Effects of dose and duration of Robot-Assisted Gait Training on walking ability of children affected by cerebral palsy

Can muscle synergies shed light on the mechanisms underlying motor gains in response to robot-assisted gait training in children with cerebral palsy?

BACKGROUND

Children with cerebral palsy (CP) often experience gait impairments. Robot-assisted gait training (RGT) has been shown to have beneficial effects in this patient population. However, clinical outcomes of RGT vary substantially from patient to patient. This study explored the hypothesis that clinical outcomes are associated with changes in muscle synergies in response to RGT.

METHODS

Thirteen children with CP and Gross Motor Function Classification Scale (GMFCS) levels I-IV were recruited in the study. Children participated in a 6 week-RGT intervention and underwent clinical evaluations and gait studies-with focus on the analysis of electromyographic (EMG) data-pre- and post-training. Lower-limb muscle synergies were derived from the EMG recordings. Pre- vs. post-RGT clinical outcomes and muscle synergies were compared to explore potential relationships.

RESULTS

Three and, less often, two muscle synergies were detected in study participants pre-RGT. Linear mixed effect models showed that composition of the muscle synergies and their temporal activation coefficients present deviations from normative data proportional to the severity of functional limitations (i.e., GMFCS levels, p < 0.01). At a group level, changes in muscle synergies pre- vs. post-RGT did not significantly correlate with changes in clinical outcomes (p > 0.05). However, it was observed that participants who displayed prominent changes in muscle synergies also displayed large improvements in clinical scores.

CONCLUSIONS

Gait impairments in children with CP were associated with muscle synergies that deviated from normative. Participants who demonstrated the most substantial improvements in clinical scores following RGT exhibited multiple changes in the muscle synergies. However, no statistically significant correlations were identified at the group level. Future studies relying on larger datasets are needed to further investigate this observation and potential underlying mechanisms.

Influence of Robotic Neurorehabilitation in Cerebral Palsy on Motor Function and Gait

Background and aim: Cerebral palsy (CP) is a nonprogressive neurological disorder characterized by permanent developmental disorders of movement and posture. One of the most common goals of rehabilitation is the treatment of gait disorders. Ataxic gait disorder tends to worsen in the adolescent period. Research indicates a positive therapeutic effect of the combined application of conventional rehabilitation, robotic neurorehabilitation (RNR) and virtual reality, but there is no consensus on the length of treatment and frequency of application. The aim of this case report was to contribute to the definition of the RNR protocol for the treatment of ataxic gait disorder in adolescents with CP. Case report: In a female child with an ataxic form of CP who was on regular conventional kinesitherapy in the age period between 13 to 15 years, robotic-assisted gait training (RAGT) was applied for the treatment of gait disorders. The rehabilitation protocol lasted 10 weeks, 5 times a week, and included individual, conventional kinesitherapy for 30 min and RAGT for 30 min. Combined RNR treatment was conducted once a year in the period between July and September. The results of the therapeutic evaluation revealed that the functional motor level remained unchanged, while the improved functional motor status for the category of standing and gait was maintained during treatment between the patient's 13 and 15 years age. In their 15th year, independent gait over a shorter distance (14 m) was achieved, as well as a normal gait frequency (83 steps/minute), with a desirable duration of the left leg support phase of 65% and 70% for the right leg support phase. Conclusions: The results of our research indicate that the application of conventional kinesitherapy and RAGT, over the period of 10 weeks a year, can have a positive effect on improving the postural and locomotor functions of ataxic gait in adolescents with CP.

Evaluation of the effectiveness of Lokomat® robot-assisted gait training in children with cerebral palsy: A systematic review

Background

Children with cerebral palsy (CP) may present motor and gait impairment.

Objective

This systematic review aims to assess the potential of robot-assisted gait training (RAGT) with Lokomat® exoskeleton to improve gait in children with CP.

Methods

The search was conducted and repoted according to PRISMA guidelines on PubMed, Scopus, Cochrane Library and PEDro databases. All randomised controlled trials (RCT) including children with CP who underwent RAGT with Lokomat® were considered eligible. Risk of bias was assessed with the Rob2 tool by two blinded reviewers. The review was previously registered on the PROSPERO database (CRD42023488699).

Results

948 articles were found, and 9 studies involving 403 children with CP met the inclusion criteria. We found a heterogeneity in the RAGT protocol and a higher risk of bias for two included studies. Seven out nine studies reported a statistically significant improvement ( p < 0.05) on gait, balance, or global functions with respect to control groups. Specifically, walking speed and stride length were improved after RAGT.

