WHAT THIS ADDS TO THE EVIDENCE

Current evidence: Exoskeletons have been used to ameliorate a number of secondary conditions in individuals with neurologic conditions. Based on a comprehensive review of the literature, incorporating exoskeletons into physical therapy practice is proving to be beneficial.1-44

Gap in the evidence: It is important to take into account the end users' (both clinician and child/caregiver) opinions when deciding to implement new technology into an existing therapy practice.

How does this study fill this evidence gap? Using a Design Thinking framework, we worked with clinicians, children, caregivers, and engineers to implement the use of pediatric exoskeletons into an already existing physical therapy practice.

Implication of all the evidence: Ultimately, we improved on the design of the exoskeleton as well as improving on the efficiency of the clinic.

BACKGROUND AND PURPOSE

Inadequate physical fitness is a significant problem for individuals with neurologic disorders, ultimately impacting their health and function.1 Standing improves muscle strength and postural control, and visual, upper limb, and oral motor skills. It also increases social communication and bowel function in children with cerebral palsy (CP).2 A study of a standing program of 8 weeks, for 60 minutes, 4-5 times per week, significantly increased bone mineral density in the patella, tibial plateau, and supracondylar femur.3

Research on exoskeletons, including clinical use, has increased over the past 10 to 15 years. Exoskeletons are robotic trainers used for the rehabilitation of deficits after injury or due to illness. Exoskeletons have been used to rehabilitate knee extension,4-7 ankle strength,8,9 incline walking and stair ascent,10 neuromuscular control of the ankle,11 finger individuation,12 hand function,13-15 upper limb impairments16 gross motor function,17-20 trunk control,18 spasticity,21 and, most often, gait/walking.22-44 A systematic review found that robot-assisted gait training with powered lower limb exoskeletons has shown positive evidence for effectiveness with minimal adverse effects.45

Similar to exoskeletons, researchers found that 6 weeks of body weight-supported treadmill training with 2- to 4-year-olds improved gross motor function and trunk control.18 Others found that using a robotic exoskeleton improved gross motor function, walking speed, walking endurance, and efficiency.33 Additionally, Delgado and colleagues27 investigated an exoskeleton for improving range of motion, strength, and spasticity and found that all improved after 1 month (10 sessions).

Further, researchers8,9,25 found that treadmill training using an ankle exoskeleton improved ankle strength, walking efficiency, general mobility,46 muscle recruitment,9 and motor control.11 Another study investigated the use of the CPWalker with 8 individuals with CP and found evidence of improved muscular strength and gait parameters.23 Fang and Lerner28 researched ankle assistance plus biofeedback on improving walking mechanics. Furthermore, Orekhov and colleagues39,40 looked at improving walking economy, mechanics, and energetics. A pilot randomized controlled trial31 investigated gait parameters in 10 children with CP and found that the affected limb's maximum hip flexion and extension angle improved, as did limb symmetry and propulsion force. Incorporating exoskeletons into physical therapy practice is proving to be beneficial from these research findings. However, it is also important to consider how technology modalities are implemented and how they can ultimately benefit the users. An approach to including end users in the implementation is through Design Thinking.

Design Thinking methodology was used throughout this journey to 1 000 000 steps (Figure 1). Design Thinking is a “mindset and approach to problem-solving and innovation anchored in human-centered design.”47 Historically, this method has been used in the business and development industries. However, it is being used more in health care. Innovative ideas and products are necessary to meet the needs of children and health care professionals continuously. Design Thinking ensures the efficient creation of useful products by considering the end user, clarifying needs, generating ideas, developing/prototyping, and finally, implementation.47 A research report found that “Design Thinking interventions” resulted in greater satisfaction, usability, and effectiveness compared with traditional methods.48 A central component of Design Thinking success is working collaboratively in multidisciplinary teams.48 All levels of health care practitioners can implement this method of thinking and collaboration. Design Thinking can be applied to innovative treatment techniques, modalities, and technology used in rehabilitative medicine.

Fig. 1.:

Example of Design Thinking Model utilized during the journey to achieving 1 000 000 steps to enhance the exoskeleton device.

