Robot-Assisted Gait Training and Changes In Motor Function and Brain Activation In Children With Cerebral Palsy: Preliminary Findings From A Pilot Study.

Studies on robot-assisted gait training rehabilitation in multiple sclerosis have reported positive effects on mobility and quality of life. However, their effects on cognitive functions are difficult to determine because not all trials have included cognition assessments. Virtual reality-based training provides enhanced opportunity for stimulating cognitive abilities by repetitive practice, feedback information, and motivation for endurance practice. To compare the effects of innovative robot-assisted gait training combined with virtual reality versus standard robot-assisted gait training on information processing speed, sustained attention, working memory, and walking endurance in patients with multiple sclerosis. Seventeen outpatients were randomly assigned to receive robot-assisted gait training either with or without virtual reality. The robot assisted gait training + virtual reality group underwent end-effector system training engendered by virtual reality. The standard training group underwent end-effector system training. A blinded rater evaluated patients before and after treatment and at one month follow-up. The outcome measures were the Paced Auditory Serial Addition Test, Phonemic Fluency Test, Novel Task, Digit Symbol, Multiple Sclerosis Quality of Life-54, 2-Minutes Walk Test, 10-Meter Walking Test, Berg Balance Scale, gait analysis, and stabilometric assessment. Between-group comparisons showed a significant change on the 2-Minutes Walk Test (p = 0.023) after treatment in the robot-assisted gait training + virtual reality group. Significant improvement were obtained also in executive functions (p = 0.012). Both gains were maintained at the 1-month follow-up evaluation (p = 0.012, p = 0.012) in the robot-assisted gait training + virtual reality group. Both group improved quality of life after treatment (Multiple Sclerosis Quality of Life-54: Mental Health p = 0.018, Physical Health p = 0.017). Both training lead to positive influenced on executive functions. However larger positive effects on gait ability were noted after robot-assisted gait training engendered by virtual reality with multiple sclerosis. Robot-assisted gait training provides a therapeutic alternative and motivational of traditional motor rehabilitation.

Purpose To identify the short-term effects of robotic-assisted gait training (RAGT) on walking distance, gait speed and functionality of cerebral palsy (CP) patients, and to verify if the effects of RAGT are maintained in the long term. Methods A systematic literature review was performed in PubMed, PEDro, CINAHL, and LILACS databases. Studies were included considering: (1) population (CP individuals); (2) study design (experimental studies); (3) type of intervention (RAGT); (4) outcome (gait parameters and function); and (5) period (short and long term). Results This systematic review included seven articles in meta-analysis. Only walking distance, thru six minutes walking test, increased statistically after RAGT. However, RAGT demonstrated large clinical effects differences (minimal clinically important difference – MCID) in gait speed and Gross Motor Function Measure score (dimensions D and E), for CP population. After RAGT intervention, differences in short term (comparison 1) were maintained in long term (comparison 2) for all outcomes. Gait speed results were not significant. Conclusions Evidence from the present study demonstrated that RAGT can be an important intervention to improve gait parameters and functionality, in children with CP, that are maintained over long-term. Implications for Rehabilitation Robotic-assisted gait training (RAGT) is a beneficial treatment for children with cerebral palsy (CP). RAGT improvements in walking distance are maintained over the long-term in children with CP. RAGT demonstrated large clinical effect differences in gait speed and functionality in CP population.

Objective To evaluate the impact of combining botulinum toxin-A (BoNT-A) injection with robot-assisted gait training (RAGT) on lower limb spasticity and motor function in children with cerebral palsy. Methods A prospective study was conducted from January 2020 to January 2023, including 68 patients. Twenty patients received the combination of BoNT-A injection and RAGT, while 48 received BoNT-A injection alone. Assessments were performed before the intervention and at 1, 3, and 6 months post-injection using the Modified Tardieu Scale (MTS), sections D and E of the Gross Motor Function Measure-88 (GMFM-88), 6-minute walk test (6MWT), and 10-meter walk test (10MWT). Results Compared to the control group receiving BoNT-A alone, the combination of BoNT-A and RAGT did not significantly improve spasticity-related outcomes, including MTS scores, R1, and R2 angles (p > .05). However, the combination group demonstrated significantly improved gross motor function, particularly in walking, running (GMFM-E), short-term walking endurance (6MWT), and walking speed (10MWT) in children with cerebral palsy after the intervention (p < .05). Conclusion While the addition of RAGT did not enhance the anti-spasticity effects of BoNT-A, it significantly improved gross motor function and walking abilities in children with cerebral palsy.

