This single-center, controlled, delayed-intervention, quasi-experimental study evaluates the effectiveness of Lokomat®-assisted robotic gait training on gross motor function and health-related quality of life in children and young adults with cerebral palsy. Although previous studies have reported improvements in walking ability, gross motor function, and lower limb performance following Lokomat-assisted gait training, uncertainty remains regarding the optimal treatment intensity and dosing schedule, particularly across different age groups and levels of functional impairment. The primary objective of this study is to evaluate the effect of a 20-session (8 week) Lokomat-assisted gait training program on standing and walking function, assessed using Dimensions D and E of the Gross Motor Function Measure (GMFM-88). Secondary objectives include evaluation of lower limb muscle strength, walking speed, health-related quality of life, individualized rehabilitation goal attainment, and objective gait training parameters recorded by the Lokomat® system. The study employs a controlled, delayed-intervention, quasi-experimental design conducted over three consecutive study periods. During each study period, one intervention group receives Lokomat-assisted gait training in addition to usual rehabilitation, whereas a concurrent control group receives usual rehabilitation alone. As standard (usual) rehabilitation participants receive nationally approved standard-of-care rehabilitation, which may include neurorehabilitation, physiotherapy, and/or educational (pedagogical) rehabilitation, as appropriate to their individual clinical needs and routine care. After completion of the control period and post-intervention assessment, participants in the control group receive the same 20-session Lokomat-assisted gait training program and physiotherapy program during the subsequent study period. Participants allocated to the control group during the final study period receive the intervention after completion of the formal study period.
Motor learning theory and contemporary neurorehabilitation emphasize that intensive, task-specific, repetitive practice is essential for promoting neuroplasticity and improving functional motor performance in individuals with neurological disorders. Robot-assisted gait training has therefore become an increasingly important component of pediatric neurorehabilitation by enabling highly repetitive, standardized, and individualized gait practice while reducing the physical burden on therapists. The Lokomat® robotic gait orthosis combines body-weight-supported treadmill training with computer-controlled lower limb guidance, allowing precise adjustment of walking speed, robotic assistance, and body-weight support according to each participant's functional abilities. Previous studies have demonstrated beneficial effects of Lokomat-assisted gait training on gait performance, gross motor function, endurance, and lower limb function in children with cerebral palsy. However, the available literature shows considerable variability regarding intervention frequency, treatment intensity, total number of sessions, and participant characteristics. Consequently, no consensus currently exists regarding the optimal therapeutic dose for different age groups and functional severity levels. The intervention dose selected for the present study consists of 20 treatment sessions delivered over approximately eight weeks. This treatment schedule was determined based on two complementary considerations. First, it reflects the clinical experience of this treatment intensity has proven feasible and well tolerated in routine clinical practice. Second, the selected dose is consistent with the range of intervention protocols most frequently reported in published pediatric Lokomat studies, thereby allowing comparison of the present findings with the existing literature while evaluating the practical applicability of this protocol in a real-world rehabilitation setting. Study Objectives The primary objective of this study is to evaluate the effectiveness of Lokomat-assisted robotic gait training on standing and walking function in children and young adults with cerebral palsy. In addition, the study aims to determine whether treatment tolerance and clinical effectiveness differ according to participants' age and functional severity as classified by the Gross Motor Function Classification System (GMFCS). An important objective is to explore whether treatment response differs according to functional severity and age and to provide evidence for the development of a standardized clinical protocol for Lokomat-assisted rehabilitation within pediatric neurorehabilitation. The study also investigates whether participation in conductive education influences rehabilitation outcomes following robot-assisted gait training. Study Design This is a single-center, controlled, delayed-intervention, quasi-experimental study conducted over three consecutive study periods. Participants are enrolled according to the routine admission schedule and allocated to either an intervention group or a concurrent control group. Participants in the intervention group receive a 20-session Lokomat-assisted gait training program in addition to their usual rehabilitation. Participants in the control group continue their usual rehabilitation during the control period and subsequently receive the same Lokomat-assisted intervention after completion of the post-control assessment. Participants assigned to the final control group receive the intervention after completion of the formal study period, ensuring that all eligible participants have access to robotic gait training. Approximately 96 participants with cerebral palsy are expected to be enrolled. Outcome assessments are performed before and after each study period and include evaluation of standing and walking function using the GMFM-88 Dimensions D and E, lower limb muscle strength, walking speed, health-related quality of life, Goal Attainment Scaling (GAS), and objective gait training parameters recorded by the Lokomat® system. Functional severity is classified using the Gross Motor Function Classification System (GMFCS).
