WalkAide Efficacy on Gait and Energy Expenditure in Children with Hemiplegic Cerebral Palsy

Electrical Stimulation for Children with Cerebral Palsy: A Meta-analysis for Randomized Controlled Trials

BACKGROUND

Different types of electrical stimulation (ES) showed diverse effects on children with cerebral palsy (CP). Previous studies reported inconsistent results for effects of ES on children with CP. The present study aimed to conduct a meta-analysis to summarize these diverse results.

METHODS

We searched for studies exploring effects of ES on children with CP in databases (PubMed and Web of Science) from their inception until December 2022. Standard mean differences (SMDs) and 95% confidence intervals (CIs) were computed using STATA 12.0 software.

RESULTS

The meta-analysis included 19 randomized controlled trials (including 265 CP patients in test group and 263 CP patients in corresponding control group). The study showed an increased improvement in gross motor function, walking speed, step length, and daily living activities in ES group compared with corresponding control group with random effects models (gross motor function: SMD = 2.04, 95% CI = 1.43-2.65; walking speed: SMD = 3.71, 95% CI = 1.49-5.92; step length: SMD = 1.89, 95% CI = 0.65-3.13; daily living activities: SMD = 5.18, 95% CI = 3.04-7.31), whereas the study showed no significant difference in change of muscle strength between ES group and the corresponding control group with a random effects model (SMD = 0.42, 95% CI = -0.12 to 0.97).

CONCLUSION

The study demonstrated that ES might be used as therapy to improve gross motor function, gait, and daily living activities in children with CP.

Effect of Functional Electrical Stimulation on Gait Parameters in Children with Cerebral Palsy: A Meta-Analysis

Objective

At present, there are controversies on the effectiveness of functional electrical stimulation devices in gait improvement in the clinic, and the results reported in limited literature are contradictory. This paper summarizes and analyzes the relationship between functional electrical stimulation treatment and gait parameter changes in children with cerebral palsy, thus exploring the above controversies' results.

Methods

Two researchers conducted a detailed search of the literature from the establishment of the database to June 2022. Literature retrieved from databases, including PubMed, Embase, Ovid, Cochrane Library, and Web of Science and the search process followed the principles of Cochrane. The search keywords were “cerebral palsy”, “functional electrical stimulation”, “gait”, or “walk”. Gait and balance parameters were extracted from the literature. Gait parameters, such as walking speed and step length, were included in the meta-analysis. The study used standard mean difference (STD) and 95% confidence interval (CI) to calculate the mean difference between the two groups. The statistic I² was used to evaluate the heterogeneity between the evaluation studies. Begg's test detected publication bias and the funnel chart was used for visual analysis. Furthermore, Review Manager software was used to make a risk bias map for literature publication bias analysis.

Results

9 literatures were included in the analysis, with a total of 282 children with cerebral palsy, including 142 patients in the functional electrical stimulation treatment group and 140 patients in the comfort treatment, general nursing, or other physical therapy. The randomization scheme and result report used in most studies were low risk, which was important for the credibility of this study. Most studies have limitations in the blinding method of participants and subjects, and most of them were single-blind studies, which might have a high risk. The results showed that functional electrical stimulation could increase the walking speed of children with cerebral palsy (SMD = 0.82, P < 0.0001) and increase the walking step length of children with cerebral palsy (SMD = 1.34, 95%CI = 1.07, 1.60, Z = 9.91, P < 0.0001). Funnel plot analysis showed that the literature distribution was uniform and symmetrical, and Begg's test showed no publication bias in included literature.

Conclusion

This study compared the effects of the functional nerve stimulation treatment group and control group on improving gait parameters of children with cerebral palsy. The results indicated that functional nerve stimulation treatment could increase the gait speed and step length of children with cerebral palsy, which could improve the walking of children with cerebral palsy. Furthermore, this study needs more research data to support our findings. The results of this study might better guide the clinical practice and better use of health as well as financial resources.

Effects of a Modern Kefir on Conditions Associated with Moderate Severe Spastic Quadriparesis Cerebral Palsy

Cerebral palsy (CP) in children constitutes a set of movement and body posture disorders caused by brain injury, which in turn is associated with a series of intestinal, respiratory, and malnutrition conditions. Twenty-four children were selected and included for the present study and subdivided into two groups: (1) children who included modern kefir (containing 12 probiotic species) in their diet; and (2) control group (not including kefir in their diet). The group supplemented with modern kefir received a beverage with multi probiotic species and the control group received commercial yogurt (which included the 2 typical lactic acid bacteria) for 7 weeks. Anthropometric variables, resting energy expenditure, presence, and diagnosis of functional digestive disorders (FDD), frequency of respiratory problems, presence of elevated C-reactive protein, differential count of leukocytes were evaluated. A significant increase in weight and height was found in the kefir group at the final time point. In addition, kefir intake promoted a significant reduction in functional constipation and stool hardness and increased the absolute value of blood lymphocytes. Since the fermented milk beverage modern kefir improves constipation, which is the most important FDD in children with CP and the nutritional and immune status, it could be considered an important strategy to improve health in these children.

