## 4 Discussion
Therefore, it is important to improve the ROM in lower limbs in children with CP level IV-V of the GMFCS. While surgery combined with orthoses remains the gold standard ([PERSON] et al. 2020), future research should explore the long-term sustainability of improvements due to the effects of less invasive interventions such as aquatic therapy, standing, and the ATLAS 2030 exoskeleton on the ROM, in order to determine whether they are a good complement to the currently most effective treatments [41]. Heart rate increased after warm water immersion, aquatic therapy, and RAGT, although more prominently in the aquatic therapy and RAGT interventions. This suggests that when an intervention includes exercise and movement, as in the case of aquatic therapy and RAGT, there is a trend of heart rate increase. As expected, the greater the expenditure of energy, the greater the cardiovascular exercise. However, it is most likely this was a very short-term result resulting from the body's physiological need to adapt to each situation [44]. It would be interesting in future research to report whether HR, when performing these interventions, decreases in the long term, which could mean a good adaptation of the body to this activity [44]. Regarding our results, it is also worth mentioning that HR was, during the four interventions, within their age adequate limits (75-11 bpm) [45]. This suggests that all interventions were physiologically well tolerated and did not induce excessive cardiovascular stress in children with CP. In this study, several validated outcome observational measures were used to assess the effects of the interventions. These included the MAS and the MTS for evaluating spasticity and ROM measurements for joint mobility. These tools are widely recognized in clinical practice and research for their reliability and relevance in assessing motor function and spasticity in children with CP. The use of these standardized measures strengthens the observational findings, although the case report design limits the generalizability of the results. Therefore, while the outcomes are promising, they should be interpreted with caution since they mainly consist on observational measures, and further studies with larger sample sizes are warranted to confirm these preliminary observations. An overall consideration is that while it is easy to have a standing frame available, it is difficult to have access to a warm-water pool for aquatic therapy and the ATLAS 2030 exoskeleton, as it is a device that is not affordable for all professionals or patients. More research is needed to determine cost effectiveness, so then rehabilitation teams and families can better know which resources are needed and can significantly contribute to improving the quality of life of this population. Currently, wearable exoskeletons are being developed to incorporate aspects of the International Classification of Functioning, Disability and Health (ICF), and to emphasize the environment, function, and participation of children with CP during RAGT. These innovations may allow for more frequent and context-specific use of RAGT in everyday environments [23]. As noted, children with GMFCS levels IV and V often experience high levels of spasticity, contractures, and related complications. Therefore, it is important to understand which interventions are cost-effective and can help improve these disorders and enhance their quality of life, not only by improving autonomy but also by improving positioning, rest, reducing pain, etc. [41, 43, 46]. This study provides preliminary evidence suggesting that movement-based interventions may offer greater therapeutic benefits compared to passive approaches. It highlights the need for unified treatment protocol to facilitate interdisciplinary collaboration and optimize care. Future research should explore the long-term effects, real-life applicability and cost-effectiveness of these interventions.