Minimum Clinically Important Difference of Gross Motor Function and Gait Endurance in Children with Motor Impairment: A Comparison of Distribution-Based Approaches

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

High-Intensity Gait Training Intervention for Children With Cerebral Palsy: A Case Series

PURPOSE

The purpose of this pilot case series was to describe participation in high-intensity gait training (HIGT) and changes in (1) gait speed/endurance, (2) aerobic capacity, and (3) walking ability in children diagnosed with cerebral palsy (CP).

METHODS

Three children with CP participated in HIGT for 5 weeks in lieu of their routine physical therapy. Outcome measures were collected at baseline and post-intervention.

RESULTS

Post-intervention, all had at or above the minimal clinically important difference for 10-m walk test speed and 6-minute walk test distance. Two participants performed above the minimal clinically important difference in 7.5-m shuttle run test level and Gross Motor Function Measure-88 Dimension E score.

CONCLUSION

This case series demonstrates short-term improvements in the walking outcome measures with participation in HIGT. Further research is needed with a larger and more diverse randomized controlled trial to determine parameters and long-term effects of HIGT in this population.

Group-based progressive functional, high-intensity training in adolescents and young adults with unilateral cerebral palsy - a tool to improve gross motor function, endurance and gait? - a pilot study

PURPOSE

This pilot study assessed the safety and effects of progressive functional high-intensity training in a group setting for adolescents with unilateral cerebral palsy (CP) on daily function indicators.

METHODS

Nine adolescents (mean age 16.9 years, GMFCS levels I-II) participated in 12 weeks of training (2x/week). Evaluations included 3D gait analysis, the 6-min walking test (6MWT), clinical exams, and the Gross Motor Function Measure-66 (GMFM-66).

RESULTS

No adverse events occurred, and GMFM-66 scores significantly improved (p = .031, Δ = 2.19%). Although increases in 6MWT (p = .09, Δ = 29.8 m) performance and propulsion ratio (p = .067, Δ = 5.4%) for the affected leg were observed, they were not statistically significant.

DISCUSSION

The study suggests that this training is safe and may enhance gross motor function, endurance, and gait asymmetry in unilateral CP. Future research should include upper limb evaluations and out-of-clinic motion analysis with wearable inertial measurement units (IMUs) to provide a more comprehensive assessment of functional movements.

Exploring the Efficacy of a Dynamic Harness System on Gross Motor Development and Motivation for Infants With Down Syndrome: A Pilot Study

PURPOSE

To explore the benefits of a Partial Body Weight Support (PBWS) harness system within a play enriched environment on gross motor development and mastery motivation of infants with Down Syndrome (DS).

METHODS

A randomized crossover study with 17 pre-walking infants with DS in two conditions-play with or without the harness engaged-each for 3×/week over 3 weeks with a 1-week washout. Assessments took place at baseline, crossover, and completion.

RESULTS

Statistically and clinically significant changes were evident on the Gross Motor Function Measure-88; however, there were no significant changes in parent-reported mastery motivation.

CONCLUSION

The combination of PBWS harness system support and high frequency-facilitated play within an enriched play environment positively affected gross motor development. The intervention did not impact mastery motivation skills, and the direct impact of the harness remains unclear.

Functional impairments in NBIA patients: Preliminary results

Neurodegeneration with brain iron accumulation (NBIA) is a heterogeneous group (genetically and phenotypically) of genetically determined disorders. Up to date there is no cure for this disease, so the applied treatments focus on symptoms control and palliative care. The main problems are delayed motor development, gait deterioration, postural instability, cognitive dysfunctions, abnormal muscle tone and many others. As gait and balance deficits are predominant features of NBIA patients this study aimed at the use of the objective, instrumented functional tests as well as functional assessment scales to assess their functional impairments. Twenty three NBIA patients recruited for the study underwent objective, instrumented gait analysis, balance assessment, pedobarography and functional evaluation with Gross Motor Function Measure (GMFM-88). The results showed high variability and heterogeneity of NBIA functional status (GMFM from 27.5 to 100.0), but also showed some differences in gait pattern between their types (p < 0.05 at the pelvis, hip and knee). We think that these results could help design objective assessment protocols in future clinical studies.

Training intensity of robot-assisted gait training in children with cerebral palsy

AIM

We compared three different intensities of robot-assisted gait training (RAGT) for achieving favourable outcomes in children with cerebral palsy (CP).

METHOD

This study was conducted using a randomized controlled, single-blind design. Thirty children (19 males and 11 females; mean age 6 years 1 month, SD 2 years) with CP classified in Gross Motor Function Classification System levels II and III were assigned to three different RAGT intensity groups: high-intensity (fastest walking speed and lowest body weight support [BWS]), low-intensity (slowest speed and highest BWS), and comfortable intensity (intermediate speed and intermediate BWS). The RAGT intervention was performed three times a week for 6 weeks. Outcome measures included the 88-item Gross Motor Function Measure, stability index, spatiotemporal parameters of gait analysis, paediatric functional independence measure, and the Canadian Occupational Performance Measure.

RESULTS

The 88-item Gross Motor Function Measure was significantly improved after training in the high-intensity (D Δ8.3 ± 15.6; E Δ3.8 ± 4.1) and comfortable intensity (D Δ2.9 ± 3.1; E Δ1.2 ± 2.0) groups, whereas gait speed was improved in the comfortable intensity group, without statistically significant group differences. Only the low-intensity group showed improvement on the stability index (Δ -0.6 ± 0.9, p = 0.05). Everyday functional performance significantly improved in all three groups, with the comfortable intensity group showing the greatest improvement.

INTERPRETATION

Different training intensities produced improvement in different areas; individualized RAGT intensity adjustment is therefore needed based on the rehabilitation goal.

Overground Gait Training With a Wearable Robot in Children With Cerebral Palsy: A Randomized Clinical Trial

Importance

Cerebral palsy (CP) is the most common developmental motor disorder in children. Robot-assisted gait training (RAGT) using a wearable robot can provide intensive overground walking experience.

Objective

To investigate the effectiveness of overground RAGT in children with CP using an untethered, torque-assisted, wearable exoskeletal robot.

Design, Setting, and Participants

This multicenter, single-blind randomized clinical trial was conducted from September 1, 2021, to March 31, 2023, at 5 rehabilitation institutions in Korea. Ninety children with CP in Gross Motor Function Classification System levels II to IV were randomized.

Intervention

The RAGT group underwent 18 sessions of RAGT during 6 weeks, whereas the control group received standard physical therapy for the same number of sessions during the same period.

Main Outcome and Measures

The primary outcome measure was the Gross Motor Function Measure 88 (GMFM-88) score. Secondary outcome measures were the GMFM-66, Pediatric Balance Scale, selective control assessment of the lower extremity, Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), 6-minute walking test scores (distance and oxygen consumption), muscle and fat mass via bioelectrical impedance analysis, and gait parameters measured via 3-dimensional analysis. All assessments were performed for all patients at baseline, at the end of the 6-week intervention, and after the 4-week follow-up.

