Evaluation of lower body positive pressure supported treadmill training for children with cerebral palsy

Simulating space walking: a systematic review on anti-gravity technology in neurorehabilitation

Neurological disorders, such as Parkinson's disease (PD), multiple sclerosis (MS), cerebral palsy (CP) and stroke are well-known causes of gait and balance alterations. Innovative devices (i.e., robotics) are often used to promote motor recovery. As an alternative, anti-gravity treadmills, which were developed by NASA, allow early mobilization, walking with less effort to reduce gait energy costs and fatigue. A systematic search, according to PRISMA guidelines, was conducted for all peer-reviewed articles published from January 2010 through September 2023, using the following databases: PubMed, Scopus, PEDro and IEEE Xplore. After an accurate screening, we selected only 16 articles (e.g., 5 RCTs, 2 clinical trials, 7 pilot studies, 1 prospective study and 1 exploratory study). The evidence collected in this systematic review reported promising results in the field of anti-gravity technology for neurological patients, in terms of improvement in gait and balance outcomes. However, we are not able to provide any clinical recommendation about the dose and parameters of anti-gravity treadmill training, because of the lack of robust high-quality RCT studies and large samples. Registration number CRD42023459665.

Research progress on the application of anti-gravity treadmill in the rehabilitation of Parkinson's disease patients: a mini review

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by motor and non-motor symptoms. It is the second most common chronic progressive neurodegenerative disease. PD still lacks a known cure or prophylactic medication. Current treatments primarily address symptoms without halting the progression of PD, and the side effects of dopaminergic therapy become more apparent over time. In contrast, physical therapy, with its lower risk of side effects and potential cardiovascular benefits, may provide greater benefits to patients. The Anti-Gravity Treadmill is an emerging rehabilitation therapy device with high safety, which minimizes patients' fear and allows them to focus more on a normal, correct gait, and has a promising clinical application. Based on this premise, this study aims to summarize and analyze the relevant studies on the application of the anti-gravity treadmill in PD patients, providing a reference for PD rehabilitation practice and establishing a theoretical basis for future research in this area.

A preliminary study on the effect of loaded and unloaded exercise on N-propeptide of type II collagen and serum cartilage oligomeric matrix protein activity of articular cartilage in healthy young adults

The serum concentration of cartilage oligomeric matrix protein (sCOMP) is considered a mechanosensitive biomarker of articular cartilage turnover, and N-propeptide of type II collagen (PIIANP), a proposed biomarker of type II collagen synthesis. Few studies have investigated the anabolic and turnover response of articular cartilage in response to acute changes in body mass during exercise. Using a repeated measure cross-over design, 15 healthy adults (age 18-30 years) performed three 30 min bouts of treadmill walking exercise under three loading conditions: (1) control (no alteration to body mass); (2) loaded (12% increase in body mass using a weighted vest); and (3) unloaded (12% decrease in body mass using lower body positive pressure). Venous blood was collected before, immediately after, and 15 and 30 min after exercise to investigate cartilage turnover (sCOMP) and anabolism (PIIANP). A main time effect (p ≤ 0.05) revealed that sCOMP levels were significantly greater post-exercise (for all three body loading conditions) as compared to before exercise, 15 and 30 min post-exercise. There was a significant condition × time interaction (p ≤ 0.05) for PIIANP, indicating that in the loaded condition, PIIANP concentrations at 15 min post-exercise were 13.8% greater than immediately following exercise, and 12.9% greater than before exercise. In summary, sCOMP concentration was acutely increased with all three loading conditions. However, PIIANP increased only after exercise in the loaded condition, suggesting an acute anabolic effect on articular cartilage. NCT05925244.

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.

AlterG Anti-Gravity Treadmill Accuracy of Unloading Is Affected by Support Frame Height

ABSTRACT

de Heer, HD, Kaufman, A, Repka, CP, Rojas, K, Charley, B, and Bounds, R. AlterG Anti-Gravity Treadmill accuracy of unloading is affected by support frame height. J Strength Cond Res 35(10): 2910-2914, 2021-The AlterG Anti-Gravity Treadmill uses air pressure to provide partial body-weight support (BWS), lowering impact forces and metabolic demand of walking and running. Users wear specialized shorts that zip onto a bag supported by a metal bar frame covering the treadmill. The frame is placed at hip height in positions numbered 1-9, adjusted up or down based on preference. Machine accuracy in providing BWS is important to achieve desired training effects, but it is unknown whether frame placement impacts accuracy. Twenty subjects (10 men/women) were weighed in 10% increments from 0 to 60% BWS with the frame at hip height (iliac crest), the "neutral" position, and reweighed with the frame placed up to 3 numbers above or below hip height. Although the machine displayed the same proportion BWS, placing the frame higher than the neutral position resulted in significantly more support, whereas placing the frame lower led to less support. At 10% BWS, placing the frame 3 positions higher resulted in 3% more support compared with the neutral position (13.1% BWS, p < 0.001) and 3 positions lower in 4.7% less support (5.3% BWS, p < 0.001). Deviances were greater with more BWS. At 60% BWS, 3 positions higher than neutral resulted in 71.2% BWS (11.2% more than expected, p < 0.001) and 3 below 48.1% BWS (12.9% below expected, p < 0.001), total 24.1% difference. These findings suggest that the position of the support frame significantly impacts the AlterG accuracy in providing BWS, with placement higher than hip height resulting in more support than displayed by the machine and lower placement resulting in less support.