An example of innovative rehab technology includes exoskeletons and robotics. One type of pediatric exoskeleton currently available is the Trexo Plus. We have been using the Trexo Plus (Figure 2) in the clinic since October 25, 2019. On February 9, 2022, through Design Thinking and studying its clinical effectiveness, we were the first therapy clinic/rehab hospital to achieve the milestone of reaching 1 000 000 steps in the Trexo Plus device. The Trexo is an exoskeleton that enables children and teenagers of any ability level to walk over ground. The device is a pair of wearable robotic lower extremities that attach to a specific gait trainer, providing additional support to children to improve safety, posture, and stability. The device offers 4 sizes to accommodate an extensive range of users. It features a set of adjustable hip and knee joints controlled and operated through a tablet interface by a trained clinician. The speed, range of motion, support forces, modes, and sizing are customizable based on each user's needs.

Fig. 2.:

Trexo Plus Robotic Exoskeleton.

This retrospective case series describes the implementation of this new technology, a new exoskeleton, into an already established outpatient therapy clinic, including collaboration and elements of Design Thinking that occurred during our journey to achieving 1 000 000 steps walked in the Trexo Plus devices. Additionally, 3 pediatric case examples will be discussed to review outcomes and development opportunities that occurred.

METHODS: DESCRIPTION OF PROGRAM IMPLEMENTATION

Good Shepherd Rehabilitation Network–Outpatient Pediatrics received and began using its first Trexo Plus in October 2019. The outpatient clinic has 6 physical therapists (PTs) and 2 physical therapy assistants. The clinic started with a medium-sized device. Before use, 6 qualified clinicians completed a training course to become certified to use the device. The training course taught clinicians how the device functions, user safety, and potential benefits. Through education received from the training, the ongoing open and constant communication with the company, and the frequent use of the devices with various children, the therapists at the clinic quickly became effective and efficient users of the new technology.

More children began using the device, and the need to know more information about potential incoming users was necessary. Exoskeleton evaluations were scheduled for 90 minutes to allow time to complete a thorough assessment and initial trial of the device. Children of various ages and diagnoses were trialed as long as they met the measurement criteria and did not have safety concerns. Considerations and precautions for use included hip subluxation greater than 40%, severe spasticity, seizures not controlled by medication, weight bearing restrictions, 2 or more fractures within the past year, knee valgus more than 40°, hip extension less than 0°, and knee flexion contracture more than 20°. These considerations were set by the Trexo development team and clinicians used their expertise and clinical knowledge to make final determination on if a child was safe to use the exoskeleton. The trained therapy team also participated in peer discussions and peer review sessions to determine best practice for assessment and tolerance of the exoskeleton in addition to conducting independent research reviews. Through more clinical use and through these peer discussions and research reviews, clinicians discerned benefits other than improvements in gait quality. For example, those children who were more medically complex and/or not walking, observations were made that noted improved head and trunk control in upright positions and improved tolerance to being upright. For children who were walking, it was observed that their endurance for walking longer distances and assistance level needed for walking improved. Families observed that their children enjoyed the device and became more engaged in the therapy sessions, noting improvements in their desire to walk, bowel habits, and sleep at home.

Due to the daily use of 3 sizes and having trained and competent clinicians, Good Shepherd was named a center of excellence for the use of the Trexo Plus. Due to this distinction, referrals increased from a larger geographic reach. As patients with different and new diagnoses and complexity levels were evaluated and used the device in their plan of care, the clinical team stayed connected to the robotic engineers through a device-specific Chat App. Initial conversations were surrounding break/fix solutions of the devices; however, through more clinical practice, therapists provided enhancement feedback to engineers to meet the needs of their practice. Consistent with the iteration phase of Design Thinking, specific child case scenarios and recommendations that could enhance patient care with alterations or different features of the devices were shared with the company. To allow for consistent communication between the company and all of the therapists using the device, monthly video meetings were held for 30 minutes. Over time, as clinicians continued to excel in their knowledge and use of the devices, and as modifications to the device lessened, those meetings were decreased to every other month.

During the video meetings and messaging through the communication app, the therapy team was able to assist with the features of the device. The team was implementing Design Thinking to create a better pediatric exoskeleton to meet the needs of the pediatric therapists and the children. One key example of this, and an example of the prototyping phase of Design Thinking, was the addition of the device's ability to monitor initiation percentage on each lower extremity. Initially, the tablet would report an overall combined initiation percentage in real time and a combined average. However, the therapists determined that it would be most useful to have this data separated between the right and left legs, allowing the therapist better to tailor their intervention outside the robotic gait trainer and provide more specific home recommendations. Additionally, it would enable the therapists to monitor and modify the support forces provided by the motors. The team at the company was receptive to the clinician's feedback and started prototyping ways to make this work. When prototyping was completed, they released an update to the clinic's devices. The clinicians tested the new individualized leg initiation percentages with patients and completed the implementation phase of Design Thinking. Once determined this was successful and beneficial, the company made this standard for all Trexo Plus exoskeletons. Other features and ideas have been implemented using this same process of Design Thinking to improve the pediatric exoskeleton. This process must continue with this device and throughout health care to ensure products and devices are being created with the needs of children and health care professionals in mind.