Conclusions

Children with CP can benefit from the add-on therapy with RAGT through Lokomat® to improve walking and balance function. There is a need for RCTs with better patient stratification and with less heterogeneity in outcomes to improve the quality of the pooled evidence.

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.

Benefits of robotic gait assistance with ATLAS 2030 in children with cerebral palsy

Objective

This study aims to assess the impact of integrating ATLAS 2030 into the conventional therapy regimen for children with Cerebral Palsy (CP) compared to conventional therapy alone regarding gross motor function, range of motion (ROM) and spasticity.

Design

A non-randomized controlled trial conducted in outpatient rehabilitation settings and special education schools, following the recommendations by the Consolidated Standards of Reporting Trials (CONSORT) statement.

Participants

Thirty children with CP divided into intervention and control groups.

Intervention

The intervention group received three months of therapy (twice per week) with the ATLAS 2030 device in addition to their standard therapy, while the control group underwent standard therapy alone.

Main outcome measure

Gross motor function assessed using the Gross Motor Function Measure of 88 items (GMFM-88).

Secondary outcomes

Spasticity, measured by the Modified Ashworth Scale (MAS), and ROM of the lower limbs.

Results

Statistically significant differences were observed between groups, in favour the intervention group, in both the GMFM-88 total score and dimension A, B and D. Similar findings were noted for spasticity and ROM, demonstrating significant improvements in the intervention group.

Conclusion

ATLAS 2030 proves to be a safe and valuable tool for the rehabilitation of children with CP, showing improvements in motor function, spasticity and ROM.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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.

Systematic review and network meta-analysis of robot-assisted gait training on lower limb function in patients with cerebral palsy

OBJECTIVE

This study aimed to evaluate the effectiveness of robot-assisted gait training (RAGT) in treating lower extremity function in patients with cerebral palsy (CP) and compare the efficacy differences between different robotic systems.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, CNKI, VIP, CBM, and Wanfang databases were searched to collect randomized controlled trials of RAGT for lower extremity dysfunction in patients with CP from the time the databases were created until December 26, 2022. The D and E of Gross Motor Function Measure-88 (GMFM-88) assessed lower limb motor function. Berg Balance Scale (BBS) was used to assess balance function. Walking endurance and speed were assessed using the 6-minute walk test (6MWT) and walking speed. The modified Ashworth Scale (MAS) was used to assess the degree of muscle spasticity in the lower extremities. The Cochrane Risk Assessment Scale and the Physiotherapy Evidence Database (PEDro) scale were used for qualitative assessment in the studies included. RevMan 5.4 was used for data merging and statistical analysis. R 4.2.0 and ADDIS 1.16.8 were used to map the network relationships and to perform the network meta-analysis.

RESULTS

A total of 14 studies were included in the review. The meta-analysis showed that RAGT significantly improved GMFM-88 D and E, BBS, and 6MWT scores in CP patients compared with conventional rehabilitation. However, for walking speed and MAS, the intervention effect of RAGT was insignificant. The network meta-analysis showed that the best probability ranking for the effect of the 3 different robots on the GMFM-88 D score was LokoHelp (P = 0.66) > Lokomat (P = 0.28) > 3DCaLT (P = 0.06) and the best probability ranking for the GMFM-88 E score was LokoHelp (P = 0.63) > 3DCaLT (P = 0.21) > Lokomat (P = 0.16).

CONCLUSION

RAGT positively affects walking and balance function in patients with CP, while efficacy in improving gait speed and muscle spasticity is unknown. The best treatment among the different robots is LokoHelp. Future high-quality, long-term follow-up studies are needed to explore the clinical efficacy of RAGT in depth.

Effects and Safety of Wearable Exoskeleton for Robot-Assisted Gait Training: A Retrospective Preliminary Study

BACKGROUND

Wearable devices for robot-assisted gait training (RAGT) provide overground gait training for the rehabilitation of neurological injuries. We aimed to evaluate the effectiveness and safety of RAGT in patients with a neurologic deficit.