Results

Of the 90 children (mean [SD] age, 9.51 [2.48] years; 49 [54.4%] male and 41 [45.6%] female) in the study, 78 (86.7%) completed the intervention, with 37 participants (mean [SD] age, 9.57 [2.38] years; 19 [51.4%] male) and 41 participants (mean [SD] age, 9.32 [2.37] years; 26 [63.4%] male) randomly assigned to the RAGT and control groups, respectively. Changes in the RAGT group significantly exceeded changes in the control group in GMFM-88 total (mean difference, 2.64; 95% CI, 0.50-4.78), GMFM-E (mean difference, 2.70; 95% CI, 0.08-5.33), GMFM-66 (mean difference, 1.31; 95% CI, 0.01-2.60), and PEDI-CAT responsibility domain scores (mean difference, 2.52; 95% CI, 0.42-4.63), indicating independence in daily living at postintervention assessment. At the 4-week follow-up, the RAGT group showed significantly greater improvements in balance control (mean difference, 1.48; 95% CI, 0.03-2.94) and Gait Deviation Index (mean difference, 6.48; 95% CI, 2.77-10.19) compared with the control group.

Conclusions and Relevance

In this randomized clinical trial, overground RAGT using a wearable robot significantly improved gross motor function and gait pattern. This new torque-assisted wearable exoskeletal robot, based on assist-as-needed control, may complement standard rehabilitation by providing adequate assistance and therapeutic support to children with CP.

Trial Registration

CRIS Identifier: KCT0006273.

Clinical study on the safety and feasibility of AiWalker-K for lower limbs exercise rehabilitation in children with cerebral palsy

BACKGROUND

Robotic-assisted gait training (RAGT) devices are effective for children with cerebral palsy (CP). Many RAGT devices have been created and put into clinical rehabilitation treatment. Therefore, we aimed to investigate the safety and feasibility of a new RAGT for children with CP.

METHODS

This study is a cross-over design with 23 subjects randomly divided into two groups. The occurrence of adverse events and changes in heart rate and blood pressure were recorded during each AiWalker-K training. Additionally, Gross Motor Function Measure-88 (GMFM-88), Pediatric Balance Scale (PBS), 6 Minutes Walking Test (6MWT), Physiological Cost Index, and Edinburgh Visual Gait Score (EVGS) were used to assess treatment, period, carry-over, and follow-up effects in this study.

RESULTS

Adverse events included joint pain, skin pain, and injury. Heart rate and blood pressure were higher with the AiWalker-K compared to the rest (P < 0.05), but remained within safe ranges. After combined treatment with AiWalker-K and routine rehabilitation treatment, significant improvements in 6MWT, GMFM-88 D and E, PBS, and EVGS were observed compared to routine rehabilitation treatment alone (P < 0.05).

CONCLUSIONS

Under the guidance of experienced medical personnel, AiWalker-K can be used for rehabilitation in children with CP.

Efficacy of a Soft Robotic Exoskeleton to Improve Lower Limb Motor Function in Children with Spastic Cerebral Palsy: A Single-Blinded Randomized Controlled Trial

PURPOSE

Soft robotic exoskeletons (SREs) are portable, lightweight assistive technology with therapeutic potential for improving lower limb motor function in children with cerebral palsy. To understand the effects of long-term SRE-assisted walking training on children with spastic cerebral palsy (SCP), we designed a study aiming to elucidate the effects of SRE-assisted walking training on lower limb motor function in this population.

METHODS

In this randomized, single-blinded (outcome assessor) controlled trial, forty children diagnosed with SCP were randomized into the routine rehabilitation (RR) group (N = 20) and the SRE group (N = 20) for comparison. The RR group received routine rehabilitation training, and the SRE group received routine rehabilitation training combined with SRE-assisted overground walking training. Assessments (without SRE) were conducted pre- and post-intervention (8 weeks after the intervention). The primary outcome measures included the 10 m walk test (10MWT) and the 6 min walk test (6MWT). Secondary outcome measures comprised the gross motor function measure-88, pediatric balance scale modified Ashworth scale, and physiological cost index.

RESULTS

Both groups showed significant improvements (p < 0.01) across all outcome measures after the 8-week intervention. Between-group comparisons using ANCOVA revealed that the SRE group demonstrated greater improvement in walking speed from the 10MWT (+6.78 m/min, 95% CI [5.74-7.83]; p < 0.001) and walking distance during the 6MWT (+34.42 m, 95% CI [28.84-39.99]; p < 0.001). The SRE group showed greater improvement in all secondary outcome measures (p < 0.001).

CONCLUSIONS

The study findings suggested that the integration of SRE-assisted overground walking training with routine rehabilitation more effectively enhances lower limb motor function in children with SCP compared to routine rehabilitation alone.

Pairing taVNS and CIMT is feasible and may improve upper extremity function in infants

In this study we combined non-invasive transcutaneous auricular vagal nerve stimulation (taVNS) with 40 h of constraint induced movement therapy (CIMT) in infants. All infants completed the full intervention with no adverse events. Therapists were able to maintain high treatment fidelity and reported high ratings for ease of use and child tolerance. Preliminary results show promising gains on motor outcomes: Mean QUEST increase 19.17 (minimal clinically important difference, MCID 4.89); Mean GMFM increase 13.33 (MCID 1%-3%). Infants also exceeded expectations on Goal Attainment Scores (+1). Early data is promising that taVNS paired with intensive motor CIMT is feasible, reliable, and safe in young infants with hemiplegia, and may help harness activity-dependent plasticity to enhance functional movement.

Walking on Real-world Terrain with an Ankle Exoskeleton in Cerebral Palsy

Despite medical treatment focused on addressing walking disability, many millions of people with neurological conditions, like cerebral palsy (CP), struggle to maintain independent mobility. Lower limb exoskeletons and exosuits may hold potential for augmenting walking ability. However, it remains unknown whether these wearable robots are safe and beneficial for use outside of highly controlled laboratory environments, the demonstration of which is necessary for clinical translation. Here, we show that a lightweight, portable, ankle exoskeleton with an adaptable one-size-works-for-all assistance controller can improve energy efficiency and walking speed for individuals with CP spanning a wide spectrum of lower limb impairment in a multi-terrain real-world environment. Tested on an outdoor walking route with level, sloped, and stair terrain, robotic assistance resulted in a 15-18% (p = 0.013-0.026) reduction in estimated energy cost and a 7-8% (p = 0.001-0.004) increase in average walking speed across "shorter" 6-minute and "longer" 20-minute walking durations relative to unassisted walking. This study provides evidence that wearable robots may soon improve mobility in neighborhood, school, and community settings for individuals with CP.

Beyond pediatrics: noninvasive spinal neuromodulation improves motor function in an adult with cerebral palsy

Regaining motor function in individuals with cerebral palsy (CP) has been predominantly studied in children, resulting in an underrepresentation of adults in research efforts. We tested the efficacy of noninvasive spinal neuromodulation with neurorehabilitation (Spinal Cord Innovation in Pediatrics; SCiP™ therapy). A 60-year-old CP participant underwent 8 weeks of SCiP™ therapy, resulting in significant motor recovery measured by 14.2-points increase in gross motor function measure (GMFM-88) score, ~ three times the Minimal Clinically Important Difference (MCID) of 5-points. This represented gains in kneeling, sitting, and walking functions. The improvement in GMFM-88 score was maintained above the MCID at the follow up visit (10.3 points above the baseline), twenty weeks following the last therapy session, indicating a persistent effect of the therapy. Our preliminary findings support the therapeutic promise of SCiP™ therapy for enhancing motor function in CP adults. Broader investigations are needed to establish its wider applicability.