Robot-assisted gait training (RAGT) provides a task-based support of walking using exoskeletons. Evidence shows moderate, but positive effects in the therapy of patients with cerebral palsy (CP). This study investigates the impact of RAGT on walking speed and gait parameters in pediatric CP patients. Thirty subjects (male = 23; female = 7), with a mean age of 13.0 ± 2.5 (9–17) years, and with spastic CP, were recruited. The intervention group (n = 15) underwent six 20-minute RAGT sessions with the Hybrid Assistive Limb (HAL) during an 11-day hospital stay. Additionally, a therapy concept including physiotherapy, physician-performed manual medicine, massage and exercise therapy was provided. The control group (n = 15) was treated with the therapy concept only. The outcome was based on a 10-Metre Walking Test (10MWT), 6-Minute Walking Test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion. The intervention group achieved a mean increase in walking speed in the 10MWT (self-selected walking speed SSW) of 5.5 s (p = 0.378). There were no significant differences between the groups in the 10MWT (max) (p = 0.123) and the 6MWT (p = 0.8). Changes in the GMFM (total) and in the dimension standing and walking, running and jumping (D + E) showed clinically relevant significant results (p = 0.002 and p = 0.046). RAGT as a supplement to an inpatient therapy stay appears to have a positive, yet not significant impact on the gait parameters of pediatric CP patients as well as motivating them to practice walking. Further studies with adapted study designs are needed to evaluate different influencing factors.

This study investigated the effects of robot-assisted gait training (RAGT) on gait function in burn patients. Briefly, 40 burn patients were randomly divided into an RAGT group or a conventional training (CON) group. SUBAR® (Cretem, Korea) is a wearable robot with a footplate that simulates normal gait cycles. The RAGT group underwent 30 min of robot-assisted training using SUBAR® with 30 min of conventional physiotherapy once a day, 5 days a week for 12 weeks. Patients in the CON group received 30 min of overground gait training and range-of-motion (ROM) exercises twice a day for 5 days a week for 12 weeks. The RAGT group and the CON group underwent 60 min of training per day. The intervention frequency and duration did not differ between the RAGT group and the CON group. The main outcomes were functional ambulatory category (FAC); 6-min walking test (6MWT); visual analogue scale (VAS) during gait movement; ROM; and isometric forces of bilateral hip, knee, and ankle muscles before and after 12 weeks of training. The results of the VAS, FAC, and 6MWT (8.06 ± 0.66, 1.76 ± 0.56, and 204.41 ± 85.60) before training in the RAGT group improved significantly (4.41 ± 1.18, 4.18 ± 0.39, and 298.53 ± 47.75) after training (p < 0.001, p < 0.001, and p < 0.001). The results of the VAS, FAC, and 6MWT (8.00 ± 1.21, 1.75 ± 0.58, and 220.94 ± 116.88) before training in the CON group improved significantly (5.00 ± 1.03, 3.81 ± 1.05, and 272.19 ± 110.14) after training (p < 0.001, p < 0.001, and p = 0.05). There were differences in the improvement of results of the VAS, FAC, and 6MWT between groups after training, but they were not statistically significant (p = 0.23, p = 0.14, and p = 0.05). The isometric strengths of the right hip extensor (p = 0.02), bilateral knee flexor (p = 0.04 in the right, and p = 0.001 in the left), bilateral knee extensor (p = 0.003 in the right, and p = 0.002 in the left), bilateral ankle dorsiflexor (p = 0.04 in the right, and p = 0.02 in the left), and bilateral ankle plantarflexor (p = 0.001 in the right, and p = 0.008 in the left) after training were significantly improved compared with those before training in the RAGT group. The ROMs of the right knee extension (p = 0.03) and bilateral ankle plantarflexion (p = 0.008 in the right, and p = 0.03 in the left) were significantly improved compared with measurements before training in the RAGT. There were no significant differences of the isometric strengths and ROMs of the bilateral hip, knee, and ankle muscles after training in the CON group. There were significant improvements in the isometric strengths of the left knee flexor (p = 0.01), left ankle dorsiflexor (p = 0.01), and left ankle plantarflexor (p = 0.003) between the two groups. The results suggested that RAGT is effective to facilitate early recovery of muscles strength after a burn injury. This is the first study to evaluate the effectiveness of RAGT in patients with burns compared with those receiving conventional training. The absence of complications in burn patients provides an opportunity to enlarge the application area of RAGT.

