Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies.

Purpose: To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Methods: Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results: Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Conclusions: Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level of evidence: Level III, Systematic review of level III studies.

Combination of different noninvasive brain stimulation treatments for upper limb recovery in stroke patients: A systematic review.

We report a review of Pubmed (Medline), CENTRAL, Web of Science, and Scopus to test the effectiveness of the combined application of repetitive transcranial magnetic stimulation and transcranial direct current stimulation in the improvement of different functional variables of the upper limb in people with stroke. Two independent reviewers assessed eligibility and evaluated the quality of the studies. Five articles were included in the final review according to the inclusion criteria: Most show statistically significant differences in motor function improvement in favor of the experimental group, but not in activity. Due to the heterogeneity of the observed studies, the results should be interpreted with caution-more high-quality studies are needed to investigate the effectiveness of these interventions in different stages of stroke patients.

Motor imagery ability in children and adolescents with cerebral palsy: a systematic review and evidence map.

Background: Cerebral palsy (CP) refers to a group of permanent movement and posture disorders. Motor imagery (MI) therapy is known to provide potential benefits, but data on MI ability in children and adolescents with CP is lacking. Objective: A systematic review was performed to explore MI abilities in children and adolescents with CP compared to typically developed (TD) subjects. Methods: We searched on PubMed, Web of Science (WOS), EBSCO, Google Scholar, and PEDro including observational studies. Methodological quality was assessed with the modified Newcastle-Ottawa Scale and evidence map was created to synthesize the evidence qualitatively and quantitatively. Results: Seven cross-sectional studies were selected, which included 174 patients with CP and 321 TD subjects. Three studies explored explicit MI, two MI-execution synchrony, and four implicit MI domains. Methodological quality ranged from 6 to 8 stars. Moderate evidence supported the absence of differences in vividness between the groups. As there was only limited evidence, establishing a clear direction for the results was not possible, especially for the capacity to generate MI, mental chronometry features, and MI-execution synchrony domains. Moderate evidence supported a lower efficiency in cases for hand recognition, derived from a lower accuracy rate, while reaction time remained similar between the two groups. Moderate evidence indicated that patients with CP and TD controls showed similar features on whole-body recognition. Conclusion: Moderate evidence suggests that patients with CP present a reduced ability in hand recognition, which is not observed for whole-body recognition compared to healthy controls. Severe limitations concerning sample size calculations and validity of assessment tools clearly limits establishing a direction of results, especially for explicit MI and MI-Execution synchrony domains. Further research is needed to address these limitations to enhance our comprehension of MI abilities in children, which is crucial for prescribing suitable MI-based therapies in this child population.

Development and validation of the dizziness fear-avoidance behaviours and beliefs inventory for patients with vestibular disorders.

The purpose of this study is to present the development and analysis of the factorial structure and psychometric properties of a new self-administered questionnaire (Dizziness Fear-Avoidance Behaviours and Beliefs Inventory (D-FABBI)) designed to measure fear-avoidance behaviors and cognitions related to dizziness disability. A mixed-method design combining a qualitative study with an observational and cross-sectional study was employed to develop (content validity) and psychometrically validate (construct validity, reliability, and convergent/discriminant validity) a new instrument. A total of 198 patients with vestibular disorders (acute vestibular syndrome (AVS), 23.2%; chronic vestibular syndrome (CVS), 35.4%; and episodic vestibular syndrome (EVS) 41.4%) were recruited. Sociodemographic characteristics, the Dizziness Handicap Inventory (DHI) and the Hospital Anxiety and Depression Scale (HADS) and D-FABBI were evaluated. The final version of the D-FABBI consists of 17 items distributed across two subscales: activities of daily living fear-avoidance and movement fear-avoidance. The D-FABBI showed high internal consistency (Cronbach α = 0.932; 95% CI [0.91-0.94]) and so did the subscales (Cronbach α > 0.8). The exploratory structural equation model and confirmatory factor analysis provided better fit results, with a comparative fit index and root mean square error of approximation values of 0.907 to 0.081. No floor or ceiling effects were identified. There was a positive, significant, and moderate-strong magnitude correlation with the total DHI (r = 0.62) and low-moderate with respect to the HADS depression (r = 0.35) and HADS anxiety subscales (r = 0.26). The patients with CVS had a higher D-FABBI score than those with AVS or EVS. The D-FABBI appears to be a valid and reliable instrument for measuring the fear-avoidance behaviors and cognition related to dizziness disability of patients with vestibular disorders.

