The efficacy of functional gait training in children and young adults with cerebral palsy: a systematic review and meta-analysis

Overground, conventional treadmill, and aquatic treadmill walking joint kinematics differ in typically developing children and adolescents

Gait training is a common rehabilitation tool using repeated gait cycles to promote motor learning and improve overall walking ability (Booth et al., 2018; Kim & Lee, 2016;Novy et al., 2013). The purpose of this study was to quantify differences in peak and time-to-peak ankle plantarflexion, knee flexion, and hip flexion in typically developing children (7 males, 8 females, age 11.3 ± 4.1 years, 1.46 ± 0.18 m, and 44.2 ± 16.8 kg) during overground, conventional treadmill, and aquatic treadmill walking at three walking speeds (slow, normal, and fast). We hypothesized that increasing walking speeds and different walking environments would affect peak and time-to-peak kinematics of the lower limb. Faster speeds significantly increased peak kinematics, with peak plantarflexion increasing from 19.6⁰ during the slow speed condition to 25.7⁰ during the fast speed condition (p < 0.01). The overground environment had the highest peak knee flexion (67.4⁰), a 24.7⁰ increase compared to conventional treadmill and a 34.2⁰ increase compared to the aquatic treadmill (p < 0.01). Time-to-peak kinematics for peak ankle plantarflexion occurred 7.8 % and 9.9 % earlier in the gait cycle when compared to overground (p < 0.01) and conventional treadmill (p < 0.01). Faster speeds also resulted in earlier time-to-peak kinematics compared to slow speeds for ankle plantarflexion (p < 0.01) and hip flexion (p < 0.01). Findings of this study suggest that walking speed and environment significantly influence lower limb kinematics in typically developing children. Therefore, researchers should consider environmental factors when designing and evaluating gait training interventions.

Effectiveness of school-based physiotherapy intervention for children

PURPOSE

To evaluate the effectiveness of school-based physiotherapy interventions for improving students' participation in school settings.

METHOD

A systematic review was reported using PRISMA guidelines. Four databases were searched for studies investigating physiotherapy outcomes of school-based physiotherapy interventions in children. Studies were categorised by intervention type and evaluated based on evidence level and conduct.

RESULTS

Fifteen intervention types (23 studies) met criteria. Strong positive evidence supported treadmill training without bodyweight support (n = 1), and upper limb interventions (n = 2). Moderate positive evidence supported robotic-assisted gait training (n = 1), Gross Motor Activity Training with Multimodal Education-Based Therapy (GMAT + MET) (n = 2), neurodevelopmental treatment (n = 2), and rock climbing (n = 1). Weak positive evidence supported environmental modifications (n = 1), Ergonomic Health Literacy (n = 3), GMAT (n = 1), GMAT with progressive resistance exercise (GMAT-PRE) (n = 1), hippotherapy (n = 1), MET alone (n = 7), overground gait training (n = 2), treadmill training with partial body-weight support (n = 1), and non-immersive virtual reality (n = 3).

CONCLUSION

There is preliminary supporting evidence for a variety of school-based physiotherapy interventions which is consistent with evidence for interventions with established efficacy in other contexts. The evidence for interventions in school contexts alone is insufficient to guide current practice. Future research should specifically evaluate the effectiveness of physiotherapy approaches in school settings.

The Impact of Aquatic Exercise on Walking Ability, Quality of Life, and Enjoyment in Children with Cerebral Palsy: A Systematic Review

BACKGROUND/OBJECTIVES

Aquatic exercise is attracting attention as a method of rehabilitation for children with cerebral palsy (CP). The purpose of this systematic review was to evaluate whether aquatic exercise for children with CP improves their walking ability and quality of life (QOL) and is enjoyable for them.

METHODS

A literature search was conducted on 2 August 2024 using three databases: PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials through Evidence-Based Medicine Reviews. Studies included in the review focused on aquatic exercise interventions for children with CP, with outcomes related to walking ability, QOL, or enjoyment. Studies that did not isolate the effects of aquatic exercise (except when combined with conventional interventions) were excluded. Two reviewers independently conducted screening and risk of bias assessments.

RESULTS

Seven studies involving 94 participants in total were included in the review. Three of these studies had a control group. All four studies reported improvements in walking ability, including walking endurance and efficiency. One of two studies showed improvement in health-related QOL (HRQOL) compared to the control group, whereas the other did not show significant differences between groups. All three studies that assessed enjoyment reported high levels of enjoyment of aquatic exercise. However, all studies were at risk of bias.

CONCLUSIONS

The reviewed studies suggest that aquatic exercise for children with CP may be enjoyable and may improve walking ability. Further research is needed to accurately assess the effects of aquatic exercise and compare it to other interventions.

Exoskeleton gait training on real-world terrain improves spatiotemporal performance in cerebral palsy

Introduction

Walking is essential for daily life but poses a significant challenge for many individuals with neurological conditions like cerebral palsy (CP), which is the leading cause of childhood walking disability. Although lower-limb exoskeletons show promise in improving walking ability in laboratory and controlled overground settings, it remains unknown whether these benefits translate to real-world environments, where they could have the greatest impact.

Methods

This feasibility study evaluated whether an untethered ankle exoskeleton with an adaptable controller can improve spatiotemporal outcomes in eight individuals with CP after low-frequency exoskeleton-assisted gait training on real-world terrain.

Results

Comparing post- and pre-assessment, assisted walking speed increased by 11% and cadence by 7% (p = 0.003; p = 0.006), while unassisted walking speed increased by 8% and cadence by 5% (p = 0.009; p = 0.012). In the post-assessment, assisted walking speed increased by 9% and stride length by 8% relative to unassisted walking (p < 0.001; p < 0.001). Improvements in walking speed were more strongly associated with longer strides than higher cadence (R 2 = 0.92; R 2 = 0.68). Muscle activity outcomes, including co-contraction of the soleus and tibialis anterior, did not significantly change after training.

Discussion

These findings highlight the spatiotemporal benefits of an adaptive ankle exoskeleton for individuals with CP in real-world settings after short-term training. This work paves the way for future randomized controlled trials (RCTs) to evaluate the isolated effects of adaptive ankle exoskeletons on gait performance and neuromuscular outcomes in individuals with CP in real-world environments.

Effects of various exercise interventions on motor function in cerebral palsy patients: a systematic review and network meta-analysis

PURPOSE

A network meta-analysis was utilized to compare the rehabilitative effectiveness of different exercise interventions on motor function in cerebral palsy(CP) patients.

METHODS

Computer searches were conducted across 9 databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase, and others, to identify randomized controlled trials focusing on different exercise interventions aimed at enhancing motor function in CP patients. The search spanned from the inception of the databases to January 31, 2024.

RESULTS

20 articles, encompassing 570 patients and evaluating three types of exercise interventions, were included in the analysis. Results showed that aerobic training, resistance training, and mixed training exhibited superior outcomes compared to the control group, as evidenced by improvements in Gross Motor Function Measure scores, muscle strength, gait speed, and 10-Meter Walk Test scores (P < 0.05). Furthermore, the network meta-analysis revealed that resistance training ranked highest in enhancing gross motor function and gait speed among CP patients, while mixed training was deemed most effective in improving muscle strength and 10-Meter Walk Test scores.

CONCLUSION

Exercise interventions have been shown to significantly improve motor function in CP patients. Among these, resistance training and mixed training stand out for their effectiveness in enhancing walking capabilities. Resistance training is specifically aimed at improving gross motor function, while mixed training focuses on increasing muscle strength.

Efficacy and threshold dose of intensive training targeting mobility for children with cerebral palsy: A systematic review and meta-analysis

AIM

To systematically review the evidence for intensive mobility training in cerebral palsy (CP) and to determine the minimum effective dose to improve mobility.

METHOD

Randomized controlled trials (RCTs) or quasi-RCTs that included participants with CP, and which used intensive task-oriented training (TOT) mobility interventions and reported mobility outcomes, were included. Five databases were searched; two independent reviewers selected studies and extracted data. The Grading of Recommendations Assessment, Development, and Evaluation system and the Cochrane Risk of Bias 2 tool were used to rate the certainty of evidence at the outcomes level and to determine the risk of bias respectively. Meta-analyses were conducted with clinically homogeneous studies. Threshold dose was analysed through meta-regression.

RESULTS

Forty-six RCTs with 1449 participants (mean age range 1 year 2 months to 16 years 4 months) were included. TOT had statistically and clinically significant effects on walking speed (p = 0.001), cadence (p = 0.02), gross motor function (p = 0.03), and functional mobility (p = 0.009) compared with control interventions. The threshold dose was undeterminable owing to the high heterogeneity of studies.

