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

Effects of various exercise interventions on motor function in cerebral palsy patients: a systematic review and network meta-analysis

PURPOSE

A network meta-analysis was utilized to compare the rehabilitative effectiveness of different exercise interventions on motor function in cerebral palsy(CP) patients.

METHODS

Computer searches were conducted across 9 databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase, and others, to identify randomized controlled trials focusing on different exercise interventions aimed at enhancing motor function in CP patients. The search spanned from the inception of the databases to January 31, 2024.

RESULTS

20 articles, encompassing 570 patients and evaluating three types of exercise interventions, were included in the analysis. Results showed that aerobic training, resistance training, and mixed training exhibited superior outcomes compared to the control group, as evidenced by improvements in Gross Motor Function Measure scores, muscle strength, gait speed, and 10-Meter Walk Test scores (P < 0.05). Furthermore, the network meta-analysis revealed that resistance training ranked highest in enhancing gross motor function and gait speed among CP patients, while mixed training was deemed most effective in improving muscle strength and 10-Meter Walk Test scores.

CONCLUSION

Exercise interventions have been shown to significantly improve motor function in CP patients. Among these, resistance training and mixed training stand out for their effectiveness in enhancing walking capabilities. Resistance training is specifically aimed at improving gross motor function, while mixed training focuses on increasing muscle strength.

Robot-assisted gait training improves walking and cerebral connectivity in children with unilateral cerebral palsy

BACKGROUND

Robot-assisted gait training (RAGT) is promising to help walking rehabilitation in cerebral palsy, but training-induced neuroplastic effects have little been investigated.

METHODS

Forty unilateral cerebral palsy children aged 4-18 years were randomly allocated in a monocentric study to ten 20-minute RAGT sessions with the G-EO system, five days a week (n = 20) or to a control group (who continued conventional care with six 30-minute physiotherapy sessions, three days a week) (n = 20), two weeks running, from September 2020 to December 2021. Clinical and MRI outcomes were compared before and one month after therapy. The primary outcome was gait speed. Secondary outcomes were a 6-minute walking test distance, Gross Motor Function Measure-88 (GMFM-88) dimensions D and E, Patient Global Impression of Improvement, resting-state functional connectivity within the sensorimotor network, and structural connectivity in the corticospinal tracts.

RESULTS

Gait speed and the 6-minute walking test distance improved more after RAGT. Resting-state functional connectivity increased after RAGT but decreased in controls between superior and lateral healthy or lateral injured sensorimotor networks. GMFM-88 and structural connectivity in corticospinal tracts were unchanged. Impression of improvement in children was better after RAGT.

CONCLUSION

Short-term benefit of repetitive RAGT on walking abilities and functional cerebral connectivity was found in unilateral cerebral palsy children.

IMPACT STATEMENT

Short-term repetitive robot-assisted gait training improves gait speed and walking resistance and increases cerebral functional connectivity in unilateral cerebral palsy. GMFM dimensions D and E were unchanged after short-term repetitive robot-assisted gait training in unilateral cerebral palsy.

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.

Effects of robot rehabilitation on the motor function and gait in children with cerebral palsy: a systematic review and meta-analysis

This study was to determine the effects of robot rehabilitation on motor function and gait in children with cerebral palsy (CP) and the effect of robot type. Inclusion criteria were children with any type of CP, robot rehabilitation studies, non-robot rehabilitation comparison groups, outcomes related to motor function and gait, and randomized controlled trials. PubMed, Embase, Cochrane Library, CINAHL, and Web of Science databases were searched. Risk of bias was assessed using physiotherapy evidence database. Seven studies with a total of 228 participants were selected. Motor function was significantly improved in three studies comparing robot rehabilitation and control groups (standard mean difference [SMD], 0.79; 95% confidence intervals [CIs], 0.34-1.24; I 2=73%). Gait was not significantly improved in five studies comparing robot rehabilitation and control groups (SMD, 0.27; 95% CI, -0.09 to 0.63; I 2=45%). When comparing effects by robot type, robotic-assisted gate training (RAGT) showed significant improvements in both motor function (SMD, 0.89; 95% CI, 0.36-1.43; I 2=77%) and gait (SMD, 0.62; 95% CI, 0.12-1.11; I 2=44%). Robot rehabilitation effectively improved motor function, and among the robot types, RAGT was found to be effective in improving motor function and gait.