Prescription of therapeutic exercise in migraine, an evidence-based clinical practice guideline.

The main objective of this clinical practice guideline is to provide a series of recommendations for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, regarding exercise prescription for patients with migraine.This guideline was developed following the methodology and procedures recommended in the Appraisal of Guidelines for Research and Evaluation (AGREE). The quality of evidence and strength of recommendations were evaluated with the Scottish Intercollegiate Guidelines Network (SIGN). A systematic literature review was performed and an established appraisal process was employed to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology).The evaluation of the current evidence, the elaboration of the grades of recommendation, and their validation show a B grade of recommendation for aerobic exercise, moderate-continuous aerobic exercise, yoga, and exercise and lifestyle recommendations for the improvement of symptoms, disability, and quality of life in patients with migraine. Relaxation techniques, high-intensity interval training, low-intensity continuous aerobic exercise, exercise and relaxation techniques, Tai Chi, and resistance exercise obtained a C grade of recommendation for the improvement of migraine symptoms and disability.

Transcranial Direct Current Stimulation (tDCS) Effects on Quantitative Sensory Testing (QST) and Nociceptive Processing in Healthy Subjects: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of this study is to determine the effect that different tDCS protocols have on pain processing in healthy people, assessed using quantitative sensory tests (QST) and evoked pain intensity. METHODS: We systematically searched in EMBASE, CINAHL, PubMed, PEDro, PsycInfo, and Web of Science. Articles on tDCS on a healthy population and regarding QST, such as pressure pain thresholds (PPT), heat pain thresholds (HPT), cold pain threshold (CPT), or evoked pain intensity were selected. Quality was analyzed using the Cochrane Risk of Bias Tool and PEDro scale. RESULTS: Twenty-six RCTs were included in the qualitative analysis and sixteen in the meta-analysis. There were no significant differences in PPTs between tDCS and sham, but differences were observed when applying tDCS over S1 in PPTs compared to sham. Significant differences in CPTs were observed between tDCS and sham over DLPFC and differences in pain intensity were observed between tDCS and sham over M1. Non-significant effects were found for the effects of tDCS on HPTs. CONCLUSION: tDCS anodic over S1 stimulation increases PPTs, while a-tDCS over DLPFC affects CPTs. The HPTs with tDCS are worse. Finally, M1 a-tDCS seems to reduce evoked pain intensity in healthy subjects.

Musculoskeletal and Gait Characteristics in Patients with Stickler Syndrome: A Cross-Sectional Study.

BACKGROUND: Stickler syndrome (SS) is a connective tissue disorder of fibrillary collagen with very variable clinical manifestations, including premature osteoarthritis and osteopenia. This musculoskeletal alteration may affect gait maturity or produce strength difficulties. OBJECTIVE: Our aim was to describe the musculoskeletal characteristics, bone stiffness, gait kinematics, and kinetics of SS patients. METHODS: This is a cross-sectional study of children and youngsters with SS recruited by telephone calls through the Spanish SS Association. All participants underwent an analysis of musculoskeletal characteristics, including a 3D gait analysis. RESULTS: The sample included 26 SS patients, mainly boys (65.4%) with a median age of 11 (IQR 5-14). The manual muscle testing was normal in 88.5% of patients. The median distance covered in the 6-min walking test was 560.1 ± 113.4 m. Bone stiffness index scores were 70.9 ± 19.7 for children under 10 years and 88.3 ± 17.5 for children older than 10 years. The gait indicators GPS and GDI were: 7.4 ± 1.9 and 95.3 ± 9.7, respectively, for the left side and 6.8 ± 2.0 and 97.7 ± 9.5 for the right side, respectively. CONCLUSIONS: In our series of patients with SS, we found muscle-articular involvement does not have a high impact on strength or gait problems. More work is needed to understand the effect of SS on the musculoskeletal system.

Studying the Research-Practice Gap in Physical Therapies for Cerebral Palsy: Preliminary Outcomes Based on a Survey of Spanish Clinicians.