INTERPRETATION

TOT may improve walking speed, walking endurance, and balance. Studies with homogeneous samples and outcomes are needed to support clinical recommendations for intensive mobility interventions.

Motor and Cognitive Trajectories in Infants and Toddlers with and at Risk of Cerebral Palsy Following a Community-Based Intervention

BACKGROUND

Early motor development is fundamental in driving cognitive skill acquisition. Motor delays in children with cerebral palsy (CP) often limit exploratory behaviors, decreasing opportunities or the quality of cognitive development, emphasizing the importance of early intervention. This study aimed to assess immediate and 5-month motor and cognitive changes in infants and toddlers at risk of or with CP after participation in a community-based program.

METHODS

Twenty-two children (mean age: 22 ± 7 months) classified using the Gross Motor Function Classification System (GMFCS) and mini-Manual Ability Classification System (mini-MACS) participated in a 6-day community-based activity program, with outcomes assessed using the Developmental Assessment of Young Children (DAYC-2).

RESULTS

Participants who met their motor goals post-participation had significantly higher cognitive scores (p = 0.006) 5 months after the program. Participants with higher functional motor abilities (GMFCS levels I-II, p = 0.052; mini-MACS levels I-II, p = 0.004) demonstrated better cognitive scores at 5 months, adjusted for baseline scores, than those with lower functional motor abilities.

CONCLUSIONS

This study highlights the impact of motor improvements following an evidence-based community program on later cognitive development. Prospective studies investigating the mechanisms and mediation of cognitive progress in children with CP should investigate the effects of early motor interventions on long-term developmental trajectories.

The Methodological Quality of Studies on Physical Exercise in Adolescents with Cerebral Palsy: A Scoping Review of Systematic Reviews and Meta-Analyses

INTRODUCTION

Systematic reviews and meta-analyses point to the benefits of physical exercise for adolescents with cerebral palsy, improving physical conditioning, muscle strength, balance, and walking speed. However, given the high number of reviews that include randomized and non-randomized studies, it is increasingly necessary to assess the methodological quality of these reviews. This scoping review investigated the methodological quality of systematic reviews and meta-analyses on the effects of physical exercise in adolescents with cerebral palsy to elucidate the methodological limitations of the research and the priorities to be observed in future research.

METHOD

The electronic search used PubMed, Web of Science, and Cochrane. Studies published between 2016 and 2023 were selected. The terms used were "cerebral palsy" combined with "physical fitness", "exercise", and "physical activity".

RESULTS

A total of 219 original reviews were selected. Of these, 19 reviews were included for data analysis. AMSTAR2 was used to assess the methodological quality of the reviews. Three reviews presented high methodological quality (15.78%) and three had moderate methodological quality (15.78%). The remaining reviews had low or critically low methodological quality, according to AMSTAR2.

INTERPRETATION

This study evidenced that systematic reviews have variable methodological quality and that new studies are still needed.

Integrating Heart Rate Monitoring Into a Camp for Children With Neuromotor Disorders: A Case Series

PURPOSE

This case series investigated the implementation fidelity, feasibility, and effectiveness of integrating continuous heart rate monitoring with visual feedback into an established, intensive physical therapy camp for children with neuromotor disorders.

SUMMARY OF KEY POINTS

The provision of continuous visual feedback through color-coded, individually calculated heart rate zones was a feasible and effective intervention, encouraging pediatric gait camp participants to exercise at intensities that produced aerobic and functional gains. The use of technology facilitated participation with peers, an outcome equally as important as their endurance and functional improvements.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Pediatric physical therapists play a crucial role in enhancing the well-being and physical fitness of children with disabilities. Encouraging regular exercise in a social environment fosters enjoyable, inclusive experiences while promoting overall health. It is important for clinicians in various pediatric rehabilitation settings to establish programs that offer such opportunities for children with neuromotor disorders.

Reliability and validity of a measure of service providers' perceptions of child and parent engagement in pediatric rehabilitation therapy sessions

BACKGROUND

There is growing interest in client engagement in pediatric rehabilitation. This article investigated the psychometric properties of a measure of service providers' perceptions of the affective, cognitive and behavioural engagement of both children with disabilities and their parents in pediatric rehabilitation therapy sessions.

METHODS

Test-retest reliability of the Pediatric Rehabilitation Intervention Measure of Engagement-Service Provider version (PRIME-SP) was examined using engagement ratings made by 60 service providers for 77 children and 73 parents. Construct validity was examined using the known-group validity technique, utilizing service providers' ratings of the engagement of parents and their children attending the same session with the service provider. We hypothesized that there would be significantly different, yet moderately correlated engagement ratings for children and their parents.

RESULTS

There was evidence of moderate test-retest reliability for the child ratings, indicative of dynamicity across occasions, but also a degree of consistency, as aligned with our expectations. Service providers' ratings of parent and child engagement were not significantly correlated and paired t-tests indicated significantly higher engagement scores for parents than children.

CONCLUSIONS

The study provides preliminary evidence to support the reliability and validity of the PRIME-SP as a tool for service providers to document, reflect on and monitor child and/or parent engagement.

Effects of exercise intervention on balance function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effectiveness of exercise intervention on postural balance, gait parameters, and muscle strength in children with cerebral palsy by quantifying the information from randomized controlled trials (RCTs).

METHODS

We conducted a systematical search for RCTs from the databases, including PubMed, ISI Web of Science, and Scopus using a between-group design involving children with cerebral palsy and assessing the effect of exercise intervention on postural balance, gait parameters, and muscle strength. The specified inclusion criteria were determined by the PICOS tool. The outcomes of included studies were evaluated by meta-analysis, and subgroup and sensitivity analyses were conducted to analyze the observed heterogeneities using Review Manager 5.4 and Stata version 18.0. The revised Cochrane risk of bias tool for randomized trials (RoB 2) was used to evaluate the risk of bias and quality of the included studies.

RESULTS

Twenty-four studies were included in this meta-analysis, with 579 children with cerebral palsy. Exercise intervention showed a statistically significant favorable effect on gross motor function (SMD = 0.32; 95%CI [0.03 to 0.61]; I2 = 16%), anteroposterior stability index (SMD = -0.93; 95%CI [-1.69 to -0.18]; I2 = 80%), and mediolateral stability index (SMD = -0.60; 95%CI [-1.16 to -0.03]; I2 = 73%) compared to control group among children with cerebral palsy. None of the above meta-analyses exhibited publication bias, as indicated by Egger's test with p-values greater than 0.05 for all.

CONCLUSIONS

Exercise is effective in improving gross motor function and balance in children with cerebral palsy. Due to the lack of studies examining the efficacy of each exercise type, we are unable to provide definitive training recommendations.

The Impact of Botulinum Toxin Combined with Robot-Assisted Gait Training on Spasticity and Gross Motor Function on Children with Spastic Cerebral Palsy

OBJECTIVE

To evaluate the impact of combining botulinum toxin-A (BoNT-A) injection with robot-assisted gait training (RAGT) on lower limb spasticity and motor function in children with cerebral palsy.

METHODS

A prospective study was conducted from January 2020 to January 2023, including 68 patients. Twenty patients received the combination of BoNT-A injection and RAGT, while 48 received BoNT-A injection alone. Assessments were performed before the intervention and at 1, 3, and 6 months post-injection using the Modified Tardieu Scale (MTS), sections D and E of the Gross Motor Function Measure-88 (GMFM-88), 6-minute walk test (6MWT), and 10-meter walk test (10MWT).

RESULTS

Compared to the control group receiving BoNT-A alone, the combination of BoNT-A and RAGT did not significantly improve spasticity-related outcomes, including MTS scores, R1, and R2 angles (p > .05). However, the combination group demonstrated significantly improved gross motor function, particularly in walking, running (GMFM-E), short-term walking endurance (6MWT), and walking speed (10MWT) in children with cerebral palsy after the intervention (p < .05).

CONCLUSION

While the addition of RAGT did not enhance the anti-spasticity effects of BoNT-A, it significantly improved gross motor function and walking abilities in children with cerebral palsy.

Effects of 12-week aquatic exercises on gross motor function, swimming skills and walking ability in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disability in childhood defined as a group of permanent disorders of movement. The aim of this study was to determine the effects of 12-week aquatic exercise program on gross motor function, swimming skills, and walking ability in children with cerebral palsy.

METHODS

Eighteen children (mean±SD age: 12.3±3 years) with cerebral palsy classified at levels I, II and III on the Gross Motor Function Classification System were allocated to one group, where the first 12 weeks were a control period while another 12 weeks were an experimental period. The participants underwent the same battery of tests focusing gross motor function, swimming skills, and walking ability on three occasions.