Efficacy of robot-assisted gait training in multiple sclerosis: A systematic review and meta-analysis

No general recommendations are yet available for the application of robot-assisted treadmill therapy for children with cerebral palsy regarding the length and intensity of the intervention. The aim of the study was to evaluate patient-specific determinants of responsiveness to robot-assisted gait training (RAGT) in patients with bilateral spastic cerebral palsy. During 12 months, the patients underwent 1-4 blocks of RAGT, representing 16-82 TUs. The following parameters were evaluated before (V0) and after each therapeutic block (V1-V4): dimension A (lying and rolling), B (sitting), C (crawling and kneeling), D (standing), E (walking, running and jumping) of the Gross Motor Function Measure (GMFM-88). We evaluated the change in motor functions in relation to the severity of disability, age, gender and number of therapeutic units. Ninety-seven patients aged between 3.7 and 27 years (mean age 10.02 years (SD±5.29); Gross Motor Function Classification System level I [n = 5], II [n = 25], III [n = 48], IV [n = 19]) underwent 16-82 TUs (overall average number 34.06 TUs, SD±16.41) of RAGT. In the patient group, we recorded clinically meaningful improvement and statistically significant improvement (p < 0.001) in gross motor functions with gradual increase in the effect size after each therapeutic block. Using correlation and regression analysis, we found a statistically significant associations between the number of therapeutic units, severity of disability, and improvement in motor functions after RAGT. We have identified two determinants -the severity of disability and the number of therapeutic units -which could have a decisive and predictive character in setting rehabilitation/designing programmes. The duration of the applied RAGT period, frequency and intensity could be a crucial factor for the potential of improvement in children with BS-CP.

A vital objective to treat people with cerebral palsy (CP) is to increase gait velocity and improve gross motor function. This study aimed to evaluate the relative effectiveness of gait training interventions for persons with CP. Studies published up to October 26, 2022 were searched from four electronic databases [including Medline (via PubMed), Web of Science, Embase and Cochrane]. Studies with randomized controlled trials (RCTs), people with CP, comparisons of different gait training interventions and outcomes of gait velocity and gross motor function measures (GMFM) were included in this study. The quality of the literature was evaluated using the risk of bias tool in the Cochrane Handbook, the extracted data were analyzed through network meta-analysis (NMA) using Stata16.0 and RevMan5.4 software. Twenty RCTs with a total of 516 individuals with CP were included in accordance with the criteria of this study. The results of the NMA analysis indicated that both external cues treadmill training (ECTT) [mean difference (MD) = 0.10, 95% confidence interval CI (0.04, 0.17), P < 0.05] and partial body weight supported treadmill training (BWSTT) [MD = 0.12, 95% CI (0.01, 0.23), P < 0.05] had better gait velocity than over ground gait training (OGT), BWSTT [MD = 0.09, 95%CI(0.01,0.18), P < 0.05] had a better gait velocity than robot-assisted gait training (RAGT), BWSTT [MD = 0.09, 95% CI (0.06, 0.13) P < 0.05] had a better gait velocity than treadmill training (TT), and BWSTT [MD = 0.14, 95% CI (0.07, 0.21), P < 0.05] had a better gait velocity than conventional physical therapy (CON). The SUCRA ranking indicated that BWSTT optimally improved the gait velocity, and the other followed an order of BWSTT (91.7%) > ECTT (80.9%) > RAGT (46.2%) > TT (44%) > OGT (21.6%) > CON (11.1%). In terms of GMFM, for dimension D (GMFM-D), there was no statistical difference between each comparison; for dimension E (GMFM-E), RAGT [MD = 10.45, 95% CI (2.51, 18.40), P < 0.05] was significantly more effective than CON. Both SUCRA ranking results showed that RAGT improved GMFM-D/E optimally, with rankings of RAGT (69.7%) > TT (69.3%) > BWSTT (67.7%) > OGT (24%) > CON (20.3%), and RAGT (86.1%) > BWSTT (68.2%) > TT (58%) > CON (20.1%) > OGT (17.6%) respectively. This study suggested that BWSTT was optimal in increasing the gait velocity and RAGT was optimal in optimizing GMFM in persons with CP. Impacted by the limitations of the number and quality of studies, randomized controlled trials with larger sample sizes, multiple centers, and high quality should be conducted to validate the above conclusion. Further studies will be required to focus on the total duration of the intervention, duration and frequency of sessions, and intensity that are optimal for the promotion of gait ability in this population. https://doi.org/10.37766/inplasy2022.10.0108, identifier: INPLASY2022100108.