Evidence for gait improvement with robotic-assisted gait training of children with cerebral palsy remains uncertain

BACKGROUND

Cerebral palsy (CP) is a group of neuromotor diseases that develops as a result of damage to the developing central nervous system during the perinatal period. The condition is usually accompanied by musculoskeletal problems resulting in movement disorders. Gait improvement therefore, is an important part of its treatment. Roboticassisted gait training (RAGT) is a new potential rehabilitation tool for CP patients, however there is no clear evidence for the effectiveness of this method.

RESEARCH QUESTION

Can robotic-assisted gait training improve walking function in children with CP?

METHODS

A systematic search was performed in five databases: MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Scopus, and Web of Science. Eligible studies were randomized controlled trials (RCT) with CP patients under the age of 18. Gross motor function and kinematic gait parameters of patients were the main outcomes. Two authors determined the risk of bias of the RCTs independently using the revised Risk of Bias 2 (ROB 2) tool. Mean Differences (MDs) along with their 95% Confidence Interval (CI) were calculated when at least three studies were present for an outcome, subgroup analysis was performed based on the treatment of the control group.

RESULTS

Of the 7363 screened articles, 13 papers met our inclusion criteria and among them, 7 studies could be used in our meta-analyses. The results related to RAGT suggest nonsignificant improvement in standing and walking function (Gross Motor Function Measure D, E), moreover changes in gait speed, step length, and in cadence were also only comparable to controls.

SIGNIFICANCE

The results indicate that there is a trend in some gait parameters where the improvement was higher in the intervention group than in control group. The therapeutic effect of RAGT was probably not superior to physiotherapy combined with treadmill training.

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.

Impact of Robotic-Assisted Gait Training in Subacute Spinal Cord Injury Patients on Outcome Measure

The improvement of walking ability is a primary goal for spinal cord injury (SCI) patients. Robotic-assisted gait training (RAGT) is an innovative method for its improvement. This study evaluates the influence of RAGT vs. dynamic parapodium training (DPT) in improving gait motor functions in SCI patients. In this single-centre, single-blinded study, we enrolled 105 (39 and 64 with complete and incomplete SCI, respectively) patients. The investigated subjects received gait training with RAGT (experimental S1-group) and DPT (control S0-group), with six training sessions per week over seven weeks. The American Spinal Cord Injury Association Impairment Scale Motor Score (MS), Spinal Cord Independence Measure, version-III (SCIM-III), Walking Index for Spinal Cord Injury, version-II (WISCI-II), and Barthel Index (BI) were assessed in each patient before and after sessions. Patients with incomplete SCI assigned to the S1 rehabilitation group achieved more significant improvement in MS [2.58 (SE 1.21, p < 0.05)] and WISCI-II [3.07 (SE 1.02, p < 0.01])] scores in comparison with patients assigned to the S0 group. Despite the described improvement in the MS motor score, no progression between grades of AIS (A to B to C to D) was observed. A nonsignificant improvement between the groups for SCIM-III and BI was found. RAGT significantly improved gait functional parameters in SCI patients in comparison with conventional gait training with DPT. RAGT is a valid treatment option in SCI patients in the subacute phase. DPT should not be recommended for patients with incomplete SCI (AIS-C); in those patients, RAGT rehabilitation programs should be taken into consideration.

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 Gait Training with Trexo Home: Users, Usage and Initial Impacts

Robotic gait training has the potential to improve secondary health conditions for people with severe neurological impairment. The purpose of this study was to describe who is using the Trexo robotic gait trainer, how much training is achieved in the home and community, and what impacts are observed after the initial month of use. In this prospective observational single-cohort study, parent-reported questionnaires were collected pre- and post-training. Of the 70 participants, the median age was 7 years (range 2 to 24), 83% had CP, and 95% did not walk for mobility. Users trained 2–5 times/week. After the initial month, families reported a significant reduction in sleep disturbance (p = 0.0066). Changes in bowel function, positive affect, and physical activity were not statistically significant. These findings suggest that families with children who have significant mobility impairments can use a robotic gait trainer frequently in a community setting and that sleep significantly improves within the first month of use. This intervention holds promise as a novel strategy to impact multi-modal impairments for this population. Future work should include an experimental study design over a longer training period to begin to understand the relationship between training volume and its full potential.

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.

