Robot-assisted gait training for lower limb motor recovery in cerebral palsy: A meta-analysis of combined and standalone approaches.

BACKGROUND: Cerebral palsy (CP), a leading cause of childhood motor disability, severely impacts lower limb function. Conventional gait training (CGT) faces challenges in standardization, while robot-assisted gait training (RAGT) offers biomechanical consistency but conflicting efficacy evidence. This meta-analysis evaluates RAGT monotherapy versus combined RAGT+CGT, therapeutic dose, and exoskeleton treadmill versus wearable robotic systems. METHODS: A systematic search across seven databases identified 19 randomized controlled trials (n = 1129). Outcomes included Gross Motor Function Measure-88 (GMFM-88) domains D/E, Berg Balance Scale (BBS), 6-minute walk test (6MWT), walking speed, and Modified Ashworth Scale (MAS). Subgroup analyses assessed therapeutic dose and robot type. Random- and fixed-effects models were applied. RESULTS: Combined RAGT+CGT significantly outperformed RAGT alone and CGT in GMFM-D [MD= 8.39,95 %CI(5.56,11.23) vs. 5.11,95 %CI(1.22,9.00),P < 0.00001], BBS [MD= 6.15,95 %CI(4.81,7.48) vs. 2.45,95 %CI(0.94,3.96),P < 0.00001], 6MWT [MD= 41.35,95 %CI(17.65,65.06) vs. 21.50,95 %CI(12.67,30.33),P = 0.0006],Walking speed [MD= 5.69,95 %CI(0.75,10.63) vs. 0.98,95 %CI(-0.78,2.75),P = 0.02] and MAS [MD= -0.37,95 %CI(-0.63,-0.12) vs. 0.19,95 %CI(-0.27,0.65),P = 0.004]. Low-to-medium dose interventions (1000-4000 min) achieved superior gains in GMFM-D/E compared to long-term protocols. Exoskeleton treadmills (e.g., Lokomat) outperformed wearable devices in GMFM-D/E improvements. Heterogeneity was moderate-to-high (I²=69-88 %), but sensitivity analyses confirmed robustness. CONCLUSIONS: Combined RAGT and conventional rehabilitation significantly enhances lower limb motor function, balance, walking endurance/speed, and reduces spasticity in children with CP compared to RAGT alone (excluding GMFM-E). Medium-term interventions (8 weeks;dose:1000-4000 min) using exoskeleton treadmills yield superior outcomes to both extended protocols (>8 weeks;>4000 min) and wearable devices. Standardized assessments are needed to clarify GMFM-E improvements.