Effect of Body Weight-Supported Exercise on Symptoms of Knee Osteoarthritis: A Follow-up Investigation

OBJECTIVE

To examine the long-term effect of participation in a 12-week lower-body positive pressure (LBPP)-supported low-load treadmill exercise regime on knee joint pain, physical function, and thigh muscle strength in patients with knee osteoarthritis (OA).

DESIGN

Prospective, observational, repeated measures.

SETTING

Clinical orthopedic setting.

PATIENTS

Nineteen overweight patients with knee OA.

INTERVENTION

Participants exercised under low-load treadmill walking conditions 2×/week for 12 weeks using an amount of LBPP support that minimized knee pain while walking for a period of 30 minutes at a set speed of 3.1 mph at 0-degree incline.

MAIN OUTCOME MEASURES

Knee pain, function, thigh muscle strength, and body anthropometry were reassessed a minimum of 6 months after completion of the initial exercise regime and compared with results from baseline and postexercise evaluation.

RESULTS

Data suggested that: (1) patients were able to maintain improvements in knee joint pain and symptoms; (2) patients continued to report enhanced joint function and improved quality of life; and (3) patients maintained thigh muscle strength gains. Finally, a majority of patients continued to experience significant reductions in acute knee pain during full weight-bearing treadmill walking.

CONCLUSIONS

Data suggest that improvements in knee pain, joint function, and thigh muscle strength associated with participation in a 12-week LBPP-supported low-load exercise regime were maintained well after cessation of the program. These findings have important implications for the development and refinement of exercise strategies and interventions used in the long-term management of joint symptoms associated with knee OA in overweight patients.

Therapeutic Effects of an Anti-Gravity Treadmill (AlterG) Training on Neuromuscular Abnormalities Associated with Spasticity in Children with Cerebral Palsy

We aimed to characterize the therapeutic effects of Anti-Gravity Treadmill (AlterG) Training on neuromuscular abnormalities associated with spasticity in children with cerebral palsy (CP). Eighteen subjects were divided into two groups; AlterG and control. All subjects received up to 40 minutes of training 3 times a week for 8 weeks. The control group received conventional occupational therapy. The advanced parallel-cascade system identification technique was used to characterize the neuromuscular abnormalities associated with spasticity and separated its intrinsic and reflex components. Reflex stiffness gain (GR) and intrinsic stiffness gain (K) were used to track the therapeutic effects of training on neural and muscular abnormalities. Both K and GR were strongly positioned dependent; they varied linearly with the ankle angle at dorsiflexion. Their position dependence was quantified by fitting a linear model to K and GR over dorsiflexion positions. The evaluations were performed at four-time points; i.e. the baseline (before starting the training), 1 and 2 months after starting the training, and 1 month after the completion of the training to assess the persistent effects. We determined the changes in K and GR intercept and slope parameters over these 3 months to evaluate the therapeutic effects of training on neuromuscular abnormalities. The results revealed that all K and GR parameters decreased substantially following using AlterG training and these changes were greater than those observed in the control. The results also showed that these therapeutic effects were persistent to a high extent, particularly in the AlterG group. Our findings suggested that AlterG training could be considered as a robust therapeutic intervention to reduce neuromuscular abnormalities and manage spasticity.

Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial

Importance

Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA).

Objective

To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol.

Design, Setting, and Participants

This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019.

Interventions

The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation.

Main Outcomes and Measures

Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy.

Results

Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60).

Conclusions and Relevance

This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02426190.

Foot and Ankle Somatosensory Deficits Affect Balance and Motor Function in Children With Cerebral Palsy

Sensory dysfunction is prevalent in cerebral palsy (CP). Evidence suggests that sensory deficits can contribute to manual ability impairments in children with CP, yet it is still unclear how they contribute to balance and motor performance. Therefore, the objective of this study was to investigate the relationship between lower extremity (LE) somatosensation and functional performance in children with CP. Ten participants with spastic diplegia (Gross Motor Function Classification Scale: I-III) and who were able to stand independently completed the study. Threshold of light touch pressure, two-point discriminatory ability of the plantar side of the foot, duration of cutaneous vibration sensation, and error in the joint position sense of the ankle were assessed to quantify somatosensory function. The balance was tested by the Balance Evaluation System Test (BESTest) and postural sway measures during a standing task. Motor performance was evaluated by using a battery of clinical assessments: (1) Gross Motor Function Measure (GMFM-66-IS) to test gross motor ability; (2) spatiotemporal gait characteristics (velocity, step length) to evaluate walking ability; (3) Timed Up and Go (TUG) and 6 Min Walk (6MWT) tests to assess functional mobility; and (4) an isokinetic dynamometer was used to test the Maximum Volitional Isometric Contraction (MVIC) of the plantar flexor muscles. The results showed that the light touch pressure measure was strongly associated only with the 6MWT. Vibration and two-point discrimination were strongly related to balance performance. Further, the vibration sensation of the first metatarsal head demonstrated a significantly strong relationship with motor performance as measured by GMFM-66-IS, spatiotemporal gait parameters, TUG, and ankle plantar flexors strength test. The joint position sense of the ankle was only related to one subdomain of the BESTest (Postural Responses). This study provides preliminary evidence that LE sensory deficits can possibly contribute to the pronounced balance and motor impairments in CP. The findings emphasize the importance of developing a thorough LE sensory test battery that can guide traditional treatment protocols toward a more holistic therapeutic approach by combining both motor and sensory rehabilitative strategies to improve motor function in CP.

