Comparing Walking-Related Everyday Life Tasks of Children with Gait Disorders in a Virtual Reality Setup With a Physical Setup: Cross-Sectional Noninferiority Study.

BACKGROUND: A frequent rehabilitation goal for children with gait disorders is to practice daily-life walking activities. Unfortunately, these are often difficult to practice in a conventional therapeutic setting. Virtual reality (VR) with head-mounted displays (HMDs) could be a promising approach in neurorehabilitation to train such activities in a safe environment. First, however, we must know whether obstacles in VR are indeed mastered as obstacles. OBJECTIVE: This study aimed to provide information on whether VR is feasible and motivating to induce and practice movements needed to master real obstacles in children and adolescents with gait disorders. Furthermore, this project aims to evaluate which kinds of everyday walking activities are appropriate to be practiced in VR. METHODS: In this cross-sectional study, participants stepped over a bar, crossed a gap, balanced over a beam, and circumvented stationary obstructions arranged in a course under real physical and virtual conditions wearing a VR HMD. We recorded the respective primary outcomes (step height, step length, step width, and minimal shoulder-obstacle distance) with motion capture. We then calculated the mean differences and 95% CI of the spatiotemporal parameters between the VR and physical setup and later compared them using noninferiority analysis with margins defined a priori by a clinical expert panel. Additionally, the participants responded to a standardized questionnaire while the therapists observed and evaluated their movement performance. RESULTS: We recruited 20 participants (mean age 12.0, range 6.6-17.8 years) with various diagnoses affecting their walking ability. At 3.77 (95% CI 1.28 to 6.26) cm, the mean difference in step height of the leading foot in the overstepping task did not exceed the predefined margin of -2 cm, thus signifying noninferiority of the VR condition compared to mastering the physical obstacles. The same was true for step length (-1.75, 95% CI -4.91 to 1.41 cm; margin -10 cm), step width (1.05, 95% CI 0.20 to -1.90 cm; margin 3 cm), and the minimal shoulder-obstacle distance (0.25, 95% CI -0.85 to 0.35 cm; margin -2 cm) in the other tasks. Only the trailing foot in the overstepping task yielded inconclusive results. CONCLUSIONS: Children with gait disorders perform everyday walking tasks like overstepping, crossing, balancing, or circumventing similarly in physical and VR environments, suggesting that VR could be a feasible therapeutic tool to practice everyday walking tasks.

Differences in gait parameters when crossing real versus projected everyday life obstacles in healthy children and adolescents.

Practicing complex everyday life walking activities is challenging in paediatric neurorehabilitation, although it would prepare patients more comprehensively for the requirements of daily life. Floor projections allow simulation and training of such situations in therapy. Twenty healthy youths aged 6-18 years stepped over a tree trunk and balanced over kerbstones in a real and projected condition. Spatiotemporal and kinematic parameters of the two conditions were compared by equivalence analysis, using the medians of the differences between the two conditions with their bootstrapped 95% confidence intervals. Velocity, step and stride length, step width, and single support time were generally equivalent between the two conditions. Knee and hip joint angles and toe clearance decreased substantially during the execution phase of the projected tree trunk condition. The largest differences were found at the end of the execution phase in both tasks for the ankle joints. As spatiotemporal parameters were equivalent between the conditions, floor projections seem suitable to train precise foot placement. However, differences in knee and hip joint kinematics and toe clearance revealed that floor projections are not applicable for obstacles with a vertical extension. Therefore, exercises aiming at knee and hip flexion improvement should favourably be trained with real objects.

Virtual Reality as a Therapy Tool for Walking Activities in Pediatric Neurorehabilitation: Usability and User Experience Evaluation.

