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

Effect of Robotic Rehabilitation on Hand Functions and Quality of Life in Children With Cerebral Palsy: A Prospective Randomized Controlled Study

OBJECTIVE

This study aimed to examine the impact of robotic hand rehabilitation on hand function and quality of life in children with cerebral palsy.

DESIGN

Children with cerebral palsy aged 7-16 yrs were divided into robotic rehabilitation ( n = 9) or conventional rehabilitation ( n = 10) groups for hand rehabilitation of 30 sessions. The primary outcomes were the Fugl-Meyer Assessment for Upper Extremity and Box and Block Test. The secondary outcomes were the Manual Ability Classification System, modified Ashworth scale, hand grasp and finger strengths, ABILHAND-Kids, Functional Independence Measure for Children, and PedsQL Quality of Life Inventory-CP Module.

RESULTS

In the robotic rehabilitation group, a significant improvement was found in all parameters after treatment ( P < 0.05), except for the Functional Independence Measure ( P = 0.081). In the conventional rehabilitation group, there was significant improvement after treatment in the modified Ashworth scale, Fugl-Meyer Assessment for Upper Extremity, hand grasp strength, Box and Block Test, ABILHAND-Kids, and PedsQL Quality of Life Inventory-CP Module ( P < 0.05). Before and after treatment, all outcome parameters in the groups were similar ( P > 0.05).

CONCLUSIONS

Robotic hand rehabilitation is effective in improving motor function, manual dexterity, spasticity, and quality of life in children with cerebral palsy. However, it was not demonstrated to be superior to conventional rehabilitation.

Treatment with robot-assisted gait trainer Walkbot along with physiotherapy vs. isolated physiotherapy in children and adolescents with cerebral palsy. Experimental study

BACKGROUND

Improving walking ability is a key objective in the treatment of children and adolescents with cerebral palsy, since it directly affects their activity and participation. In recent years, robotic technology has been implemented in gait treatment, which allows training of longer duration and repetition of the movement. To know the effectiveness of a treatment with the robotic-assisted gait trainer Walkbot combined with physiotherapy compared to the isolated physiotherapy treatment in children and adolescents with cerebral palsy, we carried out a clinical trial.

METHODS

23 participants, were divided into two groups: experimental and control. During 5 weeks, both groups received their physiotherapy sessions scheduled, in addition experimental group received 4 sessions per week of 40 min of robot. An evaluation of the participants was carried out before the intervention, at the end of the intervention, and at follow-up (two months after the end of the intervention). Gait was assessed with the Gross Motor Function Measure-88 dimensions D and E, strength was measured with a hydraulic dynamometer, and range of motion was assessed using the goniometer. A mixed ANOVA was performed when the assumptions of normality and homoscedasticity were met, and a robust mixed ANOVA was performed when these assumptions were not met. Statistical significance was stipulated at p < 0.05. For the effect size, η2 was calculated.

RESULTS

Significant differences were found regarding the time x group interaction in the Gross Motor Function Measure-88 in dimension D [η2 = 0.016], in the flexion strength of the left [η2 = 0.128] and right [η2 = 0.142] hips, in the extension strength of the right hip [η2 = 0.035], in the abduction strength of the left hip [η2 = 0.179] and right [η2 = 0.196], in the flexion strength of the left knee [η2 = 0.222] and right [η2 = 0.147], and in the range of motion of left [η2 = 0.071] and right [η2 = 0.053] knee flexion.

CONCLUSIONS

Compared to treatments without walking robot, physiotherapy treatment including Walkbot improves standing, muscle strength, and knee range of motion in children and adolescents with cerebral palsy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04329793. First posted: April 1, 2020.

Joystick-Operated Ride-On Toy Navigation Training for Children With Hemiplegic Cerebral Palsy: A Pilot Study

IMPORTANCE

Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

OBJECTIVE

To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

OUTCOMES AND MEASURES

We assessed children's acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children's affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

RESULTS

Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

CONCLUSIONS AND RELEVANCE

Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP. Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick-operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children's motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

The Role of Immersive Virtual Reality Interventions in Pediatric Cerebral Palsy: A Systematic Review across Motor and Cognitive Domains

Background: In recent years, new technologies have been applied in cerebral palsy. Among these, immersive virtual reality is one with promising motor and cognitive effects along with the reduced costs of its application. The level of immersion of the subject in the illusional world gives the feeling of being a real part of the virtual environment. This study aims to investigate the safety and the efficacy of immersive virtual reality in children affected by cerebral palsy. Methods: PubMed, Embase, Cochrane Database of Systematic Reviews, RehabData, and Web of Science were screened up to February 2023 to identify eligible clinical studies. Results: Out of 788, we included 15 studies involving CP patients. There was high heterogeneity in the outcomes considered, and the results showed non-inferiority to conventional therapy and initial additional benefits in comparison with conventional rehabilitation. Conclusions: Immersive virtual reality emerges as a pivotal technological tool in rehabilitation, seamlessly integrating with conventional therapy within CP rehabilitation programs. Indeed, it not only enhances motivation but significantly increases children's functional capacity and abilities.

The 'heROIC' trial: Does the use of a robotic rehabilitation trainer change quality of life, range of movement and function in children with cerebral palsy?

BACKGROUND

Children with severe cerebral palsy (CP) (GMFCS IV/V) can find it difficult to access equipment that allows them to exercise effectively, potentially impacting their quality of life. Physiotherapists working within special schools are well placed to facilitate increased physical activity as part of the school day. This study explored whether the Innowalk Pro, a robotic rehabilitation trainer, could influence quality of life (measured by the CPCHILD questionnaire), in children with CP, alongside, joint range of movement, spasticity and functional goals of the lower limbs, measured by goniometry, modified Tardieu scale and goal attainment scoring, GAS, respectively.

METHODS

A prospective single-arm, pre-post trial was undertaken. The Innowalk Pro was used four times a week for 30 min alongside usual physiotherapy care in a school setting over a 6-week period. Outcomes were evaluated immediately pre/post intervention and at 6 weeks and 3 months post intervention. Analysis also explored differences between primary and secondary age participants.

