, and adherence was high where recorded. Mechanistic evidence indicates a pathway connecting quadrupedal loading to activation of spinal and interlimb networks, bilateral proximal muscles, and functional improvements. Conclusion: Quadrupedal-based training is a biologically plausible, resource-efficient, and clinically practical method for improving trunk and balance issues after a stroke. More well-designed studies that include standardized progression, dose-response evaluations, and neurophysiological biomarkers are needed.