RESULTS

Control period was stable with no significant changes in any of measurements. After the 12-week experimental program, a statistically significant improvement was determined in gross motor function (P=0.005), swimming skills (P=0.000), walking endurance and walking velocity (P=0.000). No significant differences (P>0.05) were observed for walking efficiency.

CONCLUSIONS

The 12-week aquatic exercise program (3/week, 60 minutes), combining Halliwick method, swimming and walking activities may improve the gross motor function, swimming skills, walking endurance and velocity in ambulatory children with cerebral palsy.

The efficacy of dance interventions for the activity and participation of individuals with cerebral palsy - a systematic review and meta-analysis

PURPOSE

The aim of this review was to examine the efficacy of dance interventions for individuals with cerebral palsy (CP), measured at any level of the International Classification of Functioning, Disability and Health (ICF).

METHODS

A systematic review and meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search of peer-reviewed articles was performed using six electronic databases.

RESULTS

Fourteen studies were included in this review, nine of which were also included in the meta-analysis. The meta-analyses yielded a large overall effect for cognitive, motor, and social-emotional function outcomes, with a high degree of heterogeneity between outcome effects, attributable to differences in study design.

CONCLUSION

Although recent studies provide support for the acceptance and efficacy of dance interventions for people with CP, the systematic review revealed significant limitations in study design (only 2 randomised control trials). High-quality research that measures outcomes across all dimensions of the ICF, and particularly at the level of participation, are needed to improve the level of empirical support for dance-based interventions.

Improving the reliability of underwater gait analysis using wearable pressure and inertial sensors

This work addresses the lack of reliable wearable methods to assess walking gaits in underwater environments by evaluating the lateral hydrodynamic pressure exerted on lower limbs. Sixteen healthy adults were outfitted with waterproof wearable inertial and pressure sensors. Gait analysis was conducted on land in a motion analysis laboratory using an optoelectronic system as reference, and subsequently underwater in a rehabilitation swimming pool. Differences between the normalized land and underwater gaits were evaluated using temporal gait parameters, knee joint angles and the total water pressure on the lower limbs. The proposed method was validated against the optoelectronic system on land; gait events were identified with low bias (0.01s) using Bland-Altman plots for the stride time, and an acceptable error was observed when estimating the knee angle (10.96° RMSE, Bland-Altman bias -2.94°). The kinematic differences between the land and underwater environments were quantified, where it was observed that the temporal parameters increased by more than a factor of two underwater (p<0.001). The subdivision of swing and stance phases remained consistent between land and water trials. A higher variability of the knee angle was observed in water (CV = 60.75%) as compared to land (CV = 31.02%). The intra-subject variability of the hydrodynamic pressure on the foot ([Formula: see text] = 39.65%) was found to be substantially lower than that of the knee angle (CVz = 67.69%). The major finding of this work is that the hydrodynamic pressure on the lower limbs may offer a new and more reliable parameter for underwater motion analysis as it provided a reduced intra-subject variability as compared to conventional gait parameters applied in land-based studies.

Design and validation of a pediatric gait assistance exoskeleton system with fast non-singular terminal sliding mode controller

Existing exoskeletons for pediatric gait assistance have limitations in anthropometric design, structure weight, cost, user safety features, and adaptability to diverse users. Additionally, creating precise models for pediatric rehabilitation is difficult because the rapid anthropometric changes in children result in unknown model parameters. Furthermore, external disruptions, like unpredictable movements and involuntary muscle contractions, add complexity to the control schemes that need to be managed. To overcome these limitations, this study aims to develop an affordable stand-aided lower-limb exoskeleton specifically for pediatric subjects (8-12 years, 25-40 kg, 128-132 cm) in passive-assist mode. The authors modified a previously developed model (LLESv1) for improved rigidity, reduced mass, simplified motor arrangement, variable waist size, and enhanced mobility. A computer-aided design of the new exoskeleton system (LLESv2) is presented. The developed prototype of the exoskeleton appended with a pediatric subject (age: 12 years old, body mass: 40 kg, body height: 132 cm) is presented with real-time hardware architecture. Thereafter, an improved fast non-singular terminal sliding mode (IFNSTSM) control scheme is proposed, incorporating a double exponential reaching law for expedited error convergence and enhanced stability. The Lyapunov stability warrants the control system's performance despite uncertainties and disturbances. In contrast to fast non-singular terminal sliding mode (FNSTSM) control and time-scaling sliding mode (TSSM) control, experimental validation demonstrates the effectiveness of IFNSTSM control by a respective average of 5.39% and 42.1% in tracking desired joint trajectories with minimal and rapid finite time converging errors. Moreover, the exoskeleton with the proposed IFNSTSM control requires significantly lesser control efforts than the exoskeleton using contrast FNSTSM control. The Bland-Altman analysis indicates that although there is a minimal mean difference in variables when employing FNSTSM and IFNSTSM controllers, the latter exhibits significant performance variations as the mean of variables changes. This research contributes to affordable and effective pediatric gait assistance, improving rehabilitation outcomes and enhancing mobility support.

Effects of the EXECP Intervention on Motor Function, Muscle Strength, and Joint Flexibility in Individuals with Cerebral Palsy

PURPOSE

Numerous exercise interventions to enhance motor function in cerebral palsy (CP) have been proposed, with varying degrees of effectiveness. Because motor function requires a combination of muscle strength, joint flexibility, and motor coordination, we designed a supervised multicomponent exercise intervention (EXErcise for Cerebral Palsy, or EXECP) for individuals with CP. Our aim was to evaluate the effects of the EXECP intervention and its retention after it ceased.

METHODS

The EXECP intervention combined strength training for the lower limbs and trunk muscles, passive stretching for the lower limb muscles, and inclined treadmill gait training. Eighteen participants with CP (mean age, 14 yr; 13 were male) were tested twice before the 3-month intervention and twice after the intervention, each test separated by 3 months. Seventeen typically developing age- and sex-matched controls were tested twice. Motor function was assessed with the 6-min walking test (6MWT) and the gross motor function measure dimensions D and E. Passive joint flexibility was measured with goniometry. Isometric and concentric muscle strength were assessed at the knee, ankle, and trunk joints.

RESULTS

The EXECP intervention successfully increased 6MWT ( P < 0.001), gross motor function measure ( P = 0.004), and muscle strength for knee and trunk muscles ( P < 0.05), although no changes were observed for ankle joint muscles. Hip and knee joint flexibility also increased ( P < 0.05). After the retention period, all tested variables except the 6MWT and knee joint flexibility regressed and were not different from the pretests.

CONCLUSIONS

The improvements in strength, flexibility, and possibly motor coordination brought by the EXECP intervention were transferred to significant functional gains. The regression toward baseline after the intervention highlights that training must be a lifelong decision for individuals with CP.

Effectiveness of Partial Body Weight-Supported Treadmill Training on Various Outcomes in Different Contexts among Children and Adolescents with Cerebral Palsy: A Systematic Review and Meta-Analysis

The efficiency of partial body weight-supported treadmill training (PBWSTT) for treating various conditions in children and adolescents with cerebral palsy (CP) in diverse contexts of rehabilitation, households, or schools is unknown. The major objective of this systematic review and meta-analysis was to analyze the effectiveness of PBWSTT on various outcomes in different contexts among children and adolescents with CP. We incorporated full-text, randomized controlled trial studies that specifically assessed the effects of PBWSTT walking, motor function, stride, balance, and endurance in children and adolescents aged 3 to 18 years with CP. The literature search was carried out using Google Scholar, PubMed, Web of Science, CINAHL Plus, Scopus, PEDro, and ResearchGate databases. The methodological quality was evaluated using a Cochrane risk of bias instrument. A meta-analysis of pooled data from 10 studies with 255 participants demonstrated that PBWSTT for 4-12 weeks in rehabilitation (mean difference [MD] = 1.94, 95% confidence interval [CI] = 1.40-2.48, p < 0.0001), at home or in a school context (MD = 13.5, 95% CI = 13.9-16.0, p < 0.0001), was significantly effective for treating various conditions in children and adolescents suffering with CP. The period of 4-12 weeks of PBWSTT in rehabilitation and at-home/school settings is effective on various outcomes in children or adolescents with CP.

Audiovisual biofeedback amplifies plantarflexor adaptation during walking among children with cerebral palsy

BACKGROUND

Biofeedback is a promising noninvasive strategy to enhance gait training among individuals with cerebral palsy (CP). Commonly, biofeedback systems are designed to guide movement correction using audio, visual, or sensorimotor (i.e., tactile or proprioceptive) cues, each of which has demonstrated measurable success in CP. However, it is currently unclear how the modality of biofeedback may influence user response which has significant implications if systems are to be consistently adopted into clinical care.