RESULTS

Twenty-seven participants aged 5-18 years with a diagnosis of CP GMFCS IV/V (10 female, 17 male, mean age 12 years) were included from a convenience sample in a special school. Quality of life improved in 36% of participants, the majority of these being secondary aged. Knee extension reduced significantly 3 months post intervention. There were no meaningful changes in spasticity. GAS goals improved in 88% of participants after using the Innowalk Pro. GAS goals tended to decline after a break from using the equipment, with 21% declining by two or more units at 3 months post intervention.

CONCLUSION

A 6-week course of the Innowalk Pro can improve quality of life and functional goals for children with CP aged 5-18 years. After a break of 6-12 weeks, functional goals tend to return to baseline. Further research is needed to explore different prescriptions of the Innowalk Pro, to see if increasing the time used/increasing the frequency or number of weeks it is used for can provide longer lasting benefits.

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.

Test-retest reliability of upper limb robotic exoskeleton assessments in children and youths with brain lesions

In children with congenital or acquired brain lesions, impaired upper limb function can affect independence. Assessing upper limb function is important for planning and evaluating neurorehabilitative interventions. Robotic devices increase measurement-objectivity and enable measuring parameters reflecting more complex motor functions. We investigated the relative and absolute test–retest reliability of assessments to measure upper limb functions in children and adolescents with brain lesions with the exoskeleton ChARMin. Thirty children (9 females, mean age ± SD = 12.5 ± 3.3 years) with congenital brain injuries (n = 15), acquired (n = 14), both (n = 1) and impaired upper limb function participated. They performed the following ChARMin assessments and repeated them within three to seven days: active and passive Range of Motion (ROM), Strength, Resistance to Passive Movement, Quality of Movement, Circle, and Workspace. We calculated the systematic difference, Intraclass Correlation Coefficient (ICC) and Smallest Real Difference (SRD) for each parameter. Six parameters of three assessments showed systematic errors. ICCs ranged from little to very high and SRD values varied considerably. Test–retest reliability and measurement errors ranged widely between the assessments. Systematic differences indicated that random day-to-day variability in performance would be responsible for reduced reliability of those parameters. While it remains debatable whether robot-derived outcomes should replace certain routine assessments (e.g., ROM, strength), we recommend applying certain technology-based assessments also in clinical practice.

Trial registration: This study was registered prospectively at ClinicalTrials.gov (identifier: NCT02443857) on May 14, 2015.

Technology-assisted balance assessment and rehabilitation in individuals with spinal cord injury: A systematic review

BACKGROUND: Balance is a crucial function of basic Activities of Daily Living (ADL) and is often considered the priority in Spinal Cord Injury (SCI) patients’ rehabilitation. Technological devices have been developed to support balance assessment and training, ensuring an earlier, intensive, and goal-oriented motor therapy. OBJECTIVE: The aim of this systematic review is to explore the technology-assisted strategies to assess and rehabilitate balance function in persons with SCI. METHODS: A systematic review was conducted in the databases PubMed, Scopus, IEEE Xplore, Cochrane Library, and Embase. Full reports on Randomized Clinical Trials (RCTs) of parallel-group or cross-over design and non-RCTs were included according to the following criteria: i) publication year from 1990 to 2021; ii) balance considered as a primary or secondary outcome; iii) population of individuals with SCI with age over 18 years old, regardless of traumatic or non-traumatic lesions, Time Since Injury, lesion level, Asia Impairment Scale score and gender. The methodological quality was determined for each included study according to the recognized Downs and Black (D&B) tool. RESULTS: Nineteen articles met the inclusion criteria and were included in the analysis. Four articles focused on balance assessment while 15 targeted rehabilitation interventions to improve balance by using Treadmill-Based Devices (TBD), OverGround Devices (OGD) and Tilt Table Devices (TTD). Statistically significant effects on balance can be found in TBD subcategory, in the hip-knee guidance subcategory of OGD and in the study of TTD category. CONCLUSION: Although different studies reported positive effects, improvements due to technology-assisted rehabilitation were not greater than those obtained by means of other rehabilitation therapies. The heterogeneity, low methodological quality, and the small number of the studies included do not allow general conclusions about the usefulness of technology-assisted balance assessment and training in individuals with SCI, even if significant improvements have been reported in some studies.

Usability evaluation of an interactive leg press training robot for children with neuromuscular impairments

BACKGROUND:

The use of robotic technology for neurorehabilitative applications has become increasingly important for adults and children with different motor impairments.

OBJECTIVE:

The aim of this study was to evaluate the technical feasibility and usability of a new interactive leg-press training robot that was developed to train leg muscle strength and control, suitable for children with neuromuscular impairments.

METHODS:

An interactive robotic training system was designed and constructed with various control strategies, actuators and force/position sensors to enable the performance of different training modes (passive, active resistance, and exergames). Five paediatric patients, aged between 7 and 16 years (one girl, age 13.0 ± 3.7 years, [mean ± SD]), with different neuromuscular impairments were recruited to participate in this study. Patients evaluated the device based on a user satisfaction questionnaire and Visual Analog Scale (VAS) scores, and therapists evaluated the device with the modified System Usability Scale (SUS).

RESULTS:

One patient could not perform the training session because of his small knee range of motion. Visual Analog Scale scores were given by the 4 patients who performed the training sessions. All the patients adjudged the training with the interactive device as satisfactory. The average SUS score given by the therapists was 61.2 ± 18.4.

CONCLUSION:

This study proposed an interactive lower limb training device for children with different neuromuscular impairments. The device is deemed feasible for paediatric rehabilitation applications, both in terms of technical feasibility and usability acceptance. Both patients and therapists provided positive feedback regarding the training with the device.

Caring in the in-between: a proposal to introduce responsible AI and robotics to healthcare

In the scenario of growing polarization of promises and dangers that surround artificial intelligence (AI), how to introduce responsible AI and robotics in healthcare? In this paper, we develop an ethical–political approach to introduce democratic mechanisms to technological development, what we call “Caring in the In-Between”. Focusing on the multiple possibilities for action that emerge in the realm of uncertainty, we propose an ethical and responsible framework focused on care actions in between fears and hopes. Using the theoretical perspective of Science and Technology Studies and empirical research, “Caring in the In-Between” is based on three movements: the first is a change of focus from the world of promises and dangers to the world of uncertainties; the second is a conceptual shift from assuming a relationship with robotics based on a Human–Robot Interaction to another focused on the network in which the robot is embedded (the “Robot Embedded in a Network”); and the last is an ethical shift from a general normative framework to a discussion on the context of use. Based on these suggestions, “Caring in the In-Between” implies institutional challenges, as well as new practices in healthcare systems. It is articulated around three simultaneous processes, each of them related to practical actions in the “in-between” dimensions considered: monitoring relations and caring processes, through public engagement and institutional changes; including concerns and priorities of stakeholders, with the organization of participatory processes and alternative forms of representation; and making fears and hopes commensurable, through the choice of progressive and reversible actions.