Effectiveness of neuromuscular electrical stimulation in improving mobility in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate whether neuromuscular electrical stimulation improves mobility in children with spastic cerebral palsy.

METHODS

PubMed, Cochrane, EMBASE, and Scopus were searched for randomized controlled trials studying the effects of NMES on the lower limbs in children with spastic CP. Randomized controlled trials comparing the effect of neuromuscular electrical stimulation with that of placebo or conventional therapy on mobility in children with cerebral palsy were eligible for inclusion. Two reviewers independently screened studies, extracted data, and examined the risk of bias and quality of evidence by using the revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2.0) and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method. The final search was conducted on May 23, 2022.

RESULTS

A total of 14 randomized controlled trials (2 crossover studies and 12 parallel studies including 421 patients) were included in this meta-analysis. Compared with the control group (conventional physical therapy), the treatment group exhibited greater improvement in walking speed (standardized mean difference = 0.29; 95% confidence interval = 0.02-0.57) and the standing, walking, running, and jumping dimension of the Gross Motor Function Measure (standardized mean difference = 1.24; 95% confidence interval = 0.64-1.83).

CONCLUSION

Neuromuscular electrical stimulation improved mobility in children with spastic cerebral palsy, particularly in standing, running, and jumping function, and it is safe for children with spastic cerebral palsy.

Relationship between ankle function and walking ability for children and young adults with cerebral palsy: A systematic review of deficits and targeted interventions

BACKGROUND

A primary goal of treatment for children with cerebral palsy is improved walking ability to allow for a more active and independent lifestyle. With the importance of ankle function to walking ability, and the deficits in ankle function associated with cerebral palsy, there is good rationale for targeting this joint in an effort to improve walking ability for this population.

RESEARCH QUESTION

How do deficits and targeted interventions of the ankle joint influence walking ability in children with cerebral palsy?

METHODS

A specific search criteria was used to identify articles that either (1) provided information on the relationship between ankle function and walking ability or (2) investigated the effect of a targeted ankle intervention on walking ability in cerebral palsy. PubMed, Embase, CINAHL, and Web of Science databases were searched from 1980-April, 2020. Resulting citations were compared against a prospective set of inclusion and exclusion criteria. Data relevant to the original research question was extracted, and the level of evidence for each intervention study was scored. Interpretation was focused on specific, pre-determined mobility measures.

RESULTS

Sixty-one citations met all criteria for data extraction, six of which were observational, and fifty-five of which were interventional. Level of evidence ranged from 2 to 4. Self-selected walking speed was the most common measure of walking ability, while physical activity level was the least common.

SIGNIFICANCE

Ankle function is an important contributor to the walking ability of children with cerebral palsy, and most interventions targeting the ankle seem to demonstrate a benefit on walking ability, but future higher-powered and/or controlled studies are necessary to confirm these findings.

Effect of functional electrical stimulation versus TheraTogs on gait and balance in children with hemiplegic cerebral palsy: a randomized controlled trial

Background

Children with cerebral palsy exhibit postural restrictions and gait problems as a result of both primary and secondary brain damage impairments. One of the main goals of cerebral palsy rehabilitation is to improve gait and balance. As a result, the purpose of this study was to compare the effects of FES and TheraTogs on gait and balance in children with hemiplegic CP. A randomized controlled study was conducted on 30 children with hemiplegic CP (18 boys and 12 girls) between the ages of 8 and 12 years. The children were divided into two equal groups. In addition to the traditional physical treatment program, the FES group received functional electrical stimulation (pulse width 300 μs, frequency 33 Hz, 2 h/day, 3 days/week, 3 months). The TheraTogs group, on the other hand, received the TheraTogs strapping system as well as the same traditional program for the same time period. The 3-D motion analysis and the Biodex balance system were used to analyze gait parameters and postural stability at baseline and 3 months after the intervention.

Results

When comparing the mean values of the gait parameters and postural stability indices of children in both groups before and after treatment, a significant improvement was reported. Furthermore, the FES group showed a greater improvement in all of the measured outcomes (P < 0.001).

Conclusion

Functional electrical stimulation improves gait pattern and postural stability in children with hemiplegic cerebral palsy significantly more than TheraTogs strapping systems.

Clinical trial registration

This study was registered in the ClinicalTrial.gov PRS (NCT05020834).