Cerebral palsy is a neurological disorder affecting motor function in children with cerebral palsy and requires new rehabilitation perspective beyond traditional pediatric treatments. Robotic-assisted gait training and other assistive devices as methods of robotic rehabilitation became popular as a way to improve motor function in pediatric patients with cerebral palsy. This meta-analysis evaluated the effectiveness of robotic rehabilitation on motor impairments in children with cerebral palsy, focusing on functional outcomes like gait, balance and gross motor skills. PubMed, Embase, Cochrane Library, Scopus and Web of Science databases were searched and research papers were included up to 2024. Studies with robotic interventions for children with cerebral palsy were included using the PICOS criteria. The primary outcome was to evaluate the improvement in motor function by measuring gross motor skills and gait parameters. Data analysis used effect size calculation, I² statistic for heterogeneity, Egger test and funnel plot analysis for publication bias, as well as meta regression analysis. This review included 56 research papers. Robotic-assisted rehabilitation showed improvements in motor skills, walking speed, balance and functional mobility with robotic-assisted gait training being the most effective. Moderate heterogeneity was I²=52% and no publication bias was found through this review. Robotic rehabilitation with focus on robotic-assisted gait training is showing improvements in motor function for children with cerebral palsy and has many advantages over traditional rehabilitation methods by allowing controlled repetitive training. Future research should focus on continuous outcomes and optimization protocols to assure that robotic-assisted rehabilitation is relevant to the field of pediatric neurorehabilitation. Keywords: Cerebral palsy, robotic rehabilitation, motor impairments, robotic-assisted gait training, children.

In modern terms, cerebral palsy is defined as a childhood condition in which a motor deficit occurs due to a static, nonprogressive lesion of the brain. From a historical perspective, William John Little was the first to characterize spastic cerebral palsy in the 1830s [1]. He described it as a brain injury due to oxygen deprivation to the brain at birth. Sir William Osler was one of the first early researchers to study cerebral palsy and wrote the first book on the topic, The Cerebral Palsies of Children [2]. Cerebral palsy is a heterogeneous condition. The size and location of the brain lesion approximates both the severity and characterization of motor involvement. Gait problems are common in ambulatory patients with cerebral palsy. Ambulatory ability may vary from independent ambulation to the need for ambulatory aids such as a walker. In the latter case, ambulatory ability may also depend on good upper extremity function. In this symposium, “Current Approaches in Cerebral Palsy, A Focus on Gait Problems,” pediatric orthopaedic surgeons from cerebral palsy centers in various countries have been invited to focus on current problems that affect ambulatory children with cerebral palsy. The initial article highlights current assessment and outcome measurement tools for the upper extremity. These tools are helpful in assessing upper extremity function in patients who may require upper limb function for the use of an ambulatory aid. As clinicians, we recognize the alteration in muscle both physiologically and structurally between normal individuals and patients with cerebral palsy and between muscle agonist and antagonist in the patients with cerebral palsy. The second provocative article focuses on the basic science of the difference in the expression of myosin heavy chain fibers between wrist flexor and extensor muscles as one of these possible ultrastructural changes that occur in spastic muscle. Another structural difference frequently confronted by the orthopaedic surgeon is the muscle volume differences seen in cerebral palsy, especially the child with spastic hemiplegia. The next article compares the relationship between muscle volumes and concentric muscle work differences between involved and uninvolved sides in spastic hemiplegic cerebral palsy and their potential relationship to gait deviations. Even within the ambulatory population, walking performance is quite heterogeneous, influencing both treatment methods and outcomes. To this end, it is important to characterize ambulatory ability across the cerebral palsy population according to different variables. A large cross-sectional study of a population of children with cerebral palsy characterizes walking performance at different distances and environments according to gross motor function, cerebral palsy subtype, and age. A final group of articles focuses on outcomes after a variety of surgical procedures performed to treat common deformities in ambulatory children with cerebral palsy. Multilevel surgery is uncommon in the spastic hemiplegic population but more common in the Type 4 hemiplegic (hip, knee, and ankle involvement) population. The first article in this group focuses on multilevel surgery in this subgroup of children with spastic hemiplegia and describes the outcomes of surgery in treating hip dysplasia in these patients. A stiff knee gait pattern is common in patients with cerebral palsy with the diplegic pattern and interferes with swing phase clearance during gait. Indications for treatment include difficulty with gait due to toe drag, a decrease and delay in swing phase peak knee flexion by kinematics, and out-of-phase rectus femoris activity during swing by dynamic EMG on gait analysis. The next two articles look at the outcomes of two different surgical treatments for stiff knee gait secondary to rectus femoris spasticity. Hamstring contracture causes both a shortened step length and instability during stance. The next case series explores the effect of selective voluntary motor control on hamstring lengthening. The gastrocnemius muscle is perhaps one of the most important muscles for walking, providing 60% of power during gait. Lever arm dysfunction causes a decrease in gastrocnemius push-off power, is common in the child with cerebral palsy, and can result from both torsional deformity of the tibia and planovalgus foot deformity. The final two articles look at outcomes after correctional surgery for external tibial torsion and a different approach to the correction of severe planovalgus foot deformity, respectively. We believe the broad range of articles in this symposium will be both beneficial and stimulating for the orthopaedic surgeon who treats children with cerebral palsy. We have purposely solicited a range of topics from both basic science and clinical studies to provide guidance in treatment and stimulate questions for future research. We would like to thank each group of authors who contributed to this symposium and the reviewers who both challenged the authors and provided the invaluable input that improved each article. We hope the readers will find this symposium both useful and provocative. Fig. 1 Kirk W. Dabney, MD, is shown. Fig. 2 Freeman Miller, MD, is shown.