Effects of Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: A Network Meta-Analysis

Gait disturbances are common in children and adolescents with cerebral palsy (CP). Robotic-assisted gait training (RAGT) is becoming increasingly widespread, and hence it is important to examine its effectiveness. A network meta-analysis (NMA) of clinical trials comparing treatments with RAGT vs. other physical therapy treatments was carried out. This study was conducted according to the NMA version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-NMA) guidelines and following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. The outcome variables used were the D and E dimensions of the Gross Motor Function Measure (GMFM), gait speed, resistance, and stride length. Among 120 records, 8 trials were included. This NMA did not find statistically significant results for any of the comparisons examined in any of the outcomes studied and the magnitude of the effect size estimates was low or very low. Our NMA results should be interpreted with caution due to the high clinical heterogeneity of the studies included.

Robotic devices for paediatric rehabilitation: a review of design features

Children with physical disabilities often have limited performance in daily activities, hindering their physical development, social development and mental health. Therefore, rehabilitation is essential to mitigate the adverse effects of the different causes of physical disabilities and improve independence and quality of life. In the last decade, robotic rehabilitation has shown the potential to augment traditional physical rehabilitation. However, to date, most robotic rehabilitation devices are designed for adult patients who differ in their needs compared to paediatric patients, limiting the devices' potential because the paediatric patients' needs are not adequately considered. With this in mind, the current work reviews the existing literature on robotic rehabilitation for children with physical disabilities, intending to summarise how the rehabilitation robots could fulfil children's needs and inspire researchers to develop new devices. A literature search was conducted utilising the Web of Science, PubMed and Scopus databases. Based on the inclusion-exclusion criteria, 206 publications were included, and 58 robotic devices used by children with a physical disability were identified. Different design factors and the treated conditions using robotic technology were compared. Through the analyses, it was identified that weight, safety, operability and motivation were crucial factors to the successful design of devices for children. The majority of the current devices were used for lower limb rehabilitation. Neurological disorders, in particular cerebral palsy, were the most common conditions for which devices were designed. By far, the most common actuator was the electric motor. Usually, the devices present more than one training strategy being the assistive strategy the most used. The admittance/impedance method is the most popular to interface the robot with the children. Currently, there is a trend on developing exoskeletons, as they can assist children with daily life activities outside of the rehabilitation setting, propitiating a wider adoption of the technology. With this shift in focus, it appears likely that new technologies to actuate the system (e.g. serial elastic actuators) and to detect the intention (e.g. physiological signals) of children as they go about their daily activities will be required.

An Interactive Computer Game for Improving Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Development and Preliminary Feasibility Study

Background

Computer game–based interventions are emerging in pediatric neurorehabilitation, as they can provide two key elements for motor learning—motivating environments that enable long-term compliance, which is particularly relevant for children, and augmented feedback for improving movement performance.

Objective

The overall aim of this study is to develop an interactive computer play for children with upper motor neuron lesions to train selective voluntary motor control and give particular attention to motivation and feedback. We also aim to determine features that make games engaging, investigate which sensory feedback modality is noticed the fastest during play, develop an interactive game, and evaluate its feasibility.

Methods

We identified engaging game features by interviewing 19 children and adolescents undergoing rehabilitation. By using a test version of the game, we determined the response times of 10 patients who had to react to visual, auditory, or combined feedback signals. On the basis of the results of these two subprojects, we developed and designed a game environment. Feasibility was studied in terms of the practicability and acceptability of the intervention among 5 children with upper motor neuron lesions.

Results

The game features deemed the most important by pediatric patients were strategic gameplay (13/29, 45% of answers) and choice (6/29, 21%). While playing the game, an acoustic alarm signal (reaction time: median 2.8 seconds) was detected significantly faster (P=.01) than conditions with other feedback modalities (avatar velocity reduction: median 7.8 seconds; color desaturation: median 5.7 seconds). Most children enjoyed playing the game, despite some technical issues.

Conclusions

The careful identification of game features that increase motivation and feedback modalities that inform children quickly led to the development of an interactive computer play for training selective voluntary motor control in children and adolescents with upper motor neuron lesions.

Effectiveness of robotic-assisted therapy for upper extremity function in children and adolescents with cerebral palsy: a systematic review protocol

INTRODUCTION

The application of advanced technologies in paediatric rehabilitation to improve performance and enhance everyday functioning shows considerable promise. The aims of this systematic review are to investigate the effectiveness of robotic-assisted therapy for upper extremity function in children and adolescents with cerebral palsy and to extend the scope of intervention from empirical evidence.

METHODS AND ANALYSIS

Multiple databases, including MEDLINE (Ovid), PubMed, CINAHL, Scopus, Web of Science, Cochrane Library and IEEE Xplore, will be comprehensively searched for relevant randomised controlled trials and non-randomised studies. The grey literature will be accessed on the ProQuest Dissertations & Theses Global database, and a hand search from reference lists of previous articles will be performed. The papers written in English language will be considered, with no limitation on publication date. Two independent reviewers will identify eligible studies, evaluate the level of evidence (the Oxford Centre for Evidence-Based Medicine) and appraise methodological quality and risk of bias (the Standard quality assessment criteria for evaluating primary research papers from a variety of fields (QualSyst tool); the Grading of Recommendations Assessment, Development and Evaluation). Data will be appropriately extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. A narrative synthesis will be provided to summarise the results, and a meta-analysis will be conducted if there is sufficient homogeneity across outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020205818.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The findings will be disseminated via a peer-reviewed journal and international conferences.

