The NuStep: Does It Step Up to the Plate?

You may be infinitely surprised to hear this, but I just recently started putting patients on the NuStep (also known as SciFit or any number of other recumbent cross trainers, pick your poison) for the first time. Personally, I have always been timid about using this piece of technology, which clinics around the country spend anywhere from $2,000 to $9,000 on, to try to lead an evidence-based approach with my patients. Through my educational journey in Mizzou’s DPT program, I have been inspired to find exercises that push my creativity and relate to anything functional for my patients. The NuStep always seemed to give me the vibe of a sort of “cop-out” to get minutes in during a treatment session. However, when I take a step back, I can see that there is likely some prejudice in my thinking, as I had no evidence to base my notions on.

The Claims Versus Reality

For the purpose of this article, we will focus on claims made directly by NuStep regarding the benefits of their machine. Knowingly, there are other options for these types of machines, but we will assume that their claimed benefits are very similar, as the mode of exercise is mostly identical. Below is a list of some of the major claims made directly by NuStep, or that I have personally heard in my clinical experience.

Claim 1: Low-Impact, Joint Friendly Exercise

Breakdown: To prove or disprove this claim, we do not really need to dive deep into any evidence beyond your grade-school physics classes and some critical thinking. Machines such as these essentially provide a workout in an “anti-gravity” position, replacing gravity with whatever resistance you decide to apply for your patient. Therefore, in the spirit of lessening the effect of gravity on joint compression, “low-impact” is a valid claim for this machine, depending on how therapists modulate resistance for their patients.

Given the simple nature of this claim, there is not a large body of evidence to refute it. However, a 2013 study looking at the safety of recumbent cross trainers for adults with cerebral palsy found that all participants avoided any serious adverse events, and transient pain was only reported in a few cases that could not be directly tied to the machines.¹ All in all, claim #1 gets a green light.

Claim 2: Full Body Workout

Breakdown: These machines have two handles and two footplates, but does that mean they effectively work everything? Evidence suggests there is good reason to believe this. Studies from 2004 and 2013, looking at neural coupling of upper and lower extremities during use, and at how arm movements increase leg muscle activity substantiate this claim, showing that active use of both arms and legs during recumbent stepping increases neuromuscular activation in the lower limbs, likely enhancing muscle balance and coordination.¹²

Additionally, this bilateral, reciprocal movement pattern is associated with improvements in lower limb impairment and balance in chronic stroke patients, according to a 2008 randomized study observing reciprocal upper- and lower-limb locomotor training.³ Cardiovascularly, the aforementioned 2013 study with participants with CP found that 10 of 11 participants saw a significant elevation in oxygen consumption, up to approximately 60% of their maximum heart rate. Claim #2: green light.

Claim 3: A, safe accessible modality for populations with mobility limitations

Breakdown: Regarding safety and accessibility, the American College of Sports Medicine, in its 2025 Expert Consensus Statement, affirms that exercise prescriptions for people with disabilities should be individualized and that accessible modalities such as recumbent cross-trainers are appropriate and effective for overcoming personal and environmental barriers to physical activity participation.⁴

For individuals with moderate-severity multiple sclerosis, NuStep and similar machines are perceived as safe and accessible, especially compared to modalities requiring upright positioning or transfers, and they elicit significant aerobic responses suitable for rehabilitation.⁵ Another green light for claim #3.

Claim 4: Improvements in cardiovascular fitness, endurance, strength, and functional mobility

Breakdown: This one surprised me, given what we know about principles of exercise specificity for transference to functional performance. Evidence shows that participants in a randomized trial with chronic obstructive pulmonary disease (COPD) completing 12 weeks of total body recumbent stepper (TBRS) training significantly increased 6-minute walk distance, reduced dyspnea, and lowered acute exacerbation rates, indicating enhanced cardiovascular fitness and endurance.⁶

In sedentary adults, 12 weeks of TBRS training at progressive intensities (50–75% heart rate reserve) resulted in significant increases in maximal oxygen uptake, exercise time, muscle strength, muscle endurance, and lean body mass, with reductions in fat mass supporting improvements in both cardiovascular and muscular fitness.⁷

For individuals with chronic stroke, resistance-based reciprocal training using NuStep improves lower limb impairment and dynamic balance, reflected by increased Fugl-Meyer lower extremity scores (+4.3 and +2.2 points) and higher Berg Balance Scale scores (+4.0 points in both groups), while a home exercise program produced only nominal or no changes.³ Meta-analyses of ergometer training in stroke rehabilitation confirm significant improvements in walking ability, cardiorespiratory fitness, lower limb force, and balance.⁸

The American Physical Therapy Association (APTA) clinical practice guideline states that recumbent stepping and cycling at higher aerobic intensities can improve locomotor outcomes and cardiovascular endurance in chronic stroke, incomplete spinal cord injury, and brain injury populations.⁹ Yet again, green light on #4.