BACKGROUND: Many essential walking activities in daily life, such as crossing a street, are challenging to practice in conventional therapeutic settings. Virtual environments (VEs) delivered through a virtual reality (VR) head-mounted display (HMD) would allow training such activities in a safe and attractive environment. Furthermore, the game-like character and high degree of immersion in these applications might help maintain or increase children's motivation and active participation during the rehabilitation process. OBJECTIVE: This study aimed to investigate the usability, user experience, and acceptability of an immersive VE experienced through a VR HMD to train everyday life walking activities in pediatric neurorehabilitation. METHODS: In a cross-sectional study, 21 youths (median age 12.1 years; range 6.8-17.7 years) with a neuromotor impairment undergoing inpatient or outpatient neurorehabilitation tested a VE experienced through the VR HMD Oculus Quest. The participants, accompanied by their physiotherapists, moved freely around a 4.4 by 10-meter VE, displaying a magical forest and featuring various gamified everyday activities in different game designs. Using their hands, represented in the VE, the participants could interact with the virtual objects placed throughout the VE and trigger visual and auditory feedback. Symptoms of cybersickness were checked, and usability, user experience, and acceptability were evaluated using customized questionnaires with a visual analog scale for youths and a 5-point Likert scale for their therapists. RESULTS: None of the participants reported any signs of cybersickness after 20 minutes of VR HMD exposure time. They rated comfort (median 10/10) and movement ability (median 10/10) with the VR HMD as high. The VE was perceived as being really there by the majority (median 8/10), and the participants had a strong feeling of spatial presence in the VE (median 9.5/10). They enjoyed exploring the virtual world (median 10/10) and liked this new therapy approach (median 10/10). Therapists' acceptance of the VR HMD was high (4/5). There were 5 patients that needed more support than usual, mainly for supervision, when moving around with the VR HMD. Otherwise, therapists felt that the VR HMD hardly affected their patients' movement behavior (median 4.75/5), whereas it seemed to increase their level of therapy engagement (median 4/5) compared to conventional physiotherapy sessions. CONCLUSIONS: This study demonstrates the usability of an immersive VE delivered through a VR HMD to engage youths in the training of everyday walking activities. The participants' and therapists' positive ratings on user experience and acceptance further support the promising application of this technology as a future therapeutic tool in pediatric neurorehabilitation.

Walking activities beyond gait training: Priorities in everyday life for parents and adolescents in pediatric neurorehabilitation.

PURPOSE: This study aimed to gain knowledge about which walking-related everyday life activities and situations are relevant for parents of children with a neuromotor disorder and adolescents undergoing inpatient neurorehabilitation. METHODS: Two focus group interviews with purposive samples were performed, one with seven parents of children with acquired or congenital neuromotor disorders, and one with four adolescents undergoing inpatient neurorehabilitation. Data were analyzed with a qualitative descriptive research approach. RESULTS: Parents identified 120 activities that they considered as relevant in their everyday life and the adolescents identified 113 activities. Based on these activities, ten different categories that have a direct relation to walking in everyday life were identified. "Dealing with obstacles," "moving in public areas," "moving in a group," and "walking in general" were perceived as the highest priority categories by the focus group participants. CONCLUSION: Activities incorporating walking tasks related to moving in a group or public areas and dealing with obstacles are perceived as meaningful by adolescents and parents in their everyday life. Addressing these categories in the goal setting process with families could facilitate the definition of walking-related goals aimed at increasing children's and adolescents' independence in daily life.

DO YOUTHS WITH NEUROMOTOR DISORDER AND THEIR THERAPISTS PREFER A MIXED OR VIRTUAL REALITY HEAD-MOUNTED DISPLAY?

OBJECTIVE: To evaluate the usability of 2 head-mounted displays in youths undergoing neurorehabilitation; a mixed reality head-mounted display and a virtual reality head-mounted display. DESIGN: Observational cross-sectional study. PATIENTS: Thirteen youths (age range 7.8-16.5 years) with neuromotor disorder. METHODS: Youths wore a mixed reality or a virtual reality head-mounted display while being verbally guided through a scene with virtual objects. Differences between the 2 systems, regarding usability, user experience, and acceptability, were evaluated using standardized questions for the youths and their therapists. System preferences and symptoms of cybersickness were noted. RESULTS: Both head-mounted displays were easy to mount and adjust to the children's heads, but the mixed reality system was unstable in 40% of the youths. Participants stated that they could move naturally with both devices. Object appearance scored higher with the virtual reality system, while therapists rated youths' movement execution and needed additional support in favour of the mixed reality system. Most youths preferred the virtual reality device, mainly due to the more distinct appearance of objects and the objects' richer colours. Therapists' preferences were balanced. Two children reported minimal signs of cybersickness. CONCLUSION: Youths and therapists accepted both systems well, with advantages regarding usability, user experience, and preference for the virtual reality, and acceptability for the mixed reality head-mounted display.

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.

Concurrent Validity of Two Gait Performance Measures in Children with Neuromotor Disorders.