Having pediatric patients walk 1 000 000 total steps in a time frame of approximately 27 months is an extraordinary achievement. To achieve this, our team needed to become knowledgeable about the device and collaborate with the company frequently. The clinic needed to integrate this new technology efficiently and via the most up-to-date best practice guidelines. To fully incorporate the latest technology into the clinical setting, the therapy team frequently collaborates with various tips and tricks to enhance the child's use of the device. Additionally, the team found ways to make the set-up more efficient, allowing children increased time to walk in the device. A rehabilitation aide was trained to complete the connection of the devices to the tablet interface system and the clinic's internet and manually adjust the length of the robot legs, saddle seat height, and overall height of the device. The aide completed this set-up just before the child's appointment. This would allow the therapist to check settings, transfer the child into the device, and start walking. On average, the children could walk 10 minutes longer than when the PT completed the device set-up.

Additionally, a clinic day was created to manage the gradual increase in evaluation referrals and meet the needs of our children. The Robotic Evaluation Clinic allowed for a 90-minute evaluation. This was after the medical history was completed via phone consultation. The phone consult and evaluation forms are unique to robotic assessment evaluation to increase efficiency and clinic flow. Creating the Robotic Evaluation Clinic allowed our clinic to reserve the same time out each week for all 3 devices to ensure all 3 sizes would be available. We found this 1 entry point allowed for standardization of evaluation and development of plan of care to allow for consistency. It also allowed clinicians to implement this new modality while maintaining a caseload of traditional physical therapy evaluations and treatment sessions. Additionally, this allowed our clinic to ensure a balance of one exoskeleton evaluation a week to create a constant and steady flow of these evaluations, rather than trying to find time to schedule multiple of these evaluations during the same week. After the evaluation, if the trial was successful and the child was recommended for ongoing services, the scheduling team could focus on finding times for one exoskeleton user at a time to ensure the family was receiving times that worked best with their schedules. After the robotic evaluation, a treatment program was discussed with the family to ensure meaningful goals were developed and the family was able to maintain the prescribed plan of care. The team also completed evaluations for families traveling prolonged distances. This evaluation was to trial the device to assess tolerance before considering obtaining a home device. As our clinic continues to be a center of excellence for this new technology, we continue to collaborate with all stakeholders to ensure the device and its integration in the clinic continue to adapt and progress.

CASE SERIES DESCRIPTION

The 1 000 000-step milestone was achieved by contributions from 36 different children. The mix of patients included children aged 1 to 14 years with varying diagnoses. Additionally, participants included both current and new patients. Three of the children who walked in the exoskeleton were randomly selected for a retrospective review of their electronic medical chart to determine whether improvements and progress toward therapy goals were noted. For each child selected, a chart review was completed, to assess age, diagnosis, date of initial trial, and frequency of visits. Information was also collected regarding outcome data, goals, and assessment of the PT before using the exoskeleton, and at the most recent progress summary or discharge, closest to the date the 1 000 000 steps were achieved. As this was a retrospective chart review, it was deemed exempt by the Research Committee.

Child 1 was a 3-year-old Hispanic-Caucasian boy with a medical diagnosis of CP who was a level V on the Gross Motor Functional Classification Scale. This child began physical therapy treatment at the clinic in October 2019. The pediatric exoskeleton was added to his plan of care on November 23, 2020. At the progress summary completed on October 12, 2020, the child had achieved 1 of his 4 PT goals. At this time, the child could take 10 consecutive steps in a Kidwalk gait trainer with total assistance to propel the gait trainer forward. In the assessment, the PT noted that the child was rolling from the prone position to and from the supine position more consistently without help, but that poor sitting balance and head control continued. A Hensinger collar for cervical support was recommended. Additionally, use of the exoskeleton was recommended. The child then started attending PT appointments 3 times per week, including 2 exoskeleton sessions and 1 aquatic PT session. On January 13, 2022, a progress summary resulted in the child achieving 4 out of 7 PT goals, with an additional new goal added. The child was noted to be walking more than 1000 steps in the robotic-assisted gait trainer at each session at 45 to 50 steps per minute. The PT stated, “The child's head control has improved in upright sitting and standing positions and is also now able to statically sit with close supervision for 1 minute before loss of balance.” The child was noted to be able to walk 10 to 15 steps consecutively in a Kidwalk gait trainer with assistance to propel the device forward. No additional objective outcome measures were gathered for this child while using the exoskeleton.

