New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy

Stretching exercises in managing spasticity: effectiveness, risks, and adjunct therapies

Spasticity is a component of upper motor neuron disorders and can be seen in neurological conditions like stroke and multiple sclerosis. Although the incidence rate of spasticity is unknown, it can put pressure on the health condition of those with spasticity, and there is no absolute effective way to control it. In the past, stretching exercises were an accessible tool for physical therapists to manage and control spasticity, but opinions on the optimal dose, aftereffects, and mechanism of effects were controversial. Therefore, this article tries to provide an overview of the effectiveness and risks of stretching exercises. Furthermore, there are several adjunct therapies, such as brain stimulation and botulinum injection, that can increase the effectiveness of a simple stretch by increasing cortical excitability and reducing muscle tone and their role is evaluated in this regard. The results of this study propose that several prospective and case studies have demonstrated the benefits of stretching to control spasticity, but it seems that other methods such as casting can be more effective than a simple stretch. Therefore, it is better to use stretching in combination with other therapeutic regimes to increase its effectivity of it.

Effects of Therapies Involving Plyometric-Jump Training on Physical Fitness of Youth with Cerebral Palsy: A Systematic Review with Meta-Analysis

The aim of this systematic review was to assess the effects of plyometric-jump training (PJT) on the physical fitness of youth with cerebral palsy (CP) compared with controls (i.e., standard therapy). The PRISMA 2020 guidelines were followed. Eligibility was assessed using the PICOS approach. Literature searches were conducted using the PubMed, Web of Science, and SCOPUS databases. Methodological study quality was assessed using the PEDro scale. Data were meta-analyzed by applying a random-effects model to calculate Hedges' g effect sizes (ES), along with 95% confidence intervals (95% CI). The impact of heterogeneity was assessed (I2 statistic), and the certainty of evidence was determined using the GRADE approach. Eight randomized-controlled studies with low-to-moderate methodological quality were included, involving male (n = 225) and female (n = 138) youth aged 9.5 to 14.6 years. PJT interventions lasted between 8 and 12 weeks with 2-4 weekly sessions. Compared with controls, PJT improved the muscle strength (ES = 0.66 [moderate], 95% CI = 0.36-0.96, p < 0.001, I2 = 5.4%), static (ES = 0.69 [moderate], 95% CI= 0.33-1.04, p < 0.001, I2 = 0.0%) and dynamic balance (ES = 0.85 [moderate], 95% CI = 0.12-1.58, p = 0.023, I2 = 81.6%) of youth with CP. Therefore, PJT improves muscle strength and static and dynamic balance in youth with CP compared with controls. However, more high-quality randomized-controlled trials with larger sample sizes are needed to provide a more definitive recommendation regarding the use and safety of PJT to improve measures of physical fitness.

The Rehabilitation Interventions and Adaptive Technologies Used for Treating Patients With Cerebral Palsy

Cerebral palsy (CP) is one of the most common disorders in pediatric patients. The prevalence of CP is 2-3 in 1,000 live births, but various changes in some trends are seen in different groups. This article is a systematic review of multiple sources available for interventions and new adaptive techniques used for treating patients for their better lifestyles. With recent advancements, it is possible to diagnose a child who is below six months to two years. For achieving goals, proper interventions and techniques are necessary in the early stages of the disease. This article summarizes the rehabilitation and interventions available for treating these children with the best procedures.

Systematic review: exercise training for equinus deformity in children with cerebral palsy

Background

Children with spastic cerebral palsy have motor deficits that can lead to joint contractures. Ankle equinus deformity is the most common foot deformity among children with CP. It is caused by spasticity and muscular imbalance in the gastrocnemius-soleus complex. Exercise enhances ankle function, improves gait in children with CP, and prevents permanent impairment. Therefore, there is a need to investigate the effectiveness of different types of exercise used in equine management. The aim of this review is to assess the evidence of the effectiveness of exercise training on equinus deformity in children with cerebral palsy.

Methodology

The American Academy for Cerebral Palsy and Developmental Medicine and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology were used to conduct this systematic review. Four databases (PubMed, Cochrane Library, Physiotherapy Evidence Database (PEDro), and Google Scholar) were searched till January 2022 using predefined terms by two independent reviewers. Randomized controlled trials published in English were included. This review included seven studies with 203 participants ranging in age from 5 to 18 years. Methodological quality was assessed using AACPDM, PEDro scale; also, levels of evidence adopted from modified Sacket’s scale were used for each study. Primary outcomes were dorsiflexion angle, plantar flexion angle, and plantar flexors strength.

Results

The quality of studies ranged from good (six studies) to fair (one study). The level of evidence was level 1 (six studies) and level 2 (one study) on modified Sacket’s scale. There is a low risk of bias in the included studies. Meta-analysis revealed a non-significant difference in plantar flexor strength, plantar flexion angle, and dorsiflexion angle between the study and control group.

Conclusions

There is a need for high-quality studies to draw a clear conclusion as the current level of evidence supporting the effectiveness of various types of exercises on equinus deformity in children with cerebral palsy is still weak.

Botulinum Toxin Intervention in Cerebral Palsy-Induced Spasticity Management: Projected and Contradictory Effects on Skeletal Muscles

Spasticity, following the neurological disorder of cerebral palsy (CP), describes a pathological condition, the central feature of which is involuntary and prolonged muscle contraction. The persistent resistance of spastic muscles to stretching is often followed by structural and mechanical changes in musculature. This leads to functional limitations at the respective joint. Focal injection of botulinum toxin type-A (BTX-A) is effectively used to manage spasticity and improve the quality of life of the patients. By blocking acetylcholine release at the neuromuscular junction and causing temporary muscle paralysis, BTX-A aims to reduce spasticity and hereby improve joint function. However, recent studies have indicated some contradictory effects such as increased muscle stiffness or a narrower range of active force production. The potential of these toxin- and atrophy-related alterations in worsening the condition of spastic muscles that are already subjected to changes should be further investigated and quantified. By focusing on the effects of BTX-A on muscle biomechanics and overall function in children with CP, this review deals with which of these goals have been achieved and to what extent, and what can await us in the future.

Designing a robust controller for a lower limb exoskeleton to treat an individual with crouch gait pattern in the presence of actuator saturation

Crouch gait is a gait anomaly observed in youngsters with cerebral palsy (CP). Rehabilitation robots are useful for treating individuals with crouch gait. Multiple factors have impact on crouch, including contracture, spasticity, weak motor control, and muscle feebleness, which make the designing and controlling of these exoskeletons for this population a challenging job. A harsh kinematic trajectory enforced by an exoskeleton control strategy may place individuals with spasticity at a high risk of muscle tissue injury. Therefore, in this article, a multi-input multi-output (MIMO) control method is proposed to reduce this risk and improve crouch gait pattern. A constrained control law is used in the model since high power demands may threaten the wearer. In addition, the controller needs to be robust enough against external disturbances and uncertainties. Thus, a nonlinear disturbance observer (NDO) is presented to compute the wearer-generated muscular torque and the uncertainties in the modeling. In addition, a robust constrained MIMO backstepping sliding controller (CMBSC) based on NDO is used to deal with the effect of actuator saturation and uncertainties. A simulation test was used to validate the proposed model and controller. The results of Simulation confirmed the efficiency of the proposed control method when applied to crouch gait with subject specific gait reference. Then, some experimental tests were undertaken to validate the efficiency of the proposed controller.

