Treatment with robot-assisted gait trainer Walkbot along with physiotherapy vs isolated physiotherapy in children and adolescents with cerebral palsy. Experimental study.

Treatment with robot-assisted gait trainer Walkbot along with physiotherapy vs isolated physiotherapy in children and adolescents with cerebral palsy. 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Experimental study. Raquel Olmos-Gómez, Inmaculada Calvo-Muñoz, Antonia Gómez-Conesa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3910627/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Jul, 2024 Read the published version in BMC Neurology → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Improving walking ability is a key objective in the treatment of children and adolescents with cerebral palsy (CP), since it directly affects their activity and participation. In recent years, robotic technology has been implemented in gait treatment, which allows training of longer duration and repetition of the movement. To know the effectiveness of a treatment with the robotic-assisted gait trainer (RAGT) Walkbot combined with physiotherapy compared to the isolated physiotherapy treatment in children and adolescents with CP, we carried out a clinical trial. Methods: 23 participants (mean age 8.56), were divided into two groups: experimental (EG) and control (CG). During 5 weeks, both groups received their physiotherapy sessions scheduled, in addition EG received 4 sessions per week of 40 minutes of RAGT. An evaluation of the participants was carried out before the intervention, at the end of the intervention, and at follow-up (two months after the end of the intervention). Gait was assessed with the Gross Motor Function Measure-88 (GMFM-88) dimensions D and E, strength was measured with a hydraulic dynamometer, and range of motion ( ROM) was assessed using the goniometer. A mixed ANOVA was performed when the assumptions of normality and homoscedasticity were met, and a robust mixed ANOVA was performed when these assumptions were not met. Statistical significance was stipulated at p < 0.05. For the effect size, η 2 was calculated. Results: Significant differences were found regarding the time x group interaction in the GMFM-88 in dimension D [η 2 = 0.016], in the flexion strength of the left [η 2 =0.128] and right [η 2 =0.142] hips, in the extension strength of the right hip [η 2 =0.035], in the abduction strength of the left hip [η 2 =0.179] and right [η 2 =0.196], in the flexion strength of the left knee [η 2 =0.222] and right [η 2 =0.147], and in the ROM of left [η 2 = 0.071] and right [η 2 =0.053] knee flexion. Conclusions: Compared to treatments without walking robot, physiotherapy treatment including RAGT Walkbot improves standing, muscle strength, and knee ROM in children and adolescents with CP. Trial registration: ClinicalTrials.gov: NCT04329793. cerebral palsy robotic walkbot gait children adolescents physical therapy modalities experimental study Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background Cerebral Palsy (CP) is one of the main causes of locomotor and postural disorders in children, being the most common cause of physical disability in childhood (1). Disturbances in movement and posture often lead to spasticity, muscle weakness, and disturbances in selective motor control, making walking difficult (2,3). Abnormal gait patterns can cause secondary deformities and reduce their quality of life, limiting the opportunity to explore the environment and restricting their participation and independence (3). From physiotherapy there are different approaches to address this limitation in participation and activity, including the robotic-assisted gait training (RAGT) (4–6). The RAGT provides conditions that support motor learning principles such as intensity, repetition, task specificity, and participation (7–9), as well as presenting beneficial effects for improving walking in subjects with brain and spinal cord damage (10–14). Some studies have investigated the effects of the RAGT in improving gait function in CP subjects, showing an overall improvement in gait parameters (mainly gait speed, stride length and frequency), endurance, and gross motor function (Gross Motor Function Measure-88 (GMFM-88) dimensions D and E (15–21) A recent network meta-analysis of clinical trials concluded that although there is evidence to suggest that RAGT treatments are effective in children and adolescents with CP, no significant difference was found between RAGT and physiotherapy treatments in improving gait and standing (22). Among the RAGT systems, there is the Walkbot (P&S Mechanics, Seoul, Korea) which consists of an exoskeletal RAGT system that is attached to the patient and helps him move his lower extremities on a treadmill, being attached by a harness to a crane, generating a personalized gait pattern for the patient (23), and provides ambulation that is closest to human kinematics and kinetics (24). To our knowledge, only one study has been conducted in the paediatric population with CP, investigating the effects of the Walkbot-K system and comparing two groups in which both used the robot, with significant treatment effects in dimensions D and E of the GMFM (25). Methods The objective of this study is to know the effectiveness of RAGT treatment with Walkbot combined with physiotherapy compared to the isolated physiotherapy treatment in children and adolescents with CP, to improve gait function, and to increase muscle strength and range of motion in the lower limbs. A quasi-experimental, prospective, longitudinal study was carried out with a non-equivalent control group. It was registered with number: NCT04329793, respecting the ethical principles of the 2013 Helsinki declaration and the ethical protocol set by the Ethics and Research Commission of the University of Murcia, being approved by them. The parents of the patients or their legal guardians were duly informed and they were given an informed consent form, which was read, understood and signed in order to participate in the study. Study population and recruitment The sample was made up of children and adolescents diagnosed with CP from different reference hospitals, associations and educational guidance teams from six provinces in the south and east of Spain. The inclusion criteria were as follows: non-progressive bilateral CP, age from 3 to 18 years, Gross Motor Function Classification System – Expanded & Revised (GMFCS-ER) levels II, III and IV, not having received or being receiving treatment with RAGT or partially weight-bearing walking treadmill in the last year, and acceptance of participation in the study with the signing of the informed consent. The exclusion criteria were: serious psychiatric problems that prevent placement in the robot, serious heart problems that prevent physical exercise, active tumour processes, serious degenerative joint problems, degenerative diseases of the nervous system, mitochondrial diseases, recent surgeries, ununited fractures, severe osteoporosis, uncontrolled epileptic seizures, open wounds on the lower half of the body, extreme fear of being placed in robotic devices, pain that prevents you from carrying out the treatment, and that their anthropomorphic measurements are below the minimum required to be able to use the device. 23 subjects were recruited, 13 being assigned to the experimental group (EG) and 10 to the control group (CG). Of the 13 assigned to the EG, 10 underwent the treatment and were administered pretest, posttest, and 8 follow-up measures, while the remaining 3 were evaluated in the pretest. Figure 1 shows the progress of subjects through the phases of the clinical trial. The groups were not randomized. The criterion for assignment to the EG was being able to attend the treatment sessions at the clinic where the therapy with the RAGT was performed. Figure 1. Flowchart of sample selection process Intervention EG participants underwent the RAGT treatment along with their usual physiotherapy treatment, while CG participants received physiotherapy treatment without the RAGT. The EG participants received 4 treatment sessions per week consisting of 40 minutes in the RAGT in addition to their physiotherapy sessions that were scheduled for the same number of weeks. The total number of sessions was 20, in uninterrupted weeks. The CG participants received the scheduled physiotherapy sessions during the same weeks, performing between 3 and 5 weekly sessions. The physiotherapy treatment in both groups was applied by the physiotherapists in their respective educational, health centres or associations. Assessments The evaluation was carried out before starting the treatment (pretest), at the end of the treatment (posttest) and two months after finishing the intervention (follow-up), by the same evaluator in the same conditions. They were carried out at a private clinic in Murcia or Granada (Spain). Gait was evaluated with the GMFM-88 (26). The strength of the large muscle groups in the lower extremities in the movements of hip flexion and extension, knee flexion and extension and hip abduction were measured with the Baseline® hydraulic push-pull dynamometer. The range of motion (ROM) of the joints of the lower limbs, specifically, knee flexion-extension, were evaluated by measurements carried out with the Enraf / Nonius Universal goniometer. Data analysis The analyses were carried out with the free statistical package R, version 4.0.3 (R Core Team 2020). A descriptive analysis of the variables was carried out, using the mean as a measure of central tendency and the standard deviation, maximum value and minimum value as a measure of dispersion. Before performing the inferential statistics, the assumptions of normality were checked using the