Child 2 was a 4-year-old Hispanic-Caucasian boy with a diagnosis of holoprosencephaly and developmental delay. This child started outpatient PT treatment at the pediatric outpatient clinic in July 2019. The pediatric exoskeleton modality was added to his plan of care on December 3, 2020. On November 18, 2020, a review of his treatment plan was completed for the child before initiating the use of the exoskeleton. It was noted that 3 out of 7 PT goals had been met. At this time, the child could stand independently for up to 45 seconds, cruise laterally at a support surface, and complete floor-to-stand transitions using a support surface without help from another person. He was unable to walk independently outside of an exoskeleton but could walk household distances with bilateral hand-held assistance. After obtaining necessary clearance and a referral, the child started using the exoskeleton 1 time per week. This child's last visit at the outpatient clinic was on December 29, 2021, and the child was discharged due to not returning for appointments. At that time, the child had met 3 out of 7 PT goals; however, goals could not be formally reassessed due to the child not returning to the clinic. The therapist noted that the child could walk at least 5 steps independently at discharge but required single-hand-held assistance for prolonged mobility. The child was tolerating full 45-minute PT sessions in the exoskeleton, walking 800 to 1200 steps. The child continued to improve their independent standing balance and was working toward a 2-minute standing goal; however, he was limited by poor attention and distractibility. No additional objective outcome measures were completed for this child.

Child 3 was a non-Hispanic Caucasian girl who had diagnoses of periventricular leukomalacia, microcephaly, and spastic quadriplegic CP and was 5 years old. The child began outpatient PT services using the exoskeleton on June 29, 2019, after hamstring, adductor, and iliopsoas tendon lengthening surgery was completed in March 2019. At the time of the evaluation, the child was determined to have a medical and functional need for the device and met the technical and safety specifics for walking in the exoskeleton. The child required complete assistance to perform transfers in and out of bed or chairs and could walk with assistance in the exoskeleton. A goal related to improving walking was set at the evaluation. The child trialed the device on evaluation for approximately 200-ft distance and was then seen ongoing 1 to 2 times per week for use of the exoskeleton. Due to the COVID-19 pandemic, the child stopped PT from February 18, 2020, until returning August 26, 2020. Upon return, a progress summary was completed, noting that the child would still benefit from using the exoskeleton to improve overground walking skills, global strength, and gait quality. Three new PT goals were established at that time, focusing on walking, tolerance, use of the pediatric exoskeleton, and monitoring for additional equipment needs. No formal outcome measure was completed. The child then continued use of the exoskeleton 1 to 2 times per week. On April 12, 2021, a discharge was completed for this child. The child achieved 1 out of the 3 PT goals and was noted to have progressed toward the remaining 2 goals. The child's mother noted that the child was walking more (longer and farther) using a Kidwalk gait trainer at home than at evaluation. The child was also consistently completing between 350 and 550 steps at speeds of 15 to 35 steps per minute in the exoskeleton during PT sessions and was noted to have achieved 1000 steps intermittently. No additional objective outcomes were completed at discharge.

Table 1 has the findings described for each child in the case series. For time walking tolerated in the device, on average, the total time depended on when the child arrived for their appointment and the time it took to get set up in the device. All appointments were standardized at 45 minutes; setting up the device and securing the child in the device is estimated to take 10 to 15 minutes. In this chart, the term “pre” refers to either the progress summary completed before using the exoskeleton or the initial evaluation. The term “post” refers to discharge or progress summary completed closest to the date of achieving the 1 000 000-step milestone. All users tolerated the exoskeleton well. Tolerance was assessed by monitoring child facial expressions and body language for signs of discomfort or fatigue. For example, Child 1 tolerated the exoskeleton at near maximal speed, while Child 3 tolerated the device well but required walking at a slower speed. A feature of the Trexo Plus is that it is customizable to each child; therefore, all children can walk at their optimal speed and receive individualized treatment. Table 2 lists physical therapy goals. Goals that are italicized are the goals that were met at the plan of care review completed closest to the date the 1 000 000 steps were achieved or at the child's discharge before that date (Figure 3). Goals in regular font were not determined to be met; however, progress was noted toward these goal areas.