METHODS

Twenty-eight patients receiving more than ten sessions of overground RAGT using a joint-torque-assisting wearable exoskeletal robot were retrospectively analyzed in this study. Nineteen patients with brain injury, seven patients with spinal cord injury and two patients with peripheral nerve injury were included. Clinical outcomes, such as the Medical Research Council scale for muscle strength, Berg balance scale, functional ambulation category, trunk control tests, and Fugl-Meyer motor assessment of the lower extremities, were recorded before and after RAGT. Parameters for RAGT and adverse events were also recorded.

RESULTS

The Medical Research Council scale scores for muscle strength (36.6 to 37.8), Berg balance scale (24.9 to 32.2), and functional ambulation category (1.8 to 2.7) significantly improved after overground RAGT (p < 0.05). The familiarization process was completed within six sessions of RAGT. Only two mild adverse events were reported.

CONCLUSIONS

Overground RAGT using wearable devices can improve muscle strength, balance, and gait function. It is safe in patients with neurologic injury.

Robot-assisted rehabilitation for children with neurological disabilities: Results of the Italian consensus conference CICERONE

BACKGROUND

The use of robotic technologies in pediatric rehabilitation has seen a large increase, but with a lack of a comprehensive framework about their effectiveness.

OBJECTIVE

An Italian Consensus Conference has been promoted to develop recommendations on these technologies: definitions and classification criteria of devices, indications and limits of their use in neurological diseases, theoretical models, ethical and legal implications. In this paper, we present the results for the pediatric age.

METHODS

A systematic search on Cochrane Library, PEDro and PubMed was performed. Papers published up to March 1st, 2020, in English, were included and analyzed using the methodology of the Centre for Evidence-Based Medicine in Oxford, AMSTAR2 and PEDro scales for systematic reviews and RCT, respectively.

RESULTS

Some positives aspects emerged in the area of gait: an increased number of children reaching the stance, an improvement in walking distance, speed and endurance. Critical aspects include the heterogeneity of the studied cases, measurements and training protocols.

CONCLUSION

Many studies demonstrate the benefits of robotic training in developmental age. However, it is necessary to increase the number of trials to achieve greater homogeneity between protocols and to confirm the effectiveness of pediatric robotic rehabilitation.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

[Effectiveness of robotic technology and virtual reality for the rehabilitation of motor function in cerebral palsy. Systematic review]

INTRODUCTION

Cerebral palsy (CP) is a health condition secondary to non-progressive damage that occurs during brain development in the fetal or infant stage. To evaluate the effectiveness of robotic technology and virtual reality on motor function in patients with CP compared to conventional rehabilitation strategies such as physical therapy, occupational therapy, neurodevelopmental intervention, and transcranial stimulation. A review of randomized controlled trials of the last 5 years was carried out. For the evaluation of the methodological quality of the included studies, the PEDro scale was used, with evaluation of the level of evidence and degree of recommendation according to the Oxford classification.

RESULTS

Seventeen articles met the eligibility criteria. Robotic technology and virtual reality proved to be effective in improving motor function, manual skills, and visual-perceptual skills in patients with CP, compared to the use of conventional rehabilitation strategies.

Is robotic gait training effective for individuals with cerebral palsy? A systematic review and meta-analysis of randomized controlled trials

AIM

To determine if robotic gait training for individuals with cerebral palsy is more effective than the standard of care for improving function.

METHOD

PubMed, Embase, Scopus, and Cochrane databases were searched from 1980-January, 2022 for articles that investigated robotic gait training versus standard of care (i.e. physical therapy or standard gait training) for individuals with cerebral palsy. Articles were included if a randomized controlled trial design was used, and excluded if robotic gait training was combined with another neuromuscular intervention, such as functional electrical stimulation. A meta-analysis of outcomes measured in at least four studies was conducted.

RESULTS

Eight citations met all criteria for full-text review and inclusion in the meta-analysis. A total of 188 individuals with cerebral palsy, ages four to 35, and Gross Motor Function Classification System levels I-IV were studied. Level of evidence ranged from 2b-1b. All studies utilized a tethered, assistive device for robotic gait training. The overall effect was not significantly different between the robotic gait training and control interventions for six minute walk test performance (95% CI: -0.17, 0.73; P = 0.22), free walking speed (95% CI: -0.18, 0.57; P = 0.30), or Gross Motor Function Measures D (Standing) (95% CI: -0.29, 0.39; P = 0.77) and E (Walking, Running and Jumping) (95% CI: -0.11, 0.57; P = 0.19).

CONCLUSION

Tethered robotic devices that provide assistive gait training for individuals with cerebral palsy do not provide a greater benefit for improving mobility than the standard of care.