Effect of functional electrical stimulation on postural control in children with hemiplegic cerebral palsy: a randomized controlled trial

Background

Children with cerebral palsy have impairments of postural control during static and dynamic activities. Improving postural control is one of the primary objectives of rehabilitation for children with cerebral palsy. Therefore, the objective of this study was to study the effect of functional electric stimulation on postural control in children with hemiplegic cerebral palsy. A randomized controlled study was conducted on 30 children with hemiplegic cerebral palsy (18 boys and 12 girls) between the ages of 8 and 12 years. The children were distributed in two equal groups. The experimental group received functional electrical stimulation (pulse width 300 μs, frequency 33 Hz, 2 h/day, 3 days/week, / 3 consecutive months) in addition to the traditional physical therapy program. While the control group received the traditional physiotherapy program only for the same duration. The outcomes included postural stability indices that were measured at baseline and following 3 months of intervention using the Biodex balance system.

Results

A significant improvement was found in the postural stability indices of children in both groups, comparing their mean values before and after treatment. Furthermore, the results revealed a greater improvement in the postural stability of the experimental group (P < 0.001).

Conclusion

Functional electrical stimulation may be a useful tool to enhance the postural stability of children with hemiplegic cerebral palsy.

Clinical trial registration

This study was registered in the ClinicalTrial.gov PRS (NCT04269798). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009LHP&selectaction=Edit&uid=U0003GAI&ts=4&cx=74k74l

Neuromuscular electrical stimulation for motor recovery in pediatric neurological conditions: a scoping review

AIM

To explore the breadth of pediatric neurological conditions for which neuromuscular electrical stimulation (NMES) has been studied.

METHOD

Databases (PubMed, Google Scholar, Scopus, and Embase) were searched from 2000 to 2020, using the search terms 'neuromuscular electrical stimulation' OR 'functional electrical stimulation' with at least one of the words 'pediatric OR child OR children OR adolescent', and without the words 'dysphagia OR implanted OR enuresis OR constipation'. Articles focused on adults or individuals with cerebral palsy (CP) were excluded.

RESULTS

Thirty-five studies met the inclusion criteria, with a total of 353 pediatric participants (293 unique participants; mean age 7y 4mo, range 1wk-38y). NMES was applied in a range of pediatric conditions other than CP, including stroke, spinal cord injury, myelomeningocele, scoliosis, congenital clubfoot, obstetric brachial plexus injury, genetic neuromuscular diseases, and other neuromuscular conditions causing weakness.

INTERPRETATION

All 35 studies concluded that NMES was well-tolerated and most studies suggested that NMES could augment traditional therapy methods to improve strength. Outcome measurements were heterogeneous. Further research on NMES with larger, randomized studies will help clarify its potential to improve physiology and mobility in pediatric patients with neuromuscular conditions. What this paper adds Neuromuscular electrical stimulation (NMES) appears to be tolerated by pediatric patients. NMES shows potential for augmenting recovery in pediatric patients with a range of rehabilitation needs.

Gait Classification in Unilateral Cerebral Palsy

As unilateral cerebral palsy represents a complex disorder, gait classification is difficult. Knowledge of the most frequent gait patterns and functional impairment is crucial for proper decision-making. This study analyzes the prevalence of gait patterns as well as the relation of different gait patterns and the Gross Motor Function Classification System (GMFCS). Eighty-nine patients were classified retrospectively using the GMFCS, the classification of Winters, Gage, and Hicks (WGH), and Sutherland et al. The distribution of GMFCS levels among the different gait patterns was analyzed using Chi-squared test. The most common subtypes were GMFCS level I, WGH type I, and recurvatum knee. Seventeen percent (WGH) and 59% (Sutherland) of the patients did not match any criteria. Applying both classifications complementarily reduced the number of unclassified patients significantly. There was no significant difference concerning the distribution of GMFCS levels or age among the different gait patterns. A combined use of various classification systems is beneficial for proper decision-making. Unclassified patients seem to be a heterogeneous subgroup concerning functional impairment. There is a need of further characterization of the unclassifiable gait patterns and the caused functional impairment. Instrumented gait analysis remains the gold standard and should be broadly used for future studies and in clinical practice.

A Scoping Review of Neuromuscular Electrical Stimulation to Improve Gait in Cerebral Palsy: The Arc of Progress and Future Strategies

Background: Neuromuscular deficits of children with spastic cerebral palsy (CP) limits mobility, due to muscle weakness, short muscle-tendon unit, spasticity, and impaired selective motor control. Surgical and pharmaceutical strategies have been partially effective but often cause further weakness. Neuromuscular electrical stimulation (NMES) is an evolving technology that can improve neuromuscular physiology, strength, and mobility. This review aims to identify gaps in knowledge to motivate future NMES research.

