# Cable-Driven Exoskeleton for Ankle Rehabilitation in Children with Cerebral Palsy
## 4 Discussion
Integrating these biologically inspired algorithms into cable-driven exoskeletons could therefore boost patient engagement and rehabilitation efficacy, ultimately yielding a more intuitive and responsive assistive device. Recent studies further support this direction by incorporating adaptive central pattern generators for online trajectory modulation [52], reflex-based neuromechanical models to enhance balance control [53], and systematic overviews of biologically inspired strategies such as rhythmic movement generators and modular motion primitives applied to wearable robotic systems [54]. At present, such bio-inspired controllers exist only at the conceptual level within this project; they have not yet been implemented. Consequently, all tests reported here were performed exclusively with the mechanical impedance control based on the AAN model described above. One of the main challenges in the clinical validation of our prototype lies in the difficulty of comparing it with similar existing devices due to its novel design and targeted application. Within the limited group of cable-driven exoskeletons aimed at both ankle rehabilitation and gait assistance--while preserving high flexibility and freedom of movement--we identify two partially comparable systems: the C-LREX and the exoskeleton developed by [PERSON] et al. [37,38]. However, both present key differences in scope and implementation compared with D2W, and neither has been tested on children with cerebral palsy (which is often not their target population). C-LREX remains in the simulation stage, which limits direct comparison due to the absence of evidence from physical prototypes or clinical studies, especially in pediatric populations. Additionally, its focus is not on the ankle joint but on the lower limb as a whole, aiming to assist hip abduction/adduction and hip and knee flexion/extension using four cables to guide full-leg trajectories toward normative gait patterns [35,36]. In contrast, the system proposed by [PERSON] et al. [37,38] shares structural similarities with D2W, being built on a prismatic frame and actuated via cables. However, it uses only two cables per ankle to assist a single DOF during the swing phase of adult patients with incomplete spinal cord injury. Its primary objective is to increase walking speed and endurance. While the level of ankle control is limited compared with D2W, the device has shown improvements in gait capacity in tested subjects. In summary, although it is difficult to establish direct comparisons with existing systems due to differences in target populations, articulation focus, and validation stage, the results reported by these cable-driven platforms highlight the versatility and clinical potential of this technology. The tests performed with D2W further support its ability to improve gait quality in children with cerebral palsy, reinforcing its value as a novel and flexible rehabilitation tool. The experiments performed on the prototype demonstrate the feasibility of the project and the ability to maintain a safe interaction with the patient and represent the first steps in the clinical validation process. However, for its approval for use in full therapy with children with CP, it is still necessary to conduct more tests with patients, all under the supervision and advice of health professionals. Therefore, the collaboration between the D2W project and the Nino Jesus Hospital (Madrid, Spain) for its development is a great advantage.