Robot-assisted gait training: more randomized controlled trials are needed! Or maybe not?

I was encouraged by the recent article by Kuo et al. entitled “Prediction of robotic neurorehabilitation functional ambulatory outcome in patients with neurological disorders” to write an opinion piece on the possible further development of stationary robot-assisted gait training research. Randomized clinical trials investigating stationary gait robots have not shown the superiority of these devices over comparable interventions regarding clinical effectiveness, and there are clinical practice guidelines that even recommend against their use. Nevertheless, these devices are still widely used, and our field needs to find ways to apply these devices more effectively. The authors of the article mentioned above feed different machine learning algorithms with patients’ data from the beginning of a robot-assisted gait training intervention using the robot Lokomat. The output of these algorithms allows predictions of the clinical outcome (i.e., functional ambulation categories) while the patients are still participating in the intervention. Such an analysis based on the collection of the device’s data could optimize the application of these devices. The article provides an example of how our field of research could make progress as we advance, and in this opinion piece, I would like to present my view on the prioritization of upcoming research on robot-assisted gait training. Furthermore, I briefly speculate on some drawbacks of randomized clinical trials in the field of robot-assisted gait training and how the quality and thus the effectiveness of robot-assisted gait training could potentially be improved based on the collection and analysis of clinical training data, a better patient selection and by giving greater weight to the motivational aspects for the participants.

Settings matter: a scoping review on parameters in robot-assisted gait therapy identifies the importance of reporting standards

BACKGROUND

Lokomat therapy for gait rehabilitation has become increasingly popular. Most evidence suggests that Lokomat therapy is equally effective as but not superior to standard therapy approaches. One reason might be that the Lokomat parameters to personalize therapy, such as gait speed, body weight support and Guidance Force, are not optimally used. However, there is little evidence available about the influence of Lokomat parameters on the effectiveness of the therapy. Nevertheless, an appropriate reporting of the applied therapy parameters is key to the successful clinical transfer of study results. The aim of this scoping review was therefore to evaluate how the currently available clinical studies report Lokomat parameter settings and map the current literature on Lokomat therapy parameters.

METHODS AND RESULTS

A systematic literature search was performed in three databases: Pubmed, Scopus and Embase. All primary research articles performing therapy with the Lokomat in neurologic populations in English or German were included. The quality of reporting of all clinical studies was assessed with a framework developed for this particular purpose. We identified 208 studies investigating Lokomat therapy in patients with neurologic diseases. The reporting quality was generally poor. Less than a third of the studies indicate which parameter settings have been applied. The usability of the reporting for a clinical transfer of promising results is therefore limited.

CONCLUSION

Although the currently available evidence on Lokomat parameters suggests that therapy parameters might have an influence on the effectiveness, there is currently not enough evidence available to provide detailed recommendations. Nevertheless, clinicians should pay close attention to the reported therapy parameters when translating research findings to their own clinical practice. To this end, we propose that the quality of reporting should be improved and we provide a reporting framework for authors as a quality control before submitting a Lokomat-related article.

Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury

OBJECTIVE

To understand the benefits and harms of physical activity in people who may require a wheelchair with a focus on people with multiple sclerosis (MS), cerebral palsy (CP), and spinal cord injury (SCI).

DATA SOURCES

Searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO, Cochrane CENTRAL, and Embase (January 2008 through November 2020).

STUDY SELECTION

Randomized controlled trials, nonrandomized trials, and cohort studies of observed physical activity (at least 10 sessions on 10 days) in participants with MS, CP, and SCI.

DATA EXTRACTION

We conducted dual data abstraction, quality assessment, and strength of evidence. Measures of physical functioning are reported individually where sufficient data exist and grouped as "function" where data are scant.

DATA SYNTHESIS

No studies provided evidence for prevention of cardiovascular conditions, development of diabetes, or obesity. Among 168 included studies, 44% enrolled participants with MS (38% CP, 18% SCI). Studies in MS found walking ability may be improved with treadmill training and multimodal exercises; function may be improved with treadmill, balance exercises, and motion gaming; balance is likely improved with balance exercises and may be improved with aquatic exercises, robot-assisted gait training (RAGT), motion gaming, and multimodal exercises; activities of daily living (ADL), female sexual function, and spasticity may be improved with aquatic therapy; sleep may be improved with aerobic exercises and aerobic fitness with multimodal exercises. In CP, balance may be improved with hippotherapy and motion gaming; function may be improved with cycling, treadmill, and hippotherapy. In SCI, ADL may be improved with RAGT.