AIMS: To investigate the concurrent validity of two mobility performance measures, the Functional Mobility Scale (FMS) and the Gillette Functional Assessment Questionnaire - walking scale (FAQ) in an inpatient pediatric neurorehabilitation setting. METHODS: Cross-sectional data were collected on 71 children (mean age 12.7 years) with neuromotor gait impairments who participated in an inpatient rehabilitation program to evaluate aspects of concurrent validity of the FMS and FAQ. Physiotherapists independently performed ratings. Comparator instruments included the walking item of the Functional Independence Measure for children, 10-m and 6-minute walking tests, and Gross Motor Function Measure-88 dimension E. All tests were completed within 7 days. Spearman correlation coefficients were calculated to test a priori formulated hypotheses regarding the strength and direction of the measures relationships. RESULTS: The children had a broad spectrum of mobility levels, including all levels of FMS and levels 2-10 of FAQ. Spearman correlation coefficients with comparator measures varied between 0.58-0.79 for the FMS and 0.69-0.73 for the FAQ. Hypotheses concerning correlation strengths and directions were met for FMS and FAQ. CONCLUSIONS: The findings demonstrate that the FMS and FAQ are valid to evaluate functional mobility in pediatric inpatient neurorehabilitation.

Measuring change in gait performance of children with motor disorders: assessing the Functional Mobility Scale and the Gillette Functional Assessment Questionnaire walking scale.

AIM: To examine the responsiveness and minimal important change (MIC) of two gait performance measures, the Functional Mobility Scale (FMS) and the Gillette Functional Assessment Questionnaire walking scale (FAQ), in a paediatric inpatient setting. METHOD: Sixty-four children and adolescents with a motor disorder, including cerebral palsy, traumatic brain injury, or stroke (25 females, 39 males; mean age [SD] 12y 6mo [3y 2mo], range 6-18y 6mo), were recruited. Physiotherapists scored the FMS and FAQ at the start and end of active gait rehabilitation. Change scores were compared with changes in gait capacity tests, the walking item of the Functional Independence Measure for Children, and a global rating scale (GRS) on the physiotherapists' perceived change of the child's functional mobility. The GRS was also used to define the MIC. RESULTS: Change scores of the FMS and FAQ correlated between 0.35 and 0.49 with those of the capacity tests, 0.54 to 0.76 with the Functional Independence Measure for Children walking item change scores, and 0.57 to 0.76 with the GRS. The MIC values for the FMS and FAQ were 0.5 and 1.5 respectively. INTERPRETATION: FMS and FAQ can illustrate change in inpatient gait performance of children and adolescents with motor disorders. An improvement of one level in the FMS and two levels in the FAQ is considered as a clinically meaningful change. WHAT THIS PAPER ADDS: The Functional Mobility Scale (FMS) can detect change in children's inpatient gait performance. The Gillette Functional Assessment Questionnaire walking scale (FAQ) can also detect change in children's inpatient gait performance. A one-level improvement in the FMS is clinically relevant. A two-level improvement in the FAQ is clinically relevant.

MEDICIÓN DEL CAMBIO EN EL DESEMPEÑO DE LA MARCHA EN NIÑOS CON TRASTORNOS MOTORES: EVALUACIÓN DE LA ESCALA DE MOVILIDAD FUNCIONAL Y EL CUESTIONARIO DE EVALUACIÓN FUNCIONAL DE GILLETTE: OBJETIVO: Examinar la sensibilidad y el cambio mínimo significativo de dos mediciones de desempeño de la marcha, la Escala de Movilidad Funcional (FMS) y el Cuestionario de Evaluación Funcional de Gillette (FAQ), en una población de pacientes pediátricos hospitalizados. MÉTODO: Se reclutaron sesenta y cuatro niños y adolescentes con algún trastorno motor, incluyendo parálisis cerebral, lesión cerebral traumática o accidente cerebrovascular (25 mujeres, 39 varones; edad promedio [DE] 12a 6m [3a 2m], rango 6a - 18a 6m). Fisioterapeutas aplicaron las escalas FMS y FAQ al principio y final del proceso de rehabilitación activa de la marcha. Los puntajes de cambio fueron comparados con los cambios en pruebas de capacidad de marcha, el ítem de marcha de la escala WeeFIM (Functional Independence Measure for Children) y una escala global de calificación (EGC) sobre la percepción del fisioterapeuta del cambio en la movilidad funcional del niño. La EGC se utilizó, además, para definir el cambio mínimo significativo. RESULTADOS: Los puntajes de cambio de la FMS y el FAQ tuvieron una correlación de 0,35 a 0,49 con lo de la prueba de capacidad de marcha, 0,54 a 0,76 con el ítem de marcha de la escala WeeFIM, y 0,57 a 0,76 con la EGC. El cambio mínimo significativo para la FMS y el FAQ fueron 0,5 y 1,5, respectivamente. INTERPRETACIÓN: La FMS y el FAQ permiten observar cambios en el desempeño de la marcha de pacientes pediátricos y adolescentes hospitalizados con trastornos motores. Un cambio positivo de un nivel en la FMS y de dos niveles en el FAQ se considera un cambio clínicamente significativo.

