Next Article in Journal / Special Issue
Assessment and Intervention for Tool-Use in Learning Powered Mobility Intervention: A Focus on Tyro Learners
Previous Article in Journal
The Perceived Role of Healthcare Providers and Systems in the Development of Secondary Health Conditions among Adults with Spinal Cord Injury
Previous Article in Special Issue
Mobility on Demand for Everybody—Investigation of the Current Challenges in Establishing Ride-Pooling Services for Persons with Mobility Impairments in Germany
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:

A Narrative Review on Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: Training Parameters, Choice of Settings, and Perspectives

Department of Rehabilitation, Faculty of Medicine, Laval University, Québec City, QC G1V 0A6, Canada
Interdisciplinary Research Center for Rehabilitation and Social Integration, Québec City, QC G1M 2S8, Canada
Laboratory of Simulation and Modelling of Movement, University of Montreal, Montréal, QC H3T 1J4, Canada
Interdisciplinary Center for Brain and Learning Research, Université de Montréal, Montréal, QC H3T 1J4, Canada
International Laboratory for Brain, Music, and Sound Research (BRAMS), Department of Psychology, University of Montreal, Montréal, QC H3T 1J4, Canada
Author to whom correspondence should be addressed.
Disabilities 2022, 2(2), 293-303;
Submission received: 12 April 2022 / Revised: 16 May 2022 / Accepted: 19 May 2022 / Published: 27 May 2022
(This article belongs to the Special Issue Technology for People with Disabilities: Opportunities and Challenges)


About 70% of children and adolescents with cerebral palsy experience gait impairments which affect their autonomy and well-being. Robotic-assisted gait training using the Lokomat is particularly promising for rehabilitation as it provides a standardized environment favoring the massive repetition of the movement, in which physical demands are low on the therapist and high training loads can be achieved. As no guidelines exist regarding training protocols and Lokomat settings, the goal of this narrative review was to summarize previously published information on the use of RAGT in children and adolescents with cerebral palsy and to provide an opinion on possibilities for improving future research. The thirteen studies reviewed reported both positive and null effects of Lokomat training on gait. Half of the studies combined the Lokomat with other types of training, and only five used a control intervention to assess its benefit. Overall, training was administered 1–5 times per week for 20–60 min, over 1–12 weeks. Although Lokomat settings were not always described, progressively decreasing body weight support and guidance while increasing the treadmill speed appeared to be prioritized. The variety of training protocols and settings used did not allow pooling of the studies to assess the effects of interventions on gait parameters in children and adolescents with cerebral palsy. This narrative review highlights the need for homogenization of interventions so that clear guidelines can emerge and be applied in rehabilitation centers.

1. Introduction: A Summary of Pertinent Research

Walking plays a key role in functional autonomy and active involvement in social life. Impairments resulting from cerebral palsy (CP), such as muscle weakness, altered coordination, pain, spasticity, and poor balance, lead to persistent gait disorders [1,2,3]. About 70% of children and adolescents with CP experience a gait disorder which deteriorates over time [4]. Impairments include a limited range of motion, reduced walking speed, increased double-support time, and poor endurance [1,2,3]. Due to the high impact these disorders have on the integration and quality of life of CP children and adolescents [5,6], gait rehabilitation is one of physiotherapists’ top priorities.
Various training modalities exist for gait rehabilitation in individuals with neurological disorders. In the early 1990s, body weight support treadmill training (BWSTT) was introduced for gait rehabilitation of this patient population. However, BWSTT is physically demanding and requires two physiotherapists to assist each leg’s movements. As a result, the training time is limited. In recent decades, robotic-assisted gait training (RAGT) has emerged as a promising modality for gait rehabilitation in individuals with neurologic disorders [7]. RAGT has been shown to be as effective as overground stepping with the support of physiotherapists [8]. Advantages such as the possibility to achieve a high number of repetitions and the reduced physical demands on the therapist make RAGT a valuable training modality. Furthermore, this approach provides a standardized training environment and allows an objective assessment of gait improvements throughout rehabilitation [9]. A systematic review that investigated the effects of RAGT in post-stroke participants showed that patients receiving such training were more likely to achieve independent walking than those who received gait training without robotic assistance [10]. To date, the most widely used robotic assistance for gait rehabilitation is the Lokomat (Hocoma AG, Volketswil, Switzerland) [11]. The Lokomat allows gait training on a treadmill using a partial body weight support (BWS) harness and robotic assistance (guidance) for both legs. The treadmill speed, BWS, and guidance provided by the Lokomat are fully adjustable. In addition to providing multisensory and task-oriented rehabilitation, RAGT can be carried out in a safe and fun environment [12], thus maintaining a higher level of motivation and adherence to treatment, especially in the pediatric population. Unlike in adults with neurologic disorders [13,14], the current evidence regarding the clinical effectiveness and applicability of Lokomat training in pediatrics is weak [15]. The inconsistency of the results makes it unclear whether Lokomat training is truly beneficial to children with CP.
Several studies have highlighted the importance of the therapist in personalizing training [16,17,18,19]. However, since there are currently no guidelines, each clinic and even therapist may adjust training settings based on their own experience and training. Yet, there is some evidence from clinical trials that Lokomat settings might be important to achieve the expected results [20,21]. As the patient groups trained are heterogeneous, and the optimal Lokomat settings are patient-dependent, evidence remains scarce in the current literature. To optimize the Lokomat therapeutic contribution, it is now appearing essential that guidelines for selecting appropriate Lokomat settings be generated. The purpose of this narrative review was thus to summarize the current literature and generate clinical recommendations about training protocols and Lokomat settings, with the aim to improve gait in children and adolescents with CP.