Kolmogorov-Smirnov test, and homogeneity using the Breusch-Pagan and Fligner-Killeen tests for homogeneity of variances, taking into account that both tests assume normality and homogeneity of variances as the null hypothesis. Durbin-Watson test was used for autocorrelation. A mixed ANOVA was performed when the assumptions of normality and homoscedasticity were met, and a robust mixed ANOVA was performed when these assumptions were not met. Statistical significance was stipulated at p 0.14 considered high, moderate between 0.14 and 0.06, and small ones between 0.06 and 0.01. To test the differences between the mean values in the initial evaluation and the final evaluation, the repeated measures ANOVA of a mixed factor was used, with an inter-subject factor and within-subjects repeated measures ANOVA. Results The characteristics of the sample are detailed in table 1. The participants in the EG had a mean age of 7.31 (sd: 3.09), while in the CG the average age was 10.20 (sd: 4.71). The percentage of men in the EG was 69.23% and 90% in the CG. Regarding the type of CP according to the anatomical distribution, 6 children with diplegia and 7 with tetraplegia participated in the EG. In the CG, 4 with diplegia, 1 with triplegia and 5 with tetraplegia participated. The distribution by GMFCS levels in the EG was 2 children at level II, 6 at level III and 5 at level IV, while in the CG it was 5 level II, 2 level III and 3 level IV. There are no differences between groups that influence the results. Table 1. Characteristics of the sample. EG CG N 13 10 Mean age (sd) 7.31 (3.09) 10.20 (4.71) Men 69.23% 90% CP Type 1 Diplegia 46.15% 40% Triplegia 0% 10% Tetraplegia 53.85% 50% CP Type 2 Mixed 23.08% 10% Spastic 76.92% 90% GMFCS Level II 15.38% 50% III 46.15% 20% IV 38.46% 30% Cognitive impairment Yes 61.54% 50% No 38.46% 50% Average number of weekly physiotherapy sessions (sd) 2.92 (0.95) 3.50 (1.43) EG: experimental group, CG: control group, sd: standard deviation, CP: cerebral palsy, GMFCS: Gross Motor Function Classification System Gait In the GMFM-88, dimension D, the EG participants obtained an average of 0.21 in the pretest, and 0.30 in the post-test. The CG participants obtained an average of 0.47 and 0.46 in the pretest and post-test, respectively. At follow-up, the EG and CG obtained a mean of 0.41 and 0.46, respectively. The pretest-post-test and follow-up analysis of variance showed differences with respect to the time x group interaction [F (2.32) =12.7585, p= 8.425406e-05, η 2 =0.016], with small effect sizes. In the GMFM -88, dimension E, the EG participants obtained an average of 0.16 and 0.24, in the pretest and in the post-test, respectively. In the CG they obtained an average of 0.44 in the pretest and 0.47 in the post-test. At follow-up, the EG and CG participants obtained an average of 0.27 and 0.44, respectively. In the robust mixed ANOVA pretest-posttest and follow-up, no differences were found regarding interaction (p=0.1579). Table 2 shows the comparisons between groups of GMFM D, GMFM E. Figure 2 shows the interaction between time and group. Table 2. Comparisons between groups of GMFM D and GMFM E. Pretest Mean (SD) Postest Mean (SD) Follow-up Mean (SD) Pretest-post-test and follow-up analysis of variance EG (n=10) CG (n=10) EG (n=10) CG (n=10) EG (n=8) CG (n=10) p η 2 GMFMD 0.21 (0.24) 0.47 (0.37) 0.36 (0.25) 0.46 (0.37) 0.41 (0.30) 0.46 (0.36) 8.425406e-05 0.016 GMFME 0.16 (0.16) 0.44 (0.37) 0.24 (0.20) 0.47 (0.36) 0.27 (0.23) 0.44 (0.37) 0.1579 -- SD: standard deviation, EG: experimental group, CG: control group, GMFMD: Gross Motor Function Measure Dimension D, GMFME: Gross Motor Function Measure Dimension E, p: statistical significant, η 2 : effect size Figure 2. Interaction graph between time and group of GMFMD GMFMD: Gross Motor Function Measure Dimension D Muscular strength Hip flexion In the flexion strength in the left hip, the EG obtained an average of 1.46 and 2.35, in the pretest and in the posttest, respectively. In the CG they obtained an average of 3.62 in the pretest and 3.10 in the posttest. At follow-up, the EG and CG obtained a mean of 3.56 and 3.25, respectively. In the right hip, in the EG they obtained an average of 1.25 and 2.45, in the pretest and in the posttest, respectively. In the CG they obtained an average of 3.45 and 2.85, in the pretest and in the posttest, respectively. At follow-up, the EG and CG obtained a mean of 3.19 and 3.15, respectively. The pretest-posttest and follow-up analysis of variance showed differences with respect to the group x time interaction [F (2.32) = 7.358, p= 2.350e-03, η 2 = 0.128], in left hip flexion strength. In the right hip, differences were also found with respect to the interaction [F (2.32) = 8.045, p= 1.478e- 03, η 2 = 0.142]. (Figures 3 and 4). (Table 3). Figure 3. Interaction graph between time and group of left hip flexion strength Figure 4. Interaction graph between time and group of right hip flexion strength Hip extension In the extension strength in the left hip, the EG participants obtained an average of 0.10 and 0.60, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 0.95 in the pretest and 0.70 in the posttest. At follow-up, the EG and CG obtained a mean of 1.12 and 0.75, respectively. In the right hip, the EG obtained an average of 0.10 and 0.53, in the pretest and in the posttest, respectively. The CG obtained an average of 1.20 in the pretest and 0.80 in the posttest. At follow-up, the EG and CG obtained a mean of 0.88 and 0.95, respectively. In the pretest-posttest and follow-up analysis of variance, differences were found with respect to the interaction [F (2.32) = 4.672, p= 0.017, η 2 = 0.035], in right hip extension strength. (Figure 5). In the left hip, no differences were found with respect to the interaction [F (2.32) = 3.0606, p=0.0608, η 2 =0.04119]. (Table 3). Figure 5. Interaction graph between time and group of right hip extension strength Hip abduction In the abduction strength in the left hip, the EG participants obtained an average of 0.32 and 1.35, in the pretest and in the posttest, respectively. Those from the CG obtained an average of 2.05 and 1.30, in the pretest and in the posttest, respectively. At follow-up, the EG and CG obtained a mean of 2.22 and 1.15, respectively. In the right hip, the EG participants obtained an average of 0.42 and 1.25, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 2.25 in the pretest and 1.30 in the posttest. At follow-up, the EG and CG participants obtained a mean of 1.88 and 1.00, respectively. In the analysis of variance pretest-posttest and follow-up, differences were found with respect to the interaction [p=0.0147, η 2 = 0.179] in the left hip. In the abduction strength of the right hip, differences were also found with respect to the interaction [F (2.32) = 8.721, p= 9.481e-04, η 2 = 0.196]. (Figures 6 and 7). (Table 3). Figure 6. Interaction graph between time and group of left hip abduction strength Figure 7. Interaction graph between time and group of right hip abduction strength Knee flexion In the flexion strength in the left knee, the EG participants obtained an average of 1.18 and 2.23, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 2.65 in the pretest and 1.95 in the posttest. At follow-up, the EG and CG obtained, respectively, a mean of 2.60 and 2.30. In the right knee, the mean EG in the pretest was 1.25, and in the posttest it was 2.20. In the CG, the pretest mean was 2.75 and the posttest mean was 2.15. At follow-up, the EG and CG participants obtained a mean of 2.66 and 2.35, respectively. In the ANOVA, differences were found in the strength of the left knee with respect to the group x time interaction [F (2.32) = 9.762, p = 4.899e-04, η 2 = 0.222]. In right knee strength, differences were also found in the group x time interaction [F (2.32) = 4.867, p= 1.427e-02, η 2 = 0.147]. (Figures 8 and 9). (Table 3). Figure 8. Interaction graph between time and group of left knee flexion strength Figure 9. Interaction graph between time and group of right knee flexion strength Knee extension In the extension strength in the left knee, the EG participants obtained an average of 1.00 and 1.99, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 1.84 in the pretest and 2.20 in the posttest. At follow-up, the EG and CG obtained a mean of 2.09 and 2.35, respectively. In the right knee, the EG participants obtained an average of 1.10 and 2.40, in the pretest and in the posttest, respectively. The CG participants obtained an average of 1.95 in the pretest and 2.45 in the posttest. At follow-up, the EG and CG participants obtained an average of 2.05 and 2.55, respectively. In right knee extension, no differences were found with respect to the interaction [F (2.32) = 0 .3893, p=0.6807, η 2 =0.00496], as in left knee extension (p=0.4747). (Table 3) Table 3. Comparisons between groups of hip and knee strength. Pretest Mean (SD) Posttest Mean (SD) Follow-up Mean (SD) Pretest-post-test and follow-up analysis of variance Strength EG (n=10) CG (n=10) EG (n=10) CG (n=10) EG (n=8) CG (n=10) p η 2 Left hip flexion 1.46 (0.78) 3.62 (1.97) 2.35 (0.26) 3.10 (1.15) 3.56 (2.29) 3.25 (1.27) 2.350e-03 0.128 Right hip flexion 1.25 (0.75) 3.45 (1.86) 2.45 (0.28) 2.85 (1.18) 3.19 (1.46) 3.15 (1.16) 1.478e- 03 0.142 Left hip extension 0.10 (0.32) 0.95 (1.71) 0.60 (0.94) 0.70 (1.03) 1.12 (1.79) 0.75 (1.23) 0.0608 0.04119 Right hip extension 0.10 (0.32) 1.20 (1.86) 0.53 (0.82) 0.80 (1.21) 0.88 (1.22) 0.95 (1.32) 0.017 0.035 Left hip abduction 0.32 (0.53) 2.05 (1.88) 1.35 (0.82) 1.30 (0.98) 2.22 (1.77) 1.15 (1.11) 0.0147 0.179 Right hip abduction 0.42 (0.50) 2.25 (1.72) 1.25 (0.75) 1.30 (1.01) 1.88 (1.58) 1 (0.97) 9.481e-04 0.196 Left knee flexion 1.18 (0.72) 2.65 (1.25) 2.23 (0.48) 1.95 (0.86) 2.60 (0.92) 2.30 (0.71) 4.899e-04 0.222 Right knee flexion 1.25 (0.68) 2.75 (1.89) 2.20 (0.48) 2.15 (0.63) 2.66 (1.03) 2.35 (0.78) 1.427e-02 0.147 Left knee extension 1 (0.85) 1.84 (1.73) 1.99 (0.62) 2.20 (1.7) 2.09 (1.26) 2.35 (1.73) 0.4747 ------ Right knee extension 1.10 (0.84) 1.95 (1.59) 2.40 (1.26) 2.45 (2.05) 2.05 (1.7) 2.55 (2.34) 0.6807 0.00496 SD: standard deviation, EG: Experimental Group, CG: Control Group, n: sample ROM Knee flexion In the flexion movement of the left knee, the EG participants obtained an average of 126.5 and 119, in the pretest and in the posttest, respectively. The CG participants obtained an average of 127 and 128 in the pretest and posttest, respectively. At follow-up, EG and CG participants scored an average of 130 and 128, respectively. In the right knee, the EG participants obtained an average of 128 and 121, in the pretest and in the posttest, respectively. The CG participants obtained an average of 127 and 127 in the pretest and posttest, respectively. At follow-up, EG and CG participants scored an average of 130 and 128, respectively. In the left knee flexion ROM, the pretest-posttest and follow-up analysis of variance showed differences with respect to interaction (p=0.0054, η 2 = 0.071). with medium effect size. In the ROM of right knee flexion, the analysis showed differences with respect to interaction (p=0.0054, η 2 = 0.053), with medium and small effect sizes respectively. (Table 4). Knee extension In the extension movement in the left knee, the EG participants obtained an average of -2.30 in the pretest, and -1.30 in the posttest. The CG participants obtained an average of -2 and -1.5, in the pretest and in the posttest, respectively. At follow-up, EG and CG participants obtained a mean of -0.62 and -1, respectively. In the right knee, the EG participants obtained an average of -2.50 and -1.30, in the pretest and in the posttest, respectively. The CG participants obtained an average of -3 and -3.50, in the pretest and in the posttest, respectively. At follow-up, EG and CG participants obtained a mean of -0.62 and -1, respectively. In the left knee extension ROM, the ANOVA pretest-posttest and follow-up showed no differences with respect to interaction [F (2.32) = 0.0097, p=0.9903]. In the right knee extension ROM, no differences were found with respect to interaction [F (2,32) = 0.4777, p=0.6245]. (Table 4) Table 4. Comparisons between groups of knee ROM. Pretest Mean (SD) Posttest Mean (SD) Follow-up Mean (SD) Pretest-post-test and follow-up analysis of variance ROM EG (n=10) CG (n=10) EG (n=10) CG (n=10) EG (n=8) CG (n=10) p η 2 Left knee flexion 126.50 (11.07) 127 (15.67) 119 (7.38) 128 (11.35) 130 (0) 128 (10.33) 0.0054 0.071 Right knee flexion 128 (6.32) 127 (15.67) 121 (3.16) 127 (13.37) 130 (0) 128 (10.33) 0.0054 0.053 Left knee extension -2.30 (3.89) -2 (6.32) -1.30 (2.16) -1.50 (4.74) -0.62 (1.77) -1 (3.16) 0.9903 6.026e-05 Right knee extension -2.50 (4.25) -3 (9.49) -1.30 (2.16) -3.50 (9.44) -0.62 (1.77) -2.50 (6.35) 0.6245 0.002 SD: standard deviation, EG: Experimental Group, CG: Control Group, n: sample, ROM: range of motion Discussion The objective of the present study was to evaluate the comparative effectiveness of RAGT treatment with Walkbot combined with physiotherapy, compared to isolated physiotherapy treatment, in children and adolescents with CP, to improve gait and increase muscle strength and range of motion in the lower extremities. In our study, positive changes in the EG have been observed in the GMFM-88, both in the post-test and in the follow-up. Dimension D obtained a significant difference. And in dimension E, no significant differences were observed. Regarding previous studies, some of them found improvements in dimension D and E (19–21,27), and one study in dimension E (17). These studies mentioned included children with GMFCS-ER levels between I and III, and none included level IV, unlike our study. Furthermore, in our study all children had bilateral involvement, and others included unilateral involvement along with bilateral (20), or only unilateral involvement (21). Our study is the first clinical trial that compares Walkbot together with physiotherapy with physiotherapy treatments in CP in a European population. A study (25) use Walkbot comparing two groups in which both used the RAGT, without a control group. In our study, significant results were observed in the comparison of the Walkbot treatment together with physiotherapy with physiotherapy treatments in standing, muscle strength, and lower limb ROM. Other CTs that use RAGT report improvement in standing (19–21,27). However, previous CTs do not measure strength or ROM like our study. Some previous clinical trials have demonstrated improvements in walking ability in participants with neurological damage, such as stroke and spinal cord injury, who used a walking robot in their rehabilitation (10–14). In children with CP, reviews and meta-analyses have not found significant differences in the use of the walking robot compared to other physiotherapy treatments aimed at rehabilitating walking function (22, 28,29). In a recent meta-analysis that included 8 clinical trials (2 non-randomized), no significant differences were found compared to physical therapy treatments (22). Regarding limitations, the groups were not randomized, since participants who were willing to travel to the place where the treatment was carried out were assigned to the EG, and the final sample size was reduced compared to what was expected. In clinical practice, the results of our study stand out because adding training with the robotic-assisted gait training Walkbot to the physiotherapy treatment improves standing, muscle strength and ROM in children with CP compared to physiotherapy treatments without Walkbot, and this improvement may predispose to an increase in activity and participation. In future research, it would be advisable to conduct RCTs, with homogeneous groups in terms of levels of impairment in the GMFCS-ER, and with larger samples. It would also be convenient to compare the treatment with specific physiotherapy treatments, and to contrast whether treatment times are shortened by including the use of the walking robot. Conclusions Physiotherapy treatment including the RAGT Walkbot improves standing, muscle strength in the lower limbs, and knee ROM in children and adolescents with CP, compared to physiotherapy treatments without RAGT. No changes have been found between both treatments regarding the GMFM dimension E of the study participants. Abbreviations CP: Cerebral Palsy RAGT: robotic-assisted gait training GMFM: Gross Motor Function Measure GMFCS-ER: Gross Motor Function Classification System – Expanded & Revised EG: experimental group CG: control group ROM: range of motion RCT: randomise clinical trial Declarations Ethics approval and consent to participate Respecting the ethical principles of the 2013 Helsinki declaration and the ethical protocol set by the Ethics and Research Commission of the University of Murcia, being approved by them. The parents of the patients or their legal guardians were duly informed and they were given an informed consent form, which was read, understood and signed in order to participate in the study. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to Organic Law 3/2018 on Protection of Personal Data of Spanish legislation, but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No applicable. Authors’ contributions ROG conceived the study, participated in the data collection, intervention, analysis, interpretation and writing of the manuscript. AGC and ICM participated in the analysis, interpretation and writing of the manuscript. All authors read and gave approval of the final version to be published. Acknowledgements We wish to thank the parents and children that took part in this study, the different professionals who contributed to the recruitment of the sample, and the Clern clinic in Yecla- Murcia (Spain) where the intervention with Walkbot was carried out. Authors' information: 1 International Doctoral School of the University of Murcia (EIDUM), University of Murcia, 30100 Murcia, Spain, [email protected] 2 Faculty of Physiotherapy, Occupational Therapy and Podiatry, UCAM Catholic University of Murcia, Guadalupe 30107, Murcia, Spain, [email protected] 3 Research Group Research Methods and Evaluation in Social Sciences, Mare Nostrum Campus of International Excellence, University of Murcia, 30100 Murcia, Spain, [email protected] References European Commission. Joint Research Centre. Surveillance of cerebral palsy in Europe: development of the JRC SCPE central database and public health indicators. LU: Publications Office, 2017. 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Use-dependent plasticity in spinal stepping and standing. Adv Neurol. 1997,72:233-47. Dobkin BH. Rehabilitation after Stroke. N Engl J Med. 2005,352(16):1677-84. DOI: 10.1056/NEJMcp043511 Bruni MF, Melegari C, De Cola MC, Bramanti A, Bramanti P, Calabrò RS. What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis. J Clin Neurosci. 2018,48:11-7. DOI: 10.1016/j.jocn.2017.10.048 Tefertiller C, Pharo B, Evans N, Winchester P. Efficacy of rehabilitation robotics for walking training in neurological disorders: A review. J Rehabil Res Dev. 2011,48(4):387. DOI: 10.1682/JRRD.2010.04.0055 Smania N, Bonetti P, Gandolfi M, Cosentino A, Waldner A, Hesse S, et al. Improved gait after repetitive locomotor training in children with cerebral palsy. Am J Phys Med Rehabil. 