The Effects of Anti-gravity Treadmill Training on Gait Characteristics in Children with Cerebral Palsy

Cerebral palsy is a disorder that affects muscle tone, movement and motor skills. Most of the children with cerebral palsy (CP) are not able to walk or can walk in incorrect pattern and are dependent on assistive devices. Recently an antigravity treadmill has been found to be beneficial as a new therapeutic approach. Thus, we aimed to investigate the effects of antigravity treadmill training (AlterG) on gait characteristic in children with cerebral palsy. We provided a 45-minute training program, 3 times a week for 8 weeks for six CP children as our experimental group. Our control group was a group consisted of four CP children who took typical occupational therapy, accordingly. All subjects in both AlterG and control groups were evaluated at the gait lab before and after 8 weeks training. Gait patterns were characterized using spatiotemporal parameters and dynamic balance features. We also evaluated the popular clinical gait measures including walking speed and endurance, and mobility and balance.Our results demonstrated that spatiotemporal, dynamic balance and clinical features all improved more after 8 weeks AlterG training rather than control group ones. These findings suggest that AlterG training can be considered as an effective approach for improving walking ability and gait characteristics in children with cerebral palsy.

Comparison of the effectiveness of partial body weight-supported treadmill exercises, robotic-assisted treadmill exercises, and anti-gravity treadmill exercises in spastic cerebral palsy

Objectives

This study aims to compare the effectiveness of the partial body weight-supported treadmill exercise (PBWSTE), robotic-assisted treadmill exercise (RATE), and anti-gravity treadmill exercise (ATE) in children with spastic cerebral palsy (CP).

Patients and methods

Between December 01, 2015 and May 01, 2016, a total of 29 children (18 males, 11 females; mean age 9.3±2.3 years; range, 6 to 14 years) with spastic CP were included in the study. The patients were randomly divided into three groups as the PBWSTE group (n=10), RATE group (n=10), and ATE group (n=9). Each group underwent a total of 20 treadmill exercise sessions for 45 min for five days a week for a total of four weeks. The patients were assessed using three-dimensional gait analysis, open-circle indirect calorimeter, six-minute walking test, and Gross Motor Functional Measurement (GMFM) scale before and after treatment and at two months of follow-up.

Results

No significant change compared to baseline was found in the walking speed on gait analysis among the groups after the treatment. There was no statistically significant difference among the groups in terms of the GFMF-D, GMFM-E and six-minute walking test (p>0.05). There was a significant improvement in the oxygen consumption in the ATE group (p>0.05) and RATE group (p>0.05), but not in the PBWSTE group (p<0.05).

Conclusion

Our study findings indicate that all three treadmill exercises have a positive impact on walking, and RATE and ATE can be used more actively in patients with spastic CP.

Short-burst interval treadmill training walking capacity and performance in cerebral palsy: a pilot study

PURPOSE

To examine the effect of short-burst interval locomotor treadmill training (SBLTT) on walking capacity and performance in cerebral palsy (CP).

METHODS

Twelve children with spastic diplegic CP (average 8.6 years) across Gross Motor Function Classification System levels II (8) and III (4) were randomized to 20 SBLTT sessions over 4 or 10 weeks. SBLTT consisted of alternating 30 seconds of slow and fast walking for 30 minutes/session. Outcomes included the 10 m walk test, one-minute walk test (1MWT), and timed-up-and go (TUG) (capacity) and StepWatch (performance) collected at baseline, post, and 6 weeks post.

RESULTS

Fast speed (+.11, p = .04; +.11 m/s, p = .006), 1MWT (+11.2; +11.7 m, p = .006) and TUG (-1.7; -1.9 seconds, p = .006) improved post SBLTT and 6 weeks, respectively. Walking performance increased: average strides/day (+948; +1712, p < .001) and percent time in high strides rates (+0.4, p = 0.07; +0.2, p = .008).

CONCLUSIONS

Pilot study suggests SBLTT may improve short-term walking capacity and performance.

The Effects of Lower Body Positive Pressure Treadmill Training on Dynamic Balance of Children with Cerebral Palsy

We aimed to characterize the therapeutic effects of Anti-gravity (AlterG) body weight supported treadmill training on the impaired balance of children with cerebral palsy (CP). Four spastic CP children participated; two received AlterG training 3 times a week for 8 weeks and the other two received typical occupational therapy accordingly. Their dynamic balance was evaluated before the start of the treatment and 2 months after it. Features related to the center of pressure (COP) and the center of mass (COM) were considered as dynamic balance parameters. Our results showed that the maximum velocity and acceleration of the COP and COM, the average variability (RMS) and peak to peak of the COM-COP separation, and RMS of velocity and acceleration of the COM and COP were all improved for both AlterG training patients (15-90%), though there was a limited improvement of 0.2-24% in some features of the control patients. Our results demonstrate that intensive sessions of the AlterG training program could have the potential to be used as a therapeutic tool that can produce dynamic balance improvements in CP children compared to that of typical occupational therapy.