METHODS

In this study, we evaluated the extent to which adolescents with CP (7M/1F; 14 [12.5,15.5] years) adapted their gait patterns during treadmill walking (6 min/modality) with audiovisual (AV), sensorimotor (SM), and combined AV + SM biofeedback before and after four acclimation sessions (20 min/session) and at a two-week follow-up. Both biofeedback systems were designed to target plantarflexor activity on the more-affected limb, as these muscles are commonly impaired in CP and impact walking function. SM biofeedback was administered using a resistive ankle exoskeleton and AV biofeedback displayed soleus activity from electromyography recordings during gait. At every visit, we measured the time-course response to each biofeedback modality to understand how the rate and magnitude of gait adaptation differed between modalities and following acclimation.

RESULTS

Participants significantly increased soleus activity from baseline using AV + SM (42.8% [15.1, 59.6]), AV (28.5% [19.2, 58.5]), and SM (10.3% [3.2, 15.2]) biofeedback, but the rate of soleus adaptation was faster using AV + SM biofeedback than either modality alone. Further, SM-only biofeedback produced small initial increases in plantarflexor activity, but these responses were transient within and across sessions (p > 0.11). Following multi-session acclimation and at the two-week follow-up, responses to AV and AV + SM biofeedback were maintained.

CONCLUSIONS

This study demonstrated that AV biofeedback was critical to increase plantarflexor engagement during walking, but that combining AV and SM modalities further amplified the rate of gait adaptation. Beyond improving our understanding of how individuals may differentially prioritize distinct forms of afferent information, outcomes from this study may inform the design and selection of biofeedback systems for use in clinical care.

The effects of power exercises on body structure and function, activity and participation in children with cerebral palsy: an ICF-based systematic review

PURPOSE

To systematically review the literature for evidence of effectiveness of power exercises on physical, physiological, and functional outcomes in children and adolescents with cerebral palsy (CP).

MATERIALS AND METHODS

Methodological quality and evidence synthesis were assessed with using the Cochrane Risk of Bias (RoB) Tools and Modified Bakker Scale. Using the International Classification of Functioning (ICF), outcome measures for muscle agriculture, gait, balance, motor function, aerobic/anaerobic fitness, daily living, mobility, and school participation were categorised.

RESULTS

The overall RoB of four randomised clinical trials was low, one had some concerns and two were rated as high. Moderate evidence was found that power exercises increased walking speed, activities of daily living, muscle strength, and enhanced gross motor function more than a routine physical therapy program.

CONCLUSIONS

The lack of stronger evidence for power training interventions to improve muscle architecture, muscle function, walking capacity, and mobility in children with CP might be explained by the differences in training protocols and degree to which these meet the physiological definition of power, different methods of measuring power, limited durations of training, and the relative effectiveness of control interventions. Future studies should include a stronger focus on child and family-centred participation goals.Implications For RehabilitationPower training can improve gross motor function, walking speed, muscle strength, and activities of daily living more than routine physical therapy.Results comparing power training versus traditional strength training were less pronounced likely because both are intensive and may have positive effects.More research is needed to investigate effects of power training on participation.

Functional Repetitive Neuromuscular Magnetic Stimulation (frNMS) Targeting the Tibialis Anterior Muscle in Children with Upper Motor Neuron Syndrome: A Feasibility Study

Non-invasive neurostimulation as an adjunctive intervention to task-specific motor training is an approach to foster motor performance in patients affected by upper motor neuron syndrome (UMNS). Here, we present first-line data of repetitive neuromuscular magnetic stimulation (rNMS) in combination with personalized task-specific physical exercises targeting the tibialis anterior muscle to improve ankle dorsiflexion (functional rNMS (frNMS)). The main objective of this pilot study was to assess the feasibility in terms of adherence to frNMS, safety and practicability of frNMS, and satisfaction with frNMS. First, during 10 training sessions, only physical exercises were performed (study period (SP) A). After a 1 week break, frNMS was delivered during 10 sessions (SPC). Twelve children affected by UMNS (mean age 8.9 ± 1.6 years) adhered to 93% (SPA) and 94% (SPC) of the sessions, and omittance was not related to the intervention itself in any case. frNMS was safe (no AEs reported in 88% of sessions, no AE-related discontinuation). The practicability of and satisfaction with frNMS were high. Patient/caregiver-reported outcomes revealed meaningful benefits on the individual level. The strength of the ankle dorsiflexors (MRC score) clinically meaningfully increased in four participants as spasticity of ankle plantar flexors (Tardieu scores) decreased in four participants after SPC. frNMS was experienced as a feasible intervention for children affected by UMNS. Together with the beneficial effects achieved on the individual level in some participants, this first study supports further real-world, large-scale, sham-controlled investigations to investigate the specific effects and distinct mechanisms of action of frNMS.

Cost-effectiveness analysis of robot-assisted gait training in patients with bilateral spastic cerebral palsy

BACKGROUND

To date, there have been no published studies evaluating the cost-effectiveness of robot-assisted gait training (RAGT) in adolescent and adult patients with cerebral palsy (CP). The study´s aim was to analyse the cost-effectiveness of RAGT versus conventional kinesiotherapy (CON) from the health care provider's perspective.

METHODS

We expressed the cost-effectiveness of RAGT in the Lokomat® system after analysing the costs and effects of RAGT and conventional therapy through the Incremental Cost-Effectiveness Ratio (ICER) based on a bicentric randomized controlled study, in which we demonstrated that the intensive RAGT regimen is more effective than conventional therapy in terms of improvements in gross motor functions in adolescent and adult patients with bilateral spastic CP.

RESULTS

According to the calculated ICER ratio for Lokomat®, an additional improvement per unit of effect (1% in GMFM), compared to conventional therapy, results in an average cost increase of EUR70.38 per patient in a therapeutic block consisting of 20 TUs (Therapeutic Units).

CONCLUSION

However, from the comprehensive analysis of the results and evaluation of the long-term effects, it follows that RAGT applied in adolescent and adult patients with bilateral spastic CP is not only more effective in terms of evaluation of monitored clinical parameters, but in the long term it is also more cost-effective compared to conventional therapy.

Harnessing the Power of Movement: A Body-Weight Support System & Assistive Robot Case Study

Young children with motor disabilities face extra obstacles to engaging in movement and initiating social interaction. A body-weight support harness system (BWSS) allows a child to take steps, explore the environment, and interact with people and objects, but further research is needed to understand how this type of system can help children with motor disabilities. Assistive robots have the potential to keep a child engaged and motivated during physical therapy sessions with a BWSS. We conducted a case study over three and a half months to understand if the BWSS alone and if the BWSS with an assistive robot could promote child movement and engagement. Our results show that the child tended to increase their amount of movement over each session with the BWSS. The assistive robots used in this study also tended to keep the child engaged. The products of this work can benefit clinicians and researchers interested in early mobility intervention technologies, as well as roboticists working in the child mobility domain.

Effectiveness of Sensory Integration Therapy on Functional Mobility in Children With Spastic Diplegic Cerebral Palsy

Background  A set of non-progressive brain abnormalities and nervous system dysfunctions are referred to as cerebral palsy (CP). Due to this, the child's mobility, eyesight, learning, and thought processes are affected. It can evolve before, through birth, or the first year of a child's life. The activity through which the brain organizes and analyses external sensations like touch, motion, body awareness, vision, hearing, and gravity is indicated as sensory integration. The use of sensory integration therapy (SIT) necessitates that the sensorimotor exercises target the specific parts of difficulties that the child experiences daily. This study aims to study the effectiveness of SIT on functional mobility in children with spastic diplegic CP. Methods In this study, 40 children of CP with spastic diplegic who met the inclusion and exclusion criterion were enlisted and were separated into two groups, with Group A (n=20) receiving SIT for 25 minutes along with conventional physiotherapy for 20 minutes, and Group B (n=20) were given conventional physiotherapy for 45 minutes. A four-week therapy plan was followed. Short sensory profile (SSP) and Gross Motor Function Classification System (GMFCS), Pediatric mini-mental state examination (MMSE), and Modified Ashworth Scale were taken as outcome measures. Results SIT along with traditional treatment is described in the study protocol which aids CP children to improve themselves. Following a four-week protocol, combined therapy of SIT and conventional physiotherapy show an effect on the motor function of the children. After therapy, scores in GMFCS and SSP improved. By using Student's paired t-test, a statistically significant difference was found in GMFCS score at pre and post-test treatment in group A (7.28, p=0.0001) and group B (4.48, p=0.0001), in SSP score at pre and post-test treatment in group A (27.91, p=0.0001) and group B (11.31, p=0.0001), in MMSE score at pre- and post-test treatment in group A (6.89, p=0.0001) and group B (6.32, p=0.0001). The significance threshold was p<0.0001. Conclusion Under the study's experimental conditions, both groups showed substantial improvements in the functional mobility of children. When the efficacy of SIT along with conventional physiotherapy was examined, the impact resulted in a significantly greater improvement in the functional mobility of spastic diplegic CP children.