2011,90(2):137-49. DOI: 10.1097/PHM.0b013e318201741e Arellano-Martínez IT, Rodríguez-Reyes G, Quiñones-Uriostegui I, Arellano-Saldaña ME. [Spatial-temporal analysis and clinical findings of gait: comparison of two modalities of treatment in children with cerebral palsy-spastic hemiplegia. Preliminary report]. Cir Cir. 2013,81(1):14-20. Peri E, Turconi AC, Biffi E, Maghini C, Panzeri D, Morganti R, et al. Effects of dose and duration of Robot-Assisted Gait Training on walking ability of children affected by cerebral palsy. Technol Health Care Off J Eur Soc Eng Med. 2017,25(4):671-81. DOI: 10.3233/THC-160668 Wu M, Kim J, Arora P, Gaebler-Spira DJ, Zhang Y. Effects of the Integration of Dynamic Weight Shifting Training Into Treadmill Training on Walking Function of Children with Cerebral Palsy: A Randomized Controlled Study. Am J Phys Med Rehabil. 2017,96(11):765-72. DOI: 10.1097/PHM.0000000000000776 Wallard L, Dietrich G, Kerlirzin Y, Bredin J. Effect of robotic-assisted gait rehabilitation on dynamic equilibrium control in the gait of children with cerebral palsy. Gait Posture. 2018,60:55-60. DOI: 10.1016/j.gaitpost.2017.11.007 Aras B, Yaşar E, Kesikburun S, Türker D, Tok F, Yılmaz B. Comparison of the effectiveness of partial body weight-supported treadmill exercises, robotic-assisted treadmill exercises, and anti-gravity treadmill exercises in spastic cerebral palsy. Turk J Phys Med Rehabil. 2019,65(4):361-70. DOI: 10.5606/tftrd.2019.3078 Yazıcı M, Livanelioğlu A, Gücüyener K, Tekin L, Sümer E, Yakut Y. Effects of robotic rehabilitation on walking and balance in pediatric patients with hemiparetic cerebral palsy. Gait Posture. 2019,70:397-402. DOI: 10.1016/j.gaitpost.2019.03.017 Olmos-Gómez R, Gómez-Conesa A, Calvo-Muñoz I, López-López JA. Effects of Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: A Network Meta-Analysis. J Clin Med. 2021,10(21):4908. DOI: 10.3390/jcm10214908 Jung JH, Lee NG, You JH, Lee DC. Validity and feasibility of intelligent Walkbot system. Electron Lett. 2009,45(20):1016. DOI: 10.1049/el.2009.0879 Lee DR, Shin YK, Park JH, You JH. Concurrent validity and test-retest reliability of the Walkbot-k system for robotic gait training. J Mech Med Biol. 2016,16(08):1640029. DOI: 10.1142/S0219519416400297 Jin LH, Yang S seung, Choi JY, Sohn MK. The Effect of Robot-Assisted Gait Training on Locomotor Function and Functional Capability for Daily Activities in Children with Cerebral Palsy: A Single-Blinded, Randomized Cross-Over Trial. Brain Sci. 2020,10(11):801. DOI: 10.3390/brainsci10110801 Russell DJ, Rosenbaum PL, Cadman DT, Gowland C, Hardy S, Jarvis S. The gross motor function measure: a means to evaluate the effects of physical therapy. Dev Med Child Neurol. 2008,31(3):341-52. DOI: 10.1111/j.1469-8749.1989.tb04003.x Romei M, Montinaro A, Piccinini L, Maghini C, Germiniasi C, Bo I, et al. Efficacy of robotic-assisted gait training compared with intensive task-oriented physiotherapy for children with Cerebral Palsy. En: 2012 4th IEEE RAS & EMBS International Conference on Biomedical Robotics and Biomechatronics (BioRob) [Internet]. Rome, Italy: IEEE, 2012. p. 1890-4. DOI: 10.1109/BioRob.2012.6290748 Carvalho I, Pinto SM, Chagas D das V, Praxedes Dos Santos JL, de Sousa Oliveira T, Batista LA. Robotic Gait Training for Individuals with Cerebral Palsy: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2017,98(11):2332-44. DOI: 10.1016/j.apmr.2017.06.018 Lefmann S, Russo R, Hillier S. The effectiveness of robotic-assisted gait training for paediatric gait disorders: systematic review. J Neuroengineering Rehabil. 2017,14(1):1. DOI: 10.1186/s12984-016-0214-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Jul, 2024 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 31 Jan, 2024 Submission checks completed at journal 30 Jan, 2024 Editor assigned by journal 30 Jan, 2024 First submitted to journal 30 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3910627","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270260363,"identity":"63d3e222-d299-4549-84d2-e99e6eccd9ea","order_by":0,"name":"Raquel 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16:26:11","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":88096,"visible":true,"origin":"","legend":"\u003cp\u003eInteraction graph between time and group of right knee flexion strength\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-3910627/v1/e7e15c68d81dd95cbbbdd7e7.png"},{"id":61595319,"identity":"0289d89b-6f3a-4d0d-b862-8c431f5d48ec","added_by":"auto","created_at":"2024-08-01 17:22:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1173779,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3910627/v1/efbb7d6c-2cf6-4f70-99f7-b451dfaea6ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Treatment with robot-assisted gait trainer Walkbot along with physiotherapy vs isolated physiotherapy in children and adolescents with cerebral palsy. Experimental study.","fulltext":[{"header":"Background ","content":"\u003cp\u003eCerebral Palsy (CP) is one of the main causes of locomotor and postural disorders in children, being the most common cause of physical disability in childhood (1). Disturbances in movement and posture often lead to spasticity, muscle weakness, and disturbances in selective motor control, making walking difficult (2,3). Abnormal gait patterns can cause secondary deformities and reduce their quality of life, limiting the opportunity to explore the environment and restricting their participation and independence (3). From physiotherapy there are different approaches to address this limitation in participation and activity, including the robotic-assisted gait training (RAGT) (4\u0026ndash;6). The RAGT provides conditions that support motor learning principles such as intensity, repetition, task specificity, and participation (7\u0026ndash;9), as well as presenting beneficial effects for improving walking in subjects with brain and spinal cord damage (10\u0026ndash;14). Some studies have investigated the effects of the RAGT in improving gait function in CP subjects, showing an overall improvement in gait parameters (mainly gait speed, stride length and frequency), endurance, and gross motor function (Gross Motor Function Measure-88 (GMFM-88) dimensions D and E (15\u0026ndash;21) A recent network meta-analysis of clinical trials concluded that although there is evidence to suggest that RAGT treatments are effective in children and adolescents with CP, no significant difference was found between RAGT and physiotherapy treatments in improving gait and standing (22). Among the RAGT systems, there is the Walkbot (P\u0026amp;S Mechanics, Seoul, Korea) which consists of an exoskeletal RAGT system that is attached to the patient and helps him move his lower extremities on a treadmill, being attached by a harness to a crane, generating a personalized gait pattern for the patient (23), and provides ambulation that is closest to human kinematics and kinetics (24). To our knowledge, only one study has been conducted in the paediatric population with CP, investigating the effects of the Walkbot-K system and comparing two groups in which both used the robot, with significant treatment effects in dimensions D and E of the GMFM (25).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe objective of this study is to know the effectiveness of RAGT treatment with Walkbot combined with physiotherapy compared to the isolated physiotherapy treatment in children and adolescents with CP, to improve gait function, and to increase muscle strength and range of motion in the lower limbs.\u003c/p\u003e\n\u003cp\u003eA quasi-experimental, prospective, longitudinal study was carried out with a non-equivalent control group. It was registered with number: NCT04329793,\u0026nbsp;respecting the ethical principles of the 2013 Helsinki declaration and the ethical protocol set by the Ethics and Research Commission of the University of Murcia, being approved by them. The parents of the patients or their legal guardians were duly informed and they were given an informed consent form, which was read, understood and signed in order to participate in the study.\u003c/p\u003e\n\u003cp\u003eStudy population and recruitment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample was made up of children and adolescents diagnosed with CP from different reference hospitals, associations and educational guidance teams from six provinces in the south and east of Spain. The inclusion criteria were as follows: non-progressive bilateral CP, age from 3 to 18 years, Gross Motor Function Classification System \u0026ndash; Expanded \u0026amp; Revised (GMFCS-ER) levels II, III and IV, not having received or being receiving treatment with RAGT or partially weight-bearing walking treadmill in the last year, and acceptance of participation in the study with the signing of the informed consent. The exclusion criteria were: serious psychiatric problems that prevent placement in the robot, serious heart problems that prevent physical exercise, active tumour processes, serious degenerative joint problems, degenerative diseases of the nervous system, mitochondrial diseases, recent surgeries, ununited fractures, severe osteoporosis, uncontrolled epileptic seizures, open wounds on the lower half of the body, extreme fear of being placed in robotic devices, pain that prevents you from carrying out the treatment, and that their anthropomorphic measurements are below the minimum required to be able to use the device.\u003c/p\u003e\n\u003cp\u003e23 subjects were recruited, 13 being assigned to the experimental group (EG) and 10 to the control group (CG). Of the 13 assigned to the EG, 10 underwent the treatment and were administered pretest, posttest, and 8 follow-up measures, while the remaining 3 were evaluated in the pretest. Figure 1 shows the progress of subjects through the phases of the clinical trial. The groups were not randomized. The criterion for assignment to the EG was being able to attend the treatment sessions at the clinic where the therapy with the RAGT was performed.