2. Evidence of the Effectiveness of Robotic Gait Training in Children and Adolescents with Cerebral Palsy

There is growing evidence that RAGT in CP children and adolescents improves areas of the International Classification of Functioning, Disability and Health (ICF), such as body structures and functions (e.g., muscle power, contractures, spasticity), activity (e.g., mobility), and participation [22]. Thus, the main databases (e.g., Medline, Embase, CINHAL) were explored using search terms such as pediatric OR paediatric; Lokomat OR robotic assisted treadmill; child* OR adolescen* OR youth OR young adult* OR teenager*; robotic assisted gait training; gait. Included studies were experimental studies (e.g., randomized controlled trials, before/after studies), conducted on children or adolescents with cerebral palsy, and specifically used RAGT as a primary intervention method for > single session. The results of the included clinical trials on Lokomat training in children with CP are summarized in Table 1.
Several studies [23,24,25,26,27] highlighted an improvement in gross motor function measured by the GMFM-66 or the WeeFIM. Regarding walking ability, some studies [23,25,27,28] reported an increase in walking speed, while two studies did not observe a significant change in this outcome after Lokomat training [24,29,30]. In addition, two studies [16,31] did not highlight any effect on the locomotor pattern. However, one study reported a significant change in knee and ankle kinematics as well as better upper extremity control following Lokomat training combined with virtual reality [32]. The results from a second study by the same authors also showed improved dynamic balance during walking in children and adolescents with CP following Lokomat training [33]. Finally, only five of these studies [30,32,33,34,35] were completed in a randomized controlled process, and only three of these studies [23,24,28] provided a short-term follow-up of the observed changes. Moreover, the methodological quality of the included studies ranged from 2 to 7 out of 10, with a median score of 3 (Table 2). Only 5/13 studies [31,33,34,35,36] were of a good quality (PEDro score ≥ 6). Thus, despite the generally positive effects reported in some of the studies, no consensus has been reached regarding the effectiveness of Lokomat training.

3. Training Parameters and Settings

Training parameters (frequency, session duration, and total duration of the intervention) are displayed in Table 3. In six studies, the Lokomat training was combined with other therapies such as conventional therapy [25,29,31,34] or virtual reality [32,33]. In six studies [23,24,25,26,28,35], participants performed training with the Lokomat only. Five studies compared the effect of Lokomat training to a control intervention, such as conventional therapy [32,33,34,35] and anti-gravity or BWS treadmill training [30]. The training protocols presented across studies varied in intensity and duration (Table 2). Training was typically conducted with a frequency of one [29] to five sessions per week [25,29,32,33] with a duration of 20–60 min each and spread across 1 [25] to 12 weeks [28], although most studies favored short interventions of 3–5 weeks [23,24,27,29,30,31,32,33,34,35]. In conclusion, the proposed protocols are thus far heterogeneous, and no clear recommendation can emerge from the current literature regarding optimal training parameters.
Descriptions of Lokomat settings are presented in Table 2. Overall, these are only partially described in published clinical studies. Regarding BWS, in four studies, support exceeded 50% of the body weight [23,30,32,33], other studies never decreased the support below 50% [28,29]. Current evidence suggests that reducing BWS leads to higher muscle activations [36,37]. Additionally, a high level of BWS altered gait patterns in healthy adults in terms of joint angles and inter-joint coordination [38]. Concerning the treadmill speed, the general recommendation tends to promote an increase in this setting as the patients improve [23,28,33]. Previous research suggested that an increase in the treadmill speed increased the training intensity, one of the motor learning factors [39]. In this same context, an increase in the treadmill speed induced an increase in muscle activation in individuals with stroke and CP [40]. As for guidance, current evidence suggests that walking ability improvement requires active physical participation of patients during the intervention [41]. The current evidence comes mostly from cross-sectional studies and highlights that a reduction in guidance can increase muscle activations [37,40]. Thus, therapists aim for a low guidance, although this is not always possible. In children and adolescents with CP, the authors tended to start at high levels of guidance and then decrease according to the patient’s ability [28]. In general, studies pointed out that the effect of guidance is less obvious than that of BWS or the treadmill speed [37,42].

4. Discussion and Recommendations for Clinical Practice

This review aimed to summarize previously published information on the use and the effect of RAGT in children and adolescents with CP and to provide an opinion on possibilities for improving future research. Overall, Lokomat training showed some positive effects on lower limb function, balance, and spatiotemporal gait parameters in children and adolescents with CP. To date, despite the growing interest towards this technology, there are no guidelines to select the appropriate Lokomat settings. It is often difficult to replicate published intervention protocols in everyday clinical rehabilitation practice. This is mainly due to the complexity of interventions and the lack of information about protocols (e.g., training parameters, progression of settings) [43]. These aspects are often reported by rehabilitation professionals as a limiting factor in implementing published interventions in their clinical practices. The present review is the first to summarize the settings used in previous studies with the aim to generate some clinical recommendations.