Selective dorsal rhizotomy in non-ambulant children with cerebral palsy: a multi-center prospective study

PURPOSE

Assess the effects of selective dorsal rhizotomy (SDR) on motor function and quality of life in children with a Gross Motor Function Classification System (GMFCS) level of IV or V (non-ambulatory).

METHODS

This is a prospective, observational study in three tertiary neurosurgery units in England, UK, performing SDR on children aged 3-18 with spastic diplegic cerebral palsy, and a GMFCS level of IV or V, between 2012 and 2019. The primary outcome measure was the change in the 66-item Gross Motor Function Measure (GMFM-66) from baseline to 24 months after SDR, using a linear mixed effects model. Secondary outcomes included spasticity, bladder function, quality of life, and pain scores.

RESULTS

Between 2012 and 2019, 144 children who satisfied these inclusion criteria underwent SDR. The mean age was 8.2 years. Fifty-two percent were female. Mean GMFM-66 score was available in 77 patients (53.5%) and in 39 patients (27.1%) at 24 months after SDR. The mean increase between baseline and 24 months post-SDR was 2.4 units (95% CI 1.7-3.1, p < 0.001, annual change 1.2 units). Of the 67 patients with a GMFM-66 measurement available, a documented increase in gross motor function was seen in 77.6% (n = 52). Of 101 patients with spasticity data available, mean Ashworth scale decreased after surgery (2.74 to 0.30). Of patients' pain scores, 60.7% (n = 34) improved, and 96.4% (n = 56) of patients' pain scores remained the same or improved. Bladder function improved in 30.9% of patients.

CONCLUSIONS

SDR improved gross motor function and reduced pain in most patients at 24 months after surgery, although the improvement is less pronounced than in children with GMFCS levels II and III. SDR should be considered in non-ambulant patients.

Positive impact of the Therasuit method on gross motor function of children with autism spectrum disorder: Case series

The Therasuit method is a valuable physiotherapeutic method to improve the gross motor function of children with neuromotor disorders. This series of case studies investigates the effect of the Therasuit method on the gross motor function of children with autism spectrum disorder (ASD). Therasuit method is a therapeutic intervention that involves the use of a therapeutic suit attached to a cage to stimulate gross motor skills, muscle strengthening, stretching, task training, and balance, which is a positive intervention for other neurodevelopmental disorders. The study was conducted with nine male children (42.1 + 4.1 months old) with ASD who received the Therasuit protocol for 4 weeks (20 sessions). The Gross Motor Function Measure (GMFM-88) was used to assess the children's gross motor function before and after the Therasuit method intervention. In dimension B, several skills showed improvement, including transfer to sitting, lean forward and return, trunk rotation without support, and transfer from sitting to all four stances. In dimension C, an increase was observed in skills such as being prone to all four stance transfers and reaching above the shoulders. In dimension D, maximum scores were achieved in skills such as pulling to stand on a large bench without assistance. The dimensions with the greatest impairment were D and E, corresponding to gross motor skills in orthostasis and dynamic skills in orthostasis, respectively. The findings suggest that the Therasuit method is a promising resource for treating motor impairments in children with ASD. However, further studies with a larger sample size, an adequate control condition, and random assignment of participants would be needed to provide stronger evidence of the method's effectiveness in this population.

Minimal clinically important difference (MCID) and minimal detectable change (MDC) of Spinal Cord Ability Ruler (SCAR)

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To find minimal clinically important difference (MCID) and minimal detectable change (MDC) of Spinal Cord Ability Ruler (SCAR) in Thai participants with spinal cord injury (SCI).

SETTING

Rehabilitation ward at Maharaj Nakorn Chiang Mai Hospital.

METHODS

Data of individuals with SCI who were not diagnosed with central cord syndrome and were admitted for the first time for rehabilitation were analyzed. Upper extremities motor score, self-care and mobility items of Spinal Cord Independence Measure version III were collected and used to calculate SCAR difference between data on date of admission and discharge. MCID and MDC were calculated by distribution-based method and categorized for each subgroup according to SCI characteristics.

RESULTS

From data of 311 individuals, MCID of SCAR is approximately 4 for individual with tetraplegia AIS A, B, C; and individual with AIS D at any level, and 2 for individual with paraplegia AIS A, B, C. MDC of SCAR should be 1 for individual with tetraplegia AIS A, B, C; and individual with AIS D at any level and 0.5 for individual with paraplegia AIS A, B, C.

CONCLUSION

This study provides MCID and MDC of SCAR in each subgroup. These values could be used as a benchmark for clinicians and researchers to determine whether participant has significant improvement or not after receiving an intervention.

Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review

AIM

To identify the most frequently reported non-instrumented measures of gait, activity, and participation in children with cerebral palsy (CP) after undergoing gait corrective orthopaedic surgery.

METHOD

Four databases were searched from database inception to the 9th December 2021 for studies that evaluated functional outcomes for children with CP under 18 years undergoing gait corrective orthopaedic surgery.

RESULTS

Of 547 citations, 44 publications (n = 3535 participants, n = 1789 males, mean age 10 years 5 months [SD = 3 years 3 months], Gross Motor Function Classification System levels I-III at the time of surgery) were eligible for inclusion. Fourteen different outcome measures were used: one measure of gait, 10 measures of activity, and three measures of participation. Gait was measured with the Edinburgh Visual Gait Scale (EVGS; 4 out of 44). The most common activity and participation measures were the Functional Mobility Scale (FMS; 15 out of 44) and Pediatric Outcomes Data Collection Instrument (11 out of 44) respectively. No studies reported a combination of gait, activity, and participation measures.

INTERPRETATION

The EVGS and FMS should be considered as core outcome measures in gait corrective orthopaedic surgery, while a measure of participation is unclear. Additional considerations for developing a comprehensive suite of outcomes include identifying a combination of clinical measures and performance-reflective questionnaires that are standardized for children with CP undergoing surgery and meaningful to clinicians and families.

Feasibility and safety study of wearable cyborg Hybrid Assistive Limb for pediatric patients with cerebral palsy and spinal cord disorders

Introduction

The wearable cyborg Hybrid Assistive Limb (HAL) is the world's first cyborg-type wearable robotic device, and it assists the user's voluntary movements and facilitates muscle activities. However, since the minimum height required for using the HAL is 150 cm, a smaller HAL (2S size) has been newly developed for pediatric use. This study aimed to (1) examine the feasibility and safety of a protocol for treatments with HAL (2S size) in pediatric patients and (2) explore the optimal method for assessing the efficacy of HAL.

Methods

This clinical study included seven pediatric patients with postural and motor function disorders, who received 8-12 sessions of smaller HAL (2S size) treatment. The primary outcome was the Gross Motor Function Measure-88 (GMFM-88). The secondary outcomes were GMFM-66, 10-m walk test, 2- and 6-min walking distances, Canadian Occupational Performance Measure (COPM), a post-treatment questionnaire, adverse events, and device failures. Statistical analyses were performed using the paired samples t-test or Wilcoxon signed-rank test.