The purpose of this work is to study the gap between the research evidence and the clinical practice in the physical rehabilitation of people with cerebral palsy. A review process was performed to (1) identify physical therapies to improve postural control in children with cerebral palsy and (2) determine the scientific evidence supporting the effectiveness of those therapies. A Likert-based survey addressing a total of 43 healthcare professionals involved in pediatric physical therapy departments in Spain was carried out. The discussion was mainly supported by studies of level I or II evidence (according to the Oxford scale). The search process yielded 50 studies reporting 16 therapies. A strong positive correlation between the most used treatments and elevated levels of satisfaction was found. Some well-known but not often used techniques, such as hippotherapy, were identified. The treatment with the highest degree of use and satisfaction-neurodevelopment therapy (Bobath)-and some emerging techniques, such as virtual reality, were also identified. The fact that there is a meaningful gap between clinical practice and the scientific evidence was confirmed. The identified gap brings a certain degree of controversy. While some classic and well-known therapies had poor levels of supporting evidence, other relatively new approaches showed promising results.

Prediction of Patient Satisfaction after Treatment of Chronic Neck Pain with Mulligan's Mobilization.

Chronic neck pain is among the most common types of musculoskeletal pain. Manual therapy has been shown to have positive effects on this type of pain, but there are not yet many predictive models for determining how best to apply manual therapy to the different subtypes of neck pain. The aim of this study is to develop a predictive learning approach to determine which basal outcome could give a prognostic value (Global Rating of Change, GRoC scale) for Mulligan's mobilization technique and to identify the most important predictive factors for recovery in chronic neck pain subjects in four key areas: the number of treatments, time of treatment, reduction of pain, and range of motion (ROM) increase. A prospective cohort dataset of 80 participants with chronic neck pain diagnosed by their family doctor was analyzed. Logistic regression and machine learning modeling techniques (Generalized Boosted Models, Support Vector Machine, Kernel, Classsification and Decision Trees, Random Forest and Neural Networks) were each used to form a prognostic model for each of the nine outcomes obtained before and after intervention: disability-neck disability index (NDI), patient satisfaction (GRoC), quality of life (12-Item Short Form Survey, SF-12), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI II), pain catastrophizing scale (ECD), kinesiophobia-Tampa scale of kinesiophobia (TSK-11), Pain Intensity Visual Analogue Scale (VAS), and cervical ROM. Pain descriptions from the subjects and pain body diagrams guided the physical examination. The most important predictive factors for recovery in chronic neck pain patients indicated that the more anxiety and the lower the ROM of lateroflexion, the higher the probability of success with the Mulligan concept treatment.

Influence of Mirror Therapy (Specular Face Software) on Electromyographic Behavior of the Facial Muscles for Facial Palsy.

Introduction: Facial paralysis (FP) is a neuromuscular disorder caused by facial nerve injury. There are two main types of FP (which can be either primary or secondary): central and peripheral; Procedure of cases: This case series presents five patients with facial paralysis with different etiologies. In all cases, we assessed the facial disability index and a clinical test registering the electromyographic activity, with and without biofeedback generated by Specular Face, a new software program; Discussion: After performing the appropriate tests, we checked the patients' ability to change certain expressions when the Specular Face program was added. We can confirm that the mirror visual feedback therapy changes the behavior of synkinesis and the muscle function in these patients; Conclusion: The use of mirror therapy using a computerized treatment system of facial images yields promising results in modulating the muscle activity of patients with FP.

Reversed Polarity bi-tDCS over M1 during a Five Days Motor Task Training Did Not Influence Motor Learning. A Triple-Blind Clinical Trial.

Transcranial direct current stimulation (tDCS) has been investigated as a way of improving motor learning. Our purpose was to explore the reversal bilateral tDCS effects on manual dexterity training, during five days, with the retention component measured after 5 days to determine whether somatosensory effects were produced. In this randomized, triple-blind clinical trial, 28 healthy subjects (14 women) were recruited and randomized into tDCS and placebo groups, although only 23 participants (13 women) finished the complete protocol. Participants received the real or placebo treatment during five consecutive days, while performing a motor dexterity training program of 20 min. The motor dexterity and the sensitivity of the hand were assessed pre- and post-day 1, post 5 days of training, and 5 days after training concluded. Training improved motor dexterity, but tDCS only produced a tendency to improve retention. The intervention did not produce changes in the somatosensory variables assessed. Thus, reversal bi-tDCS had no effects during motor learning on healthy subjects, but it could favor the retention of the motor skills acquired. These results do not support the cooperative inter-hemispheric model.

Inter, intra-examiner reliability and validity of inertial sensors to measure the active cervical range of motion in patients with primary headache.