4.1. Training Parameters

In motor rehabilitation, the concept of optimal dosing to lead to improvements in motor function in children and adolescents with CP is complex. The heterogeneity of samples and the variability of training frequencies, durations, and intensity complicate the development of guidelines for optimal training parameters [44]. In a general context, higher intensities and durations have a positive effect on gait rehabilitation [45] as they promote brain plasticity. Verschuren et al. [46] attempted to provide general recommendations for the training dosage for children and adolescents with CP. The authors highlighted the beneficial effects of longer-duration interventions (e.g., two or more sessions per week for 8–16 weeks) while progressively increasing the training intensity [46]. Over time, most children and adolescents with CP present relatively severe locomotor disorders and are subject to early fatigue during prolonged exercise (e.g., continuous walking for 30–45 min). In this sense, Verschuren et al. [46] highlighted that longer-duration interventions allow these children to get used to activities perceived as difficult early on. In their systematic review, however, Cope and Mohn-Johnsen [47] pointed out that there was no evidence favoring high-frequency training over lower-frequency training in children and adolescents with CP [47]. Most Lokomat studies in children and adolescents with CP were based on a short intervention duration (3–5 weeks) with high frequencies (4–5 sessions/week). Moreover, the two studies that reported a significant post-training change in the gait pattern in children and adolescents with CP were those proposing short interventions (4 weeks) with high-frequency training (five times per week) [32,33]. It is, however, important to note that those studies present some limitations. First, they excluded children with severe impairments (GMFCS III and IV) who are the most at risk for losing their locomotor abilities. Second, the training frequency used would be difficult to control with children followed up on an outpatient basis. Finally, these studies did not report short-term follow-up after training. In conclusion, the lack of protocol reporting standardization makes the RAGT of patients with complex and varied neuromotor disorders such as CP challenging. In this context, we propose that feasibility studies should be conducted to assess the clinical relevance of existing protocols, and to better understand the needs and barriers of their implementation.

4.2. Choice of Settings

The variety of settings and the difficulty in defining those which are optimal for a specific patient group present an important barrier in achieving expected therapeutic goals following Lokomat training. Overall, the initial BWS was variable in clinical trials with CP children and adolescents. Four studies [23,30,32,33] started with a BWS higher than 50%, whereas support in other studies never exceeded 50% of the body weight [16,29]. Indeed, previous cross-sectional studies reported that high levels of BWS should be avoided, when possible, to achieve close-to-normative gait patterns [36,37,48]. Regarding the treadmill speed, most of the included studies increased this setting as the patients improved. Previous studies suggested that an increase in gait speed should be promoted as it increases the heart rate and thus the intensity of therapy [49,50]. In addition, research on children and adolescents with CP suggests that an increase in the walking speed increases muscle activation [50]. Regarding the robotic assistance, current evidence suggests that recovery/learning requires active physical participation of patients during therapy [40]; thus, a low level of guidance should be favored. More specifically, with the Lokomat, a reduction in guidance can increase muscle activation [36]. However, other studies have concluded a less obvious effect of guidance on muscle activity and coordination [37,38]. As an approach to optimize the settings, Cherni et al. [18] developed a method that uses electromyography to detect Lokomat settings that induce higher muscle activations in hip extensors in post-stroke individuals. This study was, however, a proof of concept with only two participants. Though promising, the method thus still needs to be validated in a larger sample and with other patient groups. As of today, there is a noteworthy lack of reported information on Lokomat settings, limiting the understanding of the impact of RAGT in children and adolescents with CP and the replication of proposed protocols in clinical practice. Thus, the therapist’s experience and judgment remain essential to personalize and better adjust the Lokomat settings [51].

4.3. Effectiveness of RAGT Training

Based on the ICF model, RAGT studies focused on the effect of training on locomotor activity and very little on body function/structure and participation. However, body functions and structures are major determinants of the walking ability of children and adolescents with CP [52]. Regarding the participation domain, although it is rarely directly measured, dependent variables, such as comfortable walking speed and walking endurance, are highly associated with participation [5,6,52]. After Lokomat training, significant improvements in lower limb strength [28], walking speed [23,25,26,28], step length [16,34], walking endurance [16,23,29,30] and GMFM [24,29,31] were observed in children and adolescents with CP. The improvements in GMFM score [24], endurance [16,28] and COPM [24] were maintained over time. Despite the promising effect of RAGT on walking ability, the majority of studies did not show any significant changes in gait patterns in children and adolescents with CP. Cherni et al. [28] reported a trend of changes in hip extension (p = 0.08) and knee flexion (p = 0.09) peaks during the stance phase and concluded that potentially two training sessions per week were not enough to significantly change the gait of CP children. In addition, the heterogeneity of the participants’ gait patterns included in their study could also explain the absence of significant effects on gait patterns. In fact, Wallard et al. [32] reported significant improvements in gait patterns of a homogenous patient group (i.e., CP children who walk with a jump gait only) after Lokomat training using a higher-training-frequency protocol (e.g., five sessions per week). Using the same training frequency, Beretta et al. [29] observed no effect on the gait patterns of children and adolescents with CP following Lokomat training combined with conventional therapy. In any case, such a high training frequency is often difficult to apply in clinics since it requires a considerable investment in time and effort for the children and adolescents who go to school and their parents.

4.4. Patient-Specific Determinants of Responsiveness

Given the important heterogeneity that could characterize the CP population, some studies evaluated effects of Lokomat training as a function of the participants’ ages [31] and baseline gross motor functions as measured by the GMFCS or GMFM [24,25,28,31]. Regarding participant age, Petrarca et al. [31] reported that there was a tendency towards a reduction in the effect on gait in the older participants, while a ceiling effect of the assessment tool was observed in the less affected participants. Schroeder et al. [24] highlighted that GMFM levels at baseline and age were identified as relevant determinants of responsiveness to RAGT. Indeed, the results showed that patients with higher motor abilities at baseline improved more following Lokomat training than those with lower gross motor abilities. The authors also reported that the effect on GMFM-D improvement was inversely associated with age [24]. A recent study by Petrarca et al. [31] showed a mild improvement of GMFM-D in all subjects, while dimension E changed only in the younger and more severely affected patients. In a clinical context, therapists rarely have GMFM baseline values to guide their decision making. Rather, it is common for them to rely on GMFCS levels in their clinical decision making. In addition, it has been shown that children and adolescents with levels I and II of GMFCS show similar developmental curves which differ from those with levels III and IV [4]. While investigating the benefit of RAGT as a function of GMFCS levels, Hedel et al. [25] reported that children with severe impairments (GMFCS III–IV) may benefit more from Lokomat training than children with moderate impairments (GMFCS II). In their study, children with GMFCS level II showed no significant improvement in mobility as measured by the WeeFIM, walking speed, or endurance. However, as their study participants received Lokomat training as a complement to conventional therapy, it would have been difficult to isolate Lokomat-induced improvements from those caused by other therapies. These results contradict those of Cherni et al. [28], who highlighted a significant improvement in muscle strength, walking speed, step length, and endurance in children with GMFCS level II, as well as those with severe impairments (GMFCS levels III–IV). The disparity of observations in relation to the determinants of responsiveness to RAGT does not allow determining a patient profile that is more likely to improve after training. The current evidence thus highlights that Lokomat training has a positive effect on walking ability regardless of the patient’s baseline level in gross motor function.