Effect of Community-Based Functional Aerobic Training on Motor Performance and Quality of Life of Children with Spastic Cerebral Palsy

Background

Efficacies of community-based exercise programmes have been well reported but there is scarce information on the expediency of community-based rehabilitation in a society where many of children with disabilities live in poorly resourced settings with extremely limited rehabilitative services. The study investigated the effects of community-based functional aerobic exercise (CBFAE) on gross motor function, walking distance, and quality of life of children with cerebral palsy (CP).

Methods

Quasi-experimental design was used. Children with gross motor function classification system (GMFCS) levels I – II participated in eight weeks CBFAE training four times/week, 50 minutes/day at 40–80% maximum heart rate. Gross motor function (GMF), walk distance and quality of life were assessed pre and post CBFAE training.

Results

Significant improvement observed in GMF (Dstanding) (8.2%, P=.000), GMF (E-walking+running+jumping (5.12%, P=.004), walking distance (6.09%, P=.009). Higher significant positive effects of CBFAE observed in Social wellbeing and acceptance (107.10%, P=.000), and participation and physical health (105.04%, P=.005) by children parent proxy. Self-reported results showed that for CBFAE, significant positive improvements were higher in Pain and impact of disability (67.93%, P=.049) and Participation and physical health (60.00%, P=.042).

Conclusion

CBFAE training contributes majorly to improved standing, walking, jumping and running and selfesteem, quality of life of children with spastic CP. Clinicians and exercise therapists should essentially incorporate CBFAE training and activities into the management of children with CP for improved mobility and functional performances.

Effect of Community-Based Functional Aerobic Training on Motor Performance and Quality of Life of Children with Spastic Cerebral Palsy

Background

Efficacies of community-based exercise programmes have been well reported, but there is scarce information on the expediency of community-based rehabilitation in a society where many children with disabilities live in poorly resourced settings with extremely limited rehabilitative services. This study investigated the effects of community-based functional aerobic exercise (CBFAE) on gross motor function, walking distance, and quality of life of children with cerebral palsy (CP).

Methods

Quasi-experimental design was used. Children with gross motor function classification system (GMFCS) levels I – II participated in eight weeks CBFAE training four times/week, 50 minutes/day at 40–80% maximum heart rate. Gross motor function (GMF), walking distance and quality of life were assessed pre and post CBFAE training.

Results

Significant improvement was observed in GMF (Dstanding) (8.2%, P=.000), GMF (E-walking + running+ jumping (5.12%, P=.004), walking distance (6.09%, P=.009). Higher significant positive effects of CBFAE were observed in Social wellbeing and acceptance (107.10%, P=.000), and participation and physical health (105.04%, P=.005) by children parent proxy. Self-reported results showed that for CBFAE, significant positive improvements were higher in pain and impact of disability (67.93%, P=.049) and participation and physical health (60.00%, P=.042).

Conclusion

CBFAE training contributes majorly to improved standing, walking, jumping and running and self-esteem, quality of life of children with spastic CP. Clinicians and exercise therapists should essentially incorporate CBFAE training and activities into the management of children with CP for improved mobility and functional performances.

Measuring skeletal muscle morphology and architecture with imaging modalities in children with cerebral palsy: a scoping review

AIM

To investigate the use of ultrasound and magnetic resonance imaging (MRI) methodologies to assess muscle morphology and architecture in children with cerebral palsy (CP).

METHOD

A scoping review was conducted with systematic searches of Medline, Embase, Scopus, Web of Science, PubMed, and PsycInfo for all original articles published up to January 2019 utilizing ultrasound and/or MRI to determine morphological and architectural properties of lower limb skeletal muscle in children with CP.

RESULTS

Eighty papers used ultrasound (n=44), three-dimensional ultrasound (n=16), or MRI (n=20) to measure at least one muscle parameter in children and adolescents with CP. Most research investigated single muscles, predominantly the medial gastrocnemius muscle, included children classified in Gross Motor Function Classification System levels I (n=62) and II (n=65), and assessed fascicle length (n=35) and/or muscle volume (n=35). Only 21 papers reported reliability of imaging techniques. Forty-six papers assessed measures of Impairment (n=39), Activity (n=24), and Participation (n=3).

INTERPRETATION

Current research study design, variation in methodology, and preferences towards investigation of isolated muscles may oversimplify the complexities of CP muscle but provide a foundation for the understanding of the changes in muscle parameters in children with CP.

WHAT THIS PAPER ADDS

Current evidence is biased towards the medial gastrocnemius muscle and more functionally able children with cerebral palsy (CP). Variations in imaging techniques and joint positioning limit comparisons between studies. Clinimetric testing of parameters of CP muscle is not always considered. Assessment of parameter(s) of muscle with measures of participation is sparse.

Mu Rhythm during Standing and Walking Is Altered in Children with Unilateral Cerebral Palsy Compared to Children with Typical Development

Background: Rehabilitation in cerebral palsy (CP) seeks to harness neuroplasticity to improve movement, including walking, yet cortical activation underlying gait is not well understood. Methods: We used electroencephalography (EEG) to compare motor related cortical activity, measured by mu rhythm, during quiet standing and treadmill walking in 10 children with unilateral CP and 10 age- and sex-matched children with typical development (TD). Peak mu band frequency, mu rhythm desynchronization (MRD), and gait related intra- and inter-hemispheric coherence were examined. Results: MRD during walking was observed bilaterally over motor cortex in both cohorts but peak mu band frequency showing MRD was significantly lower in CP compared to TD. Coherence during quiet standing between motor and frontal regions was significantly higher in the non-dominant compared to dominant hemisphere in CP with no hemispheric differences in TD. Conclusions: EEG-based measures should be further investigated as clinical biomarkers for atypical motor development and to assess rehabilitation effectiveness.

The effect of side-alternating vibration therapy on mobility and health outcomes in young children with mild to moderate cerebral palsy: design and rationale for the randomized controlled study

Background

Cerebral palsy (CP) is the most common cause of physical disability in early childhood. Vibration therapy (VT) is a promising rehabilitation approach for children with CP with potential to impact mobility, bone and muscle health as demonstrated by extant research. However, it is still unclear how long therapy must be conducted for and what the optimal vibration frequency is in order to gain health benefits.

Methods/design

The study is a randomized clinical trial evaluating and comparing the effects of two vibration frequency (20 Hz vs 25 Hz) and duration protocols (12 weeks vs 20 weeks) of side-alternating VT on mobility and other health parameters in children with CP. Children aged 5–12 years old with CP and GMFCS level I-III who are able to understand instruction and safely stand are eligible for the study. Exclusion criteria include bone fracture within 12 weeks of enrolment; acute conditions; the history of significant organic disease; the history of taking anabolic agents, glucocorticoids, growth hormone, and botulinum toxin injection into lower limbs within 3 months of enrolment. All participants will act as their own control with a 12-week lead-in period prior to intervention. The intervention period will consist of 20 weeks of home- or school-based VT 9 min per day, 4 times a week. After the baseline assessment, participants will be randomized to either a 20 Hz or 25 Hz vibration-frequency group. The primary outcome is mobility measured by a 6-min walking test, with analysis performed on the principle of intention to treat. Secondary outcomes include body composition, muscle strength, physical activity level, balance, gross motor function, respiratory function, and quality of life. Participants will undergo four assessment visits over the study period: baseline, at weeks 12, 24, and 32.

Discussion

The results of the study will provide evidence-based insights into the health benefits of side-alternating VT as a therapeutic tool in young children with cerebral palsy. The investigation of different vibration training protocols will help define the optimal parameters of intervention protocols (duration, frequency) of side-alternating VT to maximize outcomes on the health of 5–12-year-old children with CP.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): 12618002026202 (Registration date 18/12/2018).