Physiological Responses to Treadmill Running With Body Weight Support in Hypoxia Compared With Normoxia

CONTEXT

Anecdotal reports suggest elite sports clubs combine lower-body positive-pressure rehabilitation with a hypoxic stimulus to maintain or increase physiological and metabolic strain, which are reduced during lower-body positive pressure. However, the effects of hypoxia on cardiovascular and metabolic response during lower-body positive-pressure rehabilitation are unknown.

OBJECTIVE

Evaluate the use of normobaric hypoxia as a means to increase physiological strain during body-weight-supported (BWS) running.

DESIGN

Crossover study.

SETTING

Controlled laboratory.

PARTICIPANTS

Seven familiarized males (mean (SD): age, 20 (1) y; height, 1.77 (0.05) m; mass, 69.4 (5.1) kg; hemoglobin, 15.2 (0.8) g·dL^-1) completed a normoxic and hypoxic (fraction of inspired oxygen [O₂] = 0.14) trial, during which they ran at 8 km·h^-1 on an AlterG™ treadmill with 0%, 30%, and 60% BWS in a randomized order for 10 minutes interspersed with 5 minutes of recovery.

MAIN OUTCOME MEASURES

Arterial O₂ saturation, heart rate, O₂ delivery, and measurements of metabolic strain via indirect calorimetry.

RESULTS

Hypoxic exercise reduced hemoglobin O₂ saturation and elevated heart rate at each level of BWS compared with normoxia. However, the reduction in hemoglobin O₂ saturation was attenuated at 60% BWS compared with 0% and 30%, and consequently, O₂ delivery was better maintained at 60% BWS.

CONCLUSION

Hypoxia is a practically useful means of increasing physiological strain during BWS rehabilitation. In light of the maintenance of hemoglobin O₂ saturation and O₂ delivery at increasing levels of BWS, fixed hemoglobin saturations rather than a fixed altitude are recommended to maintain an aerobic stimulus.

Changes in lower extremity strength may be related to the walking speed improvements in children with cerebral palsy after gait training

BACKGROUND

Cerebral palsy (CP) has a high probability of resulting in lower extremity strength and walking deficits. Numerous studies have shown that gait training has the potential to improve the walking abilities of these children; however, the factors governing these improvements are unknown.

AIMS

This study aimed to evaluate the relationship between change in lower extremity strength, walking speed and endurance of children with CP following gait training.

METHODS AND PROCEDURES

Eleven children with CP (GMFCS levels=II-III) completed a gait training protocol three days a week for six weeks. Outcome measures included a 10m fast-as-possible walk test, 6min walking endurance test and lower extremity strength.

OUTCOMES AND RESULTS

The group results indicated there were improvements in walking speed, walking endurance and lower extremity strength. In addition, there was a positive correlation between percent change in lower extremity strength and walking speed and a negative correlation between the percent change in lower extremity strength and the child's age.

CONCLUSIONS

Our results imply that changes in lower extremity strength might be related to the degree of the walking speed changes seen after gait training. Younger children may be more likely to show improvements in lower extremity strength after gait training.

Effects of Antigravity Treadmill Training on Gait, Balance, and Fall Risk in Children With Diplegic Cerebral Palsy

OBJECTIVE

The aim of this study was to investigate the effects of antigravity treadmill training on gait, balance, and fall risk in children with diplegic cerebral palsy.

DESIGN

Thirty children with diplegic cerebral palsy were selected for this randomized controlled study. They were randomly assigned to (1) an experimental group that received antigravity treadmill training (20 mins/d, 3 d/wk) together with traditional physical therapy for 3 successive mos and (2) a control group that received only traditional physical therapy program for the same period. Outcomes included selected gait parameters, postural stability, and fall risk. Outcomes were measured at baseline and after 3 mos of intervention.

RESULTS

Children in both groups showed significant improvements in the mean values of all measured variables (P < 0.05), with significantly greater improvements in the experimental group than the control group. The posttreatment gait parameters (i.e., velocity, stride length, cadence, and percent of time spent in double-limb support) were 0.74 m/sec, 119 steps/min, 0.75 m/sec, 0.65 sec, and 55.9% as well as 0.5 m, 125 steps/min, 0.6 m/sec, 0.49 sec, and 50.4% for the experimental and control group, respectively.

CONCLUSIONS

Antigravity treadmill training may be a useful tool for improving gait parameters, balance, and fall risk in children with diplegic cerebral palsy.

