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.

Cervical myelomeningocele--follow-up of five patients.

Only a few series of patients with cervical myelomenigocele (cMMC) and cervical meningocele (cMC) have been published. Interventions as well as the neurologic, orthopaedic, urologic and intellectual outcomes were analysed in this retrospective description of five patients with cMMC and cMC diagnosed in the period 1984-1999. Four patients suffered from cMMC, one from cMC. The average duration of follow-up was 9.5 years. None of the patients had periconceptual prevention with folic acid. Three had a Chiari II malformation and two a hydrocephalus. Tethering of the cervical cord was demonstrated in three patients at follow-up. All children achieved an independent ambulatory function and urinary continence. Incomplete sensorimotor hemiparesis was present in two children, and a mild unilateral arm paresis in one. Two of five patients had age appropriate cognitive functions. Three patients with mild mental retardation or behavioural problems had to be placed in special classes. The outcome of patients with cMMC is favourable regarding to the neurologic, orthopaedic and urologic problems compared with lower neural tube defects. However, the burden of repeated examinations and therapies is considerable and induces high costs, therefore prevention with periconceptual folic acid is a crucial issue also in cMMC. Spinal cord dysfunction has to be considered in growing children due to persistent tethering or re-tethering, therefore regular neurologic and urodynamic investigations are of particular importance.

Spontaneous intracranial haemorrhage in children: aetiology, presentation and outcome.

We are aware of only few reports addressing spontaneous intracranial haemorrhage (SICH) in non-selected series of children. This is a retrospective analysis of clinical presentation and outcome in 34 children with SICH seen in the period 1990-2000 in our hospital. Traumatic, neonatal and subdural haemorrhages were excluded. The majority (47%, 16/34) of SICH was caused by an arteriovenous malformation (AVM). SICH was presented as an acute event in 53% (17/32) of patients. Forty-seven percent (15/32) of the cases had protracted courses, which made the diagnosis difficult. In our series, younger children had less specific symptoms. Mortality (25%, 8/32) and morbidity were considerable, particularly in infratentorial haemorrhages, in aneurysms, in children younger than 3 years and in those with underlying haematological disorders.

Measurement of muscle stiffness using robotic assisted gait orthosis in children with cerebral palsy: a proof of concept.

PURPOSE: To evaluate the feasibility and reliability of a novel stiffness assessment tool implemented in the driven gait orthosis Paediatric Lokomat; to investigate the influence of single robotic-assisted gait training (RAGT) on muscle stiffness in children with cerebral palsy (CP). METHODS: Ten children with spastic CP conducted a single standard RAGT session and stiffness was assessed before and after the RAGT. Nine of the ten subjects were tested twice on the same day to investigate test-retest reliability, intraclass correlation coefficients (ICCs), standard error of measurement (SEM), coefficient of variation of the method error (CV(ME)) and resistive torques during passive leg movements (stiffness in Nm/°) were calculated. RESULTS: ICCs showed high reliability (0.83-0.97) for hip and knee movements. SEM and CV(ME) indicated 0.028-0.085 Nm/°, 9.5-23.0% of test-retest variability in hip and 0.018-0.064 Nm/°, 13.3-43.5% in knee measures. Using the assessment tool, a significant decrease in muscle stiffness in participants, especially in children with high levels of muscle tone, could be shown after a single session of RAGT. CONCLUSIONS: The assessment tool L-STIFF is a feasible tool for automated measurement of stiffness in children with CP, but it is not sensitive enough to record small changes in muscle tone.