The orthopaedic aspect of spastic cerebral palsy

Spastic Cerebral Palsy (CP) is the most common form of CP, comprising of 80% of all cases. Spasticity is a type of hypertonia that clinically manifests as dynamic contractures. The dynamic contracture along with the reduced level of physical activity in a child with CP leads to secondary structural and morphological changes in spastic muscle, causing real musculotendinous shortening, known as fixed contractures. When fixed muscle contractures are not treated early, progressive musculoskeletal deformities develop. As a consequence, spastic CP from a static neurological pathology becomes a progressive orthopaedic pathology which needs to be managed surgically. Orthopaedic surgical management of CP has evolved from previous "multi-event single level" procedures to a "single event multilevel" procedures, with changes in selection and execution of treatment modalities. There is increasing evidence that multilevel surgery is an integral and essential part of therapeutic management of spastic CP, but more research is needed to ensure effectiveness of this intervention on all domains of physical disability in CP.

Toward a hybrid exoskeleton for crouch gait in children with cerebral palsy: neuromuscular electrical stimulation for improved knee extension

BACKGROUND

Neuromuscular Electrical Stimulation (NMES) has been utilized for many years in cerebral palsy (CP) with limited success despite its inherent potential for improving muscle size and/or strength, inhibiting or reducing spasticity, and enhancing motor performance during functional activities such as gait. While surface NMES has been shown to successfully improve foot drop in CP and stroke, correction of more complex gait abnormalities in CP such as flexed knee (crouch) gait remains challenging due to the level of stimulation needed for the quadriceps muscles that must be balanced with patient tolerability and the ability to deliver NMES assistance at precise times within a gait cycle.

METHODS

This paper outlines the design and evaluation of a custom, noninvasive NMES system that can trigger and adjust electrical stimulation in real-time. Further, this study demonstrates feasibility of one possible application for this digitally-controlled NMES system as a component of a pediatric robotic exoskeleton to provide on-demand stimulation to leg muscles within specific phases of the gait cycle for those with CP and other neurological disorders who still have lower limb sensation and volitional control. A graphical user interface was developed to digitally set stimulation parameters (amplitude, pulse width, and frequency), timing, and intensity during walking. Benchtop testing characterized system delay and power output. System performance was investigated during a single session that consisted of four overground walking conditions in a 15-year-old male with bilateral spastic CP, GMFCS Level III: (1) his current Ankle-Foot Orthosis (AFO); (2) unassisted Exoskeleton; (3) NMES of the vastus lateralis; and (4) NMES of the vastus lateralis and rectus femoris. We hypothesized in this participant with crouch gait that NMES triggered with low latency to knee extensor muscles during stance would have a modest but positive effect on knee extension during stance.

RESULTS

The system delivers four channels of NMES with average delays of 16.5 ± 13.5 ms. Walking results show NMES to the vastus lateralis and rectus femoris during stance immediately improved mean peak knee extension during mid-stance (p = 0.003*) and total knee excursion (p = 0.009*) in the more affected leg. The electrical design, microcontroller software and graphical user interface developed here are included as open source material to facilitate additional research into digitally-controlled surface stimulation ( github.com/NIHFAB/NMES ).

CONCLUSIONS

The custom, digitally-controlled NMES system can reliably trigger electrical stimulation with low latency. Precisely timed delivery of electrical stimulation to the quadriceps is a promising treatment for crouch. Our ultimate goal is to synchronize NMES with robotic knee extension assistance to create a hybrid NMES-exoskeleton device for gait rehabilitation in children with flexed knee gait from CP as well as from other pediatric disorders.

TRIAL REGISTRATION

clinicaltrials.gov, ID: NCT01961557 . Registered 11 October 2013; Last Updated 27 January 2020.

Characteristics of newly acquired gait in toddlers with unilateral cerebral palsy: Implications for early rehabilitation

BACKGROUND

Knowledge of the characteristics of newly acquired gait in toddlers with cerebral palsy (CP) is limited.

OBJECTIVES

This study compared gait characteristics (spatiotemporal parameters, kinematics and lower-limb muscle activation) within the first 6 months of independent walking in toddlers with unilateral cerebral palsy (UCP) and typically developing (TD) children.

METHODS

The gait of 28 TD toddlers and 13 toddlers with UCP, all up to 3 years old with maximum walking experience of 6 months, was recorded by using a 3-D optoelectronic system and surface electromyography (EMG). Statistical parametric mapping was used to compare the kinematic parameters and EMG envelopes. Mann-Whitney U test was used to compare spatiotemporal parameters between groups. Principal component analysis was used to determine whether the main kinematic results were related to the clinical measures.

RESULTS

Toddlers with UCP had bilateral modifications of the spatiotemporal parameters during gait as compared with TD toddlers and temporal asymmetry. The largest kinematic difference between the UCP and TD groups was external pelvic rotation on the affected side (13.3°). Foot progression angle was external during swing phase on the affected side. The groups did not differ in muscle activation for the set of muscles recorded. Pelvic rotation was not associated with any of the clinical measures on the affected or non-affected sides of toddlers with UCP.

CONCLUSIONS

Alterations in kinematic gait parameters were mostly found at the pelvis in toddlers with UCP and newly acquired gait. At that age, the external pelvic rotation on the affected side is more likely due to primary motor control disorders than compensatory mechanisms. These findings suggest that early rehabilitation should focus on proximal motor control, balance and symmetry to optimize gait development from the early stages in children with UCP.

Synergistic Improvement in Children with Cerebral Palsy Who Underwent Double-Course Human Wharton's Jelly Stem Cell Transplantation

Background

Our previous studies confirmed that human Wharton's Jelly stem cell (hWJSC) transplantation improved motor function in children with spastic cerebral palsy (CP). This study investigated the dose-effect relationship between the transplanted cell dosage and efficacy in CP children.

Methods

CP children who received one- or two-course (four or eight times lumbar puncture, 4 or 8 × 10⁷ hWJSCs) cell therapy were recruited into this study. Assessments of motor function were performed according to scales for gross motor function measurement (GMFM) and fine motor function measurement (FMFM). The measurement data obtained in the two different groups were analyzed by t-test. Univariate repeated measures analysis of variance was used to compare the data obtained at baseline and 6 or 12 months posttransplantation and met the conditions for Mauchly's sphericity test.

Results

The results for fifty-seven pediatric CP patients (including 35 male and 22 female patients) who completed follow-up showed that gross and fine motor functions improved after cell therapy. Interestingly, the GMFM and FMFM scores in patients who received one course of transplantation were significantly increased at 6 months after treatment. Moreover, another course of transplantation further improved gross and fine motor function in children. The scores for GMFM and FMFM were significantly higher at 6 months posttransplantation than at baseline and showed a linear upward trend. There was no gender difference in GMFM. Interestingly, there was a significant difference between male and female patients in the B and C dimensions of FMFM. These results reveal a gender-related susceptibility to stem cell therapy, especially for movement capability of the upper extremity joint and grasping ability. Similarly, in the group aged ≤3 years old, the improvement observed in dimension A (lying and rolling) of GMFM was nearly exponential and showed a quadratic trend. The results for FMFM were similar to those for GMFM. Moreover, the improvement in motor function was not age dependent.

Conclusions

In this study, our data collectively reveal that CP children display sex- or age-dependent responses to hWJSC therapy; these results shed light on the clinical utility of this approach in specific populations.

