Therapists' perspectives on the use of an overground lower-limb exoskeleton in physiotherapy sessions for minimally ambulatory children with cerebral palsy: a qualitative study

Background and objective: Children with cerebral palsy (CP) generally experience more sedentary lifestyles than neurotypical peers. Powered overground exoskeletons offer stable and assisted stepping that have been shown to lead to functional and exercise-linked participation opportunities. Our aim was to explore physiotherapy team experiences, perceived benefits and challenges when using an overground lower-limb exoskeleton in physiotherapy sessions with minimally ambulatory children with CP. Methods: Qualitative descriptive study within a pre/post feasibility trial involving 10 children with CP (GMFCS Level IV, 4 to 6 years) who received lower limb exoskeleton-based physiotherapy twice weekly over six weeks in school or outpatient setting. Physiotherapist (PT, n=5) and physiotherapy assistant (PTA, n=4) intervention team dyads were interviewed following completion of the exoskeleton intervention with their assigned child. Semi-structured interviews were conducted over Zoom. Coding of interview transcripts was followed by inductive thematic analysis. Results: There were 10 PT/PTA dyad interviews linked specifically to 10 children's intervention experiences in the exoskeleton study. Three themes were developed: 1) exoskeleton-based sessions provided additional exercise/gross motor options and may be a valuable adjunct to conventional therapy; 2) exoskeleton-based sessions were enjoyable, supporting enhanced inclusion and autonomy; 3) exoskeleton-based physiotherapy requires new clinical skills, added resources and individualized goal-based thinking. Therapists described exoskeleton-based therapy as a complement to, rather than a replacement for, conventional physiotherapy, since it addresses only a subset of motor goals. Therapists identified staffing, training, environmental accessibility, and equitable resource allocation as important considerations for clinical implementation. This study provides PT/PTA perspectives on their first use of an overground exoskeleton across school and outpatient settings with children with CP. Findings highlight the perceived value and logistical considerations of lower-limb exoskeleton use within physiotherapy sessions with minimally ambulatory children with CP. The findings were mapped onto the seven facets of the Theoretical Framework of Acceptability for new interventions and may inform implementation planning. Transferability to other settings should be considered in light of differences in resources, funding structures, and organizational contexts. Future research exploring ethical considerations, service delivery models, and clinical protocols is needed to support responsible integration into therapy settings across diverse clinical contexts.