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IntroductionWalking is essential for daily life but poses a significant challenge for many individuals with neurological conditions like cerebral palsy (CP), which is the leading cause of childhood walking disability. Although lower-limb exoskeletons show promise in improving walking ability in laboratory and controlled overground settings, it remains unknown whether these benefits translate to real-world environments, where they could have the greatest impact. MethodsThis feasibility study evaluated whether an untethered ankle exoskeleton with an adaptable controller can improve spatiotemporal outcomes in eight individuals with CP after low-frequency exoskeleton-assisted gait training on real-world terrain. ResultsComparing post- and pre-assessment, assisted walking speed increased by 11% and cadence by 7% (p= 0.003;p= 0.006), while unassisted walking speed increased by 8% and cadence by 5% (p= 0.009;p= 0.012). In the post-assessment, assisted walking speed increased by 9% and stride length by 8% relative to unassisted walking (p< 0.001;p< 0.001). Improvements in walking speed were more strongly associated with longer strides than higher cadence (R²= 0.92;R²= 0.68). Muscle activity outcomes, including co-contraction of the soleus and tibialis anterior, did not significantly change after training. DiscussionThese findings highlight the spatiotemporal benefits of an adaptive ankle exoskeleton for individuals with CP in real-world settings after short-term training. This work paves the way for future randomized controlled trials (RCTs) to evaluate the isolated effects of adaptive ankle exoskeletons on gait performance and neuromuscular outcomes in individuals with CP in real-world environments 

Abstract BackgroundElectromyography (EMG)-based audiovisual biofeedback systems, developed and tested in research settings to train neuromuscular control in patient populations such as cerebral palsy (CP), have inherent implementation obstacles that may limit their translation to clinical practice. The purpose of this study was to design and validate an alternative, plantar pressure-based biofeedback system for improving ankle plantar flexor recruitment during walking in individuals with CP. MethodsEight individuals with CP (11–18 years old) were recruited to test both an EMG-based and a plantar pressure-based biofeedback system while walking. Ankle plantar flexor muscle recruitment, co-contraction at the ankle, and lower limb kinematics were compared between the two systems and relative to baseline walking. ResultsRelative to baseline walking, both biofeedback systems yielded significant increases in mean soleus (43–58%, p < 0.05), and mean (68–70%, p < 0.05) and peak (71–82%, p < 0.05) medial gastrocnemius activation, with no differences between the two systems and strong relationships for all primary outcome variables (R = 0.89–0.94). Ankle co-contraction significantly increased relative to baseline only with the EMG-based system (52%, p = 0.03). ConclusionThese findings support future research on functional training with this simple, low-cost biofeedback modality.