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BackgroundVirtual reality (VR) offers powerful therapy options within a functional, purposeful and motivating context. Several studies have shown that patients' motivation plays a crucial role in determining therapy outcome. However, few studies have demonstrated the potential of VR in pediatric rehabilitation. Therefore, we developed a VR-based soccer scenario, which provided interactive elements to engage patients during robotic assisted treadmill training (RAGT). The aim of this study was to compare the immediate effect of different supportive conditions (VR versus non-VR conditions) on motor output in patients and healthy control children during training with the driven gait orthosis Lokomat®.MethodsA total of 18 children (ten patients with different neurological gait disorders, eight healthy controls) took part in this study. They were instructed to walk on the Lokomat in four different, randomly-presented conditions: (1) walk normally without supporting assistance, (2) with therapists' instructions to promote active participation, (3) with VR as a motivating tool to walk actively and (4) with the VR tool combined with therapists' instructions. The Lokomat gait orthosis is equipped with sensors at hip and knee joint to measure man-machine interaction forces. Additionally, subjects' acceptance of the RAGT with VR was assessed using a questionnaire.ResultsThe mixed ANOVA revealed significant main effects for the factor CONDITIONS (p < 0.001) and a significant interaction CONDITIONS × GROUP (p = 0.01). Tests of between-subjects effects showed no significant main effect for the GROUP (p = 0.592). Active participation in patients and control children increased significantly when supported and motivated either by therapists' instructions or by a VR scenario compared with the baseline measurement "normal walking" (p < 0.001).ConclusionsThe VR scenario used here induces an immediate effect on motor output to a similar degree as the effect resulting from verbal instructions by the therapists. Further research needs to focus on the implementation of interactive design elements, which keep motivation high across and beyond RAGT sessions, especially in pediatric rehabilitation.

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Intensive, task-specific training enabled by a driven gait orthosis (DGO) may be a cost-effective means of improving walking performance in children. A paediatric DGO has recently been developed. This study was the first paediatric trial aimed to determine the feasibility of robotic-assisted treadmill training in children with central gait impairment (n=26; 11 females, 15 males; mean age 10y 1mo [SD 4y]; range 5y 2mo-19y 5mo). Diagnoses of the study group included cerebral palsy (n=19; Gross Motor Function Classification System Levels I-IV), traumatic brain injury (n=1), Guillain-Barré syndrome (n=2), incomplete paraplegia (n=2), and haemorrhagic shock (n=1), and encephalopathy (n=1). Sixteen children were in-patients and 10 were outpatients. Twenty-four of the 26 patients completed the training which consisted of a mean of 19 sessions (SD 2.2; range 13-21) in the in-patient group and 12 sessions (SD 1.0; range 10-13) in the outpatient group. Gait speed and 6-Minute Walking Test increased significantly (p<0.01). Functional Ambulation Categories and Standing dimension (in-patient group p<0.01; outpatient group p<0.05) of the Gross Motor Function Measure improved significantly. DGO training was successfully integrated into the rehabilitation programme and findings suggest an improvement of locomotor performance.Locomotor therapy for regaining walking capacity is based on the principle of enhancing neuroplasticity by task-specific training; this therapy has been well established in the (re)habilitation process of patients with central gait disorders. 1-4 Conventional over-ground gait training (COGT) in adults has been enhanced by the body-weight supported treadmill training, thereby gaining functional benefits such as improved symmetry and increased walking speed. 5,6 However, the assign ment of human resources for manual assistance in these methods is considerable. 7 Controlled trials of adult patients with traumatic brain injury (TBI) or incomplete spinal cord injury showed no difference between body-weight supported treadmill training and COGT regarding functional improvement, when applied at the same frequency. [8][9][10] In children with cerebral palsy (CP) general functionalstrength training has been shown to improve functional performance. 11-13 Promising evidence exists that intensive body-weight supported treadmill training can improve walking capacity in these children. [14][15][16] To the authors' knowledge, locomotor treatment with treadmill training in children with acquired central gait disorders caused by stroke or TBI has not yet been studied conclusively. To restore walking ability, repetition and intensity of training seem to be crucial for motor (re)learning. 17 To this end, automated gait-training devices have been developed during the last decade to improve gait training. 18,19 The feasibility and effectiveness of retraining gait using the driven gait orthosis (DGO) has been investigated in gait rehabilitation of adults with spinal cord injury. 18,20 These devices allow an intensification of lo...