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

Abstract

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

Keywords: cerebral palsy; exoskeleton device; gait disorders neurologic; hybrid assistive limb; pediatrics; robot-assisted gait training; walk test; walking.

Figure 1

Study protocol (modified from [25]). HAL: Hybrid Assistive Limb.

Figure 2

Flowchart of the study. GMFM: Gross Motor Functions Measure; HAL: Hybrid Assistive Limb; COVID-19: Coronavirus disease 2019.

Figure 3

Results of the 10 m walking test with SSW (A) and maximum walking speed (B). Boxplots: Middle line: median; lower whisker: minimum value; upper whisker: maximum value; circles: Outliers (1.5 times interquartile range); *: extreme outliers (3.0 times interquartile range; numbers: Case numbers); p < 0.05; SSW: Self-Selected Walking Speed; T1: measurement pre-intervention; T2: measurement post-intervention; Confidence interval: 95%; n = 25.

Figure 4

Results of the distance walked in the 6 min walking test. Boxplots: Middle line: median; lower whisker: minimum value; upper whisker: maximum value; circles: Outliers (1.5 times interquartile range); p < 0.05; T1: measurement pre-intervention; T2: measurement post-intervention; Confidence interval: 95%; n = 25.

Figure 5

Results of the Gross Motor Functions Measure total (A) and Dimension D + E (B). Boxplots: Middle line: median; lower whisker: minimum value; upper whisker: maximum value; circles: Outliers (1.5 times interquartile range); p < 0.05; T1: measurement pre-intervention; T2: measurement post-intervention; Confidence interval: 95%; n = 25.

Figure 6

Changes in pedobarography results. Delta from T1 to T2. Pressure distribution (green arrows); anterior-posterior and lateral body center of gravity fluctuation (black arrows); area sway of body center of pressure (blue area); n = 16.

Figure 7

Changes in the passive range of motion of the hip joint in the intervention group and control group from T1 to T2 on average. (A): hip joint on sagittal plane; (B): hip joint on frontal plane. Green area: positive delta results from T1 to T2; red area: negative delta results from T1 to T2; IR: internal rotation; ER: external rotation; T1: measurement pre-intervention; T2: measurement post-intervention; n = 25. Source: authors’ illustration.

Figure 8

Changes in passive range of motion of the hip and knee joints in the intervention group and control group from T1 to T2 on average. (A): hip joint on frontal plane; (B): knee joint on sagittal plane. Green area: positive delta results from T1 to T2; red area: negative delta results from T1 to T2; T1: measurement pre-intervention; T2: measurement post-intervention; n = 25. Source: author’s illustration.