Long-term robot-assisted gait training in patients with cerebral palsy: meaningful changes in gait parameters require time
TL;DR
Systematic, repetitive gait training based on RAGT in patients with CP was associated with long-term positive changes in spatiotemporal gait parameters and walking endurance, while clinically meaningful changes in gait kinematics, as quantified by the GDI, were limited across all GMFCS levels.
Abstract
Introduction Robot-assisted gait training (RAGT) is increasingly used in children with cerebral palsy (CP), but evidence regarding the timing and persistence of meaningful changes in gait remains limited. This study aimed to describe long-term changes in spatiotemporal gait parameters, gait kinematics, and walking endurance in ambulatory patients with CP undergoing systematic, repetitive RAGT, and to determine whether the timing of clinically meaningful change differs between ambulatory levels. Methods A study group consisting of 211 patients with hypertonic CP (93 females, 118 males; mean age 10.33 ± 3.80 years) classified at Gross Motor Function Classification System (GMFCS) levels I–III underwent a structured 2-year RAGT program comprising four therapy sets and 40 sessions in total. Gait was assessed five times: at baseline (pre-intervention) and at 6-month intervals over 24 months. Outcomes included the Gait Deviation Index (GDI), spatiotemporal gait parameters obtained from three-dimensional gait analysis, and six-minute walk test (6MWT) distance. The follow-up values were compared with the baseline. Clinical meaningfulness was evaluated using the minimal clinically important difference (MCID) thresholds. Results In the entire group, step length and stride length increased significantly from T2 onward, walking speed from T3 onward, and 6MWT distance at each follow-up assessment. At T5, individual improvement exceeding the relevant MCID thresholds was observed in 61.61% of participants for step length, 62.09% for stride length, 52.13% for walking speed, and 51.66% for 6MWT distance. Cadence increased significantly only at T5, whereas GDI increased throughout follow-up; however, the corresponding MCID thresholds were exceeded by 32.23 and 46.92% of participants, respectively. GMFCS III showed the earliest and largest gains, while changes in GMFCS II generally emerged later. Effect sizes increased over time and reached their highest values at T5. Repeated-measures ANOVA confirmed significant time effects for most outcomes. Significant time-by-GMFCS interactions for cadence, step length, and 6MWT distance indicated that selected longitudinal trajectories differed across functional levels, although the interaction effect sizes were small. Conclusion Systematic, repetitive gait training based on RAGT in patients with CP was associated with long-term positive changes in spatiotemporal gait parameters and walking endurance. In contrast, clinically meaningful changes in gait kinematics, as quantified by the GDI, were limited across all GMFCS levels. The effects of systematic and repeated RAGT developed progressively over time, with selected outcomes following different trajectories according to the participants’ functional level.