Effect of Exercise and Motor Interventions on Physical Activity and Motor Outcomes of Adults with Cerebral Palsy: A Systematic Review

PURPOSE

Systematically review the effect of exercise and motor interventions on physical activity and motor outcomes of adults with cerebral palsy (CP).

METHODS

Eight databases were searched.

RESULTS

Twenty-five studies were included, representing 439 adults with CP. Very low to low quality evidence supports that gait training is more effective than standard care or neurodevelopmental treatment for improving gait velocity, quality of gait, and ankle stiffness; balance training is more effective than seated therapeutic activities for improving walking self-confidence and perceived change in balance; whole-body vibration is no more effective than resistance training for improving strength or gait function; and resistance training is no more effective than a person's typical exercise program for improving strength or gait function of adults with CP. Adverse events were reported for balance training, functional training, resistance training, and whole-body vibration.

DISCUSSION

Further research is needed that is adequately powered and uses well-controlled study designs.

Addressing gross motor function by functional repetitive neuromuscular magnetic stimulation targeting to the gluteal muscles in children with bilateral spastic cerebral palsy: benefits of functional repetitive neuromuscular magnetic stimulation targeting the gluteal muscles

Background

Impaired selective motor control, weakness and spasticity represent the key characteristics of motor disability in the context of bilateral spastic cerebral palsy. Independent walking ability is an important goal and training of the gluteal muscles can improve endurance and gait stability. Combining conventional physical excercises with a neuromodulatory, non-invasive technique like repetitive neuromuscular magnetic stimulation probably enhances effects of the treatment. This prospective study aimed to assess the clinical effects of repetitive neuromuscular magnetic stimulation in combination with a personalized functional physical training offered to children and adolescents with bilateral spastic cerebral palsy.

Methods

Eight participants Gross Motor Function Classification System level II and III (10.4 ± 2y5m; 50% Gross Motor Function Classification System level II) received a personalized intervention applying functional repetitive neuromuscular magnetic stimulation (12 sessions within 3 weeks; 12,600 total stimuli during each session). At baseline and follow up the following assessments were performed: 10-m-walking-test, 6-min-walking-test, GMFM-66. Six weeks after the end of treatment the patient-reported outcome measure Gait Outcome Assessment List was completed.

Results

GMFM-66 total score improved by 1.4% (p = 0.002), as did scoring in domain D for standing (1.9%, p = 0.109) and domain E for walking, jumping and running (2.6%, p = 0.021). Gait speed or distance walked during 6 min did not improve from baseline to follow up. Patient-reported outcome showed improvement in 4 patients in altogether 14 ratings. Caregiver-reported outcome reported benefits in 3 participants in altogether 10 ratings.

Conclusion

Repetitive neuromuscular magnetic stimulation promises to be a meaningful, non-invasive treatment approach for children and adolescents with bilateral spastic cerebral palsy that could be offered in a resource-efficient manner to a broad number of patients. To further investigate the promising effects of repetitive neuromuscular magnetic stimulation and its mechanisms of action, larger-scaled, controlled trials are needed as well as comprehensive neurophysiological investigations.

Comparing the Lower-Limb Muscle Activation Patterns of Simulated Walking Using an End-Effector-Type Robot with Real Level and Stair Walking in Children with Spastic Bilateral Cerebral Palsy

Cerebral palsy is a neurologic disorder caused by lesions on an immature brain, often resulting in spasticity and gait abnormality. This study aimed to compare the muscle activation patterns of real level and stair walking with those of simulated walking using an end-effector-type robot in children with spastic cerebral palsy. The electromyographic activities of the vastus lateralis, biceps femoris, tibialis anterior and medial gastrocnemius of nine children with spastic bilateral cerebral palsy were measured during gait using a wireless surface EMG device. Morning walk was used for the simulated gait. Differences in the muscle activation patterns between the real and simulated gait conditions were analyzed. In the loading response, all four muscles showed reduced activity during two simulated conditions. In mid-stance, mGCM showed reduced activity during simulated conditions, whereas BFem showed greater activity during simulated level walking. In the swing phase, BFem and TAnt activity was reduced during the simulated conditions. The onset-offset of the VLat, BFem and TAnt activity was significantly delayed during simulated versus real level walking. No differences in activity onset-offset were observed between the simulated level and stair conditions. In conclusion, the robot-simulated gait showed differences in its muscle activation patterns compared with the real gait conditions, which must be considered for gait training using an end-effector-type robot.

Towards functional improvement of motor disorders associated with cerebral palsy

Cerebral palsy is a lifelong neurodevelopmental condition arising from non-progressive disorders occurring in the fetal or infant brain. Cerebral palsy has long been categorised into discrete motor types based on the predominance of spasticity, dyskinesia, or ataxia. However, these motor disorders, muscle weakness, hypotonia, and impaired selective movements should also be discriminated across the range of presentations and along the lifespan. Although cerebral palsy is permanent, function changes across the lifespan, indicating the importance of interventions to improve outcomes in motor disorders associated with the condition. Mounting evidence exists for the inclusion of several interventions, including active surveillance, adapted physical activity, and nutrition, to prevent secondary and tertiary complications. Avenues for future research include the development of evidence-based recommendations, low-cost and high-quality alternatives to existing therapies to ensure universal access, standardised cerebral palsy registers to harmonise epidemiological and clinical information, improved adult screening and check-up programmes to facilitate positive lived experiences, and phase 3 trials for new interventions.

How does treadmill training contribute to botulinum toxin application plus routine physical therapy in ambulatory children with spastic bilateral cerebral palsy? A randomized controlled trial

BACKGROUND

In spite of treadmill training and multilevel botulinum toxin (BoNT-A) injection being the two most commonly used treatment methods in pediatric rehabilitation management, there was no study investigating the effect of treadmill training after BoNT-A injection in children with cerebral palsy (CP).

AIM

The aim of this study was to investigate the effect of treadmill training in addition to routine physical therapy after BoNT-A injection in ambulatory children with spastic bilateral CP on lower extremity muscle strength, selective motor control, and mobility.

METHODS

A total of 30 spastic bilateral children with CP classified level II-III by the Gross Motor Function Classification System were randomly assigned the study and control groups. Both groups continued routine physical therapy treatments after multilevel BoNT-A injection into lower extremities, while the study group additionally underwent 8 weeks of treadmill training (20 min, two sessions per week). Handheld dynamometer, selective control assessment of lower extremity, temporospatial evaluation of gait, and Pediatric Evaluation of Disability Inventory were assessed before and after 8 weeks.

RESULTS

In both groups, hip, knee, and ankle muscle strength increased at the end of 8 weeks (p < 0.05); however, in the study group, hip flexor/extensor muscle strength (p < 0.05, ES ≥ 0.50), selective motor control of ankle (p < 0.01, ES = 1.17), walking speed (p < 0.01, ES = 2.60), step lengths (p < 0.01, ES = 1.32), and mobility (p < 0.01, ES = 1.37) increased significantly compared to those of the control group.

CONCLUSIONS

Treadmill training in addition to routine physical therapy after BoNT-A injection is beneficial for hip muscle strength, ankle selective motor control, walking quality, and functional mobility in the short term.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03580174.

Muscle activation and rating of perceived exertion of typically developing children during DRY and aquatic treadmill walking

Aquatic treadmill gait training is a poorly understood rehabilitation method that alters bodyweight support, increases lower limb resistance, and assists with postural stability. This training could be an attractive tool for clinical populations with balance control issues or limited weight-bearing prescriptions for the lower limb. As a first step, the purpose of this study was to quantify differences in mean muscle activity of the tibialis anterior, rectus femoris, medial gastrocnemius, and semitendinosus, and perceived exertion (RPE) in typically developing children (7:8 M:F, age = 11.3 ± 4.1 years, 1.46 ± 0.18 m, and 44.2 ± 16.8 kg) during dry and aquatic treadmill walking at 75 %, 100 %, and 125 % self-selected speed. We hypothesized that the greatest mean muscle activity, normalized to percent maximum voluntary contraction and averaged across all strides, would be observed during 125 % dry treadmill walking and that aquatic treadmill walking would produce lower RPE. Overall, aquatic treadmill walking reduced mean medial gastrocnemius activity by 50.2 % (padj < 0.001), increased mean rectus femoris activity at least 32.8 % (padj < 0.006), and produced 78.0 % (padj = 0.007) greater RPE compared to dry treadmill walking. This study provides normative pediatric data for future aquatic treadmill walking studies in clinical populations to help inform gait rehabilitation protocols.