Physical therapy treatment in children with cerebral palsy after single-event multilevel surgery: a qualitative systematic review. A first step towards a clinical guideline for physical therapy after single-event multilevel surgery

BACKGROUND

The aim of this study was to review available evidence for physical therapy treatment (PTT) after single-event multilevel surgery (SEMLS), and to realize a first step towards an accurate and clinical guideline for developing effective PTT for children with cerebral palsy (CP) after SEMLS.

METHODS

A qualitative systematic review (PubMed, Medline, Embase, CINAHL, and the Cochrane Library) investigating a program of PTT after SEMLS in children aged 4-18 years with CP classified by Gross Motor Function Classification System level I-III.

RESULTS

Six articles meeting the inclusion criteria were selected. The selected studies provide only incomplete descriptions of interventions, and show no consensus regarding PTT after SEMLS. Neither do they show any consensus on the outcome measures or measuring instruments.

CONCLUSIONS

Based on the results of this literature review in combination with our best practice, we propose a preliminary protocol of PTT after SEMLS.

Effect of a Combined Stretching and Strength Training Program on Gait Function in Children with Cerebral Palsy, GMFCS Level I & II: A Randomized Controlled Trial

Background and objectives: Ambulant children with cerebral palsy (CP) often develop impaired gait, and reduced active knee extension is often a part of the problem. This study aimed to evaluate the effect of a combined intervention program including stretching and progressive resistance exercise (PRE) targeting active knee extension on gait function, in children with spastic CP. Materials and methods: Thirty-seven children (21 boys, 16 girls, mean age 10.2 (±2.3) years), classified by Gross Motor Function Classification System I-III, were randomized to an intervention (n = 17) and a comparison group (n = 20). The intervention group received a 16-week combined exercise program (3 sessions per week) including stretching of hamstrings and PRE targeting the lower extremities, followed by a 16-week maintenance program (1 session per week). The comparison group received care as usual. Gait function was evaluated by three-dimensional gait analysis (3DGA); knee, hip and pelvic kinematics in the sagittal plane, step length and speed, Gait Deviation Index (GDI), and Six-Minute Walk test (6MWT) at 0, 16, and 32 weeks. Results: There were no statistically significant differences between the intervention group and the comparison group for any of the gait parameters measured at 16 and 32 weeks. There was a significant increase in gait distance measured by 6MWT within both groups; however, no differences between the groups were found. Conclusion: A 16-week combined stretching and PRE program followed by a 16-week maintenance program did not improve gait function in ambulant children with CP.

Evaluation of biomechanical gait parameters of patients with Cerebral Palsy at three different levels of gait assistance using the CPWalker

BACKGROUND

Cerebral Palsy (CP) is the most common cause of permanent serious physical disability in childhood. Although many platforms have been developed, so far there are still not precise guidelines for the rehabilitation of the population with CP. The CPWalker is a robotic platform for the rehabilitation of children with CP, through which they can start experiencing autonomous locomotion in the rehabilitation environment. It allows the possibility of free movement and includes physical and cognitive interfaces into the therapy. The main objective of this work is to evaluate the effects of the CPWalker-based rehabilitation intervention in children with CP by comparing different gait parameters before, during and after the use of the platform.

FINDINGS

The evaluation was divided in three stages where the gait parameters and symmetry indexes of eight subjects with CP were evaluated. In the first stage patients walked only with the help they receive normally in daily life. During the second stage they walked with the CPWalker and finally, in the third stage, they repeated their gait without the platform. In all stages they wore an inertial G-Sensor ^Ⓡ while walking through the hospital facilities. The results showed statistical significant differences in several spatio-temporal parameters, pelvic angles and general gait cycle parameters, with and without the use of the robotic device. For the eight patients: cadence, speed and stride length presented similar values when comparing before and after the therapy. However, they decreased during the intervention (both means and standard deviations). No significant differences were found in the symmetry indexes with the use of the platform. In spite of this, a reduction in the pelvic angles ranges and propulsion was observed.

CONCLUSIONS

The effect of using the device was analyzed for spatio-temporal parameters, pelvic girdle angles and general gait cycle parameters. Among the eighteen initial parameters, seven presented a statistical significant difference when comparing stage 2 of the intervention with stages 1 and 3. Those changes showed the potential of the CPWalker to improve muscular strength and gait patterns of the patients with CP in the long term and to provide useful information for the design of the future generations of rehabilitation robotic devices.

iMOVE: Intensive Mobility training with Variability and Error compared to conventional rehabilitation for young children with cerebral palsy: the protocol for a single blind randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disability in children. The best opportunity to maximize lifelong independence is early in motor development when there is the most potential for neuroplastic change, but how best to optimize motor ability during this narrow window remains unknown. We have systematically developed and pilot-tested a novel intervention that incorporates overlapping principles of neurorehabilitation and infant motor learning in a context that promotes upright mobility skill and postural control development. The treatment, called iMOVE therapy, was designed to allow young children with CP to self-initiate motor learning experiences similar to their typically developing peers. This manuscript describes the protocol for a subsequent clinical trial to test the efficacy of iMOVE therapy compared to conventional therapy on gross motor development and other secondary outcomes in young children with CP.

METHODS

The study is a single-blind randomized controlled trial. Forty-two participants with CP or suspected CP between the ages of 1-3 years will be randomized to receive either the iMOVE or conventional therapy group. Distinguishing characteristics of each group are detailed. Repeated measures of gross motor function will be collected throughout the 12-24 week intervention phase and at three follow-up points over one year post therapy. Secondary outcomes include measures of postural control, physical activity, participation and caregiver satisfaction.

DISCUSSION

This clinical trial will add to a small, but growing, body of literature on early interventions to optimize the development of motor control in young children with CP. The information learned will inform clinical practice of early treatment strategies and may contribute to improving the trajectory of motor development and reducing lifelong physical disability in individuals with CP.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02340026 . Registered January 16, 2015.

An Untethered Ankle Exoskeleton Improves Walking Economy in a Pilot Study of Individuals With Cerebral Palsy

The high energy cost of walking in individuals with cerebral palsy (CP) contributes significantly to reduced mobility and quality of life. The purpose of this paper was to develop and clinically evaluate an untethered ankle exoskeleton with the ability to reduce the metabolic cost of walking in children and young adults with gait pathology from CP. We designed a battery-powered device consisting of an actuator-and-control module worn above the waist with a Bowden cable transmission used to provide torque to pulleys aligned with the ankle. Special consideration was made to minimize adding mass to the body, particularly distal portions of the lower-extremity. The exoskeleton provided plantar-flexor assistance during the mid-to-late stance phase, controlled using a real-time control algorithm and embedded sensors. We conducted a device feasibility and a pilot clinical evaluation study with five individuals with CP ages five through thirty years old. Participants completed an average of 130 min of exoskeleton-assisted walking practice. We observed a 19±5% improvement in the metabolic cost of transport (p = 0.011) during walking with untethered exoskeleton assistance compared to how participants walked normally. These preliminary findings support the future investigation of powered ankle assistance for improving mobility in this patient population.

Does Home-Based Progressive Resistance or High-Intensity Circuit Training Improve Strength, Function, Activity or Participation in Children With Cerebral Palsy?

OBJECTIVE

Does home-based progressive resistance or high-intensity circuit training improve strength, function, activity, or participation in children with cerebral palsy (CP)?

DESIGN

This was the first study on high-intensity circuit training for children with CP. This study was conducted as a randomized prospective controlled pilot study.