4.5. Perspectives

In terms of future research, further clinical trials should aim for higher-quality designs that are reproducible. Moreover, multi-site collaborations would facilitate the recruitment of large sample sizes, which would enable generalization of the results and making inferences based on the severity of the impairments. Assessing the effects of Lokomat training in the medium and long terms by conducting post-training follow-ups would also contribute to evaluating the effectiveness of this robotic technology. Future studies should integrate models such as the ICF to help guide and standardize the assessment of RAGT (e.g., body function and structure, activities, and participation) in children and adolescents with CP. In addition, there is a need to develop methods that will help better select RAGT settings according to a therapeutic objective, for example, by using electromyography to select the settings that will mostly involve a deficient muscle group. Additionally, methods must be developed to determine the optimal dose and intensity of the training. For example, the intensity during training can be monitored and quantified by using accelerometers or heart rate monitors. These tools could also provide information about the patient’s daily life-based gait performance, as a complement to laboratory-based assessments, improving the understanding of the patient’s overall gait challenges and shaping the goals developed with the families and children.

5. Conclusions

This review summarized intervention protocols, Lokomat settings, and the main effects of RAGT training on children and adolescents with CP. The heterogeneity of the studies did not allow the generation of guidelines and highlights the need for protocol standardization in reporting intervention protocols. Indeed, standardization will be essential to ensure that the Lokomat is used to its full potential to provide the greatest possible gait benefits to this population. Finally, this study consists of a narrative review that is based on subjective analysis of the literature on RAGT in children and adolescents with CP. Thus, a systematic review and meta-analysis is needed in future research to generate more substantial conclusions and clinical recommendations on this topic.

Author Contributions

Conceptualization, Y.C.; methodology, Y.C.; writing—original draft preparation, Y.C.; writing—review and editing, Y.C. and C.Z. All authors have read and agreed to the published version of the manuscript.


Y.C. receives a fellowship from Fonds de recherche du Québec-Santé (FRQS).

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.