To find out functional strength training exercise on improving gross motor function among the children with spastic hemiplegic cerebral palsy children. Single group pre-experimental research design. The most common cause of movement disability in infancy is cerebral palsy. Cerebral palsy patients have impairments such as spasticity, low muscle strength and selective motor control in their body function. Such deficiencies may limit activity performance and participation in everyday life. Improving and optimising activities and involvement are crucial treatment objectives. Functional strength workouts are vital to overcoming obstacles to improving the functionality of children with neurological issues. 92 subjects of spastic hemiplegic cerebral palsied aged 4-8, male and female with spastic hemiplegic cerebral palsy were selected under purposive sampling technique and received functional strength training exercise for a period of ten weeks. To assess the gross motor function (functional independence) pre and post the exercise program, Gross motor functional measure was used. Results: The pre and post measurements shows significant changes in the gross motor function among children with spastic hemiplegic cerebral palsy. The results of the post-test mean values show improvement in gross motor functions after functional strength training program (p&lt;0.05). The functional strength training program proves that increased gross motor function and thereby improvement in functional abilities among children with spastic hemiplegic cerebral palsy after ten weeks of intervention.

Recently, robot-assisted gait training (RAGT) has attracted attention as a rehabilitation method to efficiently improve walking function. The purpose of this case report is to examine whether there is a change in gait function after RAGT with HAL in children with cerebral palsy (CP). Three children with CP participated in this study. Case 1 was an 8-year-old boy with Gross Motor Function Classification System (GMFCS) level II. Case 2 involved a 9-year-old girl with a class IV GMFCS. Case 3 was that of a 10-year-old boy with class IV GMFCS. RAGT was conducted once a day for 20 min for a total of 11-12 sessions. Gait was assessed before and after RAGT. We assessed using three-dimensional motion analysis and surface electromyography (sEMG). The sEMG signals were recorded from the bilateral tensor fascia lata, gluteus maximus, semitendinosus, and rectus femoris. All cases showed changes in the joint angle and muscle activity in the lower limbs before and after RAGT. In Case 1, the maximum hip extension angle increased from -10.6° to -4.1° at the terminal stance, and the average muscle activity of the gluteus maximus in the right stance phase increased from 22.4% to 30.2%. In Case 2, the maximum extension angle of the left knee joint increased from -43.0° to -26.9°. In Case 3, the maximum hip extension angle increased from -39.9° to -25.9° on the left side and from -35.1° to -18.7° on the right side; the maximum knee extension angle increased from -55.7° to -38.8° on the left side and from -52.1° to -36.9° on the right side. A Case 1 had significant hip flexion during gait, but RAGT with HAL emphasized hip extension motion and enabled an efficient gait. As a result, the maximum hip extension angle increased, and the activity of the gluteus maximus muscle in the stance phase increased. Cases 2 and 3 had greater hip and knee joint flexion angles, however increased knee extension angles after RAGT. The increased hip and knee joint extension angles during the stance phase increased the propulsive force propelling the walker forward.