Therapeutic effects of an anti-gravity treadmill (AlterG) training on gait and lower limbs kinematics and kinetics in children with cerebral palsy

We aimed to investigate the effects of the lower body weight support treadmill (AlterG) training on kinetics and kinematics of the lower extremities in children with cerebral palsy (CP). We provided a 45-minute training program, 3 times a week for 8 weeks. AlterG can support the subject's weight up to 70% so that the subject will be able to walk more comfortably to reach a more correct walking pattern. The kinematics and kinetics were evaluated using an isokinetic dynamometer. The locomotion parameters were assessed in the gait laboratory. Subjects performance was evaluated at four time points: baseline (prior to training), 1 and 2 months after the beginning of training, and one month after the end of the training (as a follow-up evaluation). The results showed that the major gait, kinematic, and kinetic parameters improved after the AlterG training and were persistent. These findings suggest that the AlterG training can be considered as a therapeutic tool for improving the lower limb performance and locomotion in children with CP.

Reproducibility of the Balance Evaluation Systems Test (BESTest) and the Mini-BESTest in school-aged children

This study evaluated the intra-rater, inter-rater and test-retest reproducibility of the Full-BESTest and Mini-BESTest when assessing postural control in children. Thirty-four children aged 7-17 years participated in intra-rater and inter-rater evaluation, and 22 children repeated assessment six weeks later for evaluation of test-retest reliability. Postural control was assessed using the Full Balance Evaluation Systems Test (Full-BESTest) and the short-form Mini-BESTest. Intra-rater, inter-rater and test-retest reproducibility were examined using video assessment. Test-retest reproducibility was also assessed in real-time. Reproducibility was examined by agreement and reliability statistics. Agreement was calculated using percentage of agreement, Limits of Agreement and Smallest Detectable Change. Reliability was calculated using Intra-class Correlation Coefficients. Results showed that the reliability of Total Scores was excellent for the Full-BESTest for all conditions (all ICCs>0.82), whereas the Mini-BESTest ranged from fair to excellent (ICC=0.56-0.86). Percentage of Domain Scores with good-excellent reliability (ICCs>0.60) was slightly higher for the Full-BESTest (66%) compared to the Mini-BESTest (59%). Smallest Detectable Change scores were good to excellent for the Full-BESTest (2%-6%) and for the Mini-BESTest (5%-10%) relative to total test scores. Both the Full-BESTest and Mini-BESTest can discriminate postural control abilities within and between days in school-aged children. The Full-BESTest has slightly better reproducibility and a broader range of items, which could be the most useful version for treatment planning. We propose minor modifications to improve reproducibility for children, and indicate the modified version by the title Kids-BESTest. Future psychometric research is recommended for specific paediatric clinical populations.

Components of Standing Postural Control Evaluated in Pediatric Balance Measures: A Scoping Review

OBJECTIVE

To identify measures of standing balance validated in pediatric populations, and to determine the components of postural control captured in each tool.

DATA SOURCES

Electronic searches of MEDLINE, Embase, and CINAHL databases using key word combinations of postural balance/equilibrium, psychometrics/reproducibility of results/predictive value of tests, and child/pediatrics; gray literature; and hand searches.

STUDY SELECTION

Inclusion criteria were measures with a stated objective to assess balance, with pediatric (≤18y) populations, with at least 1 psychometric evaluation, with at least 1 standing task, with a standardized protocol and evaluation criteria, and published in English. Two reviewers independently identified studies for inclusion. There were 21 measures included.

DATA EXTRACTION

Two reviewers extracted descriptive characteristics, and 2 investigators independently coded components of balance in each measure using a systems perspective for postural control, an established framework for balance in pediatric populations.

DATA SYNTHESIS

Components of balance evaluated in measures were underlying motor systems (100% of measures), anticipatory postural control (72%), static stability (62%), sensory integration (52%), dynamic stability (48%), functional stability limits (24%), cognitive influences (24%), verticality (9%), and reactive postural control (0%).

CONCLUSIONS

Assessing children's balance with valid and comprehensive measures is important for ensuring development of safe mobility and independence with functional tasks. Balance measures validated in pediatric populations to date do not comprehensively assess standing postural control and omit some key components for safe mobility and independence. Existing balance measures, that have been validated in adult populations and address some of the existing gaps in pediatric measures, warrant consideration for validation in children.

Physiological Responses During the Lower Body Positive Pressure Supported Treadmill Test

Objective

To quantify changes in cardiopulmonary function using a lower body positive pressure supported (LBPPS) treadmill during the exercise tolerance test (ETT) in healthy subjects before applying the LBPPS treadmill in patients with gait problems.

Methods

We evaluated 30 healthy subjects who were able to walk independently. The ETT was performed using the Modified Bruce Protocol (stages 1–5) at four levels (0%, 40%, 60%, and 80%) of LBPPS. The time interval at each level of the LBPPS treadmill test was 20 minutes to recover to baseline status. We measured systolic blood pressure, diastolic blood pressure, peak heart rate (PHR), rating of perceived exertion (RPE), metabolic equivalents (METs), and oxygen consumption rate (VO₂) during each LBPPS condition.

Results

Systolic blood pressure increased as the LBPPS level was increased (40% to 80%). PHR, RPE, METs, and VO₂ were negatively associated with the LBPPS condition, although they were not always significant different among the LBPPS levels. The equation from a random effect linear regression model was as follows: VO₂ (mL/kg/min)=(2.75×stage)+(–0.14×LBPPS level)+11.9 (r²=0.69).