CONCLUSIONS

Depending on population and type of exercise, physical activity was associated with improvements in walking, function, balance, depression, sleep, ADL, spasticity, female sexual function, and aerobic capacity. Few harms of physical activity were reported in studies. Future studies are needed to address evidence gaps and to confirm findings.

ATLAS2030 Pediatric Gait Exoskeleton: Changes on Range of Motion, Strength and Spasticity in Children With Cerebral Palsy. A Case Series Study

Background: Cerebral Palsy (CP), the most common motor disability in childhood, affects individual's motor skills, movement and posture. This results in limited activity and a low social participation. The ATLAS2030 exoskeleton is a pediatric device that enables gait rehabilitation for children with neurological or neuromuscular pathologies with gait pathology. Purpose: To study changes in relation to range of motion (ROM), strength and spasticity in children with CP after using the ATLAS2030 gait exoskeleton. Methods and Participants: Three children (mean age 8.0 ± 2.0), two girls and one boy, two of them with GMFCS IV and one with GMFCS III, received robot-assisted gait training (RAGT) with ATLAS2030 for one month. Results: The average time of exoskeleton use was 54.7 ± 10.4 min in all sessions, and all participants were able to perform all exercises. The strength of all muscle groups was increased after the 10 sessions for the participants assessed and the limited ROM in the sagittal plane (hip and knee extension and ankle dorsiflexion) decreased after the use of the exoskeleton compared to the initial state. Spasticity was reduced at the end of the sessions after the use of the exoskeleton compared to their initial state. Conclusion: The ROM, spasticity and strength were improved after RAGT with ATLAS2030 exoskeleton in these children with CP. However, further studies with larger samples should be carried out to confirm our findings.

The effect of patient-specific factors on responsiveness to robot-assisted gait training in patients with bilateral spastic cerebral palsy

BACKGROUND

No general recommendations are yet available for the application of robot-assisted treadmill therapy for children with cerebral palsy regarding the length and intensity of the intervention.

OBJECTIVE

The aim of the study was to evaluate patient-specific determinants of responsiveness to robot-assisted gait training (RAGT) in patients with bilateral spastic cerebral palsy.

METHOD

During 12 months, the patients underwent 1-4 blocks of RAGT, representing 16-82 TUs. The following parameters were evaluated before (V0) and after each therapeutic block (V1-V4): dimension A (lying and rolling), B (sitting), C (crawling and kneeling), D (standing), E (walking, running and jumping) of the Gross Motor Function Measure (GMFM-88). We evaluated the change in motor functions in relation to the severity of disability, age, gender and number of therapeutic units.

RESULTS

Ninety-seven patients aged between 3.7 and 27 years (mean age 10.02 years (SD±5.29); Gross Motor Function Classification System level I [n = 5], II [n = 25], III [n = 48], IV [n = 19]) underwent 16-82 TUs (overall average number 34.06 TUs, SD±16.41) of RAGT. In the patient group, we recorded clinically meaningful improvement and statistically significant improvement (p < 0.001) in gross motor functions with gradual increase in the effect size after each therapeutic block. Using correlation and regression analysis, we found a statistically significant associations between the number of therapeutic units, severity of disability, and improvement in motor functions after RAGT.

CONCLUSION

We have identified two determinants -the severity of disability and the number of therapeutic units -which could have a decisive and predictive character in setting rehabilitation/designing programmes. The duration of the applied RAGT period, frequency and intensity could be a crucial factor for the potential of improvement in children with BS-CP.

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

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

Clinical effects of assisted robotic gait training in walking distance, speed, and functionality are maintained over the long term in individuals with cerebral palsy: a systematic review and meta-analysis

PURPOSE

To identify the short-term effects of robotic-assisted gait training (RAGT) on walking distance, gait speed and functionality of cerebral palsy (CP) patients, and to verify if the effects of RAGT are maintained in the long term.

METHODS

A systematic literature review was performed in PubMed, PEDro, CINAHL, and LILACS databases. Studies were included considering: (1) population (CP individuals); (2) study design (experimental studies); (3) type of intervention (RAGT); (4) outcome (gait parameters and function); and (5) period (short and long term).