SETTING

Evaluation took place at the gait laboratory of the university hospital, training sessions were performed at home.

PARTICIPANTS

Children (N=22) with CP (average age: 12y, 10mo, 19 Gross Motor Function Classification System level I, 3 level II) were randomly assigned either to progressive resistance training (PRT) or high-intensity circuit training (HICT).

INTERVENTIONS

The PRT group trained with progressive overload, while the HICT group performed as many repetitions as possible within 30-second intervals (8wk, 3 times weekly in both groups).

MAIN OUTCOME MEASURES

Outcome measures stretched over all domains of the International Classification of Functioning, Disability and Health and included muscle strength, muscle power sprint test (MPST), timed stairs test (TST), 6-minute walking test, Gait Profile Score (GPS), timed Up and Go test (TUGT) and participation questionnaires.

RESULTS

Only the HICT group was able to improve strength. Furthermore, the HICT group scored better in the MPST, while PRT participants improved in the TST and TUGT. The HICT-group was able to show improvement in the subscores of the parent-reported participation questionnaire. Other measures of mobility or participation did not change.

CONCLUSIONS

Both programs improved function specific to intervention. However, only the HICT group showed significant strength and participation improvements. Compliance was decent in both groups, but the average training unit was shorter in the HICT group. Both exercise programs showed functional benefits, but HICT might be the preferable option for strengthening in highly functional children with CP.

Combined Anterior and Posterior Lumbar Rhizotomy for Treatment of Mixed Dystonia and Spasticity in Children With Cerebral Palsy

BACKGROUND

Children with cerebral palsy (CP) can present with severe secondary dystonia with or without associated spasticity of their extremities.

OBJECTIVE

To assess the outcomes of combined anterior and posterior lumbar rhizotomy for the treatment of mixed hypertonia in the lower extremities of children with CP.

METHODS

Fifty children with CP were subjected to combined anterior and posterior lumbar rhizotomies in a prospective study. Clinical outcome measurements were recorded preoperatively and were evaluated at 2, 6, and 12 months postoperatively. The operative techniques were performed by laminotomy from L1-S1, and intraoperative monitoring was used in all cases. All patients underwent intensive postoperative physiotherapy programs.

RESULTS

Changes in muscle tone, joint range of motion, and dystonia were significant (P = .000) at postoperative assessment visits.

CONCLUSION

This study demonstrated the potential of combined anterior and posterior lumbar rhizotomies to improve activities of daily living in children with CP and with mixed spasticity and dystonia.

ABBREVIATIONS

BAD, Barry-Albright Dystonia ScaleCAPR, combined anterior and posterior lumbar rhizotomyCP, cerebral palsyITB, intrathecal baclofenMAS, modified Ashworth ScaleROM, range of motionSDR, selective dorsal rhizotomy.

The Effects of Exoskeleton Assisted Knee Extension on Lower-Extremity Gait Kinematics, Kinetics, and Muscle Activity in Children with Cerebral Palsy

Individuals with cerebral palsy often exhibit crouch gait, a debilitating and inefficient walking pattern marked by excessive knee flexion that worsens with age. To address the need for improved treatment, we sought to evaluate if providing external knee extension assistance could reduce the excessive burden placed on the knee extensor muscles as measured by knee moments. We evaluated a novel pediatric exoskeleton designed to provide appropriately-timed extensor torque to the knee joint during walking in a multi-week exploratory clinical study. Seven individuals (5-19 years) with mild-moderate crouch gait from cerebral palsy (GMFCS I-II) completed the study. For six participants, powered knee extension assistance favorably reduced the excessive stance-phase knee extensor moment present during crouch gait by a mean of 35% in early stance and 76% in late stance. Peak stance-phase knee and hip extension increased by 12° and 8°, respectively. Knee extensor muscle activity decreased slightly during exoskeleton-assisted walking compared to baseline, while knee flexor activity was elevated in some participants. These findings support the use of wearable exoskeletons for the management of crouch gait and provide insights into their future implementation.

Long-term follow-up after tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy

Using Tibialis Anterior Shortening (TATS) in combination with Achilles Tendon Lengthening (TAL) to treat spastic equinus in children with cerebral palsy (CP) was described in 2011. Short-term results have indicated a good outcome, especially an improvement of the drop foot in swing phase and the correction of equinus in stance phase. The aim of this study was to analyse the results of the long-term follow-up and to determine the relapse rate of TATS and TAL. The kinematics of the sagittal, frontal and transversal planes were measured by using instrumented 3D gait analysis at three defined time points and then described using the Gait Profile Score (GPS) and Movement Analysis Profile (MAP). The data was exported into Gaitabase and then the preoperative (T0), short- term (T1) and long-term (T2) follow-up data was statistically compared. 23 patients (mean age at index-surgery=14.9years) were included, there was a mean follow-up time of 5.8 years. 3 children (13%) have shown a relapse. The data of 12 children with spastic hemiplegia (12 legs), as well as 8 children with spastic diplegia (10 legs) has been analysed. There has been a significant (p<0.05) improvement in GPS and MAP for ankle dorsiflexion (describes equinus and drop foot) of the operated legs versus not operated legs. TATS in combination with TAL shows a satisfactory long-term result after 5.8 years in the correction of fixed equinus and drop foot in children with CP. Postoperatively all subjects were able to walk without an AFO.

A lower-extremity exoskeleton improves knee extension in children with crouch gait from cerebral palsy

The ability to walk contributes considerably to physical health and overall well-being, particularly in children with motor disability, and is therefore prioritized as a rehabilitation goal. However, half of ambulatory children with cerebral palsy (CP), the most prevalent childhood movement disorder, cease to walk in adulthood. Robotic gait trainers have shown positive outcomes in initial studies, but these clinic-based systems are limited to short-term programs of insufficient length to maintain improved function in a lifelong disability such as CP. Sophisticated wearable exoskeletons are now available, but their utility in treating childhood movement disorders remains unknown. We evaluated an exoskeleton for the treatment of crouch (or flexed-knee) gait, one of the most debilitating pathologies in CP. We show that the exoskeleton reduced crouch in a cohort of ambulatory children with CP during overground walking. The exoskeleton was safe and well tolerated, and all children were able to walk independently with the device. Rather than guiding the lower limbs, the exoskeleton dynamically changed the posture by introducing bursts of knee extension assistance during discrete portions of the walking cycle, a perturbation that resulted in maintained or increased knee extensor muscle activity during exoskeleton use. Six of seven participants exhibited postural improvements equivalent to outcomes reported from invasive orthopedic surgery. We also demonstrate that improvements in crouch increased over the course of our multiweek exploratory trial. Together, these results provide evidence supporting the use of wearable exoskeletons as a treatment strategy to improve walking in children with CP.

Exergaming with a pediatric exoskeleton: Facilitating rehabilitation and research in children with cerebral palsy

Effective rehabilitation of children with cerebral palsy (CP) requires intensive task-specific exercise but many in this population lack the motor capabilities to complete the desired training tasks. Providing robotic assistance is a potential solution yet the effects of this assistance are unclear. We combined a novel exoskeleton and exercise video game (exergame) to create a new rehabilitation paradigm for children with CP. We incorporated high density electroencephalography (EEG) to assess cortical activity. Movement to targets in the game was controlled by knee extension while standing. The distance between targets was the same with and without the exoskeleton to isolate the effect of robotic assistance. Our results show that children with CP maintain or increase knee extensor muscle activity during knee extension in the presence of synergistic robotic assistance. Our EEG findings also demonstrate that participants remained engaged in the exercise with robotic assistance. Interestingly we observed a developmental trajectory of sensorimotor mu rhythm in children with CP similar, though delayed, to those reported in typically developing children. While not the goal here, the exoskeleton significantly increased knee extension in 3/6 participants during use. Future work will focus on utilizing the exoskeleton to enhance volitional knee extension capability and in combination with EMG and EEG to study sensorimotor cortex response to progressive exercise in children with CP.

