# Lower-Body Positive Pressure Treadmill Training for Pediatric Gait Disorders: A Scoping Review
## 4 Discussion
### Effect of Anti-Gravity Training on Activity  
Compared to conventional therapy, five RCT studies [11; 18; 19; 22; 24] showed greater positive changes in balance and risk of falls after anti-gravity treadmill training. These findings are particularly important for children with cerebral palsy, as they must control the postural instability caused by the decoupling they often experience between the projection of their center of mass and center of pressure during gait [46]. As this physical impairment requires more energy for walking than in typically developing children [47], the acquisition of new locomotor capacities represents one of the primary objectives in these children. Regarding gait parameters, several studies [11; 20; 22; 24; 25; 27; 28; 31] highlighted an improvement in spatiotemporal parameters after anti-gravity treadmill training. In his RCT, [PERSON] [11] showed that the group who benefited from anti-gravity treadmill training exhibited a grater improvement in gait parameters (i.e., walking speed, stride length, cadence and double-support time) compared to the control group. Despite the promising effects reported in this last study, the combination of anti-gravity training with a physical therapy program in the experimental groups limits the ability to isolate the contribution of the anti-gravity treadmill training alone. Recently, [PERSON] et al. [20] investigated the effect of anti-gravity training (AlterG) in comparison to other modalities, including traditional BWS treadmill training and robotic-assisted treadmill training (Lokomat). Despite the presence of a trend, the authors did not observe a significant change in walking speed after the three training modalities. However, in the anti-gravity group, the increase in cadence, stride length, and stride time were statistically significant, while the increases in those parameters was not significant in the robotic and BWS groups. In these RCTs studies, the authors did not compare change scores to establish differences between groups but rather compared beginning and end values. In our opinion, this is a statistical limitation and might have influenced the results. Moreover, most of the selected outcome measures are known to be associated with walking speed [11; 20; 22; 24; 25; 27; 28; 31]. Consequently, an increase in walking speed inherently induces an improvement in the majority of these outcomes. Unfortunately, the studies only concentrated on these spatiotemporal aspects and did not present other biomechanical parameters. However, to understand the different strategies used by children in gait production, it is important to enrich the overall biomechanical data by considering other factors, such as joint kinematics and kinetics, as well as EMG data. In the pediatric population, the findings in the current literature on anti-gravity training modality show some promising benefits (i.e., balance and spatiotemporal parameters), specifically in children and adolescents with cerebral palsy. However, given the disparity of results and the variable quality of the studies conducted to date, more studies are needed to document the effectiveness of anti-gravity training compared to conventional approaches before clinical implementation can be recommended or not. In future studies, the implementation of personalized and well-designed protocols for anti-gravity training is needed to get a better understanding of how this modality could be applied in heterogenous populations of children with locomotor impairments. Moreover, additional information about the patient's gait performance during daily life, as a complement to laboratory-based assessments, could improve the understanding of the patient's overall gait difficulties, enhancing clinical care. There are some limitations to this review that need to be acknowledged. First, the major limitation of this review concerns restrictions of publication language and type of publication; therefore, publication bias might be present.