Electromechanical and robotic devices for gait and balance rehabilitation of children with neurological disability: a systematic review

In the last two decades, a growing interest has been focused on gait and balance robot-assisted rehabilitation in children with neurological disabilities. Robotic devices allow the implementation of intensive, task-specific training fostering functional recovery and neuroplasticity phenomena. However, limited attention has been paid to the protocols used in this research framework. This systematic review aims to provide an overview of the existing literature on robotic systems for the rehabilitation of gait and balance in children with neurological disabilities and their rehabilitation applications. The literature search was carried out independently and synchronously by three authors on the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, ScienceDirect, and Google Scholar. The data collected included three subsections referring to clinical, technical, and regulatory aspects. Thirty-one articles out of 81 found on the primary literature search were included in the systematic review. Most studies involved children with cerebral palsy. Only one-third of the studies were randomized controlled trials. Overall, 17 devices (nine end-effector systems and eight exoskeletons) were investigated, among which only 4 (24%) were bore the CE mark. Studies differ on rehabilitation protocols duration, intensity, and outcome measures. Future research should improve both rehabilitation protocols\u2019 and devices\u2019 descriptions

The Effect of Locomotor Assisted Therapy on Lower Extremity Motor Performance in Typically Developing Children and Children with Cerebral Palsy

Indiana University-Purdue University Indianapolis (IUPUI)Background: Ambulation is critical to a child’s participation, development of selfconcept, and quality of life. Children with cerebral palsy (CP) frequently exhibit limitation in walking proficiency which has been identified as the primary physical disability. Traditional rehabilitative treatment techniques to improve ambulation for children with CP reveal inconsistent results. Driven gait orthosis (DGO) training is a novel approach focusing on motor learning principles that foster cortical neural plasticity. Objective: The objectives are to determine if: (i) the lower extremity muscle activation patterns of children with CP are similar to age-matched TD children in overground (OG) walking, (ii) DGO training replicates muscle activation patterns in OG ambulation in TD children, (iii) the lower extremity muscle activation patterns in OG walking of children with CP are similar to their muscle activation patterns with DGO assistance, and (iv) DGO training promotes unimpaired muscle activation patterns in children with CP. Methods: Muscle activity patterns of the rectus femoris, semitendinosus, gluteus maximus and gluteus medius were recorded in the OG and DGO walking conditions of children with CP and age-matched TD. The gait cycles were identified and the data was averaged to produce final average gait cycle time normalized values. Results: In comparing the variability of the muscle activation patterns within the subject groups, CP DGO walking was considerably lower than CP OG. In comparing the muscle activation patterns in each condition, consistent differences (p < .05) were noted in terminal stance, pre-swing and initial swing phases of gait with the DGO condition consistently revealing greater muscle unit recruitment. Conclusion: The results indicate that training in the DGO provided the ability to practice with measurably repetitive movement as evidenced by decreased variability. Consistent differences were noted in muscle activation patterns in the terminal stance, pre-swing and initial swing phases of gait when most of these muscles are primarily inactive. The alteration in ground reaction force within the DGO environment may play a role in this variance. With the goal of normalizing gait, it is important that the effect of these parameters on ground reaction forces be considered in the use of DGO rehabilitation

Wearable Lower-Limb Exoskeleton for Children With Cerebral Palsy: A Systematic Review of Mechanical Design, Actuation Type, Control Strategy, and Clinical Evaluation

Children with a neurological disorder such as cerebral palsy (CP) severely suffer from a reduced quality of life because of decreasing independence and mobility. Although there is no cure yet, a lower-limb exoskeleton (LLE) has considerable potential to help these children experience better mobility during overground walking. The research in wearable exoskeletons for children with CP is still at an early stage. This paper shows that the number of published papers on LLEs assisting children with CP has significantly increased in recent years; however, no research has been carried out to review these studies systematically. To fill up this research gap, a systematic review from a technical and clinical perspective has been conducted, based on the PRISMA guidelines, under three extended topics associated with “lower limb”, “exoskeleton”, and “cerebral palsy” in the databases Scopus and Web of Science. After applying several exclusion criteria, seventeen articles focused on fifteen LLEs were included for careful consideration. These studies address some consistent positive evidence on the efficacy of LLEs in improving gait patterns in children with CP. Statistical findings show that knee exoskeletons, brushless DC motors, the hierarchy control architecture, and CP children with spastic diplegia are, respectively, the most common mechanical design, actuator type, control strategy, and clinical characteristics for these LLEs. Clinical studies suggest ankle-foot orthosis as the primary medical solution for most CP gait patterns; nevertheless, only one motorized ankle exoskeleton has been developed. This paper shows that more research and contribution are needed to deal with open challenges in these LLEs