Effectiveness of Robot-Assisted Gait Training on Functional Skills in Children with Cerebral Palsy

This study was aimed to investigate the effects of robot-assisted gait training (RAGT) on motor functions, spasticity status, balance, and functionality in children with cerebral palsy (CP). A total of 26 patients who were diagnosed with CP (diplegic, with gross motor function classification system [GMFCS] levels of 2–5) and who regularly participated in a rehabilitation program were recruited in the study after obtaining approval from their parents. The patients were randomly assigned to two groups. Group 1 (n = 13) received conventional physical therapy (65 minutes, 2 days/week × 8) and group 2 (n = 13) received 25 minutes of RAGT (RoboGait) in addition to conventional therapy (CT; 40 minutes, 2 days/week × 8). GMFCS was used to evaluate motor functions and the Modified Ashworth Scale was used to evaluate spasticity. The pediatric Berg balance scale, pediatric functional independence measure, and timed up and go tests were employed to assess balance and functional status. The evaluations were performed at baseline and after 8 weeks of therapy. Both rehabilitation methods led to a statistically significant decrease in spasticity (p < 0.05); however, there was no difference in this improvement of spasticity between the groups (p > 0.05). Both groups exhibited significant improvements in functional independence, balance, and performance at the end of therapy (p < 0.05), and there was no significant difference between the groups (p > 0.05). The results of this study show that addition of RAGT to CT for 8 weeks is not superior to CT alone in children with CP.

Effects of corrective insole on leg muscle activation and lower extremity alignment in rice farmers with pronated foot: a preliminary report

BACKGROUND

Execution of strenuous activities in conjunction with slippery and viscous muddy working terrain in rice cultivation leads to a high prevalence of farmer musculoskeletal disorders and malalignments. Recommended intervention strategies originally designed for congenitally disabled individuals may also be applicable to farmers, including simple corrective wedges to reduce foot eversion. The objective of the present study was to conduct a preliminary investigation of the effects of corrective wedges on lower extremity muscle activity and alignment when subjects stood on flat rigid ground or muddy terrain, simulating typical work conditions encountered by the unique but populous Thai rice farming workforce.

METHODS

Nine healthy farmers with pronated feet were recruited to participate and wedges were custom fabricated for each farmer based on physical therapy assessment and use of rapid prototyping techniques. Participants were asked to stand barefoot or with wedges on the two surface types.

RESULTS

Results revealed foot pronation and knee valgus to improve (ranging, on average between 5.5 and 16.1 degrees) when participants were equipped with corrective wedges. The muscle activity of the peroneus longus and the tibialis anterior increased for muddy terrain, as compared with the rigid surface. In general, the wedges induced less tibialis anterior activity and greater peroneus longus activity, compared to when participants were standing barefoot. An elevation in evertor muscle activity may reflect stretching of the shortened muscle as a result of the reduced degree of foot pronation.

CONCLUSIONS

Findings demonstrate potential benefits of corrective insole usage for farmers with pronated feet, including improved lower extremity alignment and invertor muscle activity reduction for both rigid and muddy terrains.

Amplitude and stride-to-stride variability of muscle activity during Lokomat guided walking and treadmill walking in children with cerebral palsy

BACKGROUND

The Lokomat is a commercially available exoskeleton for gait training in persons with cerebral palsy (CP). Because active contributions and variability over movement repetitions are determinants of training effectiveness, we studied muscle activity in children with CP, and determined (i) differences between treadmill and Lokomat walking, and (ii) the effects of Lokomat training parameters, on the amplitude and the stride-to-stride variability.

METHODS

Ten children with CP (age 13.2 ± 2.9, GMFCS level II(n = 6)/III(n = 4)) walked on a treadmill (±1 km/h; 0% bodyweight support(BWS)), and in the Lokomat (50% and 100% guidance; ±1 km/h and ±2 km/h; 0% and 50% BWS). Activity was recorded from Gluteus Medius (GM), Vastus Lateralis (VL), Biceps Femoris (BF), Medial Gastrocnemius (MG) and Tibialis Anterior (TA) of the most affected side. The averaged amplitude per gait phase, and the second order coefficient of variation was used to determine the active contribution and stride-to-stride variability, respectively.

RESULTS

Generally, the amplitude of activity was lower in the Lokomat than on the treadmill. During Lokomat walking, providing guidance and BWS resulted in slightly lower amplitudes whereas increased speed was associated with higher amplitudes. No significant differences in stride-to-stride variability were observed between Lokomat and treadmill walking, and in the Lokomat only speed (MG) and guidance (BF) affected variability.

CONCLUSIONS

Lokomat walking reduces muscle activity in children with CP, whereas altering guidance or BWS generally does not affect amplitude. This urges additional measures to encourage active patient contributions, e.g. by increasing speed or through instruction.

A pilot study on the design and validation of a hybrid exoskeleton robotic device for hand rehabilitation

STUDY DESIGN

An iterative design process was used to obtain design parameters that satisfy both kinematic and dynamic requirements for the hand exoskeleton. This design was validated through experimental studies.

INTRODUCTION

The success of hand rehabilitation after impairments depends on the timing, intensity, repetition, and frequency, as well as task-specific training. Considering the continuing constraints placed on therapist-led rehabilitation and need for better outcomes, robot-assisted rehabilitation has been explored. Soft robotic approaches have been implemented for a hand rehabilitation exoskeleton as they have more tolerance for alignment with biological joints than those of hard exoskeletons.

PURPOSE OF THE STUDY

The purpose of the study was to design, develop, and validate a soft robotic exoskeleton for hand rehabilitation.

METHODS

A motion capture system validated the kinematics of the soft robotic digit attached on top of a human index finger. A pneumatic control system and algorithms were developed to operate the exoskeleton based on three therapeutic modes: continuous passive, active assistive, and active resistive motion. Pilot studies were carried out on one healthy and one poststroke participant using continuous passive motion and bilateral/bimanual therapy modes.

RESULTS

The soft robotic digits were able to produce required range of motion and accommodate for dorsal lengthening, with trajectories of the center of rotation of the soft robotic joints in close agreement with the center of rotation of the human finger joints.

DISCUSSION

The exoskeleton showed the robust performance of the robot in applying continuous passive motion and bilateral/bimanual therapy.

CONCLUSIONS

This soft robotic exoskeleton is promising for assisting in the rehabilitation of the hand.