The robotic device used for the study was the Lokomat ® (Hocoma AG

Cerebral palsy (CP) is the most common developmental motor disorder in children. Robot-assisted gait training (RAGT) using a wearable robot can provide intensive overground walking experience. To investigate the effectiveness of overground RAGT in children with CP using an untethered, torque-assisted, wearable exoskeletal robot. This multicenter, single-blind randomized clinical trial was conducted from September 1, 2021, to March 31, 2023, at 5 rehabilitation institutions in Korea. Ninety children with CP in Gross Motor Function Classification System levels II to IV were randomized. The RAGT group underwent 18 sessions of RAGT during 6 weeks, whereas the control group received standard physical therapy for the same number of sessions during the same period. The primary outcome measure was the Gross Motor Function Measure 88 (GMFM-88) score. Secondary outcome measures were the GMFM-66, Pediatric Balance Scale, selective control assessment of the lower extremity, Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), 6-minute walking test scores (distance and oxygen consumption), muscle and fat mass via bioelectrical impedance analysis, and gait parameters measured via 3-dimensional analysis. All assessments were performed for all patients at baseline, at the end of the 6-week intervention, and after the 4-week follow-up. Of the 90 children (mean [SD] age, 9.51 [2.48] years; 49 [54.4%] male and 41 [45.6%] female) in the study, 78 (86.7%) completed the intervention, with 37 participants (mean [SD] age, 9.57 [2.38] years; 19 [51.4%] male) and 41 participants (mean [SD] age, 9.32 [2.37] years; 26 [63.4%] male) randomly assigned to the RAGT and control groups, respectively. Changes in the RAGT group significantly exceeded changes in the control group in GMFM-88 total (mean difference, 2.64; 95% CI, 0.50-4.78), GMFM-E (mean difference, 2.70; 95% CI, 0.08-5.33), GMFM-66 (mean difference, 1.31; 95% CI, 0.01-2.60), and PEDI-CAT responsibility domain scores (mean difference, 2.52; 95% CI, 0.42-4.63), indicating independence in daily living at postintervention assessment. At the 4-week follow-up, the RAGT group showed significantly greater improvements in balance control (mean difference, 1.48; 95% CI, 0.03-2.94) and Gait Deviation Index (mean difference, 6.48; 95% CI, 2.77-10.19) compared with the control group. In this randomized clinical trial, overground RAGT using a wearable robot significantly improved gross motor function and gait pattern. This new torque-assisted wearable exoskeletal robot, based on assist-as-needed control, may complement standard rehabilitation by providing adequate assistance and therapeutic support to children with CP. CRIS Identifier: KCT0006273.

Background and objectives: Cerebral palsy (CP) is the most frequent childhood motor disability. Achieving ambulation or standing in children with CP has been a major goal of physical therapy. Recently, robot-assisted gait training using the Hybrid Assistive Limb® (HAL) has been effective in improving walking ability in patients with CP. However, previous studies have not examined in detail the changes in gait pattern after HAL training for patients with spastic CP, including gait symmetry. This study aimed to evaluate the immediate effect of HAL training on the walking ability and the changes in gait pattern and gait symmetry in patients with spastic CP. Materials and Methods: We recruited 19 patients with spastic CP (13 male and six female; mean age, 15.7 years). Functional ambulation was assessed using the 10-Meter Walk Test and gait analysis in the sagittal plane before and after a single 20-min HAL intervention session. Results: The walking speed and stride length significantly increased after HAL intervention compared to the pre-intervention values. Two-dimensional gait analysis showed improvement in equinus gait, increase in the flexion angle of the swing phase in the knee and hip joints, and improvement in gait symmetry. Immediate improvements in the walking ability and gait pattern were noted after HAL training in patients with spastic CP. Conclusions: The symmetry of the joint angle of the lower limb, including the trunk, accounts for the improvement in walking ability after HAL therapy.