Conclusion

Detection of the changes in physiological parameters during a submaximal ETT using the LBPPS system may be helpful for applying the LBPPS treadmill in patients who cannot perform the ETT due to gait problems, even at submaximal intensity.

Motor intensive anti-gravity training improves performance in dynamic balance related tasks in persons with Parkinson's disease

Recent studies indicate that the effect of training on motor performance in persons with Parkinson's disease (PDP) is dependent on motor intensity. However, training of high motor intensity can be hard to apply in PDP due to e.g. bradykinesia, rigidity, tremor and postural instability. Therefore, the aim was to study the effect of motor intensive training performed in a safe anti-gravity environment using lower-body positive pressure (LBPP) technology on performance during dynamic balance related tasks. Thirteen male PDP went through an 8-week control period followed by 8 weeks of motor intensive antigravity training. Seventeen healthy males constituted a control group (CON). Performance during a five repetition sit-to-stand test (STS; sagittal plane) and a dynamic postural balance test (DPB; transversal plane) was evaluated. Effect measures were completion time, functional rates of force development, directional changes and force variance. STS completion time improved by 24% to the level of CON which was explained by shorter sitting-time and standing-time and larger numeric rate of force change during lowering to the chair, indicating faster vertical directional change and improved relaxation. DPB completion time tended to improve and was accompanied by improvements of functional medial and lateral rates of force development and higher vertical force variance during DPB. Our results suggest that the performance improvements may relate to improved inter-limb coordination. It is concluded that 8 weeks of motor intensive training in a safe LBPP environment improved performance during dynamic balance related tasks in PDP.

The effect of anti-gravity treadmill training for prosthetic rehabilitation of a case with below-knee amputation

BACKGROUND

The aim of this case study was to verify the efficacy and safety of anti-gravity treadmill training for prosthetic rehabilitation following below-knee amputation.

CASE DESCRIPTION AND METHODS

The patient underwent left below-knee amputation as a result of diabetic foot gangrene. Since his physical strength and vitality had declined during the perioperative period, anti-gravity treadmill training was introduced for his outpatient prosthetic rehabilitation.

FINDINGS AND OUTCOMES

Stable prosthetic gait exercise could be carried out under guidance on the anti-gravity treadmill, quickly resulting in improved gait. Furthermore, the patient's self-efficacy and exercise tolerance were elevated after the period of anti-gravity treadmill training. At the final evaluation following 6 weeks of rehabilitation with the anti-gravity treadmill, he had acquired prosthetic gait with the assistance of a T-cane.

CONCLUSION

The anti-gravity treadmill was found to be a useful instrument for prosthetic rehabilitation following below-knee amputation.

CLINICAL RELEVANCE

Anti-gravity treadmill training has the potential to support the prosthetic rehabilitation of below-knee amputees, especially for patients whose physical strength and vitality are decreased.

Managing Knee Osteoarthritis: The Effects of Body Weight Supported Physical Activity on Joint Pain, Function, and Thigh Muscle Strength

OBJECTIVE

To determine the effect of a 12-week lower body positive pressure (LBPP)-supported low-load treadmill walking program on knee joint pain, function, and thigh muscle strength in overweight patients with knee osteoarthritis (OA).

DESIGN

Prospective, observational, repeated measures investigation.

SETTING

Community-based, multidisciplinary sports medicine clinic.

PATIENTS

Thirty-one patients aged between 55 and 75 years, with a body mass index ≥25 kg/m and mild-to-moderate knee OA.

INTERVENTION

Twelve-week LBPP-supported low-load treadmill walking regimen.

MAIN OUTCOME MEASURES

Acute knee joint pain (visual analog scale) during full weight bearing treadmill walking, chronic knee pain, and joint function [Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire] during normal activities of daily living, and thigh muscle strength (isokinetic testing). Appropriate methods of statistical analysis were used to compare data from baseline and follow-up evaluation.

RESULTS

Participants reported significant improvements in knee joint pain and function and demonstrated significant increases in thigh muscle strength about the degenerative knee. Participants also experienced significant reductions in acute knee pain during full weight bearing treadmill walking and required dramatically less LBPP support to walk pain free on the treadmill.

CONCLUSIONS

Data suggest that an LBPP-supported low-load exercise regimen can be used to significantly diminish knee pain, enhance joint function, and increase thigh muscle strength, while safely promoting pain-free walking exercise in overweight patients with knee OA. These findings have important implications for the development of nonoperative treatment strategies that can be used in the management of joint symptoms associated with progressive knee OA in at-risk patient populations.

CLINICAL RELEVANCE

This research suggests that LBPP-supported low-load walking is a safe user-friendly mode of exercise that can be successfully used in the management of day-to-day joint symptoms associated with knee OA, helping to improve the physical health, quality of life, and social well-being of North America's aging population.

Exercise interventions improve postural control in children with cerebral palsy: a systematic review

AIM

The aim of this study was to evaluate the efficacy and effectiveness of exercise interventions that may improve postural control in children with cerebral palsy (CP).

METHOD

A systematic review was performed using American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Six databases were searched using the following keywords: ('cerebral palsy' OR 'brain injury'); AND ('postur*' OR 'balance' OR 'postural balance' [MeSH]); AND ('intervention' OR 'therapy' OR 'exercise' OR 'treatment'). Articles were evaluated based on their level of evidence and conduct.