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
96
During the intervention, participants accomplish rehabilitation sessions by using Lokomat robotic gait training system. Each participant will participate in robot-assisted rehabilitation and physiotherapy 5 times in two weeks, 20 times total during the 8 week period of rehabilitation. The robot-assisted rehabilitation session lasts approximately 60 minutes, depends on the individual needs and performance.
Participants continue their usual rehabilitation without Lokomat -assisted gait training during the control period.
Semmelweis University, András Pető Rehabilitation and Health Care Department, Institutions of Conductive Pedagogical Center
Budapest, Pest County, Hungary
Standing and walking functions
The Gross Motor Function Measure-88 (GMFM-88) is a validated observational outcome measure specifically developed to assess gross motor function in children with cerebral palsy. The study evaluates Dimensions D (Standing; 13 items) and E (Walking, Running, and Jumping; 24 items). Each item is scored on a 4-point ordinal scale (0 = does not initiate the task, 1 = initiates, 2 = partially completes, 3 = completes the task). Raw scores are converted to percentage scores ranging from 0% to 100% for each dimension. The Dimension D and E percentage scores (0-100%) will be analyzed as continuous variables and summarized using mean and standard deviation (SD). Higher scores indicate better gross motor function.
Time frame: Measurement at 0 weeks and 8 weeks
Lower limb muscle strength
Change in lower limb muscle strength assessed using a handheld dynamometer. Muscle strength will be measured in Newtons (N)/kilograms-force \[kgf\] during standardized maximal voluntary isometric contractions of predefined lower limb muscle groups. Three trials will be performed for each muscle group, and the highest value will be used for analysis. The primary outcome will be the change in muscle strength from baseline to the post-intervention assessment. Results will be summarized as mean ± standard deviation and compared between study groups using appropriate statistical methods.
Time frame: Measurement at 0 weeks, 8 weeks
Goal attainment
Goal Attainment Scaling (GAS) is a personalized outcome measure used in clinical and rehabilitation settings to track a patient's progress toward individualized goals. It allows patients and practitioners to collaboratively set specific targets and translate qualitative improvements into standardized numerical scores for statistical evaluation. Each goal will be rated on a 5-point scale ranging from -2 (baseline or much less than expected outcome) to +2 (much better than expected outcome), with 0 representing the expected level of achievement after the intervention. Individual goal scores will be converted into a standardized GAS T-score (mean = 50, standard deviation = 10) when appropriate. Changes in GAS scores from baseline to the post-intervention assessment will be summarized using mean ± standard deviation and compared between study groups using appropriate statistical methods.
Time frame: Measurement at 0 weeks and 8 weeks
Functional performance changes measured by walking speed
Walking speed will be assessed using the 10-Meter Walk Test (10MWT), a validated and reliable measure of gait performance. Participants will be instructed to walk at their self-selected comfortable walking speed along a standardized walkway. The time required to complete the test will be recorded in seconds, and walking speed will be calculated in meters per second (m/s). Changes in walking speed from baseline to the post-intervention assessment will be analyzed. Results will be summarized using mean and standard deviation (SD).
Time frame: Measurement at 0 weeks and 8 weeks.
Changes in training parameters recorded by the Lokomat system
Objective gait training parameters will be automatically recorded by the Lokomat system during the first and last treatment sessions. Recorded parameters will include walking distance (m), average walking speed (km/h), and robotic assistance level (% body weight support and/or guidance force, depending on the Lokomat settings). Changes in these parameters from baseline to the final treatment session will be analyzed. Results will be summarized as mean ± standard deviation and compared within and between study groups using appropriate statistical methods.
Time frame: Measurement at 0 weeks and 8 weeks.
Health-related quality of life
Health-related quality of life (HRQoL) will be assessed using the Pediatric Quality of Life Inventory (PedsQL™) Scales, selecting the age-appropriate version for each participant. The questionnaire will be administered at baseline and at the post-intervention assessment. For participants 2-4 years of age, the parent-proxy report will be completed by the parent or primary caregiver. For children 5-7 years of age, both the child self-report and the parent-proxy report will be obtained. Participants 8-12 years and 13-23 years will complete the age-appropriate child/adolescent self-report, while a corresponding parent-proxy report will also be collected. The PedsQL Generic Core Scales assess four domains of health-related quality of life: physical functioning, emotional functioning, social functioning, and school functioning.The total score will be analyzed as continuous variables. Results will be summarized using mean and standard deviation (SD).
Time frame: Measurement at 0 weeks and 8 weeks.
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