  1. Bell, K.J.; Õunpuu, S.; DeLuca, P.A.; Romness, M.J. Natural Progression of Gait in Children with Cerebral Palsy. J. Pediatr. Orthop. 2002, 22, 677–682. [Google Scholar] [CrossRef] [PubMed]
  2. Kim, C.J.; Son, S.M. Comparison of Spatiotemporal Gait Parameters between Children with Normal Development and Children with Diplegic Cerebral Palsy. J. Phys. Ther. Sci. 2014, 26, 1317–1319. [Google Scholar] [CrossRef] [Green Version]
  3. Cherni, Y.; Laforte, A.P.; Parent, A.; Marois, P.; Begon, M.; Ballaz, L. Lower limb extension is improved in fast walking condition in children who walk in crouch gait. Disabil. Rehabil. 2019, 41, 3210–3215. [Google Scholar] [CrossRef] [PubMed]
  4. Hanna, S.E.; Bartlett, D.J.; Rivard, L.M.; Russell, D.J. Reference Curves for the Gross Motor Function Measure: Percentiles for Clinical Description and Tracking over Time Among Children with Cerebral Palsy. Phys. Ther. 2008, 88, 596–607. [Google Scholar] [CrossRef] [PubMed]
  5. Pirpiris, M.; Gates, P.E.; McCarthy, J.J.; D’Astous, J.; Tylkowksi, C.; Sanders, J.O.; Dorey, F.J.; Ostendorff, S.; Robles, G.; Caron, C.; et al. Function and Well-Being in Ambulatory Children with Cerebral Palsy. J. Pediatr. Orthop. 2006, 26, 119–124. [Google Scholar] [CrossRef] [PubMed]
  6. Marino, F.R.; Lessard, D.M.; Saczynski, J.S.; McManus, D.D.; Silverman-Lloyd, L.G.; Benson, C.M.; Blaha, M.J.; Waring, M.E. Gait Speed and Mood, Cognition, and Quality of Life in Older Adults with Atrial Fibrillation. J. Am. Heart Assoc. 2019, 8, e013212. [Google Scholar] [CrossRef] [PubMed]
  7. Cherni, Y. Stratégies d’Optimisation d’Utilisation d’un Exosquelette pour la Réadaptation Locomotrice des Patients avec des Troubles Neuromoteurs. 2020. Available online: (accessed on 1 March 2022).
  8. Dobkin, B.; Apple, D.; Barbeau, H.; Basso, M.; Behrman, A.; Deforge, D.; Ditunno, J.; Dudley, G.; Elashoff, R.; Fugate, L.; et al. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology 2006, 66, 484–493. [Google Scholar] [CrossRef] [PubMed]
  9. Gassert, R.; Dietz, V. Rehabilitation robots for the treatment of sensorimotor deficits: A neurophysiological perspective. J. Neuroeng. Rehabil. 2018, 15, 46. [Google Scholar] [CrossRef] [Green Version]
  10. Mehrholz, J.; Werner, C.; Kugler, J.; Pohl, M. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst. Rev. 2007, 5, CD006185. [Google Scholar] [CrossRef]
  11. Nam, K.Y.; Kim, H.J.; Kwon, B.S.; Park, J.-W.; Lee, H.J.; Yoo, A. Robot-assisted gait training (Lokomat) improves walking function and activity in people with spinal cord injury: A systematic review. J. Neuroeng. Rehabil. 2017, 14, 24. [Google Scholar] [CrossRef] [Green Version]
  12. Michaud, B.; Cherni, Y.; Begon, M.; Girardin-Vignola, G.; Roussel, P. A serious game for gait rehabilitation with the Lokomat. In Proceedings of the 2017 International Conference on Virtual Rehabilitation (ICVR), Montreal, QC, Canada, 19–22 June 2017; pp. 1–2. [Google Scholar] [CrossRef]
  13. Swinnen, E.; Beckwée, D.; Meeusen, R.; Baeyens, J.-P.; Kerckhofs, E. Does Robot-Assisted Gait Rehabilitation Improve Balance in Stroke Patients? A Systematic Review. Top. Stroke Rehabil. 2014, 21, 87–100. [Google Scholar] [CrossRef] [PubMed]
  14. Tefertiller, B.C.; Pharo, N.; Evans, P. Winchester, Efficacy of rehabilitation robotics for walking training in neurological dis-orders: A review. J. Rehabil. Res. Dev. 2011, 48, 387–416. [Google Scholar] [CrossRef] [PubMed]
  15. Lefmann, S.; Russo, R.; Hillier, S. The effectiveness of robotic-assisted gait training for paediatric gait disorders: Systematic review. J. Neuroeng. Rehabil. 2017, 14, 1. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  16. Cherni, Y.; Ballaz, L.; Girarin-Vignola, G.; Begon, M. P 175—Robotic-assisted locomotion training improves walking abilities in children with bilateral cerebral palsy. Gait Posture 2018, 65, 530–531. [Google Scholar] [CrossRef]
  17. Schuler, T.A.; Müller, R.; van Hedel, H.J. Leg surface electromyography patterns in children with neuro-orthopedic disorders walking on a treadmill unassisted and assisted by a robot with and without encouragement. J. Neuroeng. Rehabil. 2013, 10, 78. [Google Scholar] [CrossRef] [Green Version]
  18. Cherni, Y.; Begon, M.; Chababe, H.; Moissenet, F. Use of electromyography to optimize Lokomat® settings for subject-specific gait rehabilitation in post-stroke hemiparetic patients: A proof-of-concept study. Neurophysiol. Clin. 2017, 47, 293–299. [Google Scholar] [CrossRef]
  19. Aurich-Schuler, T.; Grob, F.; Van Hedel, H.J.; Labruyère, R. Can Lokomat therapy with children and adolescents be improved? An adaptive clinical pilot trial comparing Guidance force, Path control, and FreeD. J. Neuroeng. Rehabil. 2017, 14, 76. [Google Scholar] [CrossRef] [Green Version]
  20. Rodrigues, T.A.; Goroso, D.G.; Westgate, P.M.; Carrico, C.; Batistella, L.R.; Sawaki, L. Slow Versus Fast Robot-Assisted Locomotor Training After Severe Stroke: A Randomized Controlled Trial. Am. J. Phys. Med. Rehabil. 2017, 96, S165–S170. [Google Scholar] [CrossRef]
  21. Park, I.J.; Park, J.-H.; Seong, H.Y.; You, J.S.H.; Kim, S.J.; Min, J.H.; Ko, H.Y.; Shin, Y.-I. Comparative Effects of Different Assistance Force during Robot-Assisted Gait Training on Locomotor Functions in Patients with Subacute Stroke: An Assessor-Blind, Randomized Controlled Trial. Am. J. Phys. Med. Rehabil. 2019, 98, 58–64. [Google Scholar] [CrossRef]
  22. World Health Organization. International Classification of Functioning, Disability and Health: Children and Youth Version: ICF-CY. Available online: (accessed on 26 May 2020).