Results

All participants completed the study protocol with no serious adverse events. GMFM-88 improved from 65.51 ± 21.97 to 66.72 ± 22.28 (p = 0.07). The improvements in the secondary outcomes were as follows: GMFM-66, 53.63 ± 11.94 to 54.96 ± 12.31, p = 0.04; step length, 0.32 ± 0.16 to 0.34 ± 0.16, p = 0.25; 2-MWD, 59.1 ± 57.0 to 62.8 ± 63.3, p = 0.54; COPM performance score, 3.7 ± 2.0 to 5.3 ± 1.9, p = 0.06; COPM satisfaction score, 3.3 ± 2.1 to 5.1 ± 2.1, p = 0.04.

Discussion

In this exploratory study, we applied a new size of wearable cyborg HAL (2S size), to children with central nervous system disorders. We evaluated its safety, feasibility, and identified an optimal assessment method for multiple treatments. All participants completed the protocol with no serious adverse events. This study suggested that the GMFM would be an optimal assessment tool for validation trials of HAL (2S size) treatment in pediatric patients with posture and motor function disorders.

Combining spinal neuromodulation and activity based neurorehabilitation therapy improves sensorimotor function in cerebral palsy

Motor dysfunction in individuals with cerebral palsy (CP) such as the inability to initiate voluntary movements, walking with compensatory movement patterns, and debilitating spasticity is due to the aberrant neural connectivity between the brain and spinal cord. We tested the efficacy of noninvasive spinal cord neuromodulation (SCiP™, SpineX Inc.) with activity-based neurorehabilitation therapy (ABNT) in improving the sensorimotor function in six children with CP. Children received 8 weeks of either SCiP™ or sham therapy with ABNT (n = 3 per group). At the end of 8 weeks, all participants received 8 weeks of SCiP™ therapy with ABNT. Follow up assessments were done at week 26 (10 weeks after the last therapy session). Sensorimotor function was measured by the Gross Motor Function Measure 88 (GMFM88) test. We observed minimal change in sham group (mean 6% improvement), however, eight weeks of SCiP™ therapy with ABNT resulted in statistically and clinically relevant improvement in GMFM88 scores (mean 23% increase from baseline). We also observed reduced scores on the modified Ashworth scale only with SCiP™ therapy (-11% vs. +5.53% with sham). Similar improvements were observed in sham group but only after the cross over to SCiP™ therapy group at the end of the first eight weeks. Finally, sixteen weeks of SCiP™ therapy with ABNT resulted in further improvement of GMFM88 score. The improvement in GMFM88 scores were maintained at week 26 (10 weeks after the end of therapy), suggesting a sustained effect of SCiP™ therapy.

sPinal cOrd neUromodulatioN to treat Cerebral palsy in pEdiatrics: POUNCE Multisite Randomized Clinical Trial

Introduction

Cerebral palsy (CP) affects up to 4 children in 1,000 live births, making it the most common motor disorder in children. It impairs the child's ability to move voluntarily and maintain balance and posture, and results in a wide range of other functional disorders during early development impairments in various sensory modalities, e.g., vision, hearing ability and proprioception. Current standard of care therapy focuses on symptom management and does not mitigate the progression of many of these underlying neurological impairments. The goal of this trial is to conduct a prospective multicenter, double-blinded, sham-controlled, crossover, randomized control trial to demonstrate the safety and efficacy of noninvasive spinal cord neuromodulation (SCiP™, SpineX Inc.) in conjunction with activity-based neurorehabilitation therapy (ABNT) to improve voluntary sensorimotor function in children with cerebral palsy.

Methods and analysis

Sixty participants (aged 2-13 years) diagnosed with CP classified as Gross Motor Function Classification Scale Levels I-V will be recruited and divided equally into two groups (G1 and G2). Both groups will receive identical ABNT 2 days/wk. G1 will initially receive sham stimulation, whereas G2 will receive therapeutic SCiP™ therapy for 8 weeks. After 8 weeks, G1 will cross over and receive therapeutic SCiP™ therapy for 8 weeks, whereas G2 will continue to receive SCiP™ therapy for another 8 weeks, for a total of 16 weeks. Primary and secondary outcome measures will include Gross Motor Function Measure-88 and Modified Ashworth Scale, respectively. Frequency and severity of adverse events will be established by safety analyses.

Ethics and dissemination

The trial is registered on clinicaltrials.gov (NCT05720208). The results from this trial will be reported on clinicaltrials.gov, published in peer-reviewed journals and presented at scientific and clinical conferences.

Intensive Therapy of the Lower Limbs and the Trunk in Children with Bilateral Spastic Cerebral Palsy: Comparing a Qualitative Functional and a Functional Approach

Few studies have examined the effect of intensive therapy on gross motor function and trunk control in children with cerebral palsy (CP). This study evaluated the effects of an intensive burst of therapy on the lower limbs and trunk by comparing qualitative functional and functional approaches. This study was designed as a quasi-randomized, controlled, and evaluator-blinded trial. Thirty-six children with bilateral spastic CP (mean age = 8 y 9 mo; Gross Motor Function Classification II and III) were randomized into functional (n = 12) and qualitative functional (n = 24) groups. The main outcome measures were the Gross Motor Function Measure (GMFM), the Quality Function Measure (QFM), and the Trunk Control Measurement Scale (TCMS). The results revealed significant time-by-approach interaction effects for all QFM attributes and the GMFM's standing dimension and total score. Post hoc tests showed immediate post-intervention gains with the qualitative functional approach for all QFM attributes, the GMFM's standing and walking/running/jumping dimension and total score, and the total TCMS score. The qualitative functional approach shows promising results with improvements in movement quality and gross motor function.

Physiotherapy strategies for functional improvement in a child with complicated hereditary spastic paraplegia: 1-year follow-up of a case report using a changing criterion design

BACKGROUND

and Purpose: Hereditary spastic paraplegias (HSP) are a group of clinically diverse genetic disorders that share the neurologic symptom of difficulty in walking due to progressive serious muscle weakness and spasticity in the legs. This study describes a physiotherapy program for improving the functional ability of a child diagnosed with complicated HSP and reports the treatment results.

METHODS

A 10-year-old boy with complicated HSP received a physiotherapy intervention that included strengthening of the leg muscles and treadmill training for 1 h per session, three to four times a week for 6 weeks. Outcome measures included sit-to-stand, 10-m walk, 1-min walk tests, and gross motor function measures (dimensions D and E).

RESULTS

After the intervention, the sit-to-stand, 1-min walk, and 10-m walk test scores improved by 6.75 times, 2.57 m, and 0.05 m/s, respectively. Furthermore, the gross motor function measure dimensions D and E scores improved by 8% (46%-54%) and 5% (22%-27%), respectively. The gains in each parameter were maintained at the 3- and 6-month and 1-year follow-ups.

CONCLUSION

These results suggest that structured physiotherapy programs can benefit the functional rehabilitation of children with complicated HSP.