Effects of an Off-Axis Pivoting Elliptical Training Program on Gait Function in Persons With Spastic Cerebral Palsy: A Preliminary Study

This preliminary study examined the effects of off-axis elliptical training on reducing transverse-plane gait deviations and improving gait function in 8 individuals with cerebral palsy (CP) (15.5 ± 4.1 years) who completed an training program using a custom-made elliptical trainer that allows transverse-plane pivoting of the footplates during exercise. Lower-extremity off-axis control during elliptical exercise was evaluated by quantifying the root-mean-square and maximal angular displacement of the footplate pivoting angle. Lower-extremity pivoting strength was assessed. Gait function and balance were evaluated using 10-m walk test, 6-minute-walk test, and Pediatric Balance Scale. Toe-in angles during gait were quantified. Participants with CP demonstrated a significant decrease in the pivoting angle (root mean square and maximal angular displacement; effect size, 1.00-2.00) and increase in the lower-extremity pivoting strength (effect size = 0.91-1.09) after training. Reduced 10-m walk test time (11.9 ± 3.7 seconds vs. 10.8 ± 3.0 seconds; P = 0.004; effect size = 1.46), increased Pediatric Balance Scale score (43.6 ± 12.9 vs. 45.6 ± 10.8; P = 0.042; effect size = 0.79), and decreased toe-in angle (3.7 ± 10.5 degrees vs. 0.7 ± 11.7 degrees; P = 0.011; effect size = 1.22) were observed after training. We present an intervention to challenge lower-extremity off-axis control during a weight-bearing and functional activity for individuals with CP. Our preliminary findings suggest that this intervention was effective in enhancing off-axis control, gait function, and balance and reducing in-toeing gait in persons with CP.

Treadmill exercise improves motor and memory functions in cerebral palsy rats through activation of PI3K-Akt pathway

Cerebral palsy (CP) is a chronic disorder characterized by physical disability and disruption of brain function. We evaluated the effects of treadmill exercise on motor and memory functions in relation with phosphatidylinositol 3-kinase (PI3K)-Akt pathway using CP rat model. Rota-rod test, step-down avoidance task, 5-bromo-2′-deoxyuridine (BrdU) immunohistochemistry, and western blot for synapsin I, postsynaptic density-95 (PSD-95), PI3K, Akt, and glycogen synthase kinase-3β (GSK-3β) were performed. CP was induced by maternal lipopolysaccharide (LPS)-injection with sensorimotor restriction. Five weeks after birth, the rats in the exercise groups were made to run on the treadmill for 30 min per one day, 5 times a week, during 4 weeks. Motor and memory functions were impaired in the LPS-induced CP rats and tread-mill exercise increased motor and memory functions in the CP rats. Cell proliferation in the hippocampus was suppressed in the LPS-induced CP rats and treadmill exercise increased hippocampal cell proliferation in the CP rats. Expressions of synapsin I, PSD-95, phosphorylated (p)-PI3K, and p-Akt were decreased in the LPS-induced CP rats and treadmill exercise enhanced the expressions of synapsin I, PSD-95, p-PI3K, and p-Akt in the CP rats. GSK-3β expression was increased in the LPS-induced CP rats and treadmill exercise suppressed GSK-3β expression in the CP rats. The present results suggest that treadmill exercise might improve motor and memory functions through activation of PI3K-Akt pathway.

Family Dog-Assisted Adapted Physical Activity: A Case Study

Purpose: The aim of this case study was to examine the individual effects of an adapted physical activity, animal-assisted intervention (APA-AAI) with the family dog on motor skills, physical activity, and quality of life of a child with cerebral palsy (CP). Method: This study used an A-B-A single-subject design. The assessment phase (phase A) occurred pre- and post-intervention. This consisted of standardized assessments of motor skills, quality of life questionnaires, physical activity (measured using the GT3X+ accelerometer) and the human-animal bond. The intervention (phase B) lasted 8 weeks and consisted of adapted physical activities performed with the family dog once a week for 60 min in a lab setting. In addition, the participant had at-home daily activities to complete with the family dog. Results: Visual analysis was used to analyze the data. Motor skill performance, physical activity, quality of life and human animal interaction gains were observed in each case. Conclusions: These preliminary results provided initial evidence that the family-dog can play a role in healthy lifestyles through APA-AAI in children with CP.

A Robotic Exoskeleton for Treatment of Crouch Gait in Children With Cerebral Palsy: Design and Initial Application

Crouch gait, a pathological pattern of walking characterized by excessive knee flexion, is one of the most common gait disorders observed in children with cerebral palsy (CP). Effective treatment of crouch during childhood is critical to maintain mobility into adulthood, yet current interventions do not adequately alleviate crouch in most individuals. Powered exoskeletons provide an untapped opportunity for intervention. The multiple contributors to crouch, including spasticity, contracture, muscle weakness, and poor motor control make design and control of such devices challenging in this population. To our knowledge, no evidence exists regarding the feasibility or efficacy of utilizing motorized assistance to alleviate knee flexion in crouch gait. Here, we present the design of and first results from a powered exoskeleton for extension assistance as a treatment for crouch gait in children with CP. Our exoskeleton, based on the architecture of a knee-ankle-foot orthosis, is lightweight (3.2 kg) and modular. On board sensors enable knee extension assistance to be provided during distinct phases of the gait cycle. We tested our device on one six-year-old male participant with spastic diplegia from CP. Our results show that the powered exoskeleton improved knee extension during stance by 18.1° while total knee range of motion improved 21.0°. Importantly, we observed no significant decrease in knee extensor muscle activity, indicating the user did not rely solely on the exoskeleton to extend the limb. These results establish the initial feasibility of robotic exoskeletons for treatment of crouch and provide impetus for continued investigation of these devices with the aim of deployment for long term gait training in this population.

Home-Based Versus Laboratory-Based Robotic Ankle Training for Children With Cerebral Palsy: A Pilot Randomized Comparative Trial

OBJECTIVE

To examine the outcomes of home-based robot-guided therapy and compare it to laboratory-based robot-guided therapy for the treatment of impaired ankles in children with cerebral palsy.

DESIGN

A randomized comparative trial design comparing a home-based training group and a laboratory-based training group.

SETTING

Home versus laboratory within a research hospital.

PARTICIPANTS

Children (N=41) with cerebral palsy who were at Gross Motor Function Classification System level I, II, or III were randomly assigned to 2 groups. Children in home-based and laboratory-based groups were 8.7±2.8 (n=23) and 10.7±6.0 (n=18) years old, respectively.

INTERVENTIONS

Six-week combined passive stretching and active movement intervention of impaired ankle in a laboratory or home environment using a portable rehabilitation robot.

MAIN OUTCOME MEASURES

Active dorsiflexion range of motion (as the primary outcome), mobility (6-minute walk test and timed Up and Go test), balance (Pediatric Balance Scale), Selective Motor Control Assessment of the Lower Extremity, Modified Ashworth Scale (MAS) for spasticity, passive range of motion (PROM), strength, and joint stiffness.