TABLE 1 - Summary of Outcomes for Each Child Descriptor Child 1 Child 2 Child 3 PT goals met (pre), n 1/4 3/7 0/3 PT goals met (post), n 4/7 3/7 1/3 Frequency of use of device

2x/wk—exoskeleton

1x/wk—pool

1x/wk 1-2x/wk Steps on average per session in device, n ≥1000 800-1000 350-550 Speed tolerated in device on average 45-50 steps/min 45-55 steps/min 15-35 steps/min Time walking tolerated in device on average 35-45 min 25-35 min 15-30 min Key Findings from therapist (post) The child's head control improved significantly in upright sitting and standing positions The child was able to walk at least 5 steps independently At home the child was walking more (longer and farther) using a Kidwalk gait trainer
TABLE 2 - Physical Therapy Goals Child 1 Child 2 Child 3 Goal 1 Child will sit on the floor with his UEs supported on a bench at chest height and touch a toy with CGA only for 5 min without LOB to demonstrate improved core strength and neck strength for functional play position. Child will ambulate >100 ft without assistance with CS for safety flat and carpeted surfaces without LOB to demonstrate improved strength and balance for (I) ambulation skills. Child will ambulate 200 ft in a gait trainer with reciprocal stepping pattern to demonstrate improved tone management, strength, and participation in functional mobility. Goal 2 Child will be able to sit on the floor unsupported × 1 min with CS to demonstrate improved trunk strength and balance for functional play position. Child will complete and tolerate robotic-assisted gait training to improve gait pattern to increase B heel strike and facilitate consistent reciprocal pattern. Child will be monitored for all equipment needs and ordered appropriate DME as medically necessary. Goal 3 Child will roll from 45° from his side in the direction of supine to prone positions to get to a toy in either direction on 2/3 trials. Child will complete standing (I) not at support surface × 2 min while engaging in play with toy or family member without LOB to demonstrate improved balance for standing unassisted to progress to walking unassisted. Child will tolerate Trexo Robotic Gait Training for >1000 steps per session to return to previous level of tolerance in therapy session to progress toward improved ambulation in a gait trainer. Goal 4 Child will roll from the supine position to and from the prone position over each side of his body with set-up assist only to demonstrate improved mobility for play with toys. Child will complete floor to stand transitions using 1/2 kneel or tripod without assistance to demonstrate improved ability to complete independent functional movements. Goal 5 Child will maintain quadruped with min (A) for 2 min during play with family members and toys to demonstrate improved core and neck stretch for functional play. Child will complete cruising at UE support surface ≥6 steps to each side without LOB with CS and symmetrical performance to demonstrate improved functional mobility. Goal 6 Child will walk distances of ≥40 ft in his Kidwalk gait trainer to demonstrate improved strength and coordination for functional mobility, with mod (A) for steering. Child will demonstrate appropriate and timely trunk righting in all directions while seated on therapy ball to demonstrate improved core strength for functional mobility. Goal 7 Child will be able to stand at UE support surface × 5 min while engaging in play without LOB with CS to demonstrate improved leg strength necessary for standing play. Child will complete transitions between prone and sitting positions over either side without assistance 3x in session to demonstrate improved strength and motor planning for functional positional changes.

Abbreviations: CGA, contact guard assist; CS, close supervision; DME, durable medical equipment; LOB, loss of balance; UE, upper extremity.

Fig. 3.:

This bar graph indicates the number of PT goals that were achieved prior to starting use of the robotic assisted gait trainer (RAGT) compared to after using the pediatric RAGT or at the date of the progress summary completed closest to the achievement of the 1 million steps milestone. In this bar graph, patient 1 was shown to have met 3 additional goals; patient 2 showed no change in goals met; and patient 3 met 1 goal, but did not have any previous PT goals met due to being a new patient coming to use the device.