Current Rehabilitation Methods for Cerebral Palsy

In rehabilitation of children with cerebral palsy (CP), varying approaches and techniques are used, ranging from very conservative and conventional techniques, such as muscle strengthening, manual stretching, and massage, to more complex motor learning-based theories, such as neurodevelopmental treatment, conductive education, and several others. The motor disorders seen in CP are frequently accompanied by disturbances of sensation, cognition, communication, perception, and/or behavior disorders; thus, therapy approaches are arranged to meet the individual child’s needs. The approaches can be divided into two groups as with equipment and without equipment. Examples for without equipment rehabilitation approaches are neurodevelopmental treatment, conductive education constraint-induced movement therapy, and task-oriented therapy, whereas robotic therapy, virtual reality, and horse-back riding therapy are the examples of rehabilitation approaches with equipment. CP is a prevalent, disabling condition. Application of evidence-based methods ensures maximum gains in children. The concept that intense, task-specific exercises capitalize on the potential plasticity of the CNS and thus improve motor recovery has led to the development of several successful interventions for children with CP. Also approaches that improve the patient’s motivation and target the activities of daily living and participation are the most effective approaches for functional recovery of the children with CP

A Pediatric Knee Exoskeleton With Real-Time Adaptive Control for Overground Walking in Ambulatory Individuals With Cerebral Palsy

Gait training via a wearable device in children with cerebral palsy (CP) offers the potential to increase therapy dosage and intensity compared to current approaches. Here, we report the design and characterization of a pediatric knee exoskeleton (P.REX) with a microcontroller based multi-layered closed loop control system to provide individualized control capability. Exoskeleton performance was evaluated through benchtop and human subject testing. Step response tests show the averaged 90% rise was 26 ± 0.2 ms for 5 Nm, 22 ± 0.2 ms for 10 Nm, 32 ± 0.4 ms for 15 Nm. Torque bandwidth of P.REX was 12 Hz and output impedance was less than 1.8 Nm with control on (Zero mode). Three different control strategies can be deployed to apply assistance to knee extension: state-based assistance, impedance-based trajectory tracking, and real-time adaptive control. One participant with typical development (TD) and one participant with crouch gait from CP were recruited to evaluate P.REX in overground walking tests. Data from the participant with TD were used to validate control system performance. Kinematic and kinetic data were collected by motion capture and compared to exoskeleton on-board sensors to evaluate control system performance with results demonstrating that the control system functioned as intended. The data from the participant with CP are part of a larger ongoing study. Results for this participant compare walking with P.REX in two control modes: a state-based approach that provided constant knee extension assistance during early stance, mid-stance and late swing (Est+Mst+Lsw mode) and an Adaptive mode providing knee extension assistance proportional to estimated knee moment during stance. Both were well tolerated and significantly improved knee extension compared to walking without extension assistance (Zero mode). There was less reduction in gait speed during use of the adaptive controller, suggesting that it may be more intuitive than state-based constant assistance for this individual. Future work will investigate the effects of exoskeleton assistance during overground gait training in children with neurological disorders and will aim to identify the optimal individualized control strategy for exoskeleton prescription

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

Bioinspired robotic rehabilitation tool for lower limb motor learning after stroke