Claim 5: Access to central pattern generators (CPGs)

Breakdown: This is one of the more common claims I hear from clinicians. Recumbent stepping elicits muscle activation patterns and neural control similar, though simpler, to walking, suggesting engagement of shared neural substrates, potentially including CPGs. However, the kinematic differences between recumbent stepping and overground walking are substantial, and the transfer of improved motor patterns from recumbent stepping to overground gait is not robustly established in clinical trials.¹⁰

The APTA clinical practice guideline states that cycling and recumbent stepping may improve cardiovascular endurance and some locomotor outcomes in chronic stroke and other CNS injuries, but gains in walking speed and endurance are inconsistent compared to task-specific gait training. The guideline emphasizes that activity-specific, repetitive, and progressively challenging practice, such as treadmill or overground walking, is more effective for improving gait patterns than non-task-specific modalities like recumbent stepping.⁹

This claim earns a yellow light at best, verging on a red light.

What Other Options Are Out There?

When stacked against other common physical therapy modalities like treadmill walking, upright cycling, and aquatic therapy, NuStep and similar recumbent machines hold their own remarkably well. Across conditions such as COPD, stroke, multiple sclerosis (MS), cerebral palsy (CP), peripheral artery disease (PAD), and osteoarthritis (OA), evidence shows that recumbent steppers produce comparable improvements in aerobic capacity, functional endurance, and quality of life.

For instance, TBRS training in COPD improves six-minute walk distance and reduces dyspnea just as effectively as treadmill-based programs, while in PAD, both modalities yield similar gains in walking distance and functional capacity.⁶^,¹¹^,¹² In stroke, incomplete spinal cord injury, and traumatic brain injury, high-intensity recumbent stepping enhances cardiovascular fitness and walking endurance, though treadmill walking remains slightly superior for locomotor-specific outcomes.⁹¹³

For musculoskeletal conditions like knee OA or chronic low back pain, recumbent exercise proves as effective as aquatic or land-based training for reducing pain and improving function, making patient preference and accessibility the deciding factors.¹⁴^,¹⁵ Safety profiles across all modalities are nearly identical, with adverse events rare and mild. Patients with significant mobility or balance limitations often prefer recumbent options for comfort, stability, and low fear of falling.¹⁵ Ultimately, the literature suggests that NuStep and comparable machines are as safe and effective as other established exercise modes, with the optimal choice guided less by inherent superiority and more by individual needs, safety, and therapeutic goals.

Pitfalls to Avoid with these Machines

While the NuStep and other recumbent steppers can be valuable tools in rehabilitation, misuse often stems from a misunderstanding of how neuroplasticity and task-specific learning drive functional recovery. Because these machines are safe and convenient, it is easy to over-rely on them for “easy minutes,” delivering subtherapeutic intensity or failing to link the activity to meaningful goals.

According to key principles of neuroplasticity (specificity, intensity, repetition, salience, etc.), the nervous system changes in direct response to the demands placed upon it. Low-resistance, non-functional stepping in a seated position does not optimally challenge the neural circuits required for upright gait or postural control, limiting transfer to real-world walking. Research consistently supports that task-specific practice produces greater gains in locomotor outcomes than impairment-based or seated exercise alone.

While recumbent stepping can provide a foundation for aerobic conditioning and bilateral limb activation, progression toward upright stepping and overground practice is necessary to fully engage locomotor pattern generators and promote cortical reorganization relevant to walking. Therapists must monitor load, joint positioning, and intensity to ensure the exercise remains safe and appropriately challenging, avoiding the assumption that “low impact” equates to risk-free. Effective use of the recumbent stepper requires thoughtful pairing with interventions that are intense, progressively challenging, and directly relevant to the patient’s functional goals.

Parting Words

Overall, I am more than impressed by the body of evidence supporting the positive claims about the NuStep and similar machines. As far as my initial skepticism, I don’t think it was completely unfounded, but it was incomplete. When we utilize this machine correctly, it can certainly improve a patient’s plan of care.