RESULTS

This systematic review included seven articles in meta-analysis. Only walking distance, thru six minutes walking test, increased statistically after RAGT. However, RAGT demonstrated large clinical effects differences (minimal clinically important difference - MCID) in gait speed and Gross Motor Function Measure score (dimensions D and E), for CP population. After RAGT intervention, differences in short term (comparison 1) were maintained in long term (comparison 2) for all outcomes. Gait speed results were not significant.

CONCLUSIONS

Evidence from the present study demonstrated that RAGT can be an important intervention to improve gait parameters and functionality, in children with CP, that are maintained over long-term.Implications for RehabilitationRobotic-assisted gait training (RAGT) is a beneficial treatment for children with cerebral palsy (CP).RAGT improvements in walking distance are maintained over the long-term in children with CP.RAGT demonstrated large clinical effect differences in gait speed and functionality in CP population.

Gait-assisted exoskeletons for children with cerebral palsy or spinal muscular atrophy: A systematic review

BACKGROUND

Cerebral Palsy (CP) and Spinal Muscular Atrophy (SMA) are common causes of motor disability in childhood. Gait exoskeletons are currently being used as part of rehabilitation for children with walking difficulties.

OBJECTIVE

To assess the safety and efficacy and describe the main characteristics of the clinical articles using robot-assisted gait training (RAGT) with exoskeleton for children with CP or SMA.

METHODS

A computer search was conducted in five bibliographic databases regarding clinical studies published in the last ten years. In order to be included in this review for further analysis, the studies had to meet the following criteria: (1) assess efficacy or safety of interventions; (2) population had to be children with CP or SMA aged between 3 and 14; (3) exoskeleton must be bilateral and assist lower limbs during walking.

RESULTS

Twenty-one articles were selected, of which only five were clinical trials. 108 participants met the inclusion criteria for this study, all with a diagnosis of CP. The evidence level of the selected papers was commonly low.

CONCLUSIONS

RAGT therapy seems to be safe for children with CP. However, further investigation is needed to confirm the results related to efficacy. There is no evidence of RAGT therapy for SMA children.

Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy

BACKGROUND

Cerebral palsy is the most common physical disability in childhood. Mechanically assisted walking training can be provided with or without body weight support to enable children with cerebral palsy to perform repetitive practice of complex gait cycles. It is important to examine the effects of mechanically assisted walking training to identify evidence-based treatments to improve walking performance.

OBJECTIVES

To assess the effects of mechanically assisted walking training compared to control for walking, participation, and quality of life in children with cerebral palsy 3 to 18 years of age.