MENSURANDO MUDANÇA NO DESEMPENHO DA MARCHA EM CRIANÇAS COM DESORDENS MOTORAS: AVALIANDO A ESCALA DE MOBILIDADE FUNCIONAL A ESCALA DA MARCHA DO QUESTIONÁRIO DE AVALIAÇÃO FUNCIONAL GILLETTE: OBJETIVO: Examinar a responsividade e mínima mudança importante (MMI) de tduas medidas do desempenho da marcha, a Escala de mobilidade funcional (FMS), e a escala da marcha do Questionário de Avaliação Funcional Gillette (FAQ), em uma unidade de internação pediátrica. MÉTODO: Sessenta e quatro crianças e adolescentes com uma desordem motora, incluindo paralisia cerebral, lesão cerebral traumática, ou acidente vascular encefálico (25 do sexo feminino, 39 do sexo masculino; média de idade [DP] 12a 6m [3a 2m], variação 6a-18a 6m), foram recrutadas. Fisioterapeutas pontuaram a FMS e FAQ no início e final da reabilitação ativa da marcha. Mudanças nos escores foram comparadas com mudanças nos testes de capacidade da marcha, no item de marcha da Medida de Independência Funcional para crianças, e uma Escala Global de Pontuação (EGP) sobre as mudanças percebidas pelos fisioterapeutas na mobilidade funcional da criança. A EGP também foi usada para determinar a MMI. RESULTADOS: Os escores de mudança da FMS e FAQ correlacionaram entre 0,35 e 0,49 com os dos testes de capacidade, 0,54 a 0,76 com a mudaça de escores no item de marcha da medida de Independência Funcional para crianças, e 0,57 a 0,76 com a EGP. A MMI para FMS e FAQ foi 0,5 e 1,5, respectivamente. INTERPRETAÇÃO: FMS e FAQ podem ilustrar mudanças no desempenho da marcha em crianças e adolescentes com desordens motoras que se encontram internados. Uma melhora de um nível na FMS e dois níveis na FAQ é considerada mudança clinicamente significativa.

Interrater reliability of two gait performance measures in children with neuromotor disorders across two different settings.

AIM: To examine the interrater agreement of the two gait performance measures - the Functional Mobility Scale (FMS) and Gillette Functional Assessment Questionnaire - walking scale (FAQ) - within health professionals and parents in children with neuromotor disorders, measured in an inpatient setting and at home. METHOD: Seventy-one children with a neuromotor diagnosis (44 males, 27 females; median age 12y 11mo [interquartile range 4y-10mo]) were consecutively recruited when starting an inpatient active gait rehabilitation programme. Physiotherapists and nurses independently scored the level of children's gait performance with the FMS and the FAQ, while parents' scores regarding the children's gait performance at home were obtained by interview or telephone call at the same measurement points. RESULTS: Linear weighted kappa coefficients were substantial to almost perfect for all comparisons. Kappa coefficients ranged from 0.62 to 0.85 for the FMS-5, from 0.79 to 0.92 for the FMS-50, from 0.83 to 0.90 for the FMS-500, and from 0.69 to 0.77 for the FAQ. Friedman tests did not reveal significant differences between the different rater groups. INTERPRETATION: The unexpectedly high level of interrater agreement between parents, physiotherapists, and nurses demonstrates that the FMS and FAQ can reliably assess gait performance in an inpatient setting. Inpatient scores correspond well to the children's performance in their usual environment. WHAT THIS PAPER ADDS: The Functional Mobility Scale and Gillette Functional Assessment Questionnaire - walking scale measure gait performance reliably at home and in an inpatient setting. Physiotherapists, nurses, and parents reliably score gait performance. Inpatient gait performance scores correspond well to children's performance at home. Physiotherapists and nurses in an inpatient setting can reliably estimate gait performance at home.

Measurement properties of gait-related outcomes in youth with neuromuscular diagnoses: a systematic review.