My favorite use of the NuStep currently is for high-intensity interval training (HIIT) for brain-derived neurotrophic factor (BDNF) release, paired with functional training. With a large body of research behind HIIT, recumbent stepping machines make it easy to monitor on-and-off times while gauging intensity. Used thoughtfully, it can prime the nervous system, enhance engagement in functional tasks, and support meaningful recovery. It’s all about intention: using the right tool, at the right dose, for the right goal.

References

1. Peterson MD, Lukasik L, Muth T, et al. Recumbent cross-training is a feasible and safe mode of physical activity for significantly motor-impaired adults with cerebral palsy. Arch Phys Med Rehabil. 2013;94(2):401-407. doi:10.1016/j.apmr.2012.09.027

2. Huang HJ, Ferris DP. Neural coupling between upper and lower limbs during recumbent stepping. J Appl Physiol (1985). 2004;97(4):1299-1308. doi:10.1152/japplphysiol.01350.2003

3. Page SJ, Levine P, Teepen J, Hartman EC. Resistance-based, reciprocal upper and lower limb locomotor training in chronic stroke: a randomized, controlled crossover study. Clin Rehabil. 2008;22(7):610-617. doi:10.1177/0269215508088987

4. Ptomey L, Morgan KA, Blauwet CA, et al. ACSM Expert Consensus Statement: Considerations and Recommendations for Prescribing Exercise and Designing Physical Activity Programs for People with Disabilities. Med Sci Sports Exerc. 2025;57(11):2588-2598. doi:10.1249/MSS.0000000000003775

5. Snyder KJ, Patsakos E, White J, Ditor DS. Accessible exercise equipment and individuals with multiple sclerosis: Aerobic demands and preferences. NeuroRehabilitation. 2019;45(3):359-367. doi:10.3233/NRE-192861

6. Duan W, Zeng D, Huang J, et al. Effect of modified Total Body Recumbent Stepper training on exercise capacity and thioredoxin in COPD: a randomized clinical trial. Sci Rep. 2022;12(1):11139. Published 2022 Jul 1. doi:10.1038/s41598-022-15466-2

7. Hass CJ, Garzarella L, de Hoyos DV, Connaughton DP, Pollock ML. Concurrent improvements in cardiorespiratory and muscle fitness in response to total body recumbent stepping in humans. Eur J Appl Physiol. 2001;85(1-2):157-163. doi:10.1007/s004210100435

8. Veldema J, Jansen P. Ergometer Training in Stroke Rehabilitation: Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2020;101(4):674-689. doi:10.1016/j.apmr.2019.09.017

9. 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

10. Stoloff RH, Zehr EP, Ferris DP. Recumbent stepping has similar but simpler neural control compared to walking. Exp Brain Res. 2007;178(4):427-438. doi:10.1007/s00221-006-0745-7

11. Salisbury DL, Swanson K, Brown RJ, Treat-Jacobson D. Total body recumbent stepping vs treadmill walking in supervised exercise therapy: A pilot study. Vasc Med. 2022;27(2):150-157. doi:10.1177/1358863X211068888

12. Tremblay R, Marcotte-Chénard A, Hamelin-Morrissette J, et al. The Effect of Exercise Modalities on Walking Capacity in Patients With Intermittent Claudication: A NETWORK META-ANALYSIS. J Cardiopulm Rehabil Prev. 2023;43(5):318-328. doi:10.1097/HCR.0000000000000780

13. Mehrholz J, Thomas S, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. 2017;8(8):CD002840. Published 2017 Aug 17. doi:10.1002/14651858.CD002840.pub4

14. Krishnamurthy A, Lang AE, Pangarkar S, Edison J, Cody J, Sall J. Synopsis of the 2020 US Department of Veterans Affairs/US Department of Defense Clinical Practice Guideline: The Non-Surgical Management of Hip and Knee Osteoarthritis. Mayo Clin Proc. 2021;96(9):2435-2447. doi:10.1016/j.mayocp.2021.03.017

15. Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022;327(17):1688-1699. doi:10.1001/jama.2022.5921

Disclaimer

We are current Doctor of Physical Therapy (DPT) students sharing information based on our formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While we strive to provide accurate and up-to-date information, our knowledge is based on our current academic and clinical rotations and ongoing learning, not extensive clinical practice.