RESULTS

Significant improvements were found for the home-based group in all biomechanical outcome measures except for PROM and all clinical outcome measures except the MAS. The laboratory-based group also showed significant improvements in all the biomechanical outcome measures and all clinical outcome measures except the MAS. There were no significant differences in the outcome measures between the 2 groups.

CONCLUSIONS

These findings suggest that the translation of repetitive, goal-directed, biofeedback training through motivating games from the laboratory to the home environment is feasible. The benefits of home-based robot-guided therapy were similar to those of laboratory-based robot-guided therapy.

Long-term ambulatory change after lower extremity orthopaedic surgery in children with cerebral palsy: a retrospective review

BACKGROUND

Long-term studies of lower extremity orthopaedic surgery in children with cerebral palsy (CP) tend to focus on gait kinematics and kinetics, with little to no emphasis on gross motor ambulatory function. The current study was undertaken to examine the long-term impact of surgery on ambulatory function in patients with CP enrolled in a government-funded, outpatient therapy program.

METHODS

Retrospective medical record review was conducted of 127 children with CP, Gross Motor Function Classification System (GMFCS) levels I to IV, followed up to 14 years after lower extremity orthopaedic surgery. Data were extracted from medical/operative records and routine physical therapy evaluations performed over the course of follow-up. Functional Mobility Scale (FMS) scores were assigned based on gross motor function information contained in each 6- to 12-month physical therapy evaluation. Data were compared statistically among GMFCS levels.

RESULTS

Average length of follow up was 11.8±4 years. Subjects underwent 0.61±0.43 surgical procedures per person-year in 0.16±0.09 operative sessions per person-year with no differences between GMFCS levels. Subjects at GMFCS level I improved significantly in community (P=0.02) but not household ambulation, reflecting the ceiling effect of the FMS. Subjects at GMFCS levels II to IV showed statistically significant improvements at all distances. Subjects at level III gained more in household than long-distance ambulation (P=0.002). Subjects functioning at GMFCS level II improved by 1 FMS level for household and school distances, and 2 FMS levels for community distances (P<0.02). Subjects at level IV exhibited small ambulatory gains at all distances (P<0.04).

CONCLUSIONS

Significant long-term improvement in functional ambulation is seen after surgery for children at all GMFCS levels. Children with more independence tend to make gains in long-distance ambulation, whereas those who use assistive devices tend to improve more in short-distance ambulation. This information may be useful to clinicians when counseling patients and their families regarding potential for ambulatory improvement after lower extremity orthopaedic surgery.

LEVEL OF EVIDENCE

Level IV: case series.

Feasibility of using a large amplitude movement therapy to improve ambulatory function in children with cerebral palsy

Cerebral palsy (CP) is the most common cause of motor disability among children. Limited evidence exists regarding the efficacy of traditional rehabilitation strategies on improving ambulatory function in this population. The purpose of the study was to investigate the feasibility and short-term effects of a novel large amplitude movement therapy on ambulatory functions in children with CP. Temporal-spatial gait characteristics were examined before and after a single intervention session, replicated over five children. Five children with CP (7.0 ± 1.0 years); Gross Motor Function Classification System Levels I-II, participated. Baseline gait parameters were obtained as the participant walked across an instrumented walkway at self-selected and fast speeds. Children then participated in a 20-30 min intervention focused on making body and limb movements as large as possible with gait assessment repeated immediately. All children tolerated testing and therapy with no adverse effects. Outcomes after one intervention included: significantly greater stride velocity; reduced double support time; and greater stride length after training for three of the five participants. Results for this pilot study suggested that the large amplitude movement therapy was feasible for children with CP. There is a need for a larger scale study to determine if the protocol can be effective at an appropriate clinical dose.

Selective dorsal rhizotomy for spastic diplegia secondary to stroke in an adult patient

Background:

Selective dorsal rhizotomy (SDR) is often recommended for children with spastic paraparesis and cerebral palsy. SDR reduces spasticity in the lower extremities for these children with spastic paraplegia. However, SDR is infrequently recommended for adults with spasticity. Spastic diplegia in adult patients can be due to stroke, brain or spinal cord injury from trauma, infection, toxic-metabolic disorders, and other causes. Although rarely considered, SDR is an option for adult patients with spastic diplegia as well.

Case Description:

The authors describe a patient who underwent a SDR with a successful postoperative outcome. This man suffered a hypertensive and hemorrhagic stroke secondary to intravenous drug abuse at age 46. A SDR was performed after two failed intrathecal baclofen pump placements due to recurrent infections, likely resulting from his immunocompromised status. The patient underwent lumbar laminectomies and dorsal rhizotomies at levels L1-S1 bilaterally. Postoperatively, the patient's spasticity was significantly reduced. His Ashworth spasticity score decreased from 4/5 to 1/5, and the reduction in tone has been durable over 3 years.

Conclusion:

SDR in older patients with spastic paraparesis may be considered as a treatment option.

The effects of whole body vibration on mobility and balance in children with cerebral palsy: a systematic review with meta-analysis

OBJECTIVE

We performed a meta-analysis to evaluate the effects of whole-body vibration on physiologic and functional measurements in children with cerebral palsy.

DESIGN AND METHODS

We searched MEDLINE, Cochrane Controlled Trials Register, EMBASE, Scielo, CINAHL (from the earliest date available to November 2014) for randomized controlled trials, that aimed to investigate the effects of whole-body vibration versus exercise and/or versus control on physiologic and functional measurements in children with cerebral palsy. Two reviewers independently selected the studies. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Six studies with 176 patients comparing whole-body vibration to exercise and/or control were included. Whole-body vibration resulted in improvement in: gait speed WMDs (0.13 95% CI: 0.05 to 0.20); gross motor function dimension E WMDs (2.97 95% CI: 0.07 to 5.86) and femur bone density (1.32 95% CI: 0.28 to 2.36). The meta-analysis also showed a nonsignificant difference in muscle strength and gross motor function dimension D for participants in the whole-body vibration compared with control group. No serious adverse events were reported.

CONCLUSIONS

Whole-body vibration may improve gait speed and standing function in children with cerebral palsy and could be considered for inclusion in rehabilitation programs.

Effect of backward walking training on postural balance in children with hemiparetic cerebral palsy: a randomized controlled study

OBJECTIVE

To study the effect of additional backward walking training on postural control in children with hemiparetic cerebral palsy.

DESIGN

Randomized controlled study.

SETTING

Physical therapy clinics.

SUBJECTS

Thirty spastic hemiparetic cerebral palsied children of both sexes (10-14 years, 14 girls and 16 boys).

INTERVENTION

Children were randomly assigned into two equal groups: experimental and control groups. Both groups received a traditional physical therapy program for 12 weeks. Experimental group additionally received backward walking training which was provided 25 min/day, 3 days/week for 3 successive months.

OUTCOME MEASURES

Baseline and post-treatment assessment for overall, anteroposterior, and mediolateral stability indices were evaluated by using Biodex balance system.

RESULTS

After treatment; two way ANOVA revealed significant improvement in overall, anteroposterior and mediolateral stability indices of experimental group at the most stable level (level 12) and moderately unstable level (level 7) (1.40 ± 0.44 and 1.73 ± 0.51; 1.11 ± 0.34 and 2.13 ± 0.52; 1.93 ± 0.51 and 2.68 ± 0.52) respectively, than control group (1.77 ± 0.44 and 2.17 ± 0.56; 1.44 ± 0.44 and 2.54 ± 0.49; 2.39 ± 0.65 and 3.11 ± 0.49) respectively, (P < 0.05). There were significant improvement in all measured variables for both groups at both levels (P < 0.05).