An open source graphical user interface for wireless communication and operation of wearable robotic technology

INTRODUCTION

Wearable robotic exoskeletons offer the potential to move gait training from the clinic to the community thereby providing greater therapy dosage in more naturalistic settings. To capitalize on this potential, intuitive and robust interfaces are necessary between robotic devices and end users. Such interfaces hold great promise for research if they are also designed to record data from the robot during its use.

METHODS

We present the design and validation of an open source graphical user interface (GUI) for wireless operation of and real-time data logging from a pediatric robotic exoskeleton. The GUI was designed for trained users such as an engineer or clinician. A simplified mobile application is also provided to enable exoskeleton operation by an end-user or their caretaker. GUI function was validated during simulated walking with the exoskeleton using a motion capture system.

RESULTS

Our results demonstrate the ability of the GUI to wirelessly operate and save data from exoskeleton sensors with high fidelity comparable to motion capture.

CONCLUSION

The GUI code, available in a public repository with a detailed description and step-by-step tutorial, is configurable to interact with any robotic device operated by a microcontroller and therefore represents a potentially powerful tool for deployment and evaluation of community based robotics.

First validation of a novel assessgame quantifying selective voluntary motor control in children with upper motor neuron lesions

The question whether novel rehabilitation interventions can exploit restorative rather than compensatory mechanisms has gained momentum in recent years. Assessments measuring selective voluntary motor control could answer this question. However, while current clinical assessments are ordinal-scaled, which could affect their sensitivity, lab-based assessments are costly and time-consuming. We propose a novel, interval-scaled, computer-based assessment game using low-cost accelerometers to evaluate selective voluntary motor control. Participants steer an avatar owl on a star-studded path by moving the targeted joint of the upper or lower extremities. We calculate a target joint accuracy metric, and an outcome score for the frequency and amplitude of involuntary movements of adjacent and contralateral joints as well as the trunk. We detail the methods and, as a first proof of concept, relate the results of select children with upper motor neuron lesions (n = 48) to reference groups of neurologically intact children (n = 62) and adults (n = 64). Linear mixed models indicated that the cumulative therapist score, rating the degree of selectivity, was a good predictor of the involuntary movements outcome score. This highlights the validity of this assessgame approach to quantify selective voluntary motor control and warrants a more thorough exploration to quantify changes induced by restorative interventions.

Validation of a robot serious game assessment protocol for upper limb motor impairment in children with cerebral palsy

BACKGROUND

The ROBiGAME project aims to implement serious games on robots to rehabilitate upper limb (UL) motor function in children with cerebral palsy (CP). Serious game characteristics (target position, level of assistance/resistance, level of force) are typically adapted based on the child's assessment before and continuously during the game (measuring UL working area, kinematics and muscle strength).

OBJECTIVE

This study developed an UL robotic motor assessment protocol to configure the serious game.

METHODS

Forty-nine healthy children and 20 CP children participated in the study. The clinical assessment consisted of the child's UL length and isometric force. The robot assessment consisted of the child's UL working area (WA), the UL isometric and isokinetic force in three directions and the UL kinematics during a pointing task toward targets placed at different distances.

RESULTS

Results showed that WA and UL isometric force were moderately to highly correlated with clinical measures. Ratios between the UL isokinetic force generated on three directions were established. The velocity and straightness indexes of all children increased when they had to reach to targets placed more distant.

CONCLUSIONS

This protocol can be integrated into different serious games in order to continuously configure the game characteristics to a child's performance.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02543424), 12 August 2015.

Improvement and sustainability of walking ability with hybrid assistive limb training in a patient with cerebral palsy after puberty: a case report

[Purpose] Cerebral palsy is one of the most common causes of childhood physical disability affecting motor development. Gait training with a wearable-robot, such as the Hybrid Assistive Limb, has been reported to improve gait ability in patients with chronic motor disabilities; however, there are no reports concerning the sustained improvement of walking ability with its use in patients with cerebral palsy. We present our observations for the use of Hybrid Assistive Limb gait training in a postpubescent cerebral palsy patient. [Participant and Methods] A 17-year-old male with spastic cerebral palsy could only ambulate slightly using a crouch gait posture and with the aid of a walker. Hybrid Assistive Limb training was performed thrice weekly for 4 weeks (total of 12 sessions) along with concurrent daily physical therapy. The follow-up period was 7 months after the intervention. [Results] The intervention resulted in improvements in the patient’s gait speed, proportion of the stance phase in a gait cycle, step length, and the flexion angle of the knees at initial contact and during late stance phase, which was sustained for 7 months following the intervention. [Conclusion] Our observations suggest that Hybrid Assistive Limb training may effectively improve and sustain walking ability even among postpubescent cerebral palsy patients who have a decreased walking ability.

Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities

Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.

Dual-task training of children with neuromotor disorders during robot-assisted gait therapy: prerequisites of patients and influence on leg muscle activity

BACKGROUND

Walking in daily life is complex entailing various prerequisites such as leg strength, trunk stability or cognitive and motor dual task (DT) activities. Conventional physiotherapy can be complemented with robot-assisted gait therapy (RAGT) and exergames to enhance the number of step repetitions, feedback, motivation, and additional simultaneously performed tasks besides walking (e.g., dual-task (DT) activities). Although DT gait training leads to improvements in daily ambulation in adult patient groups, no study has evaluated RAGT with a DT exergame in children with neurological gait disorders. Therefore, we investigated children's functional and cognitive prerequisites to walk physiologically during RAGT with a DT exergame and analysed the influence of DT on leg muscle activity.

METHODS

Children and adolescents (6-18 years) with neurological gait disorders completed RAGT with and without a DT exergame in this quasi-experimental study. We assessed several measures on the body function and activity domains (according to the International Classification of Functioning, Disability, and Health (ICF)) and determined whether these measures could distinguish well between children who walked physiologically during the DT RAGT or not. We measured leg muscle activity with surface electrodes to identify changes in EMG-amplitudes and -patterns.