  23. Borggraefe, I.; Schaefer, J.S.; Klaiber, M.; Dabrowski, E.; Ammann-Reiffer, C.; Knecht, B.; Berweck, S.; Heinen, F.; Meyer-Heim, A. Robotic-assisted treadmill therapy improves walking and standing performance in children and adolescents with cerebral palsy. Eur. J. Paediatr. Neurol. 2010, 14, 496–502. [Google Scholar] [CrossRef] [PubMed]
  24. Schroeder, A.S.; Homburg, M.; Warken, B.; Auffermann, H.; Koerte, I.; Berweck, S.; Jahn, K.; Heinen, F.; Borggraefe, I. Prospective controlled cohort study to evaluate changes of function, activity and participation in patients with bilateral spastic cerebral palsy after Robot-enhanced repetitive treadmill therapy. Eur. J. Paediatr. Neurol. 2014, 18, 502–510. [Google Scholar] [CrossRef]
  25. van Hedel, H.; Meyer-Heim, A.; Rüsch-Bohtz, C. Robot-assisted gait training might be beneficial for more severely affected children with cerebral palsy. Dev. Neurorehabilit. 2015, 19, 410–415. [Google Scholar] [CrossRef] [PubMed]
  26. Klobucká, S.; Ková, M.; Klobuck, R.; Bratislava, R.C.H. Effect of Robot-Assisted Treadmill Training on Motor Functions Depending on Severity of Impairment in Patients with Bilateral Spastic Cerebral Palsy. J. Rehabil. Robot. 2013, 1, 71–81. [Google Scholar] [CrossRef] [Green Version]
  27. Meyer-Heim, A.; Ammann-Reiffer, C.; Schmartz, A.; Schäfer, J.; Sennhauser, F.H.; Heinen, F.; Knecht, B.; Dabrowski, E.; Borggraefe, I. Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy. Arch. Dis. Child. 2009, 94, 615–620. [Google Scholar] [CrossRef] [Green Version]
  28. Cherni, Y.; Ballaz, L.; Lemaire, J.; Maso, F.D.; Begon, M. Effect of low dose robotic-gait training on walking capacity in children and adolescents with cerebral palsy. Neurophysiol. Clin. 2020, 50, 507–519. [Google Scholar] [CrossRef]
  29. Beretta, E.; Storm, F.A.; Strazzer, S.; Frascarelli, F.; Petrarca, M.; Colazza, A.; Cordone, G.; Biffi, E.; Morganti, R.; Maghini, C.; et al. Effect of Robot-Assisted Gait Training in a Large Population of Children with Motor Impairment Due to Cerebral Palsy or Acquired Brain Injury. Arch. Phys. Med. Rehabil. 2019, 101, 106–112. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  30. Aras, B.; Yaşar, E.; Kesikburun, S.; Türker, D.; Tok, F.; Yılmaz, B. Comparison of the effectiveness of partial body weight-supported treadmill exercises, robotic-assisted treadmill exercises, and anti-gravity treadmill exercises in spastic cerebral palsy. Turk. J. Phys. Med. Rehabil. 2019, 65, 361–370. [Google Scholar] [CrossRef]
  31. Petrarca, M.; Frascarelli, F.; Carniel, S.; Colazza, A.; Minosse, S.; Tavernese, E.; Castelli, E. Robotic-assisted locomotor treadmill therapy does not change gait pattern in children with cerebral palsy. Int. J. Rehabil. Res. 2021, 44, 69–76. [Google Scholar] [CrossRef]
  32. Wallard, L.; Dietrich, G.; Kerlirzin, Y.; Bredin, J. Robotic-assisted gait training improves walking abilities in diplegic children with cerebral palsy. Eur. J. Paediatr. Neurol. 2017, 21, 557–564. [Google Scholar] [CrossRef]
  33. Wallard, L.; Dietrich, G.; Kerlirzin, Y.; Bredin, J. Effect of robotic-assisted gait rehabilitation on dynamic equilibrium control in the gait of children with cerebral palsy. Gait Posture 2018, 60, 55–60. [Google Scholar] [CrossRef]
  34. Drużbicki, M.; Rusek, W.; Snela, S.; Dudek, J.; Szczepanik, M.; Zak, E.; Durmala, J.; Czernuszenko, A.; Bonikowski, M.; Sobota, G. Functional effects of robotic-assisted locomotor treadmill thearapy in children with cerebral palsy. J. Rehabil. Med. 2013, 45, 358–363. [Google Scholar] [CrossRef] [Green Version]
  35. Ammann-Reiffer, C.; Bastiaenen, C.H.; Meyer-Heim, A.D.; van Hedel, H.J. Lessons learned from conducting a pragmatic, randomized, crossover trial on robot-assisted gait training in children with cerebral palsy (PeLoGAIT). J. Pediatr. Rehabil. Med. 2020, 13, 137–148. [Google Scholar] [CrossRef]
  36. Van Kammen, K.; Boonstra, A.; Reinders-Messelink, H.; Otter, R.D. The Combined Effects of Body Weight Support and Gait Speed on Gait Related Muscle Activity: A Comparison between Walking in the Lokomat Exoskeleton and Regular Treadmill Walking. PLoS ONE 2014, 9, e107323. [Google Scholar] [CrossRef] [PubMed]
  37. Cherni, Y.; Hajizadeh, M.; Maso, F.D.; Turpin, N.A. Effects of body weight support and guidance force settings on muscle synergy during Lokomat walking. Eur. J. Appl. Physiol. 2021, 121, 2967–2980. [Google Scholar] [CrossRef]
  38. Cherni, Y.Y.; Blache, M.; Begon, L.; Ballaz, F.; Maso, D. Effects of Robotic-Assisted Gait at Different Levels of Guidance and Body Weight Support on Lower Limb Joint Kinematics and Coordination. medRxiv 2022. [Google Scholar] [CrossRef]
  39. Kleim, J.A. Neural plasticity and neurorehabilitation: Teaching the new brain old tricks. J. Commun. Disord. 2011, 44, 521–528. [Google Scholar] [CrossRef] [PubMed]
  40. van Kammen, K.; Reinders-Messelink, H.A.; Elsinghorst, A.L.; Wesselink, C.F.; Vries, B.M.-D.; van der Woude, L.H.; Boonstra, A.M.; Otter, R.D. Amplitude and stride-to-stride variability of muscle activity during Lokomat guided walking and treadmill walking in children with cerebral palsy. Eur. J. Paediatr. Neurol. 2020, 29, 108–117. [Google Scholar] [CrossRef]
  41. Ada, L.; Dorsch, S.; Canning, C.G. Strengthening interventions increase strength and improve activity after stroke: A systematic review. Aust. J. Physiother. 2006, 52, 241–248. [Google Scholar] [CrossRef] [Green Version]
  42. Van Kammen, K.; Boonstra, A.M.; van der Woude, L.H.V.; Visscher, C.; Reinders-Messelink, H.A.; Den Otter, R. Lokomat guided gait in hemiparetic stroke patients: The effects of training parameters on muscle activity and temporal symmetry. Disabil. Rehabil. 2019, 42, 2977–2985. [Google Scholar] [CrossRef] [Green Version]