A Review on Recent Advances of Cerebral Palsy

This narrative review summarizes the latest advances in cerebral palsy and identifies where more research is required. Several studies on cerebral palsy were analyzed to generate a general idea of the prevalence of, risk factors associated with, and classification of cerebral palsy (CP). Different classification systems used for the classification of CP on a functional basis were also analyzed. Diagnosis systems used along with the prevention techniques were discussed. State-of-the-art treatment strategies for CP were also analyzed. Statistical distribution was performed based on the selected studies. Prevalence was found to be 2-3/1000 lives; the factors that can be correlated are gestational age and birth weight. The risk factors identified were preconception, prenatal, perinatal, and postnatal categories. According to the evidence, CP is classified into spastic (80%), dyskinetic (15%), and ataxic (5%) forms. Diagnosis approaches were based on clinical investigation and neurological examinations that include magnetic resonance imaging (MRI), biomarkers, and cranial ultrasound. The treatment procedures found were medical and surgical interventions, physiotherapy, occupational therapy, umbilical milking, nanomedicine, and stem cell therapy. Technological advancements in CP were also discussed. CP is the most common neuromotor disability with a prevalence of 2-3/1000 lives. The highest contributing risk factor is prematurity and being underweight. Several preventions and diagnostic techniques like MRI and ultrasound were being used. Treatment like cord blood treatment nanomedicine and stem cell therapy needs to be investigated further in the future to apply in clinical practice. Future studies are indicated in the context of technological advancements among cerebral palsy children.

Virtual reality combined with robot-assisted gait training to improve walking ability of children with cerebral palsy: A randomized controlled trial

BACKGROUND

Children with cerebral palsy (CP) have disorders of posture and movement and which can limit physical activities such as walkingOBJECTIVE: This study aims to investigate the effectiveness of virtual reality (VR) combined with robot-assisted gait training (RAGT) on walking ability in children with CP and clarify the most effective degree of weight reduction.

METHODS

Sixty CP children were recruited and randomly allocated into four different groups. The control group received conventional physical therapy (n= 15), and task groups performed VR combined with RAGT with 15% (Group A, n= 15) /30% (Group B, n= 15) /45% (Group C, n= 15) weight loss. All participants were given 50 min of therapy per session four times a week for 12 weeks and were assessed pre-and post-test with the surface electromyography (EMG), the Modified Ashworth Scale, the Gross Motor Function Measure (GMFM) dimension E and D, and Six-Minute Walking Test (6-MWT).

RESULTS

All indicators had improved significantly in each group after the intervention (P< 0.05). The result of our study demonstrated that the more effective impacts of VR combined with RAGT on walking ability compared to the control group (P< 0.05), and 30% of weight loss had the best improvement in CP children (P< 0.01).

CONCLUSIONS

VR combined RAGT can effectively improve walking ability in children with CP, especially when the weight loss is 30%.

Robotic Systems for the Physiotherapy Treatment of Children with Cerebral Palsy: A Systematic Review

Cerebral palsy is a neurological condition that is associated with multiple motor alterations and dysfunctions in children. Robotic systems are new devices that are becoming increasingly popular as a part of the treatment for cerebral palsy. A systematic review of the Pubmed, Web of Science, MEDLINE, Cochrane, Dialnet, CINAHL, Scopus, Lilacs and PEDro databases from November 2021 to February 2022 was conducted to prove the effectiveness of these devices for the treatment of motor dysfunctions in children who were diagnosed with cerebral palsy. Randomized clinical trials in Spanish and English were included. In total, 653 potential manuscripts were selected but only 7 of them met the inclusion criteria. Motor dysfunctions in the lower limbs and those that are specifically related to gait are the main parameters that are affected by cerebral palsy and the robotic systems Lokomat, Innowalk, Robogait and Waltbox-K are the most commonly used. There is no consensus about the effectiveness of these devices. However, it seems clear that they have presented a good complement to conventional physical therapies, although not a therapy as themselves. Unfortunately, the low quality of some of the randomized clinical trials that were reviewed made it difficult to establish conclusive results. More studies are needed to prove and test the extent to which these devices aid in the treatment of children with cerebral palsy.

Effects of Robotic Interactive Gait Training Combined with Virtual Reality and Augmented Reality on Balance, Gross Motor Function, Gait Kinetic, and Kinematic Characteristics in Angelman Syndrome: A Case Report

Angelman syndrome (AS) is a genetic neurological disorder resulting in cognitive and neuromuscular impairments, such as lack of safety awareness and attention, as well as lack of balance and locomotor control. The robotic interactive gait training (RIGT) system is designed to provide accurate proprioceptive, kinematic, and kinetic feedback, and facilitate virtual reality and augmented reality (VR-AR) interactive exercises during gait training. In the present case report, we examined the effect of an innovative hip-knee-ankle interlimb-coordinated RIGT system. We utilized this therapeutic modality in a participant with Angelman syndrome (AS). Gross motor function measures, risk of fall, and gait-related kinetic (force), and kinematic (joint angle) biomechanical characteristics were assessed before and after 20 sessions of RIGT with VR-AR. We found RIGT with VR-AT improved gait ability, as shown by Performance-Oriented Mobility Assessment score, gross motor function by Gross Motor Function Measure score, balance by Pediatric Balance Scale score, knee and hip joint kinetics, and kinematics during gait. Our clinical and biomechanical evidence provide important clinical insights to improve the effectiveness of current neurorehabilitation approaches for treating patients with AS in balance and locomotor control and reduce the risk of falling.

