Protocol for the "Stand the Future" Trial: Robotic Exoskeleton Gait Training for Non-Ambulatory Children With Spastic Cerebral Palsy

Cerebral palsy (CP) remains the most common motor disability in childhood, affecting approximately 17 million people worldwide, with an estimated 2-3 per 1,000 live births. In China alone, the number of children with CP is estimated to exceed 6 million, with approximately 40,000 new cases occurring each year. Notably, a substantial proportion of these children are classified as Gross Motor Function Classification System (GMFCS) levels IV or V, indicating they are either non-ambulatory or severely limited in voluntary movement (Li et al., 2018). Children with GMFCS levels IV and V often exhibit pronounced spasticity, limited voluntary muscle control, and severe deficits in selective motor control. Muscle fibers in these children show altered histological features including reduced cross-sectional area, increased collagen deposition, and impaired oxidative capacity. These pathological characteristics further exacerbate limitations in force generation and movement efficiency. These children experience profound impairments in mobility, postural control, and independence, presenting critical challenges for their physical and psychological development.

As the investigators recently reported in a systematic review, current physical rehabilitation strategies for children with CP are derived from studies involving ambulatory children (GMFCS I-III), while the severely affected population (GMFCS IV-V) remains underrepresented in the literature. The absence of walking ability in these children precludes participation in many conventional physiotherapeutic or strength-based programs, resulting in stagnated motor development and a cascade of secondary complications including muscle atrophy, contractures, and social exclusion. In addition to clinical burdens, non-ambulatory children with CP present significant lifelong economic challenges for families and healthcare systems. Estimates suggest that the lifetime cost of care for a single individual with CP can exceed $1.6 million USD in high-income countries, with costs related to direct medical care, assistive equipment, caregiving, and loss of productivity. In China, the economic burden is compounded by disparities in access to rehabilitation services and limited insurance coverage for long-term care.

Recent advancements in robotics and wearable technologies have opened new avenues for restoring movement in neurologically impaired individuals. Robotic exoskeletons and powered orthoses offer the potential to provide task-specific, repetitive, and intensive gait training while minimizing therapist workload. Such devices have shown promise in adult populations with spinal cord injury and stroke, and early-stage trials have extended these technologies to pediatric neuromuscular disorders, including CP. However, empirical data on the feasibility, safety, and efficacy of prolonged robotic gait training in children with GMFCS IV and V classifications are virtually nonexistent.

This protocol outlines a prospective 6-month intervention trial aimed at evaluating the effectiveness of robotic exoskeleton gait training on motor and psychological outcomes in children with severe CP. Through this study, the investigators aim to establish initial empirical evidence for the feasibility and potential benefits of exoskeleton-assisted rehabilitation in children who are traditionally excluded from active gait training. The investigators hypothesize that children with GMFCS level IV CP will demonstrate measurable improvements in motor function, mobility, and subjective well-being. This trial addresses a major gap in pediatric neurorehabilitation and may provide a critical foundation for scaling up robotic interventions in underserved clinical populations.