SEARCH METHODS

In January 2020, we searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers. We handsearched conference abstracts and checked reference lists of included studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) or quasi-RCTs, including cross-over trials, comparing any type of mechanically assisted walking training (with or without body weight support) with no walking training or the same dose of overground walking training in children with cerebral palsy (classified as Gross Motor Function Classification System [GMFCS] Levels I to IV) 3 to 18 years of age.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 17 studies with 451 participants (GMFCS Levels I to IV; mean age range 4 to 14 years) from outpatient settings. The duration of the intervention period (4 to 12 weeks) ranged widely, as did intensity of training in terms of both length (15 minutes to 40 minutes) and frequency (two to five times a week) of sessions. Six studies were funded by grants, three had no funding support, and eight did not report information on funding. Due to the nature of the intervention, all studies were at high risk of performance bias. Mechanically assisted walking training without body weight support versus no walking training Four studies (100 participants) assessed this comparison. Compared to no walking, mechanically assisted walking training without body weight support increased walking speed (mean difference [MD] 0.05 meter per second [m/s] [change scores], 95% confidence interval [CI] 0.03 to 0.07; 1 study, 10 participants; moderate-quality evidence) as measured by the Biodex Gait Trainer 2™ (Biodex, Shirley, NY, USA) and improved gross motor function (standardized MD [SMD] 1.30 [postintervention scores], 95% CI 0.49 to 2.11; 2 studies, 60 participants; low-quality evidence) postintervention. One study (30 participants) reported no adverse events (low-quality evidence). No study measured participation or quality of life. Mechanically assisted walking training without body weight support versus the same dose of overground walking training Two studies (55 participants) assessed this comparison. Compared to the same dose of overground walking, mechanically assisted walking training without body weight support increased walking speed (MD 0.25 m/s [change or postintervention scores], 95% CI 0.13 to 0.37; 2 studies, 55 participants; moderate-quality evidence) as assessed by the 6-minute walk test or Vicon gait analysis. It also improved gross motor function (MD 11.90% [change scores], 95% CI 2.98 to 20.82; 1 study, 35 participants; moderate-quality evidence) as assessed by the Gross Motor Function Measure (GMFM) and participation (MD 8.20 [change scores], 95% CI 5.69 to 10.71; 1 study, 35 participants; moderate-quality evidence) as assessed by the Pediatric Evaluation of Disability Inventory (scored from 0 to 59), compared to the same dose of overground walking training. No study measured adverse events or quality of life. Mechanically assisted walking training with body weight support versus no walking training Eight studies (210 participants) assessed this comparison. Compared to no walking training, mechanically assisted walking training with body weight support increased walking speed (MD 0.07 m/s [change and postintervention scores], 95% CI 0.06 to 0.08; 7 studies, 161 participants; moderate-quality evidence) as assessed by the 10-meter or 8-meter walk test. There were no differences between groups in gross motor function (MD 1.09% [change and postintervention scores], 95% CI -0.57 to 2.75; 3 studies, 58 participants; low-quality evidence) as assessed by the GMFM; participation (SMD 0.33 [change scores], 95% CI -0.27 to 0.93; 2 studies, 44 participants; low-quality evidence); and quality of life (MD 9.50% [change scores], 95% CI -4.03 to 23.03; 1 study, 26 participants; low-quality evidence) as assessed by the Pediatric Quality of Life Cerebral Palsy Module (scored 0 [bad] to 100 [good]). Three studies (56 participants) reported no adverse events (low-quality evidence). Mechanically assisted walking training with body weight support versus the same dose of overground walking training Three studies (86 participants) assessed this comparison. There were no differences between groups in walking speed (MD -0.02 m/s [change and postintervention scores], 95% CI -0.08 to 0.04; 3 studies, 78 participants; low-quality evidence) as assessed by the 10-meter or 5-minute walk test; gross motor function (MD -0.73% [postintervention scores], 95% CI -14.38 to 12.92; 2 studies, 52 participants; low-quality evidence) as assessed by the GMFM; and participation (MD -4.74 [change scores], 95% CI -11.89 to 2.41; 1 study, 26 participants; moderate-quality evidence) as assessed by the School Function Assessment (scored from 19 to 76). No study measured adverse events or quality of life.

AUTHORS' CONCLUSIONS

Compared with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support). Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function. Not many studies reported adverse events, although those that did appeared to show no differences between groups. The results are largely not clinically significant, sample sizes are small, and risk of bias and intensity of intervention vary across studies, making it hard to draw robust conclusions. Mechanically assisted walking training is a means to undertake high-intensity, repetitive, task-specific training and may be useful for children with poor concentration.

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.

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

Objective

The minimum clinically important difference (MCID) is a standard way of measuring clinical relevance. The objective of this work was to establish the MCID for the 6-minute walking test (6minWT) and the Gross Motor Function Measure (GMFM-88) in pediatric gait disorders.

Methods

A cohort, pretest-posttest study was conducted in a hospitalized care setting. A total of 182 patients with acquired brain injury (ABI) or cerebral palsy (CP) performed 20 robot-assisted gait training sessions complemented with 20 sessions of physical therapy over 4 weeks. Separate MCIDs were calculated using 5 distribution-based approaches, complemented with an anonymized survey completed by clinical professionals.

Results

The MCID range for the 6minWT was 20-38 m in the ABI cohort, with subgroup ranges of 20-36 m for GMFCS I-II, 23-46 m for GMFCS III, and 24-46 m for GMFCS IV. MCIDs for the CP population were 6-23 m, with subgroup ranges of 4-28 m for GMFCS I-II, 9-19 m for GMFCS III, and 10-27 m for GMFCS IV. For GMFM-88 total score, MCID values were 1.1%-5.3% for the ABI cohort and 0.1%-3.0% for the CP population. For dimension “D” of the GMFM, MCID ranges were 2.3%-6.5% and 0.8%-5.2% for ABI and CP populations, respectively. For dimension “E,” MCID ranges were 2.8%-6.5% and 0.3%-4.9% for ABI and CP cohorts, respectively. The survey showed a large interquartile range, but the results well mimicked the distribution-based methods.