RESULTS

Searches yielded 45 studies reporting 13 exercise interventions with postural control outcomes for children with CP. Five interventions were supported by a moderate level of evidence: gross motor task training, hippotherapy, treadmill training with no body weight support (no-BWS), trunk-targeted training, and reactive balance training. Six of the interventions had weak or conflicting evidence: functional electrical stimulation (FES), hippotherapy simulators, neurodevelopmental therapy (NDT), treadmill training with body weight support, virtual reality, and visual biofeedback. Progressive resistance exercise was an ineffective intervention, and upper limb interventions lacked high-level evidence.

INTERPRETATION

The use of exercise-based treatments to improve postural control in children with CP has increased significantly in the last decade. Improved study design provides more clarity regarding broad treatment efficacy. Research is required to establish links between postural control impairments, treatment options, and outcome measures. Low-burden, low-cost, child-engaging, and mainstream interventions also need to be explored.

Effect of a single session of transcranial direct-current stimulation combined with virtual reality training on the balance of children with cerebral palsy: a randomized, controlled, double-blind trial

[Purpose] The aim of the present study was to investigate the effects of a single session of transcranial direct current stimulation combined with virtual reality training on the balance of children with cerebral palsy. [Subjetcs and Methods] Children with cerebral palsy between four and 12 years of age were randomly allocated to two groups: an experimental group which performed a single session of mobility training with virtual reality combined with active transcranial direct current stimulation; and a control group which performed a single session of mobility training with virtual reality combined with placebo transcranial direct current stimulation. The children were evaluated before and after the training protocols. Static balance (sway area, displacement, velocity and frequency of oscillations of the center of pressure on the anteroposterior and mediolateral axes) was evaluated using a force plate under four conditions (30-second measurements for each condition): feet on the force plate with the eyes open, and with the eyes closed; feet on a foam mat with the eyes open, and with the eyes closed. [Results] An increase in sway velocity was the only significant difference found. [Conclusion] A single session of anodal transcranial direct current stimulation combined with mobility training elicited to lead to an increase in the body sway velocity of children with cerebral palsy.

Increasing the clinical utility of the BESTest, mini-BESTest, and brief-BESTest: normative values in Canadian adults who are healthy and aged 50 years or older

BACKGROUND

Balance is a composite ability requiring the integration of multiple systems. The Balance Evaluation Systems Test (BESTest) and 2 abbreviated versions (the Mini-BESTest and the Brief-BESTest) are balance assessment tools that target these systems. To date, no normative data exist for any version of the BESTest.

OBJECTIVE

The purpose of this study was to determine the age-related normative scores on the BESTest, Mini-BESTest, and Brief-BESTest for Canadians who are healthy and 50 to 89 years of age.

DESIGN

A cross-sectional study design was used.

METHODS

Seventy-nine adults who were healthy and aged 50 to 89 years (mean age=68.9 years; 50.6% women) participated. Normative scores were reported by age decade.

RESULTS

Mean BESTest scores were 95.7 (95% confidence interval [CI]=94.4-97.1) for adults who were aged 50 to 59 years, 91.4 (95% CI=89.8-93.0) for those who were aged 60 to 69 years, 85.4 (95% CI=82.5-88.2) for those who were aged 70 to 79 years, and 79.4 (95% CI=74.3-84.5) for those who were aged 80 to 89 years. Similar results were obtained for the Mini-BESTest and the Brief-BESTest, and all 3 tests showed statistically significant differences in scores among the age cohorts.

LIMITATIONS

Because only adults who were 50 to 89 years of age were tested, there are still no normative data for people outside this age range. Also, the scores presented may not be generalizable to all countries.

CONCLUSIONS

These normative data enhance the clinical utility of the BESTest, Mini-BESTest, and Brief-BESTest by providing clinicians with reference points to guide treatment.

Treadmill training for a child with spina bifida without functional ambulation

PURPOSE

To describe and report the effect of an 8-week individualized, progressive, treadmill training program on the ambulatory ability of a 4-year-old child with myelomeningocele without functional ambulation.

SUMMARY OF KEY POINTS

Heart rate and speed on the 2-minute walk test (2MWT) were used to individualize training. Ambulatory outcome measures taken at baseline, postintervention, and 6 weeks postintervention included the 2MWT and the Timed "Up and Go" (TUG). The Pediatric Evaluation of Disability Index was used to measure functional mobility. Improvements were noted in ambulatory ability after training (2MWT, 64.10%; TUG, 34.66%) and at the 6-week follow-up (2MWT, 58.97%; TUG, 34.24%). The Pediatric Evaluation of Disability Index showed no significant difference.

CONCLUSION AND RECOMMENDATIONS

Use of an individualized treadmill training program may have improved the ambulatory skills of a preschooler with myelomeningocele. More rigorous studies are needed to determine the effects of treadmill training with the spina bifida population and identify optimal training parameters.

Cardiovascular responses in older adults with total knee arthroplasty at rest and with exercise on a positive pressure treadmill

PURPOSE

We investigated cardiovascular responses at rest and during submaximal exercise on a lower body positive pressure treadmill in older adults with total knee arthroplasty (TKA).