Which gait training intervention can most effectively improve gait ability in patients with cerebral palsy? A systematic review and network meta-analysis

Background

A vital objective to treat people with cerebral palsy (CP) is to increase gait velocity and improve gross motor function. This study aimed to evaluate the relative effectiveness of gait training interventions for persons with CP.

Methods

Studies published up to October 26, 2022 were searched from four electronic databases [including Medline (via PubMed), Web of Science, Embase and Cochrane]. Studies with randomized controlled trials (RCTs), people with CP, comparisons of different gait training interventions and outcomes of gait velocity and gross motor function measures (GMFM) were included in this study. The quality of the literature was evaluated using the risk of bias tool in the Cochrane Handbook, the extracted data were analyzed through network meta-analysis (NMA) using Stata16.0 and RevMan5.4 software.

Results

Twenty RCTs with a total of 516 individuals with CP were included in accordance with the criteria of this study. The results of the NMA analysis indicated that both external cues treadmill training (ECTT) [mean difference (MD) = 0.10, 95% confidence interval CI (0.04, 0.17), P < 0.05] and partial body weight supported treadmill training (BWSTT) [MD = 0.12, 95% CI (0.01, 0.23), P < 0.05] had better gait velocity than over ground gait training (OGT), BWSTT [MD = 0.09, 95%CI(0.01,0.18), P < 0.05] had a better gait velocity than robot-assisted gait training (RAGT), BWSTT [MD = 0.09, 95% CI (0.06, 0.13) P < 0.05] had a better gait velocity than treadmill training (TT), and BWSTT [MD = 0.14, 95% CI (0.07, 0.21), P < 0.05] had a better gait velocity than conventional physical therapy (CON). The SUCRA ranking indicated that BWSTT optimally improved the gait velocity, and the other followed an order of BWSTT (91.7%) > ECTT (80.9%) > RAGT (46.2%) > TT (44%) > OGT (21.6%) > CON (11.1%). In terms of GMFM, for dimension D (GMFM-D), there was no statistical difference between each comparison; for dimension E (GMFM-E), RAGT [MD = 10.45, 95% CI (2.51, 18.40), P < 0.05] was significantly more effective than CON. Both SUCRA ranking results showed that RAGT improved GMFM-D/E optimally, with rankings of RAGT (69.7%) > TT (69.3%) > BWSTT (67.7%) > OGT (24%) > CON (20.3%), and RAGT (86.1%) > BWSTT (68.2%) > TT (58%) > CON (20.1%) > OGT (17.6%) respectively.

Conclusion

This study suggested that BWSTT was optimal in increasing the gait velocity and RAGT was optimal in optimizing GMFM in persons with CP. Impacted by the limitations of the number and quality of studies, randomized controlled trials with larger sample sizes, multiple centers, and high quality should be conducted to validate the above conclusion. Further studies will be required to focus on the total duration of the intervention, duration and frequency of sessions, and intensity that are optimal for the promotion of gait ability in this population.

Systematic review registration

https://doi.org/10.37766/inplasy2022.10.0108, identifier: INPLASY2022100108.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

Feasibility of Functional Repetitive Neuromuscular Magnetic Stimulation (frNMS) Targeting the Gluteal Muscle in a Child with Cerebral Palsy: A Case Report

BACKGROUND

Motor impairment due to spasticity, weakness, and insufficient selective motor control is a key feature of cerebral palsy (CP). For standing and walking, the gluteal muscles play an important role. Physical therapy represents an evidence-based treatment to promote strength and endurance but may be limited to address selective motor control. Treatment incorporating neurostimulating techniques may increase the therapeutic benefits in these situations.

PURPOSE

The aim of this case report was to evaluate the feasibility, safety and clinical effects of a customized protocol of functional repetitive neuromuscular magnetic stimulation (frNMS).

METHODS

This case report describes a frNMS protocol applied to the gluteal muscles in an 8-year old boy with bilateral spastic CP. The protocol combines 12 sessions of customized physiotherapeutic exercises with simultaneous electromagnetic stimulation.

RESULTS

frNMS protocol was adhered to as planned, no relevant adverse events were observed. At day fourafter the intervention the patient reported clinical benefits and improvements of standing and walking assessed by Gross Motor Function Measure dimensions D (+5.1%) and E (+4.2%) were documented. Body sway as measured by center of pressure displacement during posturography decreased.

CONCLUSION

Clinical studies are warranted to assess effects of frNMS and its mechanisms of action in a controlled setting.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

[Effectiveness of robotic technology and virtual reality for the rehabilitation of motor function in cerebral palsy. Systematic review]

INTRODUCTION

Cerebral palsy (CP) is a health condition secondary to non-progressive damage that occurs during brain development in the fetal or infant stage. To evaluate the effectiveness of robotic technology and virtual reality on motor function in patients with CP compared to conventional rehabilitation strategies such as physical therapy, occupational therapy, neurodevelopmental intervention, and transcranial stimulation. A review of randomized controlled trials of the last 5 years was carried out. For the evaluation of the methodological quality of the included studies, the PEDro scale was used, with evaluation of the level of evidence and degree of recommendation according to the Oxford classification.

RESULTS

Seventeen articles met the eligibility criteria. Robotic technology and virtual reality proved to be effective in improving motor function, manual skills, and visual-perceptual skills in patients with CP, compared to the use of conventional rehabilitation strategies.

Effectiveness of virtual reality on functional mobility during treadmill training in children with cerebral palsy: a single-blind, two-arm parallel group randomised clinical trial (VirtWalkCP Project)

INTRODUCTION

Treadmill training and virtual reality have been investigated in children with cerebral palsy. However, few studies have assessed the effectiveness of the combination of both treatments on children's functional and balance activities. The project aims to compare the effects of treadmill training with and without virtual reality on walking endurance and speed, static and dynamic balance, gross motor function, functional independence, quality of life and occupational participation in children with spastic cerebral palsy between the ages of 4 and 12 years classified at levels I, II and III of the Gross Motor Function Classification System.

METHODS AND ANALYSIS

This study is a single-blind, two-arm parallel group, randomised, controlled clinical trial. Participants will be recruited at the Pediatric Department of the Vic Hospital Consortium, and the research will be conducted at the University of Vic - Central University of Catalonia. The participants will be randomly allocated into two groups: (1) the experimental group, which will receive the treadmill training at the same time as the virtual reality; and (2) the control group, which will undertake treadmill gait training alone. The training will be provided in 10 sessions over 2 weeks with 30 min for each session. Assessments will be performed on three occasions: 1 week before the intervention, 1 week following the intervention and 1 month after the end of the intervention. The evaluations will involve the 6 min walk test, stabilometry, the Berg Balance Scale, the 10 m walk test, the Gross Motor Function Measure, the Functional Independence Measure, the paediatric quality of life inventory and the Children Participation Questionnaire. For between-within group comparison, a mixed-effect linear model will be used.

ETHICS AND DISSEMINATION

The study has been approved by the Clinical Research Ethics Committee of the Osona Foundation for Health Research and Education (2021061). Results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT05131724.

Effect of an augmented reality active video game for gait training in children with cerebral palsy following single-event multilevel surgery: protocol for a randomised controlled trial

INTRODUCTION

In paediatric rehabilitation, fun and motivation are also critical keys to successful therapy. A variety of interventions have shown positive effects, high level of interest, compliance and engagement with active video game (AVG).This seems to be an interesting approach for the postoperative gait rehabilitation of children with cerebral palsy (CP). In this study, we will investigate if an overground gait training (GT) delivered through an AVG can improve walking capacity and anaerobic performance.

METHODS AND ANALYSIS

This study is a randomised clinical controlled trial. A total of 14 children and adolescents in the age of 10-18 years with CP will be included. The minimum time between surgery and inclusion will be 7 weeks. The test group will participate in the GT programme with Augmented Reality Rehabilitation of Walking-Cerebral Palsy AVG, control group will receive GT on a treadmill. The primary outcome is the 6-Min Walk Test assessing walking capacity; secondary outcomes are the Muscle Power Sprint Test for anaerobic performance and Shuttle Run Test for physical fitness level. Satisfaction is tested with the Physical Activity Enjoyment Scale.