BACKGROUND: Sound measurement properties of outcome tools are essential when evaluating outcomes of an intervention, in clinical practice and in research. PURPOSE: The purpose of this study was to review the evidence on reliability, measurement error, and responsiveness of measures of gait function in children with neuromuscular diagnoses. DATA SOURCES: The MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched up to June 15, 2012. STUDY SELECTION: Studies evaluating reliability, measurement error, or responsiveness of measures of gait function in 1- to 18-year-old children and youth with neuromuscular diagnoses were included. DATA EXTRACTION: Quality of the studies was independently rated by 2 raters using a modified COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. Studies with a fair quality rating or better were considered for best evidence synthesis. DATA SYNTHESIS: Regarding the methodological quality, 32 out of 35 reliability studies, all of the 13 measurement error studies, and 5 out of 10 responsiveness studies were of fair or good quality. Best evidence synthesis revealed moderate to strong evidence for reliability for several measures in children and youth with cerebral palsy (CP) but was limited or unknown in other diagnoses. The Functional Mobility Scale (FMS) and the Gross Motor Function Measure (GMFM) dimension E showed limited positive evidence for responsiveness in children with CP, but it was unknown or controversial in other diagnoses. No information was reported on the minimal important change; thus, evidence on measurement error remained undetermined. LIMITATIONS: As studies on validity were not included in the review, a comprehensive appraisal of the best available gait-related outcome measure per diagnosis is not possible. CONCLUSIONS: There is moderate to strong evidence on reliability for several measures of gait function in children and youth with CP, whereas evidence on responsiveness exists only for the FMS and the GMFM dimension E.

Robotic-assisted treadmill therapy improves walking and standing performance in children and adolescents with cerebral palsy.

OBJECTIVE: Task-specific body-weight-supported treadmill therapy improves walking performance in children with central gait impairment. The aim of the study was to investigate the effect of robotic-assisted treadmill therapy on standing and walking performance in children and adolescents with cerebral palsy and to determine parameters influencing outcome. METHODS: 20 Patients (mean age 11.0 ± 5.1, 10 males and 10 females) with cerebral palsy underwent 12 sessions of robotic-assisted treadmill therapy using the driven gait orthosis Lokomat. Outcome measures were the dimensions D (standing) and E (walking) of the Gross Motor Function Measure (GMFM). RESULTS: Significant improvements in dimension D by 5.9% (± 5.2, p=0.001) and dimension E by 5.3% (± 5.6, p<0.001) of the GMFM were achieved. Improvements in the GMFM D and E were significantly greater in the mildly affected cohort (GMFCS I and II) compared to the more severely affected cohort (GMFCS III and IV). Improvement of the dimension E but not of D correlated positively with the total distance and time walked during the trial (r(s)=0.748, p<0.001). CONCLUSIONS: Children and adolescents with bilateral spastic cerebral palsy showed improvements in the functional tasks of standing and walking after a 3-week trial of robotic-assisted treadmill therapy. The severity of motor impairment affects the amount of the achieved improvement.

Constraint-induced movement therapy for children with obstetric brachial plexus palsy: two single-case series.

The objective of this pilot study was to investigate the feasibility of constraint-induced movement therapy (CIMT) in children with obstetric brachial plexus palsy and receive preliminary information about functional improvements. Two patients (age 12 years) with obstetric brachial plexus palsy were included for a 126-h home-based CIMT intervention (3 and 4.5 weeks) and weekly monitored with the Melbourne Assessment of Unilateral Upper Limb function and the Nine-hole Peg Test. The Assisted Hand Assessment was performed 3 weeks before the beginning of intervention, preintervention, postintervention, and at 3 weeks follow-up (ABA single-case design). Tests were analyzed descriptively, visually, and where possible, using a time series analysis with C statistic. Results revealed changes of arm function in both patients between preintervention and follow-up test as follows: Assisted Hand Assessment from 85 to 92% in patient A and 80 to 89% in patient B, in the Melbourne Assessment of Unilateral Upper Limb function from 87 to 90% (C=0.578, z=1.876, P<0.05) in patient A and 72 to 80% (C=0.827, z=2.68, P<0.005) in patient B. There was no improvement in the Nine-hole Peg Test in both patients. Improvements as a result of CIMT found in this pilot study may not be considered substantial. However, they justify further research as some findings indicate relationship to the CIMT intervention in the 'B' phase. To enhance motivation and to plan a controlled, randomized clinical trial, child-friendly applications of the CIMT concept and adequate measures to monitor compliance are being discussed.