  43. Negrini, S.; Arienti, C.; Pollet, J.; Engkasan, J.P.; Francisco, G.E.; Frontera, W.R.; Galeri, S.; Gworys, K.; Kujawa, J.; Mazlan, M.; et al. Clinical replicability of rehabilitation interventions in randomized controlled trials reported in main journals is inadequate. J. Clin. Epidemiol. 2019, 114, 108–117. [Google Scholar] [CrossRef]
  44. Gannotti, M.E.; Christy, J.B.; Heathcock, J.C.; Kolobe, T.H. A Path Model for Evaluating Dosing Parameters for Children with Cerebral Palsy. Phys. Ther. 2014, 94, 411–421. [Google Scholar] [CrossRef] [PubMed]
  45. Lohse, K.R.; Lang, C.; Boyd, L.A. Is More Better? Using Metadata to Explore Dose–Response Relationships in Stroke Rehabilitation. Stroke 2014, 45, 2053–2058. [Google Scholar] [CrossRef] [PubMed]
  46. Verschuren, O.; Peterson, M.D.; Balemans, A.C.J.; Hurvitz, E.A. Exercise and physical activity recommendations for people with cerebral palsy. Dev. Med. Child Neurol. 2016, 58, 798–808. [Google Scholar] [CrossRef] [PubMed]
  47. Cope, S.; Mohn-Johnsen, S. The effects of dosage time and frequency on motor outcomes in children with cerebral palsy: A systematic review. Dev. Neurorehabilit. 2017, 20, 376–387. [Google Scholar] [CrossRef]
  48. Cherni, Y.; Hajizadeh, M.; Begon, M.; Turpin, N.A. Muscle Coordination during Robotic Assisted Walking Using Lokomat. Comput. Methods Biomech. Biomed. Eng. 2019, 22, S121–S123. [Google Scholar] [CrossRef]
  49. Stoller, O.; de Bruin, E.D.; Schindelholz, M.; Schuster-Amft, C.; De Bie, R.A.; Hunt, K. Efficacy of Feedback-Controlled Robotics-Assisted Treadmill Exercise to Improve Cardiovascular Fitness Early After Stroke: A Randomized Controlled Pilot Trial. J. Neurol. Phys. Ther. 2015, 39, 156–165. [Google Scholar] [CrossRef]
  50. Hesse, S.; Werner, C.; Paul, T.; Bardeleben, A.; Chaler, J. Influence of walking speed on lower limb muscle activity and energy consumption during treadmill walking of hemiparetic patients. Arch. Phys. Med. Rehabil. 2001, 82, 1547–1550. [Google Scholar] [CrossRef]
  51. Morone, G.; Paolucci, S.; Cherubini, A.; De Angelis, D.; Venturiero, V.; Coiro, P.; Iosa, M. Robot-assisted gait training for stroke patients: Current state of the art and perspectives of robotics. Neuropsychiatr. Dis. Treat. 2017, 13, 1303–1311. [Google Scholar] [CrossRef] [Green Version]
  52. Eng, J.J.; Tang, P.-F. Gait training strategies to optimize walking ability in people with stroke: A synthesis of the evidence. Expert Rev. Neurother. 2007, 7, 1417–1436. [Google Scholar] [CrossRef] [Green Version]
Table 1. Summary of the main clinical trials on Lokomat training in children and adolescents with cerebral palsy.
Table 1. Summary of the main clinical trials on Lokomat training in children and adolescents with cerebral palsy.
AuthorsDesignN of SubjectsInterventionICF DomainsMain Results
Borggraefe et al. [23]Pre/post with follow-up20 patients with CP;
age = 5–20 yrs; GMFCS = I–VI
Lokomat trianingActivityImproved GMFM-66 score, walking endurance (6-MWT), and comfortable walking speed. Improvements were maintained at follow-up.
Schroeder et al. [24]Prospective controlled cohort18 patients with CP;
age = 5–21 yrs; GMFCS = I–VI
Lokomat trainingActivity and participationSignificant improvement in GMFM-66 score and COPM (participation). Improvements were maintained after 8 weeks of follow-up.
Van Hedel et al. [25]Retrospective67 patients with CP;
age = 4–20 yrs; GMFCS II–IV
Lokomat training combined to conventional therapyActivityImproved function (as measured by the WeeFIM test) and walking speed.
Klobucká et al. [26]Pre/post51 patients with CP;
age = 4–27 yrs; GMFCS = I–IV
Lokomat trainingActivityImprovement in GMFM A, B, C, D, and E scores, maximum walking speed, and walking endurance (6-MWT).
Meyer-Heim et al. [27]Pre/post22 patients with CP;
age = 5–12 yrs; GMFCS = II–IV
Lokomat trainingActivityImprovements in GMFM D and E scores, walking endurance (6-MWT), and walking speed.
Cherni et al. [28]Pre/post with follow-up24 patients with CP;
age = 7–20 yrs; GMFCS = II–IV
Lokomat trainingBody function and activity Increased hip and knee flexors and extensors’ strength, comfortable walking speed (+20%), and step length (+14%). Increase in walking endurance (6-MWT) was maintained at follow-up. No change in gait pattern.
Beretta et al. [29]Retrospective72 patients with CP;
age = 4–18 yrs; GMFCS = I–IV
Lokomat training combined to conventional therapyActivityImprovement in walking endurance (6-MWT). No improvement in GMFM-88 scores.
Aras et al. [30]RCT30 patients with CP;
age = 6–4 yrs; GMFCS = II–III
Lokomat training (n = 10) vs. anti-gravity training (n = 10), and BWSTT (n = 10)ActivityIncreased cadence, stride length, and stride time after anti-gravity training. Decreased double-support time was significant in the anti-gravity and Lokomat training. Increased GMFM-D, GMFM-E, and walking endurance (6-MWT) in all the groups.
Petrarca et al. [31]Pre/post 24 participants with CP;
age = 4–13 yrs; GMFCS = I–IV
Lokomat training combined with conventional therapy Activity All improved GMFM D, while dimension E improved only for younger and more severely affected patients. No change in gait pattern.
Wallard et al. [32,33]RCT14 patients with CP (jump gait) age = 8–10 yrs; GMFCS II–IIILokomat training combined to virtual reality ActivityImprovement of knee and ankle sagittal kinematics as well as dynamic balance control after Lokomat training combined with virtual reality.
Druzbicki et al. [34]RCT35 patients with CP;
age = 6–13 yrs; GMFCS = II–III