ETHICS AND DISSEMINATION

The findings will be disseminated by publications in peer-reviewed journals and conferences. This study received agreement from French ethic committee (Comité de Protection des Personnes Sud-Est VI-Number 2020-A02959-30).

TRIAL REGISTRATION NUMBER

NCT04837105.

Defining usual physiotherapy care in ambulant children with cerebral palsy in the United Kingdom: A mixed methods consensus study

BACKGROUND

Ambulant children with cerebral palsy (CP) undertake physiotherapy to improve balance and walking. However, there are no relevant clinical guidelines to standardize usual physiotherapy care in the United Kingdom. A consensus process can be used to define usual physiotherapy care for children with CP. The resulting usual care checklist can support the development of clinical guidelines and be used to measure fidelity to usual care in the control groups of trials for children with CP.

METHODS

Twelve expert physiotherapists were recruited. In Phase 1, statements on usual care were developed using a survey and two nominal groups. Phase 2 included a literature review to support usual physiotherapy interventions. Phase 3 used a confirmatory survey, which also captured changes to provision during the COVID-19 pandemic. Consensus was calculated by deriving the mean of the deviations from the median score (MDM). High consensus was deemed to be where MDM < 0.42.

RESULTS

Physiotherapists reached high consensus on five outcome measures (MDM range 0-0.375) and nine areas of assessment (MDM range 0-0.25). Physiotherapists reached moderate consensus on task-specific training (MDM = 0.75), delivered at weekly intensity for 4-6 weeks (MDM = 0.43). There was high consensus (MDM = 0) that children should participate in modified sport and fitness activities and that children with Gross Motor Function Classification System Level III should be monitored on long-term pathways (MDM = 0.29).

CONCLUSIONS

Physiotherapists reached consensus on two usual care interventions, and a checklist was developed to inform the control groups of future randomized controlled trials. Further consensus work is required to establish clinical guidelines to standardize usual physiotherapy care in the United Kingdom.

Visual Feedback in Augmented Reality to Walk at Predefined Speed Cross-Sectional Study Including Children With Cerebral Palsy

In an augmented reality environment, the range of possible real-time visual feedback is extensive. This study aimed to compare the impact of six scenarios in augmented reality combining four visual feedback characteristics on achieving a target walking speed. The six scenarios have been developed for Microsoft Hololens augmented reality headset. The four feedback characteristics that we have varied were: Color; Spatial anchoring; Speed of the feedback, and Persistence. Each characteristic could have different values (for example, the color could be unicolor, bicolor, or gradient). Participants had to walk for two consecutive walking trials for each scenario: at their maximal speed and an intermediate speed. Mean speed, percentage of time spent above or around target speed, and time to reach target speed were compared between scenarios using mixed linear models. A total of 25 children with disabilities have been included. The feasibility and user experience were excellent. Mean speed during scenario 6, which displayed feedback with gradient color, attached to the world, with a speed relative to the player equal to his speed, and that disappeared over time, was significantly higher than other scenarios and control (p =0.003). Participants spent 80.98% of time above target speed during scenario 6. This scenario mixed the best combination of feedback characteristics to exceed the target walking speed (p=0.0058). Scenarios 5 and 6, which shared the same feedback characteristics for spatial anchoring (world-locked) and feedback speed (equal to the player speed), decreased the time to reach the target speed (p=0.019). Delivering multi-modal feedback has been recognized as more effective for improving motor performance. Therefore, our results showed that not all visual feedback had the same impact on performance. Further studies are required to test the weight of each feedback characteristic and their possible interactions inside each scenario. This study was registered in the ClinicalTrials.gov database (NCT04460833).

A Review on Recent Advances of Cerebral Palsy

This narrative review summarizes the latest advances in cerebral palsy and identifies where more research is required. Several studies on cerebral palsy were analyzed to generate a general idea of the prevalence of, risk factors associated with, and classification of cerebral palsy (CP). Different classification systems used for the classification of CP on a functional basis were also analyzed. Diagnosis systems used along with the prevention techniques were discussed. State-of-the-art treatment strategies for CP were also analyzed. Statistical distribution was performed based on the selected studies. Prevalence was found to be 2-3/1000 lives; the factors that can be correlated are gestational age and birth weight. The risk factors identified were preconception, prenatal, perinatal, and postnatal categories. According to the evidence, CP is classified into spastic (80%), dyskinetic (15%), and ataxic (5%) forms. Diagnosis approaches were based on clinical investigation and neurological examinations that include magnetic resonance imaging (MRI), biomarkers, and cranial ultrasound. The treatment procedures found were medical and surgical interventions, physiotherapy, occupational therapy, umbilical milking, nanomedicine, and stem cell therapy. Technological advancements in CP were also discussed. CP is the most common neuromotor disability with a prevalence of 2-3/1000 lives. The highest contributing risk factor is prematurity and being underweight. Several preventions and diagnostic techniques like MRI and ultrasound were being used. Treatment like cord blood treatment nanomedicine and stem cell therapy needs to be investigated further in the future to apply in clinical practice. Future studies are indicated in the context of technological advancements among cerebral palsy children.

A Therapeutic Approach Using the Combined Application of Virtual Reality with Robotics for the Treatment of Patients with Spinal Cord Injury: A Systematic Review

Spinal cord injury (SCI) has been associated with high mortality rates. Thanks to the multidisciplinary vision and approach of SCI, including the application of new technologies in the field of neurorehabilitation, people with SCI can survive and prosper after injury. The main aim of this systematic review was to analyze the effectiveness of the combined use of VR and robotics in the treatment of patients with SCI. The literature search was performed between May and July 2021 in the Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), PubMed, and Web of Science. The methodological quality of each study was assessed using the SCIRE system and the PEDro scale, whereas the risk of bias was analyzed using the Cochrane Collaboration’s tool. A total of six studies, involving 63 participants, were included in this systematic review. Relevant changes were found in the upper limbs, with improvements of shoulder and upper arm mobility, as well as the strengthening of weaker muscles. Combined rehabilitation may be a valuable approach to improve motor function in SCI patients. Nonetheless, further research is necessary, with a larger patient sample and a longer duration.

Repetitive Peripheral Magnetic Stimulation to Improve Ankle Function and Gait in Cerebral Palsy at Adulthood: An open-label Case Study

Repetitive peripheral magnetic stimulation (rPMS) is noninvasive and painless. It drives plasticity of the primary motor cortex (M1) in children with cerebral palsy (CP) and this improves the ankle function and gait. Our study explored whether rPMS of muscles could influence motricity in an adult CP case. A 30-year-old woman with mixed CP participated in four sessions (S1 to S4, one per week) where rPMS was applied bilaterally on leg and trunk muscles (tibialis anterior-TA, hamstrings, transverse abdominis, paraspinal multifidus). Clinical scores and M1 excitability (probed by transcranial magnetic stimulation) were tested at pre-rPMS at S1 (baseline) and S4, then 40 days later (follow-up). The active ankle dorsiflexion was significantly increased and the plantar flexors resistance to stretch reduced as compared to baseline. The improvement of the ankle function was carried-over to the quality of locomotor patterns. Changes persisted until follow-up and were paralleled by drastic changes of M1 excitability. These original findings of rPMS influence on M1 plasticity and motricity are promising for the functional improvement of adult people living with CP and should be replicated in larger-sampled studies.

Evidence-based, Implementable Motor Rehabilitation Guidelines for Individuals With Cerebral Palsy

BACKGROUND

Cerebral palsy is a life-long condition that causes heterogeneous motor disorders. Motor rehabilitation interventions must be adapted to the topography of the symptoms, ambulatory capacity and age of the individual. Current guidelines do not differentiate between the different profiles of individuals with cerebral palsy, which limits their implementation.

OBJECTIVES

To develop evidence-based, implementable guidelines for motor rehabilitation interventions for individuals with cerebral palsy according to the age, topography of the cerebral palsy and ambulatory capacity of the individual, and to determine a level of priority for each intervention.

METHODS

We used a mixed methods design that combined a systematic review of the literature on available motor rehabilitation interventions with expert opinions. Based on the French National Authority for Health methodology, recommendations were graded as strong, conditional or weak. Interventions were then prioritized by the experts according to both the evidence and their own opinions on relevance and implementability to provide a guide for clinicians. All recommendations were approved by experts who were independent from the working group.

RESULTS

Strong recommendations as first-line treatments were made for gait training, physical activities and hand-arm bimanual intensive therapy for all children and adolescents with cerebral palsy. Moderate recommendations were made against passive joint mobilizations, muscle stretching, prolonged stretching with the limb fixed, and neurodevelopmental therapies for all children and adolescents with cerebral palsy. Strong recommendations as first-line treatments were made for gait training for all adults with cerebral palsy and moderate recommendations as moderate importance interventions for strengthening exercises and ankle-foot orthoses for motor impairment of the feet and the ankles.