Conclusions

This study identified for the first time MCID ranges for 6minWT and GMFM-88 in pediatric patients with neurological impairments, offering useful insights for clinicians to evaluate the impact of treatments. Distribution-based methods should be used with caution: methods based on pre-post correlation may underestimate MCID when applied to patients with small improvements over the treatment period. Our results should be complemented with estimates obtained using consensus- and anchor-based approaches.

[Effectiveness of robotic assistance for gait training in children with cerebral palsy. a systematic review]

INTRODUCTION

In recent years, the use of gait training using robotic assistance systems has progressively increased in the paediatric population with cerebral palsy.

OBJECTIVE

To systematically assess the effects of robotic assistance for gait training compared with physical rehabilitation therapy in children with cerebral palsy (CP), based on the International Classification of Functioning, Health and Disability (ICF).

MATERIALS AND METHODS

A systematic review was carried out according to the recommendations of the Cochrane Collaboration. We included randomised or quasi-randomised clinical trials that analysed children with CP classified according to The Gross Motor Function Classification System (GMFCS) I-III. The search was carried out in PubMed, PEDro, CENTRAL, CINALH, Cochrane, Embase, Europe PMC, LILACS and Science Direct. The selection and extraction of data from the studies was carried out by two independent researchers. Disagreements were resolved by consensus. A descriptive analysis of the selected studies was performed. Assessment of risk of bias was performed with the Cochrane Collaboration tool.

RESULTS

Four studies met the eligibility criteria. Most of the temporal-spatial, kinetic and kinematic parameters of gait were evaluated, all corresponding to the activity component of the ICF.

CONCLUSIONS

Due to the methodological variability of the studies, it is not possible to determine whether robot-assisted gait training is effective for treatment in children with CP.

Lessons learned from conducting a pragmatic, randomized, crossover trial on robot-assisted gait training in children with cerebral palsy (PeLoGAIT)

PURPOSE

To investigate the effectiveness of outpatient robot-assisted gait training (RAGT) in ambulatory children with spastic cerebral palsy.

METHODS

Children were randomized to two different intervention sequences within a pragmatic crossover design. They performed five weeks of RAGT (3 sessions per week) and five weeks of usual care (UC). Dimension E of the Gross Motor Function Measure-88 (GMFM E) as the primary outcome as well as Dimension D (GMFM D), and timed walking tests were assessed before and after each treatment sequence and after a 5-week follow-up.

RESULTS

The trial was stopped early because of recruitment problems. We included 16 children with a mean age of 11.3 years (6.0-15.3 years). GMFM E median (IQR) change scores were -0.7 (-2.8 to 3.5) after RAGT and 0 (-2.4 to 2.4) after UC. Neither GMFM E nor any secondary outcome measure changed significantly after RAGT or UC, nor were any period, follow-up, or carry-over effects observable.

CONCLUSIONS

RAGT as a single intervention was not effective in improving walking abilities in the included children. It should be embedded in a holistic treatment approach, as it cannot cover all aspects relevant to gait. Furthermore, children's personalized rehabilitation goals should be carefully monitored with individualized measurement instruments.

Effects of robot-assisted gait training alongside conventional therapy on the development of walking in children with cerebral palsy

PURPOSE

To investigate the effects of robot-assisted gait training (RAGT) alongside conventional therapy on the standing and walking abilities of children with cerebral palsy (CP).

METHODS

The study sample consisted of children (aged 4-18 years) with CP whose gross motor function classification system (GMFCS) was at levels I-V. In total, 75 children with CP were evaluated and 38 patients completed the study. Patients were divided into two groups as GMFCS levels I-III (Group 1) and levels IV-V (Group 2). RAGT (30 min/session) and conventional physiotherapy (30 min/session) were applied together in the treatment. The treatment duration was 60 min per session, 3 or 4 sessions per week, for a total of 30 sessions over 8-10 weeks. 10-meter walk test (10MWT), 6-min walk test (6MinWT), gross motor functional measurement 66 (GMFM66) -D, and -E tests were performed.

RESULTS

We showed that in both groups of CP patients (mild-moderate and severe), meaningful improvements were seen in the standing (D) and walking (E) sections of GMFM-66 after treatment. When we compared the post-treatment changes in 10-m walk test, 6-min walk test, GMFM66-D, and -E between Groups 1 and 2, we noted that the improvements were statistically significant in favor of Group 1 (p< 0.01).

CONCLUSION

RAGT in combination with a conventional treatment program was significantly associated with improvements in the standing and walking abilities of children with mild to moderate CP (GMFCS levels I-III).