METHODS

Twenty-four adults (mean age 64.6 ± 7.9 SD) with unilateral TKA participated (median time since surgery 8.0 weeks). Heart rate and blood pressure responses were measured at rest standing on the positive pressure treadmill with 0, 10, 20, and 30 mmHg applied. Heart rate, blood pressure, oxygen consumption, minute ventilation, knee pain and perceived exertion were measured during submaximal exercise tests (0 and 40% body weight support) conducted 1 week apart.

RESULTS

At rest there were no differences in blood pressure across different treadmill pressures, but heart rate was significantly lower when 30 mmHg was applied compared to ambient pressure conditions (P < 0.05). Participants averaged 5.1 exercise test stages with 0% body weight support (maximum speed 2.5 mph, 0% incline) and 6.4 stages with 40% body weight support (maximum speed 3.0 mph, 10% incline). During exercise, heart rate, systolic blood pressure, oxygen consumption, and minute ventilation were lower when 40% body weight support was provided for a given test stage (P < 0.01). Diastolic blood pressure, knee pain and perceived exertion did not differ with body weight support but increased with increasing exercise test stages (P < 0.05).

CONCLUSIONS

Provision of body weight support allowed TKA patients to walk at faster speeds and/or to tolerate greater incline with relatively lower levels of heart rate, blood pressure, and oxygen consumption.

Overground body-weight-supported gait training for children and youth with neuromuscular impairments

The aim of this investigation was to determine if body-weight-supported (BWS) overground gait training has the potential to improve the walking abilities of children and youth with childhood onset motor impairments and intellectual disabilities. Eight participants (mean age of 16.3 years) completed 12 weeks of BWS overground gait training that was performed two times a week. BWS was provided during the training sessions by an overhead harness system that rolls overground. There was a significant improvement in the preferred walking speed after the training (p < .01; pre = 0.51 ± 0.2 m/s; post = 0.67 ± 0.3 m/s; Cohen's d = 0.80) and cadence (p = .04; pre = 37 ± 7 steps/min; post = 43 ± 8 steps/min; Cohen's d = 0.94). Our results indicate that overground BWS gait training may be an effective treatment strategy for improving the preferred walking speed of children and youth with motor impairments.

Lower body positive pressure: an emerging technology in the battle against knee osteoarthritis?

Background

Knee osteoarthritis (OA) is the most prevalent medical condition in individuals over the age of 65 years, and is a progressive joint degenerative condition with no known cure. Research suggests that there is a strong relationship between knee pain and loss of physical function. The resulting lifestyle modifications negatively impact not only disease onset and progression but also overall health, work productivity, and quality of life of the affected individual.

Purpose

The goal of this investigation was to examine the feasibility of using an emerging technology called lower body positive pressure (LBPP) to simulate weight loss and reduce acute knee pain during treadmill walking exercise in overweight individuals with radiographically confirmed symptomatic knee OA.

Design

Prospective case series.

Methods

Twenty-two overweight individuals with knee OA completed two 20-minute treadmill walking sessions (one full weight bearing and one LBPP supported) at a speed of 3.1 mph, 0% incline. Acute knee pain was assessed using a visual analog scale, and the percentage of LBPP support required to minimize knee pain was evaluated every 5 minutes. Knee Osteoarthritis Outcome Scores were used to quantify knee pain and functional status between walking sessions. The order of testing was randomized, with sessions occurring a minimum of 1 week apart.

Results

A mean LBPP of 12.4% of body weight provided participants with significant pain relief during walking, and prevented exacerbation of acute knee pain over the duration of the 20-minute exercise session. Patients felt safe and confident walking with LBPP support on the treadmill, and demonstrated no change in Knee Osteoarthritis Outcome Scores over the duration of the investigation.

Conclusion

Results suggest that LBPP technology can be used safely and effectively to simulate weight loss and reduce acute knee pain during weight-bearing exercise in an overweight knee OA patient population. These results could have important implications for the development of future treatment strategies used in the management of at-risk patients with progressive knee OA.

Coactivation of lower leg muscles during body weight-supported treadmill walking decreases with age in adolescents

The kinematics of children's walking are nearly adult-like by about age 3-4 years, but metabolic efficiency of walking does not reach adult values until late in adolescence or early adulthood, perhaps due to higher coactivation of agonist/antagonist muscle pairs in adolescents. Additionally, it is unknown how use of a body weight-supported treadmill device affects coactivation, but because unloading will alter the activity of anti-gravity muscles, it was hypothesized that muscle coactivation will be altered as well. Muscle coactivation during treadmill walking was evaluated for adolescents (ages 10 to 17 years, M = 13.2, SD = 2.2) and adults (ages 22 to 35 years, M = 25.2, SD = 4.3), for thigh muscles (vastus lateralis/biceps femoris) and lower leg muscles (tibialis anterior/gastrocnemius). Conditions included body weight unloadings from nearly 0% to 80% of body weight, while walking at a preferred speed (self-selected, overground speed) or a reduced speed. Unloading was accomplished using a lower body positive pressure support system. Coactivation was found to be higher in adolescents than in adults, but only for the lower leg muscles.