Lokomat training (n = 10) vs. control group (n = 9)ActivityImprovement in balance, step length, and maximum hip flexion amplitude.
Ammann-Reiffer et al. [35]RCT16 patients with CP;
age = 6.0–15.3 years; GMFCS = II–IV
Lokomat training (n = 8) vs. control group (n = 8)Activity
Neither GMFM nor walking speed and endurance (6-MWT) changed significantly after Lokomat training.
Note: RCT: randomized controlled trial; CP: cerebral palsy; GMFCS: Gross Motor Function Classification System; 6-MWT: six-minute walking test; GMFM: gross motor functional measurement; COPM: Canadian Occupational Performance Measure; BWS: body weight support.
Table 2. Results of the methodological quality of the articles using the PEDro score.
Table 2. Results of the methodological quality of the articles using the PEDro score.
Studies1234567891011Total (/10)
Borggraefe et al. [23]100000011013/10 (low)
Schroeder et al. [24]000000011114/10 (fair)
Van Hedel et al. [25]000000001012/10 (low)
Klobucká et al. [26]100000011013/10 (low)
Meyer-Heim et al. [27]100000011013/10 (low)
Cherni et al. [28]100000011013/10 (low)
Beretta et al. [29]111100011117/10 (good)
Aras et al. [30]111100110117/10 (good)
Petrarca et al. [31]100000011013/10 (low)
Wallard et al. [32,33]111100110117/10 (good)
Druzbicki et al. [34]111100100116/10 (good)
Ammann-Reiffer et al. [35]111100011117/10 (good)
Note: RCT: randomized controlled trial. The PEDro scale consists of 11 items: Item 1. eligibility criteria were specified; Item 2. subjects were randomly allocated to groups; Item 3. allocation was concealed; Item 4. the groups were similar at baseline regarding the most important prognostic indicators; Items 5, 6, and 7. there was blinding of all subjects, therapists, and assessors; Item 8. measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups; Item 9. all subjects for whom outcome measures were available received the treatment or control condition as allocated, or, where this was not the case, data for at least one key outcome were analyzed by “intention-to-treat”; Item 10. the results of between-group statistical comparisons are reported for at least one key outcome; Item 11. the study provides both point measures and measures of variability for at least one key outcome. Each item is scored as a “yes” or “no” and is worth 1 and 0 points, respectively. The total score is expressed out of 10 points. The first item is not included in the sum of the total score of the PEDro scale.
Table 3. Summary of training parameters and Lokomat settings.
Table 3. Summary of training parameters and Lokomat settings.
StudiesTraining ParametersLokomat Settings
Borggraefe et al. [23]50 min per session, 4 sessions per week for 3 weeks Speed was set at 1.1 km/h and gradually increased to 1.8 km/h. BWS started at 100% and then decreased as much as possible. Guidance was adjusted according to clinical judgement. Progression of settings not described except for speed.
Schroeder et al. [24]30–39 min per session, 4 sessions per week for 3 weeks No information about Lokomat settings.
Van Hedel et al. [25]At least one session No information about Lokomat settings.
Klobucká et al. [26]20–25 min per session, 3–5 sessions per week for 5–6 weeks Training speed ranged from 1.1 m/s for severely impaired patients to 1.8 m/s
for the mildly impaired group.
Meyer-Heim et al. [27]45–60 min per session, 3–5 sessions per week for 3–5 weeks No information about Lokomat settings.
Cherni et al. [28]30–45 min per session, 2 sessions per week for 12 weeks Speed was set at 1.2 km/h and gradually increased to 1.8 km/h. BWS started at 47% and then decreased to 22%. Guidance was initially set at 100% and gradually decreased to 65%.
Beretta et al. [29]45 min per session, 5 sessions per week for 4 weeks For all patients, the same exercises were offered with a set duration, speed, and difficulty. BWS started at 50% and gradually decreased according to the patient’s functional capacity. Guidance was initially set to 100% and gradually decreased. Progression of settings not described.
Aras et al. [30]45 min per session, 5 sessions per week for 4 weeks Speed was set to the child’s average walking speed. BWS started at 60% and gradually decreased to a level which prevented the collapse of the knee in flexion during the stance phase. No information about guidance. Progression of settings not described.
Petrarca et al. [31]30 min per session, 5 sessions per week for 4 weeks No information about Lokomat settings.
Wallard et al. [32,33]40 min per session, 5 sessions per week for 4 weeks Speed was set at 0.7 km/h and gradually increased to 1.4 km/h. BWS started at 70% and then decreased to 40%. No information about guidance.
Druzbicki et al. [34]45 min per session, 4 sessions per week for 5 weeks No information about Lokomat settings.
Ammann-Reiffer et al. [35]30–45 min per session, 3 sessions per week for 5 weeksNo information about Lokomat settings.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Cherni, Y.; Ziane, C. A Narrative Review on Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: Training Parameters, Choice of Settings, and Perspectives. Disabilities 2022, 2, 293-303.

AMA Style

Cherni Y, Ziane C. A Narrative Review on Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: Training Parameters, Choice of Settings, and Perspectives. Disabilities. 2022; 2(2):293-303.

Chicago/Turabian Style

Cherni, Yosra, and Clara Ziane. 2022. "A Narrative Review on Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: Training Parameters, Choice of Settings, and Perspectives" Disabilities 2, no. 2: 293-303.

Article Metrics

Back to TopTop