CONCLUSION

Additional backward walking training to traditional physical therapy program yields improvement in postural stability indices in children with spastic hemiparetic cerebral palsy than traditional physical therapy alone.

How does the functional mobility scale relate to capacity-based measures of walking ability in children and youth with cerebral palsy?

This study examined the relationship between walking performance rated on the Functional Mobility Scale (FMS) and measures of walking capacity in children with cerebral palsy (CP). A total of 143 participants with spastic CP (GMFCS levels I to III) were rated on the FMS and had assessment of self-selected walking speed (WS), fast 1 minute walk test (1MWT) and six minute walk test (6MWT). For each FMS distance, children rated 6 had significantly better 6MWT than children scored 5; children rated FMS 2, 3, or 4 had lower walking capacity measures but were not clearly distinguishable from each other. The 6MWT was an independent predictor of variation in FMS score, accounting for 20% to 27% of the variance across the three FMS distances. While walking capacity impacts on community mobility in children with CP much of the variance remains unexplained, suggesting that other factors play an important role.

Reliability and validity of the Korean version of the trunk control measurement scale (TCMS-K) for children with cerebral palsy

The Trunk Control Measurement Scale (TCMS) was developed by Lieve Heyrman in 2011 to evaluate the clinical features of impaired trunk control ability in patients with cerebral palsy (CP). This study aimed to demonstrate the reliability and validity of the Korean version of the Trunk Control Measurement Scale (TCMS-K) for children with CP. Fifty children with spastic CP (mean age 9.08±3.75) participated in the study. They were classified using the Gross Motor Function Classification System and the Manual Ability Classification System. The intraclass correlation coefficient (ICC) value of the inter-rater reliability for the TCMS-K was .987-.998, and the intra-rater reliability was .947-.996. The Spearman rank correlation coefficient between the TCMS-K and the Gross Motor Function Measure-B dimension was .860. The results of the study support that the TCMS-K has a high reliability and validity, which is similar to the original version. Thus, the TCMS-K is a suitable evaluation tool to assess the qualitative performance of trunk control and sitting balance for children with CP, and we expect that it will be a very useful tool for clinicians and researchers.

NeuroGame Therapy to improve wrist control in children with cerebral palsy: a case series

OBJECTIVE

This case series examines the feasibility, specificity, and preliminary effectiveness of NeuroGame Therapy (NGT) for improving wrist control in four children with cerebral palsy (CP). NGT uses surface electromyographic (sEMG) signals routed through motivating computer games to improve motor control.

METHODS

Primary outcomes of NGT included feasibility (hours of play) and specificity (changes in sEMG activity during game play). Secondary outcomes included changes in co-contraction, range of motion, segmental alignment, and spontaneous upper extremity function following intervention.

RESULTS

Participants completed a mean of 8.8 hours of NGT over 5-6 weeks. Participants demonstrated dramatic improvement of the sEMG activity during game play. Several participants also showed improvements in range of motion, co-contraction, and spontaneous upper extremity function following NGT.

CONCLUSION

This case series provides evidence for the feasibility, specificity, and effectiveness of NGT. Future studies will pair NGT with functional practice to improve transfer of learning to daily activities.

Spatio-temporal gait analysis in children with cerebral palsy using, foot-worn inertial sensors

A child's natural gait pattern may be affected by the gait laboratory environment. Wearable devices using body-worn sensors have been developed for gait analysis. The purpose of this study was to validate and explore the use of foot-worn inertial sensors for the measurement of selected spatio-temporal parameters, based on the 3D foot trajectory, in independently walking children with cerebral palsy (CP). We performed a case control study with 14 children with CP aged 6-15 years old and 15 age-matched controls. Accuracy and precision of the foot-worn device were measured using an optical motion capture system as the reference system. Mean accuracy ± precision for both groups was 3.4 ± 4.6 cm for stride length, 4.3 ± 4.2 cm/s for speed and 0.5 ± 2.9° for strike angle. Longer stance and shorter swing phases with an increase in double support were observed in children with CP (p=0.001). Stride length, speed and peak angular velocity during swing were decreased in paretic limbs, with significant differences in strike and lift-off angles. Children with cerebral palsy showed significantly higher inter-stride variability (measured by their coefficient of variation) for speed, stride length, swing and stance. During turning trajectories speed and stride length decreased significantly (p<0.01) for both groups, whereas stance increased significantly (p<0.01) in CP children only. Foot-worn inertial sensors allowed us to analyze gait spatiotemporal data outside a laboratory environment with good accuracy and precision and congruent results with what is known of gait variations during linear walking in children with CP.

Robot-assisted and computer-enhanced therapies for children with cerebral palsy: current state and clinical implementation

The field of pediatric neurorehabilitation has rapidly evolved with the introduction of technological advancements over recent years. Rehabilitation robotics and computer-assisted systems can complement conventional physiotherapeutics or occupational therapies. These systems appear promising, especially in children, where exciting and challenging virtual reality scenarios could increase motivation to train intensely in a playful therapeutic environment. Despite promising experience and a large acceptance by the patients and parents, so far, only a few therapy systems have been evaluated in children, and well-designed randomized controlled studies in this field are still lacking. This narrative review aims to provide an overview about the to-date robot-assisted and computer-based therapies and the current level of evidence and to share the authors experience about the clinical implication of these new technologies available for children with cerebral palsy.

Influence of modified solid ankle-foot orthosis to be used with and without shoe on dynamic balance and gait characteristic in asymptomatic people

BACKGROUND

Ankle-foot orthoses are usually used in combination with footwear. Shoe design can have a significant effect on kinematics of the lower limb joints and line of action of the ground reaction force during walking. But, ankle-foot orthosis-footwear combination is not appropriate for indoor barefoot walking in some Asian cultures. In this study, we have modified a solid ankle-foot orthosis in order to set it in the same position as a solid ankle-foot orthosis-footwear combination.

OBJECTIVE

To investigate the effect of a modified solid ankle-foot orthosis; a solid ankle-foot orthosis which can be locked in different positions on gait and balance performance in comparison with a conventional solid ankle-foot orthosis, a common solid ankle-foot orthosis-shoe combination in asymptomatic adults.

STUDY DESIGN

Cross sectional.

METHODS

Two standard solid ankle-foot orthoses were manufactured with the ankle joint in neutral position. Then, one of these solid ankle-foot orthoses was modified in order to allow locking in a different alignment. Walk across, limit of stability, and sit-to-stand tests of the balance master system were performed while participants wore the modified solid ankle-foot orthosis aligned in 5°-7° anterior inclination without a shoe and a conventional solid ankle-foot orthosis-shoe combination.

RESULTS

There was no significant change in walking speed, step length, and step width with the conventional and modified solid ankle-foot orthoses. In addition, movement velocity and maximum excursion of the center of gravity during the limit of stability test were not different, although the maximal forward excursion of the center of gravity was longer when wearing the modified solid ankle-foot orthosis compared to the conventional solid ankle-foot orthosis-shoe combination (P = 0.000). Sway velocity of the center of gravity did not change during the sit-to-stand test.

CONCLUSION

The results demonstrated that the modified solid ankle-foot orthosis had the same effects as the conventional solid ankle-foot orthosis-shoe combination on the gait and balance performance of asymptomatic adults. Clinical relevance The findings of the present study can be used as the basis for further investigations on the efficacy of the modified solid ankle-foot orthoses in different neuromuscular populations in order to help people who do not wear shoes at home, as is the custom in some Asian cultures.