RESULTS

Twenty-one children participated (7 females, 6.5-17.3 years, Gross Motor Function Classification System (GMFCS) levels I-IV). Most activity measures distinguished significantly between participants performing the DT exergame physiologically or not with moderate to good sensitivity (0.8 ≤ sensitivity≤1.0) and specificity (0.5 ≤ specificity≤0.9). Body function measures differentiated less well. Despite that the EMG-amplitudes of key stance muscles were significantly lower during DT versus no DT exergaming, the mean activation patterns of all muscles correlated high (ρ > 0.75) between the conditions.

CONCLUSION

This study is the first that investigated effects of a DT exergame during RAGT in children with neurological gait disorders. Several performance measures could differentiate well between patients who walked with physiological versus compensatory movements while performing the DT exergame. While the DT exergame affected the leg muscle activity amplitudes, it did not largely affect the activity patterns of the muscles.

A robot-based gait training therapy for pediatric population with cerebral palsy: goal setting, proposal and preliminary clinical implementation

BACKGROUND

The use of robotic trainers has increased with the aim of improving gait function in patients with limitations. Nevertheless, there is an absence of studies that deeply describe detailed guidelines of how to correctly implement robot-based treatments for gait rehabilitation. This contribution proposes an accurate robot-based training program for gait rehabilitation of pediatric population with Cerebral Palsy (CP).

METHODS

The program is focused on the achievement of some specifications defined by the International Classification of Functioning, Disability and Health framework, Children and Youth version (ICF-CY). It is framed on 16 non-consecutive sessions where motor control, strength and power exercises of lower limbs are performed in parallel with a postural control strategy. A clinical evaluation with four pediatric patients with CP using the CPWalker robotic platform is presented.

RESULTS

The preliminary evaluation with patients with CP shows improvements in several aspects as strength (74.03 ± 40.20%), mean velocity (21.46 ± 33.79%), step length (17.95 ± 20.45%) or gait performance (e.g. 66 ± 63.54% in Gross Motor Function Measure-88 items, E and D dimensions).

CONCLUSIONS

The improvements achieved in the short term show the importance of working strength and power functions meanwhile over-ground training with postural control. This research could serve as preliminary support for future clinical implementations in any robotic device.

TRIAL REGISTRATION

The study was carried out with the number R-0032/12 from Local Ethical Committee of the Hospital Infantil Niño Jesús. Public trial registered on March 23, 2017: ISRCTN18254257 .

Hand Robotic Therapy in Children with Hemiparesis: A Pilot Study

OBJECTIVE

The aim of this study was to understand the impact of training with a hand robotic device on hand paresis and function in a population of children with hemiparesis.

METHODS

Twelve children with hemiparesis (mean age, 9 [SD, 3.64] years) completed participation in this prospective, experimental, pilot study. Participants underwent clinical assessments at baseline and again 6 weeks later with instructions to not initiate new therapies. After these assessments, participants received 6 weeks of training with a hand robotic device, consisting of 1-hour sessions, 3 times weekly. Assessments were repeated on completion of training.

RESULTS

Results showed significant improvements after training on the Assisting Hand Assessment (mean difference, 2.0 Assisting Hand Assessment units; P = 0.011) and on the upper-extremity component of the Fugl-Meyer scale (raw score mean difference, 4.334; P = 0.001). No significant improvements between pretest and posttest were noted on the Jebsen-Taylor Test of Hand Function, the Quality of Upper Extremity Skills Test, or the Pediatric Evaluation of Disability Inventory after intervention. Total active mobility of digits and grip strength also failed to demonstrate significant changes after training.

INTERPRETATION

Participants tolerated training with the hand robotic device, and significant improvements in bimanual hand use, as well as impairment-based scales, were noted. Improvements were carried over into bimanual skills during play.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand key components of neuroplasticity; (2) Discuss the benefits of robotic therapy in the recovery of hand function in pediatric patients with hemiplegia; and (3) Appropriately incorporate robotic therapy into the treatment plan of pediatric patients with hemiplegia.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Task-Specific and Functional Effects of Speed-Focused Elliptical or Motor-Assisted Cycle Training in Children With Bilateral Cerebral Palsy: Randomized Clinical Trial

BACKGROUND

Locomotor training using treadmills or robotic devices is commonly utilized to improve gait in cerebral palsy (CP); however, effects are inconsistent and fail to exceed those of equally intense alternatives. Possible limitations of existing devices include fixed nonvariable rhythm and too much limb or body weight assistance.

OBJECTIVE

To quantify and compare effectiveness of a motor-assisted cycle and a novel alternative, an elliptical, in CP to improve interlimb reciprocal coordination through intensive speed-focused leg training.

METHODS

A total of 27 children with bilateral CP, 5 to 17 years old, were randomized to 12 weeks of 20 minutes, 5 days per week home-based training (elliptical = 14; cycle = 13) at a minimum of 40 revolutions per minute, with resistance added when speed target was achieved. Primary outcomes were self-selected and fastest voluntary cadence on the devices and gait speed. Secondary outcomes included knee muscle strength, and selective control and functional mobility measures.

RESULTS

Cadence on trained but not nontrained devices increased, demonstrating task specificity of training and increased exercise capability. Mean gait speed did not increase in either group, nor did parent-reported functional mobility. Knee extensor strength increased in both. An interaction between group and time was seen in selective control with scores slightly increasing for the elliptical and decreasing for the cycle, possibly related to tighter limb coupling with cycling.

CONCLUSIONS

Task-specific effects were similarly positive across groups, but no transfer was seen to gait or function. Training dose was low (≤20 hours) compared with intensive upper-limb training recommendations and may be insufficient to produce appreciable clinical change.

Development of a parent-reported questionnaire evaluating upper limb activity limitation in children with cerebral palsy

BACKGROUND AND PURPOSE

Upper limb activity measures for children with cerebral palsy have a number of limitations, for example, lack of validity and poor responsiveness. To overcome these limitations, we developed the Children's Arm Rehabilitation Measure (ChARM), a parent-reported questionnaire validated for children with cerebral palsy aged 5-16 years. This paper describes both the development of the ChARM items and response categories and its psychometric testing and further refinement using the Rasch measurement model.