Benefits of a Wearable Cyborg HAL (Hybrid Assistive Limb) in Patients with Childhood-Onset Motor Disabilities: A 1-Year Follow-Up Study

Rehabilitation robots have shown promise in improving the gait of children with childhood-onset motor disabilities. This study aimed to investigate the long-term benefits of training using a wearable Hybrid Assistive Limb (HAL) in these patients. Training using a HAL was performed for 20 min a day, two to four times a week, over four weeks (12 sessions in total). The Gross Motor Function Measure (GMFM) was the primary outcome measure, and the secondary outcome measures were gait speed, step length, cadence, 6-min walking distance (6MD), Pediatric Evaluation of Disability Inventory, and Canadian Occupational Performance Measure (COPM). Patients underwent assessments before the intervention, immediately after the intervention, and at 1-, 2-, 3-month and 1-year follow-ups. Nine participants (five males, four females; mean age: 18.9 years) with cerebral palsy (n = 7), critical illness polyneuropathy (n = 1), and encephalitis (n = 1) were enrolled. After training using HAL, GMFM, gait speed, cadence, 6MD, and COPM significantly improved (all p < 0.05). Improvements in GMFM were maintained one year after the intervention (p < 0.001) and in self-selected gait speed and 6MD three months after the intervention (p < 0.05). Training using HAL may be safe and feasible for childhood-onset motor disabilities and may maintain long-term improvements in motor function and walking ability.

The Minimal Clinically Important Difference Changes Greatly Based on the Different Calculation Methods

BACKGROUND

The minimal clinically important difference (MCID) for patient-reported outcome measures (PROMs) expresses both the extent of the improvement and the value that patients place on it. MCID use is becoming increasingly widespread to understand the clinical efficacy of a given treatment, define guidelines for clinical practice, and properly interpret trial results. However, there is still large heterogeneity in the different calculation methods.

PURPOSE

To calculate and compare the MCID threshold values of a PROM by applying various methods and analyzing their effect on the study results interpretation.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

The data set used to investigate the different MCID calculation approaches was based on a database of 312 patients affected by knee osteoarthritis and treated with intra-articular platelet-rich plasma. MCID values were calculated on the International Knee Documentation Committee (IKDC) subjective score at 6 months using 2 approaches: 9 methodologies referred to an anchor-based approach and 8 methodologies to a distribution-based approach. The obtained threshold values were applied to the same series of patients to understand the effect of using different MCID methods in evaluating patient response to treatment.

RESULTS

The different methods employed led to MCID values ranging from 1.8 to 25.9 points. The anchor-based methods ranged from 6.3 to 25.9, while the distribution-based ones were from 1.8 to 13.8 points, showing a 4.1× variation of the MCID values within the anchor-based methods and a 7.6× variation within the distribution-based methods. The percentage of patients who reached the MCID for the IKDC subjective score changed based on the specific calculation method used. Among the anchor-based methods, this value varied from 24.0% to 66.0%, while among the distribution-based methods, the percentage of patients reaching the MCID varied from 44.6% to 75.9%.

CONCLUSION

This study proved that different MCID calculation methods lead to highly heterogeneous values, which significantly affect the percentage of patients achieving the MCID in a given population. The wide-ranging thresholds obtained with the different methodologies make it difficult to evaluate the real effectiveness of a given treatment questioning the usefulness of MCID, as currently available, in the clinical research.

Safety and Feasibility of Robot-assisted Gait Training in Adults with Cerebral Palsy in an Inpatient Setting - an Observational Study

BACKGROUND

To investigate the safety and feasibility of six sessions of Hybrid Assistive Limb (HAL) robot-assisted gait training (RAGT) integrated into an inpatient therapy concept and their influence on walking speed and gait parameters in adult CP patients.

METHODS

Eleven subjects (male = 8, female = 3, mean age: 23 years and 2 months, ± 4.5 years) with spastic CP underwent six 20-minute RAGT sessions with the HAL during an 11-day hospital stay. Additionally, physiotherapy, physician-performed manual medicine, massage and exercise therapy were provided. Pre- (T1) and post- (T2) intervention assessments were: 10-metre walking test (10MWT), 6-minute walking test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion (pROM).

RESULTS

All subjects completed the study. No adverse events were noted. Walking speed in the 10MWT test increased from 32.5 s (± 24.5 s) at T1 to 27.5 s (± 21.4 s) at T2, without significance. Slight, but non-significant improvements were detected in the 6MWT, GMFM and pROM. Confounding factors did not significantly affect the results. Conclusion: Intensive therapy including HAL training leads to non-significant improvements. Further studies with more patients and longer intervention time could provide further insights into the RAGT therapy of adult patients with CP. Registration DRKS-ID: DRKS00020275.

Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report

PURPOSE

Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress.

METHOD

This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument.

RESULTS

The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- 'tDCS + physiotherapy' to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning.

CONCLUSIONS

tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

PROSPECTIVE SINGLE CENTER ANALYSIS OF OUTCOME STEM CELLS TRANSPLANTS IN PATIENTS WITH CEREBRAL PALSY

OBJECTIVE

Aim: To evaluate efficacy and safety of autologous bone marrow-derived mononuclear stem cell transplantation intrathecal in children with cerebral palsy.

PATIENTS AND METHODS

Materials and Methods: 35 children have levels I-V cerebral palsy aged 8-months to 8-years-old were enrolled from September (2021-2022) at Iraqi private hospital. Gross Motor Function was assessed by a pediatrician and neurologist specialist, 5 mcg/kg/day of G-CSF subcutaneous single injection daily for three consecutive days. Bone marrow harvested from posterior iliac crest under light general anesthesia. Bone marrow mononuclear cells (BMMNCs) separation was performed using density gradient centrifugation with Ficoll, the cell viability checked by propidium iodide dye in a TALI machine (Invitrogen) in average 98%. The viable BMMNCs injected intrathecal in L4-L5 over a period of 5-10 min.

RESULTS

Results: Males accounted for 57.14% (20/35) while female 42.86% (15/35), and main neurological symptoms included spastic disorder spastic disorder (quadriplegia 24 (68.6), tetraplegia 2 (5.7), diplegia 5 (14.28), hemiplegia4 (11.42)). Gross Motor Function Classification System and Gross Motor Function Measure-66 (GMFM-66) showed II 10 (28.58), III 11(31.42) and IV 14 (40). On mean follow-up of 3 months post-stem cell transplant improvement was observed in 80% cases. The improvement showed in gross motor function (6/8) p=0.01, and speech (2/4) p=0.04, neck holding (5/5) p=0.0003, sitting balance (4/4) p=0.04, postural tone (5/5) p=0.0003, as well as significant reduction in seizure frequency (2/3) p=0.04 and improvement in cognition (6/7) p=0.01 were observed.

CONCLUSION

Conclusion: Stem cell therapy for cerebral palsy shows a significant positive effect on the gross motor function, without long adverse effects.