Methods: Research publications from 1990- July 20th 2019 that investigated gait-specific NMES in CP were reviewed using the PubMed and Google Scholar databases. Results were filtered by the National Institute of Neurological Disorder and Stroke common data elements guidelines for CP. The Oxford Centre for Evidence Based Medicine guidelines were used to determine levels of evidence for each outcome. Gait-specific NMES research protocols and trends are described, with implications for future research.

Results: Eighteen studies met inclusion criteria, reporting on 212 participants, 162 of whom received NMES while walking, average age of 9.8 years, GMFCS levels I–III. Studies included 4 randomized control trials, 9 cohort studies and 5 case studies. A historical trend emerged that began with experimental multi-channel NMES device development, followed by the commercial development of single-channel devices with inertial sensor-based gait event detection to facilitate ankle dorsiflexion in swing phase. This research reported strong evidence demonstrating improved ankle dorsiflexion kinematics in swing and at initial contact. Improved walking speed, step length, and muscle volume were also reported. However, improvements in global walking scores were not consistently found, motivating a recent return to investigating multi-channel gait-specific NMES applications.

Conclusions: Research on single-channel gait-specific NMES found that it improved ankle motion in swing but was insufficient to address more complex gait abnormalities common in CP, such as flexed-knee and stiff-knee gait. Early evidence indicates that multi-channel gait-specific NMES may improve gait patterns in CP, however significantly more research is needed. The conclusions of this review are highly limited by the low level of evidence of the studies available. This review provides a historical record of past work and a technical context, with implications for future research on gait-specific NMES to improve walking patterns and mobility in CP.

Kinematic and Functional Gait Changes After the Utilization of a Foot Drop Stimulator in Pediatrics

Foot drop is one of the most common secondary conditions associated with hemiplegia post stroke and cerebral palsy (CP) in children, and is characterized by the inability to lift the foot (dorsiflexion) about the ankle. This investigation focuses on children and adolescents diagnosed with brain injury and aims to evaluate the orthotic and therapeutic effects due to continuous use of a foot drop stimulator (FDS). Seven children (10 ± 3.89 years) with foot drop and hemiplegia secondary to brain injury (stroke or CP) were evaluated at baseline and after 3 months of FDS usage during community ambulation. Primary outcome measures included using mechanistic (joint kinematics, toe displacement, temporal-spatial asymmetry), and functional gait parameters (speed, step length, time) to evaluate the orthotic and therapeutic effects. There was a significant correlation between spatial asymmetry and speed without FDS at 3 months (r = 0.76, p < 0.05, df = 5) and no correlation between temporal asymmetry and speed for all conditions. The results show orthotic effects including significant increase in toe displacement (p < 0.025 N = 7) during the swing phase of gait while using the FDS. A positive correlation exists between toe displacement and speed (with FDS at 3 months: r = 0.62, p > 0.05, without FDS at 3 months: r = 0.44, p > 0.05). The results indicate an orthotic effect of increased dorsiflexion and toe displacement during swing with the use of the FDS in children with hemiplegia. Further, the study suggests that there could be a potential long-term effect of increased dorsiflexion during swing with continuous use of FDS.

Effect of rhythmic auditory cueing on gait in cerebral palsy: a systematic review and meta-analysis

Auditory entrainment can influence gait performance in movement disorders. The entrainment can incite neurophysiological and musculoskeletal changes to enhance motor execution. However, a consensus as to its effects based on gait in people with cerebral palsy is still warranted. A systematic review and meta-analysis were carried out to analyze the effects of rhythmic auditory cueing on spatiotemporal and kinematic parameters of gait in people with cerebral palsy. Systematic identification of published literature was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and American Academy for Cerebral Palsy and Developmental Medicine guidelines, from inception until July 2017, on online databases: Web of Science, PEDro, EBSCO, Medline, Cochrane, Embase and ProQuest. Kinematic and spatiotemporal gait parameters were evaluated in a meta-analysis across studies. Of 547 records, nine studies involving 227 participants (108 children/119 adults) met our inclusion criteria. The qualitative review suggested beneficial effects of rhythmic auditory cueing on gait performance among all included studies. The meta-analysis revealed beneficial effects of rhythmic auditory cueing on gait dynamic index (Hedge's g=0.9), gait velocity (1.1), cadence (0.3), and stride length (0.5). This review for the first time suggests a converging evidence toward application of rhythmic auditory cueing to enhance gait performance and stability in people with cerebral palsy. This article details underlying neurophysiological mechanisms and use of cueing as an efficient home-based intervention. It bridges gaps in the literature, and suggests translational approaches on how rhythmic auditory cueing can be incorporated in rehabilitation approaches to enhance gait performance in people with cerebral palsy.