METHODS

To generate valid items for the ChARM, we collected goals of therapy specifically developed by therapists, children with cerebral palsy, and their parents for improving activity limitation of the upper limb. The activities, which were the focus of these goals, formed the basis for the items. Therapists typically break an activity into natural stages for the purpose of improving activity performance, and these natural orders of achievement formed each item's response options. Items underwent face validity testing with health care professionals, parents of children with cerebral palsy, academics, and lay persons. A Rasch analysis was performed on ChARM questionnaires completed by the parents of 170 children with cerebral palsy from 12 hospital paediatric services. The ChARM was amended, and the procedure repeated on 148 ChARMs (from children's mean age: 10 years and 1 month; range: 4 years and 8 months to 16 years and 11 months; 85 males; Manual Ability Classification System Levels I = 9, II = 26, III = 48, IV = 45, and V = 18).

RESULTS

The final 19-item unidimensional questionnaire displayed fit to the Rasch model (chi-square p = .18), excellent reliability (person separation index = 0.95, α = 0.95), and no floor or ceiling effects. Items showed no response bias for gender, distribution of impairment, age, or learning disability.

DISCUSSION

The ChARM is a psychometrically sound measure of upper limb activity validated for children with cerebral palsy aged 5-16 years. The ChARM is freely available for use to clinicians and nonprofit organisations.

Robot-assisted gait training might be beneficial for more severely affected children with cerebral palsy

PURPOSE

Robot-assisted gait training (RAGT) can complement conventional therapies in children with cerebral palsy. We investigated changes in walking-related outcomes between children with different Gross Motor Function Classification System (GMFCS) levels and the dose-response relationship.

METHODS

Data from 67 children (3.9-19.9 years) with GMFCS levels II-IV were evaluated retrospectively. Every child received RAGT with the Lokomat complementing a multidisciplinary rehabilitation program. Changes in various walking-related outcomes were assessed.

RESULTS

Walking-related outcomes did not improve differently between GMFCS level groups. Significant within-group improvements were mainly observed in children with GMFCS level IV. A dose-response relationship was present for children with GMFCS levels III and IV.

CONCLUSIONS

Our results indicated that, although children with a GMFCS level IV walked less during an average Lokomat session, they experienced significant improvements in walking-related outcomes. Further, training dose correlated with changes in walking-related outcomes. However, between-group differences in changes in walking-related outcomes were not significant.

Comparison of a robotic-assisted gait training program with a program of functional gait training for children with cerebral palsy: design and methods of a two group randomized controlled cross-over trial

Background

Enhancement of functional ambulation is a key goal of rehabilitation for children with cerebral palsy (CP) who experience gross motor impairment. Physiotherapy (PT) approaches often involve overground and treadmill-based gait training to promote motor learning, typically as free walking or with body-weight support. Robotic-assisted gait training (RAGT), using a device such as the Lokomat^®Pro, may permit longer training duration, faster and more variable gait speeds, and support walking pattern guidance more than overground/treadmill training to further capitalize on motor learning principles. Single group pre-/post-test studies have demonstrated an association between RAGT and moderate to large improvements in gross motor skills, gait velocity and endurance. A single published randomized controlled trial (RCT) comparing RAGT to a PT-only intervention showed no difference in gait kinematics. However, gross motor function and walking endurance were not evaluated and conclusions were limited by a large PT group drop-out rate.

Methods/design

In this two-group cross-over RCT, children are randomly allocated to the RAGT or PT arm (each with twice weekly sessions for eight weeks), with cross-over to the other intervention arm following a six-week break. Both interventions are grounded in motor learning principles with incorporation of individualized mobility-based goals. Sessions are fully operationalized through manualized, menu-based protocols and post-session documentation to enhance internal and external validity. Assessments occur pre/post each intervention arm (four time points total) by an independent assessor. The co-primary outcomes are gross motor functional ability (Gross Motor Function Measure (GMFM-66) and 6-minute walk test), with secondary outcome measures assessing: (a) individualized goals; (b) gait variables and daily walking amounts; and (c) functional abilities, participation and quality of life. Investigators and statisticians are blinded to study group allocation in the analyses, and assessors are blinded to treatment group. The primary analysis will be the pre- to post-test differences (change scores) of the GMFM-66 and 6MWT between RAGT and PT groups.

Discussion

This study is the first RCT comparing RAGT to an active gait-related PT intervention in paediatric CP that addresses gait-related gross motor, participation and individualized outcomes, and as such, is expected to provide comprehensive information as to the potential role of RAGT in clinical practice.

Trial registration ClinicalTrials.gov NCT02196298

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3535-0) contains supplementary material, which is available to authorized users.

Quantifying selective elbow movements during an exergame in children with neurological disorders: a pilot study

BACKGROUND

It is difficult to distinguish between restorative and compensatory mechanisms underlying (pediatric) neurorehabilitation, as objective measures assessing selective voluntary motor control (SVMC) are scarce.

METHODS

We aimed to quantify SVMC of elbow movements in children with brain lesions. Children played an airplane game with the glove-based YouGrabber system. Participants were instructed to steer an airplane on a screen through a cloud-free path by correctly applying bilateral elbow flexion and extension movements. Game performance measures were (i) % time on the correct path and (ii) similarity between the ideal flight path and the actually flown path. SVMC was quantified by calculating a correlation coefficient between the derivative of the ideal path and elbow movements. A therapist scored whether the child had used compensatory movements.

RESULTS

Thirty-three children with brain lesions (11 girls; 12.6 ± 3.6 years) participated. Clinical motor and cognitive scores correlated moderately with SVMC (0.50-0.74). Receiver Operating Characteristics analyses showed that SVMC could differentiate well and better than clinical and game performance measures between compensatory and physiological movements.

CONCLUSIONS

We conclude that a simple measure assessed while playing a game appears promising in quantifying SVMC. We propose how to improve the methodology, and how this approach can be easily extended to other joints.