Use of Robot-Assisted Gait Training in Pediatric Patients with Cerebral Palsy in an Inpatient Setting-A Randomized Controlled Trial

Robot-assisted gait training (RAGT) provides a task-based support of walking using exoskeletons. Evidence shows moderate, but positive effects in the therapy of patients with cerebral palsy (CP). This study investigates the impact of RAGT on walking speed and gait parameters in pediatric CP patients. Thirty subjects (male = 23; female = 7), with a mean age of 13.0 ± 2.5 (9-17) years, and with spastic CP, were recruited. The intervention group (n = 15) underwent six 20-minute RAGT sessions with the Hybrid Assistive Limb (HAL) during an 11-day hospital stay. Additionally, a therapy concept including physiotherapy, physician-performed manual medicine, massage and exercise therapy was provided. The control group (n = 15) was treated with the therapy concept only. The outcome was based on a 10-Metre Walking Test (10MWT), 6-Minute Walking Test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion. The intervention group achieved a mean increase in walking speed in the 10MWT (self-selected walking speed SSW) of 5.5 s (p = 0.378). There were no significant differences between the groups in the 10MWT (max) (p = 0.123) and the 6MWT (p = 0.8). Changes in the GMFM (total) and in the dimension standing and walking, running and jumping (D + E) showed clinically relevant significant results (p = 0.002 and p = 0.046). RAGT as a supplement to an inpatient therapy stay appears to have a positive, yet not significant impact on the gait parameters of pediatric CP patients as well as motivating them to practice walking. Further studies with adapted study designs are needed to evaluate different influencing factors.

Effectiveness of Mechanical Horse-Riding Simulator-Based Interventions in Patients with Cerebral Palsy-A Systematic Review and Meta-Analysis

BACKGROUND

Mechanical horse-riding simulator (HRS) exercises are a type of therapy based on the use of robotic or mechanical devices that produces movement similar to a real horse with the aim of simulating hippotherapy. This review analyses the effectiveness of HRS therapies in patients with cerebral palsy (CP).

METHODS

A systematic review and a meta-analysis were carried out by searching studies in PubMed Medline, SCOPUS, Web of Science, CINAHL, PEDro and SciELO up until October 2022. We selected clinical trials that assessed the effectiveness of HRS therapy, compared to other interventions, in patients with CP. The main variables were gross motor function (its global score and dimensions, such as sitting ability), functional balance, spasticity, hip range of motion (ROM), posturographic balance and satisfaction. The risk of bias was assessed using the Cochrane Risk of Bias Tool. The pooled effect was calculated using Cohen's Standardized Mean Difference (SMD) for a 95% confidence interval (95% CI).

RESULTS

Twelve studies were included in the systematic review, and 10 were included in the meta-analysis, providing data from 343 patients with spastic diplegic CP. Our findings revealed that HRS plus physiotherapy is more effective than physiotherapy in improving the total gross motor function (SMD 0.98; 95% CI 0.35-1.62), sitting ability of the gross motor function (SMD 0.84; 95% CI 0.32-1.36) and functional balance (SMD 0.6; 95% CI 0.1-1.08), and HRS therapy is better than sham to improve pelvic abduction ROM (SMD 0.79; 95% CI 0.21-1.37).

CONCLUSIONS

Horse-riding simulator-based therapy is an effective therapy to improve gross motor function, functional balance and abduction pelvic ROM in children with CP, in comparison to physiotherapy or sham.

Gross motor change after inpatient rehabilitation for children with acquired brain injury: A 10-year retrospective review

AIM

To estimate gross motor change in inpatient school-aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus.

METHOD

This retrospective chart review involved inpatient children (5-18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus.

RESULTS

Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM-88 was generally administered first, followed by other measures. GMFM-88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six-Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM-88 change (r ≥ 0.40). Twenty-five percent of GAS goals were ambulation-based.

INTERPRETATION

Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

A pilot study combining noninvasive spinal neuromodulation and activity-based neurorehabilitation therapy in children with cerebral palsy

Cerebral Palsy (CP) is the most common pediatric motor disability with multiple symptoms and etiologies. CP is exhibited through sensorimotor delays, impaired posture resulting in limited activities and participation. Our recently concluded, single arm, unblinded, pilot study (NCT04882592) explored whether an intervention combining non-invasive spinal neuromodulation during an activity-based neurorehabilitation therapy (ABNT) can improve voluntary sensory-motor function captured via the Gross Motor Function Measure (GMFM-88) scores (primary outcome). Sixteen children diagnosed with CP with Gross Motor Function Classification Scale levels I-V were recruited and received the same intervention (2x/week for 8 weeks) to correct the dysfunctional connectivity between supraspinal and spinal networks using the normally developed proprioception. We demonstrate that the intervention was associated with clinically and statistically significant improvement in GMFM-88 scores in all children, thus meeting the prespecified primary endpoint. However, the improvement with ABNT alone needs further exploration. No serious adverse events were observed (safety endpoint).

Here the authors report a single arm pilot trial to investigate combined spinal neuromodulation and activity-based neurorehabilitation therapy on voluntary sensory-motor function in children with cerebral palsy.

Effectiveness of Robotic-Assisted Gait Training and Aquatic Physical Therapy in a Child With Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency: A Case Report

PURPOSE

The purpose of this case study is to describe the outpatient rehabilitation program for a 15-year-old girl with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD).

SUMMARY OF KEY POINTS

The child presented with sudden-onset muscle weakness and fatigue with resultant dependence for all mobility and self-care. After 12 months of therapy, which included aquatic interventions and robotic-assisted gait training, the patient demonstrated independence with transfers, ambulation with a rolling walker, and stair navigation. Functional mobility, gross motor skills, and participation in activities of daily living significantly improved per the Gross Motor Function Measure and the Pediatric Evaluation of Disability Inventory.

STATEMENT OF CONCLUSION AND RECOMMENDATIONS FOR CLINICAL PRACTICE

This is the first case in the literature to outline an outpatient physical therapy treatment plan to address mobility deficits secondary to exacerbation of LCHADD. This patient's rehabilitative course will hopefully add to future research and provide patients with guidelines for their recovery.

Daily Outpatient Physical Therapy for a Toddler With a Neurodegenerative Disease: A Case Report

PURPOSE

This case report highlights the potential value of delivering a high-dose physical therapy (PT) intervention for a child with a neurodegenerative disease. We include developmental outcomes for a 23-month-old toddler with biallelic TBCD gene mutations following daily outpatient PT.

SUMMARY OF KEY POINTS

The child had clinical improvements in gross and fine motor, cognition, expressive and receptive language, socioemotional, and adaptive behavior function as determined through Goal Attainment Scaling, Gross Motor Function Measure, and Bayley Scales of Infant and Toddler Development following daily PT intervention.

STATEMENT OF CONCLUSION AND RECOMMENDATIONS FOR CLINICAL PRACTICE

High-dose outpatient PT may be beneficial for a child with a neurodegenerative disease at some time frames. In selected cases, if the neurodegenerative disease slowly progresses, high-dose PT may be a treatment option to promote motor change.

Minimal and robust clinically important difference of three fatigue measures in chronic stroke survivors

BACKGROUND

Fatigue assessment scale (FAS), fatigue subscale of the Profile of Mood States (POMS-F), and vitality subscale of the Short Form Health Survey (SF-36-VT) are among the first and most widely used adapted tools for assessing post-stroke fatigue.

OBJECTIVE

To identify the minimal clinically important difference (MCID) and robust clinically important difference (RCID) of FAS, POMS-F, and SF-36-VT in stroke survivors.

METHODS

Participants completed the FAS, POMS-F, and SF-36-VT before and after receiving 6-week intervention including graded activity training and pacing therapy. MCID was calculated using the distribution-based and anchor-based methods. Further, accuracy, sensitivity, and specificity of calculated values using the distribution-based method were used for determining RCID.