Abnormal synergistic gait mitigation in acute stroke using an innovative ankle-knee-hip interlimb humanoid robot: a preliminary randomized controlled trial

Abnormal spasticity and associated synergistic patterns are the most common neuromuscular impairments affecting ankle–knee–hip interlimb coordinated gait kinematics and kinetics in patients with hemiparetic stroke. Although patients with hemiparetic stroke undergo various treatments to improve gait and movement, it remains unknown how spasticity and associated synergistic patterns change after robot-assisted and conventional treatment. We developed an innovative ankle–knee–hip interlimb coordinated humanoid robot (ICT) to mitigate abnormal spasticity and synergistic patterns. The objective of the preliminary clinical trial was to compare the effects of ICT combined with conventional physical therapy (ICT-C) and conventional physical therapy and gait training (CPT-G) on abnormal spasticity and synergistic gait patterns in 20 patients with acute hemiparesis. We performed secondary analyses aimed at elucidating the biomechanical effects of Walkbot ICT on kinematic (spatiotemporal parameters and angles) and kinetic (active force, resistive force, and stiffness) gait parameters before and after ICT in the ICT-C group. The intervention for this group comprised 60-min conventional physical therapy plus 30-min robot-assisted training, 7 days/week, for 2 weeks. Significant biomechanical effects in knee joint kinematics; hip, knee, and ankle active forces; hip, knee, and ankle resistive forces; and hip, knee, and ankle stiffness were associated with ICT-C. Our novel findings provide promising evidence for conventional therapy supplemented by robot-assisted therapy for abnormal spasticity, synergistic, and altered biomechanical gait impairments in patients in the acute post-stroke recovery phase.

Trial Registration: Clinical Trials.gov identifier NCT03554642 (14/01/2020).

Comparative effects of community-based family-child-centered care and conventional pediatric rehabilitation for cerebral palsy

BACKGROUND

While the transdisciplinary-based rehabilitation provided ample evidence on improving impairment (body structure and functions) levels, the therapeutic effects on the international classification of functioning, disability, and health (ICF) domains are unknown in cerebral palsy (CP).

OBJECTIVE

To compare the effects of the community-based family-child-centered care (CFC) and conventional pediatric rehabilitation (CPR) on the physical, cognitive, sensory, and social integration domains in children and adolescents with CP.

METHODS

Twenty-six participants with CP (mean age = 9.37±5.24, 14 females) were assigned into either CPR or CFC groups. Clinical outcomes included gross motor function measure (GMFM-66), Pediatric Balance Scale (PBS), fine motor area of Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT-2), Functional Independence Measure (FIM) cognition area, Short Sensory Profile (sSP), COPM, Pediatrics Quality of Life (PedsQL) questionnaire, Short Falls Efficacy Scale (sFES), and Dynamic Postural Instability (DPI). An analysis of variance (ANOVA) and an analysis of covariance (ANCOVA) was conducted at P < 0.05.

RESULTS

ANOVA revealed the superior effects of CFC in GMFM-66, PBS, BOT-2, FIM, and PedsQL compared to CPR (P < 0.05). ANCOVA showed the superior effects of CFC in Z-axis of DPI than CPR (P < 0.05).

CONCLUSIONS

Our results provide novel, promising clinical evidence that CFC was more effective than CPR at improving impairment, activity, as well as participation levels in participants with 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.