Multidisciplinary rehabilitation for patients with cerebral palsy: improving long-term care

Cerebral palsy (CP) is one of the most frequent causes of child disability in developed countries. Children with CP need lifelong assistance and care. The current prevalence of CP in industrialized countries ranges from 1.5 to 2.5 per 1,000 live births, with one new case every 500 live births. Children with CP have an almost normal life expectancy and mortality is very low. Despite the low mortality rate, 5%-10% of them die during childhood, especially when the severe motor disability is comorbid with epilepsy and severe intellectual disability. Given this life expectancy, children with CP present with a lifelong disability of varying severity and complexity, which requires individualized pathways of care. There are no specific treatments that can remediate the brain damage responsible for the complex clinical-functional dysfunctions typical of CP. There are, however, a number of interventions (eg, neurorehabilitation, functional orthopedic surgery, medication, etc) aimed at limiting the damage secondary to the brain insult and improving these patients' activity level and participation and, therefore, their quality of life. The extreme variability of clinical aspects and the complexity of affected functions determine a multifaceted skill development in children with CP. There is a need to provide them with long-term care, taking into account medical and social aspects as well as rehabilitation, education, and assistance. This long-term care must be suited according to children's developmental stage and their physical, psychological, and social development within their life contexts. This impacts heavily on the national health systems which must set up a network of services for children with CP, and it also impacts heavily on the family as a whole, due to the resulting distress, adjustment efforts, and changes in quality of life. This contribution is a narrative review of the current literature on long-term care for children with CP, aiming at suggesting reflections to improve these children's care.

A pilot single-blind multicentre randomized controlled trial to evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on the arm function of children with spastic cerebral palsy

Objective:

To evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on arm function of children with spastic cerebral palsy.

Design:

A single-blind randomized controlled trial design. Power calculations indicated that 58 children would be required to demonstrate a clinically important difference.

Setting:

Intervention was home-based; recruitment took place in regional spasticity clinics.

Participants:

A total of 15 children with cerebral palsy aged five to 12 years were recruited; eight to the device group.

Interventions:

Both study groups received ‘usual follow-up treatment’ following spasticity treatment with botulinum toxin; the intervention group also received a rehabilitation gaming device.

Main measures:

ABILHAND-kids and Canadian Occupational Performance Measure were performed by blinded assessors at baseline, six and 12 weeks.

Results:

An analysis of covariance showed no group differences in mean ABILHAND-kids scores between time points. A non-parametric analysis of variance on Canadian Occupational Performance Measure scores showed a statistically significant improvement across time points (χ2 (2,15) = 6.778, p = 0.031), but this improvement did not reach minimal clinically important difference. Mean daily device use was seven minutes. Recruitment did not reach target owing to unanticipated staff shortages in clinical services. Feedback from children and their families indicated that the games were not sufficiently engaging to promote sufficient use that was likely to result in functional benefits.

Conclusion:

This study suggests that computer-assisted arm rehabilitation gaming does not benefit arm function, but a Type II error cannot be ruled out.

Preparing a neuropediatric upper limb exergame rehabilitation system for home-use: a feasibility study

Background

Home-based, computer-enhanced therapy of hand and arm function can complement conventional interventions and increase the amount and intensity of training, without interfering too much with family routines. The objective of the present study was to investigate the feasibility and usability of the new portable version of the YouGrabber® system (YouRehab AG, Zurich, Switzerland) in the home setting.

Methods

Fifteen families of children (7 girls, mean age: 11.3y) with neuromotor disorders and affected upper limbs participated. They received instructions and took the system home to train for 2 weeks. After returning it, they answered questions about usability, motivation, and their general opinion of the system (Visual Analogue Scale; 0 indicating worst score, 100 indicating best score; ≤30 not satisfied, 31–69 average, ≥70 satisfied). Furthermore, total pure playtime and number of training sessions were quantified. To prove the usability of the system, number and sort of support requests were logged.

Results

The usability of the system was considered average to satisfying (mean 60.1–93.1). The lowest score was given for the occurrence of technical errors. Parents had to motivate their children to start (mean 66.5) and continue (mean 68.5) with the training. But in general, parents estimated the therapeutic benefit as high (mean 73.1) and the whole system as very good (mean 87.4). Children played on average 7 times during the 2 weeks; total pure playtime was 185 ± 45 min. Especially at the beginning of the trial, systems were very error-prone. Fortunately, we, or the company, solved most problems before the patients took the systems home. Nevertheless, 10 of 15 families contacted us at least once because of technical problems.

Conclusions

Despite that the YouGrabber® is a promising and highly accepted training tool for home-use, currently, it is still error-prone, and the requested support exceeds the support that can be provided by clinical therapists. A technically more robust system, combined with additional attractive games, likely results in higher patient motivation and better compliance. This would reduce the need for parents to motivate their children extrinsically and allow for clinical trials to investigate the effectiveness of the system.

Trial registration

ClinicalTrials.gov NCT02368223

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0141-x) contains supplementary material, which is available to authorized users.

Feasibility of visual instrumented movement feedback therapy in individuals with motor incomplete spinal cord injury walking on a treadmill

Background: Incomplete spinal cord injury (iSCI) leads to motor and sensory deficits. Even in ambulatory persons with good motor function an impaired proprioception may result in an insecure gait. Limited internal afferent feedback (FB) can be compensated by provision of external FB by therapists or technical systems. Progress in computational power of motion analysis systems allows for implementation of instrumented real-time FB. The aim of this study was to test if individuals with iSCI can normalize their gait kinematics during FB and more importantly maintain an improvement after therapy.

Methods: Individuals with chronic iSCI had to complete 6 days (1 day per week) of treadmill-based FB training with a 2 weeks pause after 3 days of training. Each day consists of an initial gait analysis followed by 2 blocks with FB/no-FB. During FB the deviation of the mean knee angle during swing from a speed matched reference (norm distance, ND) is visualized as a number. The task consists of lowering the ND, which was updated after every stride. Prior to the tests in patients the in-house developed FB implementation was tested in healthy subjects with an artificial movement task.

Results: Four of five study participants benefited from FB in the short and medium term. Decrease of mean ND was highest during the first 3 sessions (from 3.93 ± 1.54 to 2.18 ± 1.04). After the pause mean ND stayed in the same range than before. In the last 3 sessions the mean ND decreased slower (2.40 ± 1.18 to 2.20 ± 0.90). Direct influences of FB ranged from 60 to 15% of reduction in mean ND compared to initial gait analysis and from 20 to 1% compared to no-FB sessions.

Conclusions: Instrumented kinematic real-time FB may serve as an effective adjunct to established gait therapies in normalizing the gait pattern after incomplete spinal cord injury. Further studies with larger patient groups need to prove long term learning and the successful transfer of newly acquired skills to activities of daily living.