DISCUSSION

This retrospective case series aimed to enhance the translation of knowledge of incorporating new technology into pediatric patient care by describing the implementation process, collaborative efforts, and Design Thinking the therapists at Good Shepherd Rehabilitation Network utilized when introducing exoskeletons to the outpatient clinic. Additionally, a retrospective review of 3 patient cases, selected randomly, was conducted to examine and reflect on the outcomes of using the new technology. For children with varying medical diagnoses and higher levels of medical complexity, it can be challenging to achieve standing and walking at the frequency and dosing needed to see benefits. The exoskeleton used at this clinic allowed many children the opportunity to both stand and walk with customizable support and access to trained clinicians who could individualize the treatment to each patient using the new devices. Through therapist directed research, peer discussions and communication with the manufacturing team, the therapists became expert users of the new device. Ultimately, this allowed our clinic to be the first in the nation to have these pediatric exoskeletons walk 1 000 000 steps.

A key element to this achievement was the consistent collaboration and communication with the manufacturing team. The ability to connect with the experts who designed the device at any moment, inside and outside of patient care, enhanced the therapists' learning opportunities. From these opportunities and pairing the expertise of PTs with the expertise of the engineers, the therapists efficiently became expert clinical users of the new technology. The pairing of different expertise areas allowed for the iteration and implementation phases of Design Thinking to occur. The therapists were able to use the device with children, empathize with children and each other, design a plan of what they wished the device could do to enhance care, create ideas of how to achieve this, and communicate with the engineering and design team. The company then prototyped solutions and ultimately tested those solutions with the therapy team to determine success. The continuum of Design Thinking would not have been able to be effective by the therapy team alone or the engineers alone, as both contribute differently, yet relatedly to the best possible outcome that is meaningful to the end users of the device.

Other factors may have contributed to the patient outcomes. None of these children participated in the same frequency and intensity of use of the device, and each had different diagnoses and ability levels. Due to this, the effects of time and participating in traditional therapy before using the device must be considered. It is possible that these children would have gained improvement in their goal areas over time despite using the pediatric exoskeleton. Future prospective research should focus on comparing traditional therapy methods to robotic-assisted gait training using a standardized research protocol and inclusion/exclusion criteria. Additionally, these findings should be used to help improve and standardize outcome measures to measure success with the device objectively. As the devices were new to the clinic and the clinicians, many children who used the devices did not complete an objective outcome measure. Therefore, objective outcomes were more difficult to track and trend, leading to the review of goal attainment, therapist assessments, documented parent reports, and device-specific information (steps completed, speed, time, etc). Documentation of exoskeleton sessions can also be enhanced and more consistent. Creating a specialized documentation field for tracking the output information of the device after each session, including steps completed, average speed, total time in the device, and average initiation percentage, would ensure all therapists using the device are recording the same information in the same manner for ease of documentation review for future research purposes. Lastly, more research should be conducted on the benefits of using Design Thinking in health care to create meaningful products, processes, and intervention strategies to continue providing innovative rehab options for patients and their families.

New technology, such as the pediatric exoskeleton described in this case series, can be daunting and exciting to incorporate into practice in an established clinic. To ensure the successful integration of such a device into a clinic, therapists must receive adequate and proper training. Additionally, having a line of communication that can be accessed frequently between the therapy and manufacturing teams is critical to allow for thoughtful discussion, questions, and ideas to contribute to the Design Thinking process. Design Thinking applies to the health care professions and is uniquely created to ensure that the end users, including patients and therapists, get the products they truly need. As new technology or devices come into the clinic, reviewing and formalizing a process to ensure efficiency and ease of getting patients into the clinic will be imperative. Creating a process to complete a screen of incoming patients will also be necessary to ensure that all potential children are medically appropriate and safe to trial the device. Using pediatric exoskeletons can benefit a child's therapy program and overall progress in various goal areas and is supported by this case series and previous research.

Pediatric exoskeletons are intended to help improve function and quality of life by providing opportunities to address impairments a child may be experiencing related to their medical diagnoses. Exoskeletons allow children to achieve repeated gait patterns to enhance motor learning, physical activity, and neuroplasticity. Studies show favorable outcomes with exoskeletons, including improved function, activity, and participation in children with CP.49 Additionally, improved gait speed, standing ability, and walking distance have also been improved in children with CP who use exoskeletons.50 More research with an increased number of participants and varying diagnoses is needed to continue investigating outcomes with pediatric exoskeletons.

CONCLUSION

Implementing new technology into pediatric patient care and an established outpatient therapy clinic is described. Design Thinking applies to health care professionals and improves clinical care. Exoskeletons are effective tools for use in pediatric physical therapy.

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