Robotic devices for paediatric rehabilitation: a review of design features

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

COMPARATIVE EFFECTIVENESS OF ROBOT-INTERACTIVE GAIT TRAINING WITH AND WITHOUT ANKLE ROBOTIC CONTROL IN PATIENTS WITH BRAIN DAMAGE

Although ankle robotic control has emerged as a critical component of robot-interactive gait training (RIGT), no study has investigated the neurophysiological and biomechanical effects on ankle muscle activity and joint angle kinematics in healthy adults and participants with brain damage, including stroke and cerebral palsy (CP). This study compared the effects of RIGT, with and without ankle control actuator, on ankle muscle activity and joint angle kinematics in healthy adults and participants with brain damage. Ten patients ([Formula: see text], left hemiparetic [Formula: see text], [Formula: see text]) underwent standardized surface electromyography (EMG) neurophysiological and kinematics biomechanical tests under the RIGT with and without ankle control actuator conditions. Outcome measures included the EMG amplitudes of the tibialis anterior and gastrocnemius muscle activity, and ankle movement angles recorded with a two-axis digital inclinometer. Descriptive statistical analysis demonstrated that RIGT with ankle control actuator showed superior effects on EMG (30%) and kinematics angles (25%) than RIGT without ankle control actuator. Our results provided novel, promising clinical evidence that RIGT with ankle control actuator can more effectively improve the neurophysiological EMG data and ankle dorsiflexion and plantarflexion movements than RIGT without ankle control actuator in participants with stroke and CP.

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.

[Effect of rehabilitation treatment based on the ICF-CY Core Sets on activities of daily living in children with cerebral palsy: a prospective randomized controlled study]

OBJECTIVE

To study the effect of rehabilitation treatment based on the International Classification of Functioning, Disability and Health-Children and Youth Version (ICF-CY) Core Sets on activities of daily living in children with cerebral palsy.

METHODS

The children with cerebral palsy were divided into an observation group (n=63) and a control group (n=59) using a random number table. The children in the observation group were evaluated using the brief ICF-CY Core Sets for children under 6 years to identify intervention targets and develop rehabilitation plans and goals, and then specific methods were selected for rehabilitation treatment. The children in the control group were evaluated and treated with the traditional rehabilitation mode. The scores of the Functional Independence Measure for Children (WeeFIM) and the Infants-Junior Middle School Students' Social-Life Abilities Scale were assessed for both groups before treatment and after three courses of treatment. The intervention of environmental factors was compared between the two groups.

RESULTS

There was no significant difference in the scores of the WeeFIM and Social-Life Abilities scales between the two groups before treatment (P > 0.05). After treatment, both groups had significant increases in the scores of the WeeFIM and Social-Life Abilities scales (P < 0.001). The observation group had significantly higher scores of WeeFIM and Social-Life Abilities scales than the control group after treatment (P < 0.05). There was no significant difference in the use rate of orthosis between the two groups (P > 0.05), but the use rate of assistive devices for self-help, transfer and communication, the rate of facility renovation, and the rate of family rehabilitation guidance in the observation group were significantly higher than those in the control group (P < 0.05).

CONCLUSIONS

The rehabilitation treatment regimen for cerebral palsy based on the CF-CY Core Sets pays more attention to the influence of environmental factors in the process of rehabilitation and can effectively improve the activities of daily living of children with cerebral palsy.

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.

[Effect of rehabilitation treatment based on the ICF-CY Core Sets on activities of daily living in children with cerebral palsy: a prospective randomized controlled study]

OBJECTIVE

To study the effect of rehabilitation treatment based on the International Classification of Functioning, Disability and Health-Children and Youth Version (ICF-CY) Core Sets on activities of daily living in children with cerebral palsy.

METHODS

The children with cerebral palsy were divided into an observation group (n=63) and a control group (n=59) using a random number table. The children in the observation group were evaluated using the brief ICF-CY Core Sets for children under 6 years to identify intervention targets and develop rehabilitation plans and goals, and then specific methods were selected for rehabilitation treatment. The children in the control group were evaluated and treated with the traditional rehabilitation mode. The scores of the Functional Independence Measure for Children (WeeFIM) and the Infants-Junior Middle School Students' Social-Life Abilities Scale were assessed for both groups before treatment and after three courses of treatment. The intervention of environmental factors was compared between the two groups.

RESULTS

There was no significant difference in the scores of the WeeFIM and Social-Life Abilities scales between the two groups before treatment (P > 0.05). After treatment, both groups had significant increases in the scores of the WeeFIM and Social-Life Abilities scales (P < 0.001). The observation group had significantly higher scores of WeeFIM and Social-Life Abilities scales than the control group after treatment (P < 0.05). There was no significant difference in the use rate of orthosis between the two groups (P > 0.05), but the use rate of assistive devices for self-help, transfer and communication, the rate of facility renovation, and the rate of family rehabilitation guidance in the observation group were significantly higher than those in the control group (P < 0.05).

CONCLUSIONS

The rehabilitation treatment regimen for cerebral palsy based on the CF-CY Core Sets pays more attention to the influence of environmental factors in the process of rehabilitation and can effectively improve the activities of daily living of children with cerebral palsy.