RESULT

A total of 124 stroke survivors participated in this study. MCID for FAS, POMS-F, and SF-36-VT was found to be 4.86, 3.32, and -10.10 (using score change) and 3.5, 2.5, and -10.5 (using ROC analysis), respectively. Using the distribution-based method, the MCID value obtained for the FAS was in the range of 3.16 to 8.76, for the POMS-F was in the range of 1.49 to 5.63, and for the SF-36-VT was in the range of -15.43 to -5.58. ½SD for FAS, ½ SD and 1.96 SEM for POMS-F, and 1.96 SEM and SD for SF-36-VT showed the best discriminative ability to use as the RCID.

CONCLUSIONS

The MCID and RCID were calculated for FAS, POMS-F, and SF-36-VT using different methods. The results can be used by researchers and clinicians for interpreting their findings in subjects similar to those who participated in this study.

Study protocol of a randomised controlled trial for the effectiveness of a functional partial body weight support treadmill training (FPBWSTT) on motor and functional skills of children with ataxia

INTRODUCTION

A great heterogeneity characterises the paediatric population with ataxia, which has been studied poorly. The lack of postural control and coordination, in addition with features of the 'ataxic' gait are linked with functional limitations. Studies on physiotherapy interventions for children with ataxia are highly needed for identifying optimal training strategies for improving motor and functional related skills.

METHODS AND ANALYSIS

A stratified randomised control clinical trial of a 4-week functional partial body weight support treadmill training, (5 days/week 45 min/day) and 2-month follow-up period will be applied in children with ataxia, aged 8-18 years old with Gross Motor Function Classification System II-IV. Participants will be allocated to experimental group (intervention and usual care) or control group (usual care), using stratified randomisation process into two strata (progressive and non-progressive ataxia). Participants will be assessed at baseline, by the end of the 4-week period and by the end of a 2-month period as a follow-up measurement. Motor and functional skills will be assessed using the Gross Motor Function Measure-D and E, the Pediatric Balance Scale, the 10-meter walk test, the 6-minute walk test, the Scale for Assessment and Rating Ataxia, the timed up and go test and children's spatiotemporal gait features will be assessed through GaitSens software recording over a 2 min low treadmill gait speed, while three-dimensional gait analysis will be performed for kinetic and kinematic analysis of the lower limbs in all three levels of movement. Two-way mixed Analysis of Variance (ANOVA) with factors 'intervention' (between group) and 'time' (within group) will be used for the analysis of all parameters. Analysis of Covariance (ANCOVA) will be used in case of imbalance of baseline measurements. Statistical significance will be set at p<0.05 using the statistical package SPSS V.21.00.

ETHICS AND DISSEMINATION

University of West Attica (study's protocol: 14η/26-04-2021) and 'ATTIKON' General University Hospital of Athens (study's protocol: Γ ΠΑΙΔ, ΕΒΔ 149/20-3-2020). Trial results of the main trial will be submitted for publication in a peer-reviewed journal and/or international conference.

TRAIL REGISTRATION NUMBER

ISRCTN54463720.

Ankle Exoskeleton Assistance Increases Six-Minute Walk Test Performance in Cerebral Palsy

OBJECTIVE

To determine the effects of providing battery-powered ankle dorsiflexor and plantar flexor exoskeleton assistance on six-minute walk test performance and efficiency in children and young adults with cerebral palsy by comparing distance walked under exoskeleton assisted (Assisted) and no device (Shod) walking conditions, and explore the acclimation rate to maximal walking with ankle exoskeleton assistance.

RESULTS

Six-minute walk test performance significantly improved under the final Assisted condition test compared to the Shod condition (42 ± 27 m, p = 0.02), surpassing the minimum clinically important difference range for children and young adults with CP. There was no difference in walking efficiency (-0.06 ± 0.1, p = 0.3). Participants had an average acclimation rate of 19.6 m per session.

CONCLUSIONS

Powered ankle assistance can significantly improve six-minute walk test performance in individuals with mild-to-moderate gait impairment from CP, supporting the use of this intervention to improve functional mobility and walking capacity in this patient population.

Neuromuscular Electrical Stimulation to Immobilized Lower Extremities Directly Following Orthopaedic Surgery in Three Children with Cerebral Palsy: A Case Series

Cerebral palsy (CP) is a non-progressive, neurological disorder often resulting in secondary musculoskeletal impairments affecting alignment and function which can result in orthopaedic surgery. Neuromuscular electrical stimulation (NMES) is a modality that can be used for rehabilitation; however, NMES immediately following orthopaedic surgery in children with CP using surface electrodes has not been previously reported. The purpose of this case series is to describe the novel use of NMES in the acute rehabilitation phase directly after orthopaedic surgery. This case series included three children with spastic diplegia CP, Gross Motor Function Classification System level II who underwent Single Event Multi-Level orthopaedic Surgery. Each long leg cast contained window cast cut-outs to allow for surface electrode placement for daily NMES intervention to the quadriceps muscles while immobilized. Children were assessed pre- and post-operatively using the Functional Mobility Scale (FMS), Gross Motor Function Measure (GMFM-66), and 6-Minute Walk Test (6MWT). All children demonstrated no adverse effects using NMES intervention and had improvements in the 6MWT. Most children demonstrated gains in the FMS and GMFM-66. Use of NMES through window cast-cuts in a long leg cast is a novel practice approach for delivery of early rehabilitation following lower extremity orthopaedic surgery.

Different Designs of Proximal Femoral Stems for Total Hip Arthroplasty: Mid-Term Clinical and Patient-Reported Functional Outcomes

INTRODUCTION

A comprehensive comparison of the performance of different femoral stem geometries in total hip arthroplasty (THA) is yet to be described. The primary aim of this study was to evaluate objective and subjective outcome measures in primary THA with different femoral implant styles.

METHODS

Stems were classified into the following five classes: cemented, conical, fit and fill, modular, and wedge. The objective outcomes of interest were the length of inpatient hospital stay (LOS), 90-day readmission rate, one-year revision rate, and two-year mortality rate. Preoperative and postoperative patient-reported outcome measures (PROMs), including hip disability and osteoarthritis outcome score (HOOS) - physical function shortform (HOOS-PS), patient-reported outcomes measurement information system physical function short form 10a (PROMIS PF-10a), and patient-reported outcomes measurement information system - short form - mental 10a (PROMIS M-10a) were recorded and compared between different classes.

RESULTS

Patients with a wedge stem had a significantly lower LOS versus every other stem group, while patients with a cemented stem had the highest LOS, approximately twofold that of the wedge stem group. Accounting for potential confounders, the conical and fit and fill groups had a significantly higher two-year mortality rate than the wedge stem group. Fit and fill stems conferred a slight risk of revision THA at one-year compared to wedge stems. There was no significant difference in the rates of failure to achieve the minimal clinically important difference (MCID) for the PROMs.

CONCLUSION

Placement of wedge stems resulted in a significantly lower LOS compared to every other stem class and a lower mortality rate than the conical, fit and fill, and modular stems. As for the 90-day readmission, one-year revision, and the rates of failure to achieve the MCID for general or hip-specific PROMs, stem design had no meaningful effect.