Mención Internacional en el título de doctorEsta tesis doctoral presenta, tras repasar la marcha humana, las principales patologíıas y condiciones que la afectan, y los distintos enfoques de rehabilitación con la correspondiente implicación neurofisiológica, el camino de investigación que desemboca en la herramienta robótica de rehabilitación y las terapias que se han desarrollado en el marco de los proyectos europeos BioMot: Smart Wearable Robots with Bioinspired Sensory-Motor Skills y HANK: European advanced exoskeleton for rehabilitation of Acquired Brain Damage (ABD) and/or spinal cord injury’s patients, y probado bajo el paraguas del proyecto europeo ASTONISH: Advancing Smart Optical Imaging and Sensing for Health y el proyecto nacional ASSOCIATE: A comprehensive and wearable robotics based approach to the rehabilitation and assistance to people with stroke and spinal cord injury.This doctoral thesis presents, after reviewing human gait, the main pathologies and conditions that affect it, and the different rehabilitation approaches with the corresponding neurophysiological implications, the research journey that leads to the development of the rehabilitation robotic tool, and the therapies that have been designed, within the framework of the European projects BioMot: Smart Wearable Robots with Bioinspired Sensory-Motor Skills and HANK: European advanced exoskeleton for rehabilitation of Acquired Brain Damage (ABD) and/or spinal cord injury’s patients and tested under the umbrella of the European project ASTONISH: Advancing Smart Optical Imaging and Sensing for Health and the national project ASSOCIATE: A comprehensive and wearable robotics based approach to the rehabilitation and assistance to people with stroke and spinal cord injury.This work has been carried out at the Neural Rehabilitation Group (NRG), Cajal Institute, Spanish National Research Council (CSIC). The research presented in this thesis has been funded by the Commission of the European Union under the BioMot project - Smart Wearable Robots with Bioinspired Sensory-Motor Skills (Grant Agreement number IFP7-ICT - 611695); under HANK Project - European advanced exoskeleton for rehabilitation of Acquired Brain Damage (ABD) and/or spinal cord injury’s patients (Grant Agreements number H2020-EU.2. - PRIORITY ’Industrial leadership’ and H2020-EU.3. - PRIORITY ’Societal challenges’ - 699796); also under the ASTONISH Project - Advancing Smart Optical Imaging and Sensing for Health (Grant Agreement number H2020-EU.2.1.1.7. - ECSEL - 692470); with financial support of Spanish Ministry of Economy and Competitiveness (MINECO) under the ASSOCIATE project - A comprehensive and wearable robotics based approach to the rehabilitation and assistance to people with stroke and spinal cord injury (Grant Agreement number 799158449-58449-45-514); and with grant RYC-2014-16613, also by Spanish Ministry of Economy and Competitiveness.Programa de Doctorado en Ingeniería Eléctrica, Electrónica y Automática por la Universidad Carlos III de MadridPresidente: Fernando Javier Brunetti Fernández.- Secretario: Dorin Sabin Copaci.- Vocal: Antonio Olivier

Usability evaluation of an interactive leg press training robot for children with neuromuscular impairments.

BACKGROUND The use of robotic technology for neurorehabilitative applications has become increasingly important for adults and children with different motor impairments. OBJECTIVE The aim of this study was to evaluate the technical feasibility and usability of a new interactive leg-press training robot that was developed to train leg muscle strength and control, suitable for children with neuromuscular impairments. METHODS An interactive robotic training system was designed and constructed with various control strategies, actuators and force/position sensors to enable the performance of different training modes (passive, active resistance, and exergames). Five paediatric patients, aged between 7 and 16 years (one girl, age 13.0 ± 3.7 years, [mean ± SD]), with different neuromuscular impairments were recruited to participate in this study. Patients evaluated the device based on a user satisfaction questionnaire and Visual Analog Scale (VAS) scores, and therapists evaluated the device with the modified System Usability Scale (SUS). RESULTS One patient could not perform the training session because of his small knee range of motion. Visual Analog Scale scores were given by the 4 patients who performed the training sessions. All the patients adjudged the training with the interactive device as satisfactory. The average SUS score given by the therapists was 61.2 ± 18.4. CONCLUSION This study proposed an interactive lower limb training device for children with different neuromuscular impairments. The device is deemed feasible for paediatric rehabilitation applications, both in terms of technical feasibility and usability acceptance. Both patients and therapists provided positive feedback regarding the training with the device

Design And Development of A Powered Pediatric Lower-limb Orthosis

Gait impairments from disorders such as cerebral palsy are important to address early in life. A powered lower-limb orthosis can offer therapists a rehabilitation option using robot-assisted gait training. Although there are many devices already available for the adult population, there are few powered orthoses for the pediatric population. The aim of this dissertation is to embark on the first stages of development of a powered lower-limb orthosis for gait rehabilitation and assistance of children ages 6 to 11 years with walking impairments from cerebral palsy. This dissertation presents the design requirements of the orthosis, the design and fabrication of the joint actuators, and the design and manufacturing of a provisional version of the pediatric orthosis. Preliminary results demonstrate the capabilities of the joint actuators, confirm gait tracking capabilities of the actuators in the provisional orthosis, and evaluate a standing balance control strategy on the under-actuated provisional orthosis in simulation and experiment. In addition, this dissertation presents the design methodology for an anthropometrically parametrized orthosis, the fabrication of the prototype powered orthosis using this design methodology, and experimental application of orthosis hardware in providing walking assistance with a healthy adult. The presented results suggest the developed orthosis hardware is satisfactorily capable of operation and functional with a human subject. The first stages of development in this dissertation show encouraging results and will act as a foundation for further iv development of the device for rehabilitation and assistance of children with walking impairments