\u003c/p\u003e\n\u003cp\u003eFigure 1. Flowchart of sample selection process\u003c/p\u003e\n\u003cp\u003eIntervention\u003c/p\u003e\n\u003cp\u003eEG participants underwent the RAGT treatment along with their usual physiotherapy treatment, while CG participants received physiotherapy treatment without the RAGT. The EG participants received 4 treatment sessions per week consisting of 40 minutes in the RAGT in addition to their physiotherapy sessions that were scheduled for the same number of weeks. The total number of sessions was 20, in uninterrupted weeks. The CG participants received the scheduled physiotherapy sessions during the same weeks, performing between 3 and 5 weekly sessions. The physiotherapy treatment in both groups was applied by the physiotherapists in their respective educational, health centres or associations.\u003c/p\u003e\n\u003cp\u003eAssessments\u003c/p\u003e\n\u003cp\u003eThe evaluation was carried out before starting the treatment (pretest), at the end of the treatment (posttest) and two months after finishing the intervention (follow-up), by the same evaluator in the same conditions. They were carried out at a private clinic in Murcia or Granada (Spain).\u003c/p\u003e\n\u003cp\u003eGait was evaluated with the GMFM-88\u0026nbsp;(26). The strength of the large muscle groups in the lower extremities in the movements of hip flexion and extension, knee flexion and extension and hip abduction were measured with the Baseline\u0026reg; hydraulic push-pull dynamometer. The range of motion (ROM) of the joints of the lower limbs, specifically, knee flexion-extension, were evaluated by measurements carried out with the Enraf / Nonius Universal goniometer.\u003c/p\u003e\n\u003cp\u003eData analysis\u003c/p\u003e\n\u003cp\u003eThe analyses were carried out with the free statistical package R, version 4.0.3 (R Core Team 2020). A descriptive analysis of the variables was carried out, using the mean as a measure of central tendency and the standard deviation, maximum value and minimum value as a measure of dispersion. Before performing the inferential statistics, the assumptions of normality were checked using the Kolmogorov-Smirnov test, and homogeneity using the Breusch-Pagan and Fligner-Killeen tests for homogeneity of variances, taking into account that both tests assume normality and homogeneity of variances as the null hypothesis. Durbin-Watson test was used for autocorrelation. A mixed ANOVA was performed when the assumptions of normality and homoscedasticity were met, and a robust mixed ANOVA was performed when these assumptions were not met. Statistical significance was stipulated at p \u0026lt; 0.05. For the effect size, \u0026eta;\u003csup\u003e2\u0026nbsp;\u003c/sup\u003ewas calculated, with a value \u0026gt; 0.14 considered high, moderate between 0.14 and 0.06, and small ones between 0.06 and 0.01. To test the differences between the mean values in the initial evaluation and the final evaluation, the repeated measures ANOVA of a mixed factor was used, with an inter-subject factor and within-subjects repeated measures ANOVA.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe characteristics of the sample are detailed in table 1. The participants in the EG had a mean age of 7.31 (sd: 3.09), while in the CG the average age was 10.20 (sd: 4.71). The percentage of men in the EG was 69.23% and 90% in the CG. Regarding the type of CP according to the anatomical distribution, 6 children with diplegia and 7 with tetraplegia participated in the EG. In the CG, 4 with diplegia, 1 with triplegia and 5 with tetraplegia participated. The distribution by GMFCS levels in the EG was 2 children at level II, 6 at level III and 5 at level IV, while in the CG it was 5 level II, 2 level III and 3 level IV. There are no differences between groups that influence the results.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"75.6%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTable 1.\u0026nbsp;Characteristics of the sample.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eMean age\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(sd)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e7.31 (3.09)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e10.20 (4.71)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\"\u003e\n \u003cp\u003e69.23%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eCP Type 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Diplegia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e46.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Triplegia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Tetraplegia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e53.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eCP Type 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e23.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Spastic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e76.92%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eGMFCS Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e15.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e46.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e38.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eCognitive impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e61.54%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e38.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003eAverage number of weekly physiotherapy sessions (sd)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.8%\" valign=\"top\"\u003e\n \u003cp\u003e2.92 (0.95)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.4%\" valign=\"top\"\u003e\n \u003cp\u003e3.50 (1.43)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eEG: experimental group, CG: control group, sd: standard deviation, CP: cerebral palsy, GMFCS: Gross Motor Function Classification System\u003c/p\u003e\n\u003cp\u003eGait\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the GMFM-88, dimension D, the EG participants obtained an average of 0.21 in the pretest, and 0.30 in the post-test. The CG participants obtained an average of 0.47 and 0.46 in the pretest and post-test, respectively. At follow-up, the EG and CG obtained a mean of 0.41 and 0.46, respectively. The pretest-post-test and follow-up analysis of variance showed differences with respect to the time x group interaction [F (2.32) =12.7585, p= 8.425406e-05, \u0026eta;\u003csup\u003e2\u003c/sup\u003e=0.016], with small effect sizes. In the GMFM -88, dimension E, the EG participants obtained an average of 0.16 and 0.24, in the pretest and in the post-test, respectively. In the CG they obtained an average of 0.44 in the pretest and 0.47 in the post-test. At follow-up, the EG and CG participants obtained an average of 0.27 and 0.44, respectively. In the robust mixed ANOVA pretest-posttest and follow-up, no differences were found regarding interaction (p=0.1579). Table 2 shows the comparisons between groups of GMFM D, GMFM E. Figure 2 shows the interaction between time and group.\u003c/p\u003e\n\u003cp\u003eTable 2. Comparisons between groups of GMFM D and GMFM E.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"694\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.071942446043165%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.294964028776977%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePretest Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.72661870503597%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostest Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.431654676258994%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.47482014388489%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePretest-post-test and follow-up analysis of variance\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.057471264367816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.482758620689655%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.793103448275861%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.64367816091954%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.057471264367816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGMFMD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e0.21 (0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.47 (0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.36 (0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.46 (0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.482758620689655%\" valign=\"top\"\u003e\n \u003cp\u003e0.41 (0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.46 (0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.793103448275861%\" valign=\"top\"\u003e\n \u003cp\u003e8.425406e-05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.64367816091954%\" valign=\"top\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.057471264367816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGMFME\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e0.16 (0.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.44 (0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.24 (0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.47 (0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.482758620689655%\" valign=\"top\"\u003e\n \u003cp\u003e0.27 (0.