Effects of minimally invasive surgery and functional physiotherapy on motor function of children with cerebral palsy: A non-randomised controlled trial

Purpose

This non-randomised controlled trial investigated whether a combined programme of functional physiotherapy and minimally invasive orthopaedic surgery improves the level and degree of capacity and performance of gross motor function in children with spastic cerebral palsy (CP).

Methods

Fifty-two children with spastic CP aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II-IV, were allocated to two equal groups: experimental group (selective percutaneous myofascial lengthening [SPML] procedure and 9-month functional strengthening physiotherapy programme) and control (standard physiotherapy) groups. At baseline and at the end of the 9-month intervention, the capacity and performance of gross motor function were assessed with the Gross Motor Function Measure (GMFM) D and E subcategories and Functional Mobility Scale (FMS), respectively. The level of gross motor function was measured with the GMFCS.

Results

There was a statistically significant difference in the post-intervention improvements in the GMFM D (experimental mean difference = 19.63 ± 10.46; control mean difference = 2.40 ± 4.62) and E (experimental mean difference = 19.33 ± 11.82; control mean difference = 4.20 ± 6.26) between experimental and control group (p < 0.001). There was a significant improvement in the GMFCS level and each FMS distance for the experimental group (p < 0.001), but not for the control group (p > 0.05).

Conclusion

SPML procedure combined with functional physiotherapy improves gross motor function in children with spastic CP, by raising the degree and level of motor independence.

Decline in Motor Function during the COVID-19 Pandemic Restrictions and Its Recovery in a Child with Cerebral Palsy: A Case Report

Children with cerebral palsy (CP) experience various restrictions owing to their underdeveloped mobility. Home confinement due to the coronavirus disease 2019 pandemic may further increase these restrictions. We report the case of a 7-year-old boy with CP (Gross Motor Function Classification System level IV) whose motor function declined during the period when physical therapy was discontinued due to lockdown, approximately four months. At the end of the home confinement, the patient's ability to maintain a sitting posture and weight-bearing capacity of the lower extremities decreased. His Gross Motor Function Measure total score also decreased from 34.5% to 31.9%. After resuming physical therapy, the patient recovered the function status seen before the discontinuation of physical therapy, but this took almost twice as long as the confinement period. We reaffirm that frequent physical therapy is crucial for maintaining motor function in non-ambulatory children with CP. As a countermeasure for the future, urgent efforts are needed for the development of telerehabilitation.

The Effectiveness of Robot- vs. Virtual Reality-Based Gait Rehabilitation: A Propensity Score Matched Cohort

Robot assisted gait training (RAGT) and virtual reality plus treadmill training (VRTT) are two technologies that can support locomotion rehabilitation in children and adolescents affected by acquired brain injury (ABI). The literature provides evidence of their effectiveness in this population. However, a comparison between these methods is not available. This study aims at comparing the effectiveness of RAGT and VRTT for the gait rehabilitation of children and adolescents suffering from ABI. This is a prospective cohort study with propensity score matching. Between October 2016 and September 2018, all patients undergoing an intensive gait rehabilitation treatment based on RAGT or VRTT were prospectively observed. To minimize selection bias associated with the study design, patients who underwent RAGT or VRTT were retrospectively matched for age, gender, time elapsed from injury, level of impairment, and motor impairment using propensity score in a matching ratio of 1:1. Outcome measures were Gross Motor Function Mesure-88 (GMFM-88), six-min walking test (6MWT), Gillette Functional Assessment Questionnaire (FAQ), and three-dimensional gait analysis (GA). The FAQ and the GMFM-88 had a statistically significant increase in both groups while the 6MWT improved in the RAGT group only. GA highlighted changes at the proximal level in the RAGT group, and at the distal district in the VRTT group. Although preliminary, this work suggests that RAGT and VRTT protocols foster different motor improvements, thus recommending to couple the two therapies in the paediatric population with ABI.

Sibling umbilical cord blood infusion is safe in young children with cerebral palsy

Preclinical and early phase clinical studies suggest that an appropriately dosed umbilical cord blood (CB) infusion has the potential to help improve motor function in young children with cerebral palsy (CP). As many children with CP do not have their own CB available, use of allogeneic cells would extend access to this potentially beneficial therapy to more children. In this phase I, open‐label study, 15 children, aged 1 to 6 years, with moderate to severe spastic CP were treated with a single intravenous infusion of allogeneic human leukocyte antigen (HLA) matched or partially matched sibling CB with a cell dose of ≥2.5 × 10⁷ cells/kg based on the pre‐cryopreservation count (median infused cell dose, 3.3 × 10⁷; range, 1.8‐5.2 × 10⁷). There were a total of 49 adverse events (AEs) over a 2‐year time period, but there were no AEs related to the CB infusions. Specifically, there were no acute infusion reactions and no antibody formation against platelets, red blood cells, or donor‐specific HLA antigens. Donor cells were not detected in peripheral blood 6 months later. Six months after infusion, participants were assessed for response and experienced a mean ± SD increase of 4.7 ± 2.5 points on the Gross Motor Function Measure‐66 and 1 ± 2.9 points on the Peabody Gross Motor Quotient. Appropriately dosed, allogeneic partially or fully HLA‐matched sibling CB infusion is well tolerated and potentially beneficial in young children with CP.

The Effect of Robot-Assisted Gait Training on Locomotor Function and Functional Capability for Daily Activities in Children with Cerebral Palsy: A Single-Blinded, Randomized Cross-Over Trial

Purpose: The effectiveness of robot-assisted gait training (RAGT) in children with cerebral palsy (CP), especially in terms of improving the performance of daily activities, remains unclear. Therefore, we aimed to investigate the effectiveness of RAGT in children with CP. Methods: In this single-center, single-blinded, randomized cross-over trial, we enrolled 20 children with CP with Gross Motor Function Classification System (GMFCS) levels II–IV (13 males; age range, 6.75 ± 2.15 years). The participants were randomized into the RAGT/standard care (SC) (n = 10) and SC/RAGT/SC sequence groups (n = 10). Using a Walkbot-K system, the RAGT program comprised 3 × 30-min sessions/week for 6 weeks with a continued SC program. The SC program comprised 2–4 conventional physiotherapy sessions/week for 6 weeks. The Gross Motor Function Measure-88 (GMFM-88), the pediatric functional independence measure (WeeFIM), and the Canadian occupational performance measure (COPM) scores were assessed pre- and post-RAGT or SC periods and treatment, period, follow-up, and carry-over effects were analyzed. Energy expenditure and body composition were measured pre- and post-RAGT. Results: Significant treatment effects were observed in dimensions D and E of the GMFM (D: p = 0.018; E: p = 0.021) scores, WeeFIM mobility subtotal (p = 0.007), and COPM performance (p < 0.001) and satisfaction (p = 0.001) measure scores. The period, follow-up, and carry-over effects were not statistically significant. The gross energy cost significantly decreased (p = 0.041) and the skeletal muscle mass increased (p = 0.014) at post-RAGT assessment. The factors associated with functional outcomes showed significant improvements in the GMFM D scores and were mainly observed in children with GMFCS levels II–III compared to those classified at level IV (p = 0.038). Conclusion: RAGT had training benefits for children with CP. Specifically, it improved locomotor function and functional capability for daily activities. These effects were better in ambulatory children with CP. However, as SC interventions continued during the RAGT period, these improvements may be also related to multiple treatment effects.