We analyzed the inter- and intra-examiner reliability of Werium inertial sensors and the cervical range of motion (CROM) instrument for the measurement of active CROM (AcROM) in patients with primary headache. Another objective is to analyze the validity of the inertial sensors (Werium). The literature has reported symptomatology features in patients diagnosed with primary headache similar to that of patients with cervicogenic headache. The International Classification of Headache (ICHD-III) established the presence of reduced AcROM as a diagnostic criterion for cervicogenic headache. Several instruments are used for this measurement, with limitations in their applicability in daily clinical practice. A prospective longitudinal repeated measures study was conducted to assess the intra- and inter-rater reliability and validity of Werium inertial sensors in 20 adults with chronic primary headache. For the inter-rater analysis, the intraclass correlation coefficient (ICC) values were above 0.75 for all movements, indicating a good level of reliability. For the intra-rater results, the ICC values obtained by the Werium inertial sensors for all cervical movements were good for rater A (ICC >0.80) and rater B (ICC >0.84). For the validity, the ICCs obtained by the Werium inertial sensors compared with the CROM instrument for all cervical movements were moderate for both raters (ICC > 0.70, respectively). Values obtained in the standard error of measurement, minimum detectable change at 90% and limits of agreement also indicated good agreement. Werium inertial sensors have shown good to excellent reliability results, both intra- and inter-examiner (ICC > 0.75). Likewise, when the sensors were compared with another validated instrument (CROM device) they obtained high reliability results (ICC > 0.70). These results plus its relatively low price and ease of use allow us to recommend it in daily clinical practice to measure AcROM in patients with chronic primary headache.

Transcranial direct-current stimulation (tDCS) in the primary motor cortex and its effects on sensorimotor function: a quasi-experimental single-blind sham-controlled trial.

The main aim was to assess the short-term effects of active-tDCS (a-tDCS) in the primary motor cortex (anodal stimulation-M1) on sensorimotor variables. These variables included discriminative sensation through the two-point discrimination (2-PD) test, tactile acuity threshold and pressure pain threshold (PPT), and electromyographic (EMG) activity compared with a sham-tDCS (s-tDCS) in healthy individuals. A total of 100 participants were included. Fifty of the participants received the a-tDCS application of 2 mA for 20 min, whereas the remaining fifty received the s-tDCS. The 2-PD and tactile acuity threshold in thenar eminence of the hand and in the dorsal part of the foot and also, PPT and EMG activity during maximal voluntary contraction in the biceps brachii and rectus femoris were assessed before and after the tDCS application. The a-tDCS intervention was not significantly superior to the s-tDCS in any variable. However, significant within-group pre- and post-intervention differences were found in the a-tDCS, such as the tactile acuity threshold in thenar eminence of the hand, with a small effect size (p = .012, d = 0.20) and in the PPT of the rectus femoris, also with a small effect size (p = .001, d = - 0.17). Regarding EMG activity, a trend towards greater activity was observed in participants with a-tDCS compared with s-tDCS, which showed a trend towards decreased EMG activity. In fact, although no differences were found between the groups, within-group differences were statistically significant in the biceps brachii pre- and postintervention (p = .023, d = - 0.16, and p = .002, d = 0.18, respectively), and also in the rectus femoris, only in the a-tDCS, with a small effect size (p = .011, d = - 0.14). This study showed no significant between-group differences in sensorimotor outcomes. A single session of tDCS in isolation appears to produce immediate effects in healthy participants on sensorimotor function; however, these effects were very small.

Effectiveness of Unihemispheric Concurrent Dual-Site Stimulation over M1 and Dorsolateral Prefrontal Cortex Stimulation on Pain Processing: A Triple Blind Cross-Over Control Trial.