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.919540229885058%\" valign=\"top\"\u003e\n \u003cp\u003e0.44 (0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.793103448275861%\" valign=\"top\"\u003e\n \u003cp\u003e0.1579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.64367816091954%\" valign=\"top\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: standard deviation, EG: experimental group, CG: control group, GMFMD: Gross Motor Function Measure Dimension D, GMFME: Gross Motor Function Measure Dimension E, p: statistical significant, \u0026eta;\u003csup\u003e2\u003c/sup\u003e: effect size\u003c/p\u003e\n\u003cp\u003eFigure 2. Interaction graph between time and group of GMFMD\u003c/p\u003e\n\u003cp\u003eGMFMD: Gross Motor Function Measure Dimension D\u003c/p\u003e\n\u003cp\u003eMuscular strength\u003c/p\u003e\n\u003cp\u003eHip flexion\u003c/p\u003e\n\u003cp\u003eIn the flexion strength in the left hip, the EG obtained an average of 1.46 and 2.35, in the pretest and in the posttest, respectively. In the CG they obtained an average of 3.62 in the pretest and 3.10 in the posttest. At follow-up, the EG and CG obtained a mean of 3.56 and 3.25, respectively. In the right hip, in the EG they obtained an average of 1.25 and 2.45, in the pretest and in the posttest, respectively. In the CG they obtained an average of 3.45 and 2.85, in the pretest and in the posttest, respectively. At follow-up, the EG and CG obtained a mean of 3.19 and 3.15, respectively. The pretest-posttest and follow-up analysis of variance showed differences with respect to the group x time interaction [F (2.32) = 7.358, p= 2.350e-03, \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.128], in left hip flexion strength. In the right hip, differences were also found with respect to the interaction [F (2.32) = 8.045, p= 1.478e- 03, \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.142]. (Figures 3 and 4). (Table 3).\u003c/p\u003e\n\u003cp\u003eFigure 3. Interaction graph between time and group of left hip flexion strength\u003c/p\u003e\n\u003cp\u003eFigure 4. Interaction graph between time and group of right hip flexion strength\u003c/p\u003e\n\u003cp\u003eHip extension\u003c/p\u003e\n\u003cp\u003eIn the extension strength in the left hip, the EG participants obtained an average of 0.10 and 0.60, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 0.95 in the pretest and 0.70 in the posttest. At follow-up, the EG and CG obtained a mean of 1.12 and 0.75, respectively. In the right hip, the EG obtained an average of 0.10 and 0.53, in the pretest and in the posttest, respectively. The CG obtained an average of 1.20 in the pretest and 0.80 in the posttest. At follow-up, the EG and CG obtained a mean of 0.88 and 0.95, respectively. In the pretest-posttest and follow-up analysis of variance, differences were found with respect to the interaction [F (2.32) = 4.672, p= 0.017, \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.035], in right hip extension strength. (Figure 5). In the left hip, no differences were found with respect to the interaction [F (2.32) = 3.0606, p=0.0608, \u0026eta;\u003csup\u003e2\u003c/sup\u003e=0.04119]. (Table 3).\u003c/p\u003e\n\u003cp\u003eFigure 5. Interaction graph between time and group of right hip extension strength\u003c/p\u003e\n\u003cp\u003eHip abduction\u003c/p\u003e\n\u003cp\u003eIn the abduction strength in the left hip, the EG participants obtained an average of 0.32 and 1.35, in the pretest and in the posttest, respectively. Those from the CG obtained an average of 2.05 and 1.30, in the pretest and in the posttest, respectively. At follow-up, the EG and CG obtained a mean of 2.22 and 1.15, respectively. In the right hip, the EG participants obtained an average of 0.42 and 1.25, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 2.25 in the pretest and 1.30 in the posttest. At follow-up, the EG and CG participants obtained a mean of 1.88 and 1.00, respectively. In the analysis of variance pretest-posttest and follow-up, differences were found with respect to the interaction [p=0.0147,\u0026nbsp;\u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.179] in the left hip. In the abduction strength of the right hip, differences were also found with respect to the interaction [F (2.32) = 8.721, p= 9.481e-04, \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.196]. (Figures 6 and 7). (Table 3).\u003c/p\u003e\n\u003cp\u003eFigure 6. Interaction graph between time and group of left hip abduction strength\u003c/p\u003e\n\u003cp\u003eFigure 7. Interaction graph between time and group of right hip abduction strength\u003c/p\u003e\n\u003cp\u003eKnee flexion\u003c/p\u003e\n\u003cp\u003eIn the flexion strength in the left knee, the EG participants obtained an average of 1.18 and 2.23, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 2.65 in the pretest and 1.95 in the posttest. At follow-up, the EG and CG obtained, respectively, a mean of 2.60 and 2.30. In the right knee, the mean EG in the pretest was 1.25, and in the posttest it was 2.20. In the CG, the pretest mean was 2.75 and the posttest mean was 2.15. At follow-up, the EG and CG participants obtained a mean of 2.66 and 2.35, respectively. In the ANOVA, differences were found in the strength of the left knee with respect to the group x time interaction [F (2.32) = 9.762, p = 4.899e-04, \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.222]. In right knee strength, differences were also found in the group x time interaction [F (2.32) = 4.867, p= 1.427e-02, \u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.147]. (Figures 8 and 9). (Table 3).\u003c/p\u003e\n\u003cp\u003eFigure 8. Interaction graph between time and group of left knee flexion strength\u003c/p\u003e\n\u003cp\u003eFigure 9. Interaction graph between time and group of right knee flexion strength\u003c/p\u003e\n\u003cp\u003eKnee extension\u003c/p\u003e\n\u003cp\u003eIn the extension strength in the left knee, the EG participants obtained an average of 1.00 and 1.99, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 1.84 in the pretest and 2.20 in the posttest. At follow-up, the EG and CG obtained a mean of 2.09 and 2.35, respectively. In the right knee, the EG participants obtained an average of 1.10 and 2.40, in the pretest and in the posttest, respectively. The CG participants obtained an average of 1.95 in the pretest and 2.45 in the posttest. At follow-up, the EG and CG participants obtained an average of 2.05 and 2.55, respectively. In right knee extension, no differences were found with respect to the interaction [F (2.32) = 0 .3893, p=0.6807, \u0026eta;\u003csup\u003e2\u003c/sup\u003e=0.00496], as in left knee extension (p=0.4747). (Table 3)\u003c/p\u003e\n\u003cp\u003eTable 3. Comparisons between groups of hip and knee strength.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.821138211382113%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.1869918699187%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePretest Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.349593495934958%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosttest Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.86178861788618%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.78048780487805%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePretest-post-test and follow-up analysis of variance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.821138211382113%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrength\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.308943089430894%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft hip flexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e1.46 (0.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e3.62 (1.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.35 (0.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e3.10 (1.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e3.56 (2.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3.25 (1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e2.350e-03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight hip flexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e1.25 (0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e3.45 (1.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.45 (0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.85 (1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e3.19 (1.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3.15 (1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e1.478e- 03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft hip extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e0.10 (0.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e0.95 (1.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e0.60 (0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e0.70 (1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e1.12 (1.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.75 (1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e0.0608\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.04119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight hip extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e0.10 (0.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.20 (1.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e0.53 (0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e0.80 (1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e0.88 (1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.95 (1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft hip abduction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e0.32 (0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.05 (1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.35 (0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.30 (0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e2.22 (1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.15 (1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e0.0147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.179\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight hip abduction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e0.42 (0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.25 (1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.25 (0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.30 (1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e1.88 (1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e9.481e-04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft knee flexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e1.18 (0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.65 (1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.23 (0.