DISCUSSION

These guidelines, which combine research evidence and expert opinion, could help individuals with cerebral palsy and their families to co-determine rehabilitation goals with health professionals, according to their preferences.

Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis

BACKGROUND AND OBJECTIVE

Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP.

METHODS

Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures.

CONCLUSIONS

We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.

Where words are powerless to express: Use of music in paediatric neurology

Music is an art form that strongly affects people and can elicit many different emotions at the same time, including happiness, anxiety, sadness, and even ecstasy. What is it about music that causes such a strong reaction from each of us? Music engages many senses, which in turn can produce a multiplicity of responses and help create more extensive neuronal connections, as well as influence behaviour through structural and functional changes in the brain. Music-based interventions as a therapeutic tool in rehabilitation are becoming more common. It is said that the impact of music on the human body is positive. However, what impact does music have on the young nervous system, especially the affected one? This review presents the advantages and disadvantages of the use of music in paediatric neurology to treat dyslexia, cerebral palsy, and stroke, among others. Potential negative impacts such as musicogenic epilepsy and hallucinations will be discussed.

Intervenções para promover função física de crianças e jovens com paralisia cerebral: diretriz internacional de prática clínica

OBJETIVO

Fornecer recomendações de intervenções para promoção da função física de crianças e jovens com paralisia cerebral.

MÉTODO

Um painel de especialistas priorizou perguntas e desfechos importantes para o paciente. Usando o Grading of Recommendations Assessment, Development and Evaluation (GRADE), o painel avaliou a certeza das evidências e fez recomendações, com consultoria de especialistas internacionais e consumidores.

RESULTADOS

A diretriz compreende 13 recomendações (informadas por três revisões sistemáticas, 30 estudos randomizados e cinco estudos pré‐pós). Para alcance de objetivos funcionais, recomenda‐se que a intervenção inclua objetivos escolhidos pelo cliente, prática completa da tarefa em ambientes da vida real, suporte para empoderar as famílias e uma abordagem em equipe. Idade, habilidade e preferências da criança/família precisam ser consideradas. Para melhora da habilidade da marcha, recomenda‐se marcha no solo, que pode ser complementada com treinamento em esteira. Várias abordagens podem facilitar os objetivos relacionados ao uso das mãos: terapia bimanual, terapia de contensão induzida, treino direcionado a objetivos e abordagens cognitivas. Para auto‐cuidado, prática da tarefa completa, combinada com recursos assistivos podem aumentar a independência e reduzir a sobrecarga do cuidador. A participação em objetivos de lazer pode combinar prática da tarefa completa com estratégias direcionadas para barreiras ambientais, pessoais e sociais.

INTERPRETAÇÃO

Intervenção para promoção da função de crianças e jovens com paralisia cerebral precisa incluir objetivos escolhidos pelo cliente e a prática da tarefa completa dos objetivos. Os clínicos devem considerar as preferências da criança/família, idade e habilidade ao selecionarem intervenções específicas.

Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline

AIM

To provide recommendations for interventions to improve physical function for children and young people with cerebral palsy.

METHOD

An expert panel prioritized questions and patient-important outcomes. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods, the panel assessed the certainty of evidence and made recommendations, with international expert and consumer consultation.

RESULTS

The guideline comprises 13 recommendations (informed by three systematic reviews, 30 randomized trials, and five before-after studies). To achieve functional goals, it is recommended that intervention includes client-chosen goals, whole-task practice within real-life settings, support to empower families, and a team approach. Age, ability, and child/family preferences need to be considered. To improve walking ability, overground walking is recommended and can be supplemented with treadmill training. Various approaches can facilitate hand use goals: bimanual therapy, constraint-induced movement therapy, goal-directed training, and cognitive approaches. For self-care, whole-task practice combined with assistive devices can increase independence and reduce caregiver burden. Participation in leisure goals can combine whole-task practice with strategies to address environmental, personal, and social barriers.

INTERPRETATION

Intervention to improve function for children and young people with cerebral palsy needs to include client-chosen goals and whole-task practice of goals. Clinicians should consider child/family preferences, age, and ability when selecting specific interventions.

Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled Trial

Background

Perinatal stroke injures motor regions of the brain, compromising movement for life. Early, intensive, active interventions for the upper extremity are efficacious, but interventions for the lower extremity remain understudied.

Objective

To determine the feasibility and potential efficacy of ELEVATE—Engaging the Lower Extremity Via Active Therapy Early—on gross motor function.

Methods

We conducted a single-blind, two-arm, randomized controlled trial (RCT), with the Immediate Group receiving the intervention while the Delay Group served as a 3-month waitlist control. A separate cohort living beyond commuting distance was trained by their parents with guidance from physical therapists. Participants were 8 months to 3 years old, with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis. The intervention was play-based, focused on weight-bearing, balance and walking for 1 hour/day, 4 days/week for 12 weeks. The primary outcome was the Gross Motor Function Measure-66 (GMFM-66). Secondary outcomes included steps and gait analyses. Final follow-up occurred at age 4.

Results

Thirty-four children participated (25 RCT, 9 Parent-trained). The improvement in GMFM-66 over 12 weeks was greater for the Immediate than the Delay Group in the RCT (average change 3.4 units higher) and greater in younger children. Average step counts reached 1370-3750 steps/session in the last week of training for all children. Parent-trained children also improved but with greater variability.

Conclusions

Early, activity-intensive lower extremity therapy for young children with perinatal stroke is feasible and improves gross motor function in the short term. Longer term improvement may require additional bouts of intervention.

Clinical trial registration

This study was registered at ClinicalTrials.gov (NCT01773369).

Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking

Toe-walking characterizes several neuromuscular conditions and is associated with a reduction in gait stability and efficiency, as well as in life quality. The optimal choice of treatment depends on a correct understanding of the underlying pathology and on the individual biomechanics of walking. The objective of this study was to describe gait deviations occurring in a cohort of healthy adult subjects when mimicking a unilateral toe-walking pattern compared to their normal heel-to-toe gait pattern. The focus was to characterize the functional adaptations of the major lower-limb muscles which are required in order to toe walk. Musculoskeletal modeling was used to estimate the required muscle contributions to the joint sagittal moments. The support moment, defined as the sum of the sagittal extensive moments at the ankle, knee, and hip joints, was used to evaluate the overall muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Compared to a normal heel-to-toe gait pattern, toe-walking was characterized by significantly different lower-limb kinematics and kinetics. The altered kinetic demands at each joint translated into different necessary moment contributions from most muscles. In particular, an earlier and prolonged ankle plantarflexion contribution was required from the soleus and gastrocnemius during most of the stance phase. The hip extensors had to provide a higher extensive moment during loading response, while a significantly higher knee extension contribution from the vasti was necessary during mid-stance. Compensatory muscular activations are therefore functionally required at every joint level in order to toe walk. A higher support moment during toe-walking indicates an overall higher muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Higher muscular demands during gait may lead to fatigue, pain, and reduced quality of life. Toe-walking is indeed associated with significantly larger muscle forces exerted by the quadriceps to the patella and prolonged force transmission through the Achilles tendon during stance phase. Optimal treatment options should therefore account for muscular demands and potential overloads associated with specific compensatory mechanisms.

Rehabilitation After Single-Event Multilevel Surgery for Children and Young Adults With Cerebral Palsy: A Systematic Review

ABSTRACT

This review sought to describe and analyze published protocols for rehabilitation after single-event multilevel surgery for people with cerebral palsy, to identify their differences and limits, and to introduce a common step-by-step framework for future descriptions and assessments of postoperative rehabilitation protocols.The MEDLINE, Embase, CINAHL, and the Cochrane Library databases were searched. Inclusion criteria were as follows: (1) single-event multilevel surgery, (2) full-text reports published after 1985, and (3) articles with a method section describing the rehabilitation protocol. Interventions were coded using the Oxford Levels of Evidence and the Methodological Index for Non-Randomized Studies Index.Twenty-four articles were included in the review. Studies included patients aged 4-30 yrs with spastic cerebral palsy (hemiplegia, diplegia, and quadriplegia). The mean postoperative rehabilitation duration was 4.5 mos, with 4 sessions per week, and rehabilitation took place in a rehabilitation center. This review provides relevant information about the modalities, contents, limits, and difficulties associated with the post-SEMS rehabilitation protocol reported in the literature. Pain was identified as a major problem.A more precise and comprehensive description of post-SEMS rehabilitation protocols would be useful. The proposed five-step framework could be used by future studies to standardize their protocol description in terms of objective, content, and intensity.