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.95 (0.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e2.60 (0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.30 (0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e4.899e-04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight knee flexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e1.25 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.75 (1.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.20 (0.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.15 (0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e2.66 (1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.35 (0.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e1.427e-02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft knee extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.84 (1.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.99 (0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.20 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e2.09 (1.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.35 (1.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e0.4747\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e------\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.843648208469055%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight knee extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.446254071661238%\" valign=\"top\"\u003e\n \u003cp\u003e1.10 (0.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e1.95 (1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.40 (1.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.77198697068404%\" valign=\"top\"\u003e\n \u003cp\u003e2.45 (2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.794788273615636%\" valign=\"top\"\u003e\n \u003cp\u003e2.05 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.93485342019544%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.55 (2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.006514657980455%\" valign=\"top\"\u003e\n \u003cp\u003e0.6807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.657980456026058%\" valign=\"top\"\u003e\n \u003cp\u003e0.00496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: standard deviation, EG: Experimental Group, CG: Control Group, n: sample\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eROM\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKnee flexion\u003c/p\u003e\n\u003cp\u003eIn the flexion movement of the left knee, the EG participants obtained an average of 126.5 and 119, in the pretest and in the posttest, respectively. The CG participants obtained an average of 127 and 128 in the pretest and posttest, respectively. At follow-up, EG and CG participants scored an average of 130 and 128, respectively. In the right knee, the EG participants obtained an average of 128 and 121, in the pretest and in the posttest, respectively. The CG participants obtained an average of 127 and 127 in the pretest and posttest, respectively. At follow-up, EG and CG participants scored an average of 130 and 128, respectively. In the left knee flexion ROM, the pretest-posttest and follow-up analysis of variance showed differences with respect to interaction (p=0.0054,\u0026nbsp;\u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.071). with medium effect size. In the ROM of right knee flexion, the analysis showed differences with respect to interaction (p=0.0054,\u0026nbsp;\u0026eta;\u003csup\u003e2\u003c/sup\u003e = 0.053), with medium and small effect sizes respectively. (Table 4).\u003c/p\u003e\n\u003cp\u003eKnee extension\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In the extension movement in the left knee, the EG participants obtained an average of -2.30 in the pretest, and -1.30 in the posttest. The CG participants obtained an average of -2 and -1.5, in the pretest and in the posttest, respectively. At follow-up, EG and CG participants obtained a mean of -0.62 and -1, respectively. In the right knee, the EG participants obtained an average of -2.50 and -1.30, in the pretest and in the posttest, respectively. The CG participants obtained an average of -3 and -3.50, in the pretest and in the posttest, respectively. At follow-up, EG and CG participants obtained a mean of -0.62 and -1, respectively. In the left knee extension ROM, the ANOVA pretest-posttest and follow-up showed no differences with respect to interaction [F (2.32) = 0.0097, p=0.9903]. In the right knee extension ROM, no differences were found with respect to interaction [F (2,32) = 0.4777, p=0.6245]. (Table 4)\u003c/p\u003e\n\u003cp\u003eTable 4. Comparisons between groups of knee ROM.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.2398753894081%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.560747663551403%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePretest Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.560747663551403%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosttest Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.1588785046729%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.4797507788162%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePretest-post-test and follow-up analysis of variance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.2398753894081%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eROM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.878504672897197%\" valign=\"top\"\u003e\n \u003cp\u003eEG (n=8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003eCG (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.74766355140187%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.2398753894081%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft knee flexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e126.50 (11.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e127 (15.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e119 (7.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e128 (11.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.878504672897197%\" valign=\"top\"\u003e\n \u003cp\u003e130 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e128 (10.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.74766355140187%\" valign=\"top\"\u003e\n \u003cp\u003e0.0054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.2398753894081%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight knee flexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e128 (6.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e127 (15.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e121 (3.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e127 (13.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.878504672897197%\" valign=\"top\"\u003e\n \u003cp\u003e130 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e128 (10.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.74766355140187%\" valign=\"top\"\u003e\n \u003cp\u003e0.0054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.2398753894081%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft knee extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-2.30 (3.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-2 (6.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-1.30 (2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-1.50 (4.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.878504672897197%\" valign=\"top\"\u003e\n \u003cp\u003e-0.62 (1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-1 (3.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.74766355140187%\" valign=\"top\"\u003e\n \u003cp\u003e0.9903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e6.026e-05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.2398753894081%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight knee extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-2.50 (4.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-3 (9.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-1.30 (2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-3.50 (9.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.878504672897197%\" valign=\"top\"\u003e\n \u003cp\u003e-0.62 (1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.280373831775702%\" valign=\"top\"\u003e\n \u003cp\u003e-2.50 (6.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.74766355140187%\" valign=\"top\"\u003e\n \u003cp\u003e0.6245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.73208722741433%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: standard deviation, EG: Experimental Group, CG: Control Group, n: sample, ROM: range of motion\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe objective of the present study was to evaluate the comparative effectiveness of RAGT treatment with Walkbot combined with physiotherapy, compared to isolated physiotherapy treatment, in children and adolescents with CP, to improve gait and increase muscle strength and range of motion in the lower extremities.\u003c/p\u003e\n\u003cp\u003eIn our study, positive changes in the EG have been observed in the GMFM-88, both in the post-test and in the follow-up. Dimension D obtained a significant difference. And in dimension E, no significant differences were observed. Regarding previous studies, some of them found improvements in dimension D and E\u0026nbsp;(19\u0026ndash;21,27), and one study in dimension E\u0026nbsp;(17). These studies mentioned included children with GMFCS-ER levels between I and III, and none included level IV, unlike our study. Furthermore, in our study all children had bilateral involvement, and others included unilateral involvement along with bilateral\u0026nbsp;(20), or only unilateral involvement\u0026nbsp;(21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study is the first clinical trial that compares Walkbot together with physiotherapy with physiotherapy treatments in CP in a European population. A study\u0026nbsp;(25)\u0026nbsp;use Walkbot comparing two groups in which both used the RAGT, without a control group. In our study, significant results were observed in the comparison of the Walkbot treatment together with physiotherapy with physiotherapy treatments in standing, muscle strength, and lower limb ROM. Other CTs that use RAGT report improvement in standing\u0026nbsp;(19\u0026ndash;21,27). However, previous CTs do not measure strength or ROM like our study.\u003c/p\u003e\n\u003cp\u003eSome previous clinical trials have demonstrated improvements in walking ability in participants with neurological damage, such as stroke and spinal cord injury, who used a walking robot in their rehabilitation (10\u0026ndash;14). In children with CP, reviews and meta-analyses have not found significant differences in the use of the walking robot compared to other physiotherapy treatments aimed at rehabilitating walking function (22, 28,29).\u0026nbsp;In a recent meta-analysis that included 8 clinical trials (2 non-randomized), no significant differences were found compared to physical therapy treatments (22).\u003c/p\u003e\n\u003cp\u003eRegarding limitations, the groups were not randomized, since participants who were willing to travel to the place where the treatment was carried out were assigned to the EG, and the final sample size was reduced compared to what was expected.\u003c/p\u003e\n\u003cp\u003eIn clinical practice, the results of our study stand out because adding training with the robotic-assisted gait training Walkbot to the physiotherapy treatment improves standing, muscle strength and ROM in children with CP compared to physiotherapy treatments without Walkbot, and this improvement may predispose to an increase in activity and participation.\u003c/p\u003e\n\u003cp\u003eIn future research, it would be advisable to conduct RCTs, with homogeneous groups in terms of levels of impairment in the GMFCS-ER, and with larger samples. It would also be convenient to compare the treatment with specific physiotherapy treatments, and to contrast whether treatment times are shortened by including the use of the walking robot.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePhysiotherapy treatment including the RAGT Walkbot improves standing, muscle strength in the lower limbs, and knee ROM in children and adolescents with CP, compared to physiotherapy treatments without RAGT. No changes have been found between both treatments regarding the GMFM dimension E of the study participants.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCP: Cerebral Palsy\u003c/p\u003e\n\u003cp\u003eRAGT: robotic-assisted gait training\u003c/p\u003e\n\u003cp\u003eGMFM: Gross Motor Function Measure\u003c/p\u003e\n\u003cp\u003eGMFCS-ER: Gross Motor Function Classification System \u0026ndash; Expanded \u0026amp; Revised\u003c/p\u003e\n\u003cp\u003eEG: experimental group\u003c/p\u003e\n\u003cp\u003eCG: control group\u003c/p\u003e\n\u003cp\u003eROM: range of motion\u003c/p\u003e\n\u003cp\u003eRCT: randomise clinical trial\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRespecting the ethical principles of the 2013 Helsinki declaration and the ethical protocol set by the Ethics and Research Commission of the University of Murcia, being approved by them. The parents of the patients or their legal guardians were duly informed and they were given an informed consent form, which was read, understood and signed in order to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to Organic Law 3/2018 on Protection of Personal Data of Spanish legislation, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eROG conceived the study, participated in the data collection, intervention, analysis, interpretation and writing of the manuscript. AGC and ICM participated in the analysis, interpretation and writing of the manuscript. All authors read and gave approval of the final version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to thank the parents and children that took part in this study, the different professionals who contributed to the recruitment of the sample, and the Clern clinic in Yecla- Murcia (Spain) where the intervention with Walkbot was carried out.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; information:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e International Doctoral School of the University of Murcia (EIDUM), University of Murcia, 30100 Murcia, Spain, [email protected]\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Faculty of Physiotherapy, Occupational Therapy and Podiatry, UCAM Catholic University of Murcia, Guadalupe 30107, Murcia, Spain, [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Research Group Research Methods and Evaluation in Social Sciences, Mare Nostrum Campus of International Excellence, University of Murcia, 30100 Murcia, Spain, [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEuropean Commission. 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DOI: 10.1111/j.1469-8749.1989.tb04003.x\u003c/li\u003e\n\u003cli\u003eRomei M, Montinaro A, Piccinini L, Maghini C, Germiniasi C, Bo I, et al. Efficacy of robotic-assisted gait training compared with intensive task-oriented physiotherapy for children with Cerebral Palsy. En: 2012 4th IEEE RAS \u0026amp; EMBS International Conference on Biomedical Robotics and Biomechatronics (BioRob) [Internet]. Rome, Italy: IEEE, 2012. p. 1890-4. DOI: 10.1109/BioRob.2012.6290748\u003c/li\u003e\n\u003cli\u003eCarvalho I, Pinto SM, Chagas D das V, Praxedes Dos Santos JL, de Sousa Oliveira T, Batista LA. Robotic Gait Training for Individuals with Cerebral Palsy: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2017,98(11):2332-44. DOI: 10.1016/j.apmr.2017.06.018\u003c/li\u003e\n\u003cli\u003eLefmann S, Russo R, Hillier S. The effectiveness of robotic-assisted gait training for paediatric gait disorders: systematic review. J Neuroengineering Rehabil. 2017,14(1):1. DOI: 10.1186/s12984-016-0214-x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cerebral palsy, robotic, walkbot, gait, children, adolescents, physical therapy modalities, experimental study","lastPublishedDoi":"10.21203/rs.3.rs-3910627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3910627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Improving walking ability is a key objective in the treatment of children and adolescents with cerebral palsy (CP), since it directly affects their activity and participation. In recent years, robotic technology has been implemented in gait treatment, which allows training of longer duration and repetition of the movement. To know the effectiveness of a treatment with the robotic-assisted gait trainer (RAGT) Walkbot combined with physiotherapy compared to the isolated physiotherapy treatment in children and adolescents with CP, we carried out a clinical trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u0026nbsp;23 participants (mean age 8.56), were divided into two groups: experimental (EG) and control (CG). During 5 weeks, both groups received their physiotherapy sessions scheduled, in addition EG received 4 sessions per week of 40 minutes of RAGT. An evaluation of the participants was carried out before the intervention, at the end of the intervention, and at follow-up (two months after the end of the intervention). Gait was assessed with the Gross Motor Function Measure-88 (GMFM-88) dimensions D and E, strength was measured with a hydraulic dynamometer, and \u003cem\u003erange of motion (\u003c/em\u003eROM) was assessed using the goniometer. A mixed ANOVA was performed when the assumptions of normality and homoscedasticity were met, and a robust mixed ANOVA was performed when these assumptions were not met. Statistical significance was stipulated at p \u0026lt; 0.05. For the effect size, η\u003csup\u003e2\u003c/sup\u003e was calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Significant differences were found regarding the time x group interaction in the GMFM-88 in dimension D [η\u003csup\u003e2\u003c/sup\u003e= 0.016], in the flexion strength of the left [η\u003csup\u003e2\u003c/sup\u003e=0.128] and right [η\u003csup\u003e2\u003c/sup\u003e=0.142] hips, in the extension strength of the right hip [η\u003csup\u003e2\u003c/sup\u003e=0.035], in the abduction strength of the left hip [η\u003csup\u003e2\u003c/sup\u003e=0.179] and right [η\u003csup\u003e2\u003c/sup\u003e=0.196], in the flexion strength of the left knee [η\u003csup\u003e2\u003c/sup\u003e=0.222] and right [η\u003csup\u003e2\u003c/sup\u003e=0.147], and in the ROM of left [η\u003csup\u003e2\u003c/sup\u003e= 0.071] and right [η\u003csup\u003e2\u003c/sup\u003e=0.053] knee flexion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Compared to treatments without walking robot, physiotherapy treatment including RAGT Walkbot improves standing, muscle strength, and knee ROM in children and adolescents with CP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e ClinicalTrials.gov: NCT04329793.\u003c/p\u003e","manuscriptTitle":"Treatment with robot-assisted gait trainer Walkbot along with physiotherapy vs isolated physiotherapy in children and adolescents with cerebral palsy. 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