BACKGROUND: Transcranial direct current stimulation (tDCS) of the motor cortex (M1) produces short-term inhibition of pain. Unihemispheric concurrent dual-site tDCS (UHCDS-tDCS) over the M1 and dorsolateral prefrontal cortex (DLPFC) has greater effects on cortical excitability than when applied alone, although its effect on pain is unknown. The aim of this study was to test if anodal UHCDS-tDCS over the M1 and DLPFC in healthy participants could potentiate conditioned pain modulation (CPM) and diminish pain temporal summation (TS). METHODS: Thirty participants were randomized to receive a sequence of UHCDS-tDCS, M1-tDCS and sham-tDCS. A 20 min 0.1 mA/cm2 anodal or sham-tDCS intervention was applied to each participant during three test sessions, according to a triple-blind cross-over trial design. For the assessment of pain processing before and after tDCS intervention, the following tests were performed: tourniquet conditioned pain modulation (CPM), pressure pain temporal summation (TS), pressure pain thresholds (PPTs), pressure pain tolerance, mechanosensitivity and cold hyperalgesia. Motor function before and after tDCS intervention was assessed with a dynamometer to measure maximal isometric grip strength. RESULTS: No statistically significant differences were found between groups for CPM, pressure pain TS, PPT, pressure pain tolerance, neural mechanosensitivity, cold hyperalgesia or grip strength (p > 0.05). CONCLUSIONS: Neither UHCDS-tDCS nor M1-tDCS facilitated CPM or inhibited TS in healthy subjects following one intervention session.

Intra-rater and inter-rater reliability of cervical active range of movement in young asymptomatic adults using inertial sensors.

Objectives: Current literature is scarce about the use of an inertial sensor to measure cervical active range of motion (aROM). The objective of the present study is to determine inter- and intra-reliability in the measurement of cervical aROM using inertial sensors in asymptomatic individuals.Materials and methods: Twenty asymptomatic individuals participated in the study. Two different physiotherapists measured each participant for cervical aROM (6 movements). The sequence of movements and the explanations given were standardized. The rater's order of measurement was randomized.Results: For the intra-rater results, the intraclass correlation coefficient (ICC) values for all cervical movements were good for Rater A (ICC >0.90) and Rater B (ICC >0.90). For the inter-rater results, the ICC values were above 0.75 for all movements, indicating a good level of reliability. Also, values obtained in SEM, MDC90 and LOA indicate good agreement.Conclusion: The data obtained in this study suggest that inertial sensors can be used in clinics due to their high intra- and inter-rater ICC (>0.80). Also, its low economic cost, easy handling, and various utilities make this tool a useful alternative in the measurement of cervical aROM.

Reliability and Validity of the 6-Minute Walk Test in Hypophosphatasia.

This investigation evaluated the reliability and validity of the 6-Minute Walk Test (6MWT) in patients with pediatric hypophosphatasia (HPP). Children (aged 6 to 12 years; n = 11), adolescents (13 to 17 years; n = 4), and adults (18 to 65 years; n = 9) completed the 6MWT at screening and baseline in two clinical studies of asfotase alfa. Test-retest reliability of the 6MWT, evaluated with Pearson's correlation coefficients (r) for screening versus baseline, was high for children (r = 0.95; p < 0.0001), adolescents (r = 0.81; p = 0.125), and adults (r = 0.94; p = 0.0001). The most conservative minimal clinically important differences, estimated using distribution-based methods, were 31 m (children and adults) and 43 m (adolescents). In children, the 6MWT correlated significantly with scores on measures of skeletal disease, which included the Radiographic Global Impression of Change scale (r = 0.50; p < 0.0001) and the Rickets Severity Scale (r = -0.78; p < 0.0001), such that distance walked increased as the severity of skeletal disease decreased. Significant (p < 0.0001) correlations with the 6MWT distance walked were also observed for children with scores on parent-reported measures of disability (r = -0.67), ability to function in activities of daily living (r = 0.71 to 0.77), and parent-reported measures of pain (r = -0.39). In adolescents and adults, 6MWT distance walked correlated significantly (p < 0.05) with measures of lower extremity function (r = 0.83 and 0.60, respectively), total pain severity (r = -0.41 and -0.36, respectively), and total pain interference (r = -0.41 and -0.49, respectively). Collectively, these data indicate that the 6MWT is a reliable, valid measure of physical functioning in patients with pediatric HPP. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Voluntary control of wearable robotic exoskeletons by patients with paresis via neuromechanical modeling.

BACKGROUND: Research efforts in neurorehabilitation technologies have been directed towards creating robotic exoskeletons to restore motor function in impaired individuals. However, despite advances in mechatronics and bioelectrical signal processing, current robotic exoskeletons have had only modest clinical impact. A major limitation is the inability to enable exoskeleton voluntary control in neurologically impaired individuals. This hinders the possibility of optimally inducing the activity-driven neuroplastic changes that are required for recovery. METHODS: We have developed a patient-specific computational model of the human musculoskeletal system controlled via neural surrogates, i.e., electromyography-derived neural activations to muscles. The electromyography-driven musculoskeletal model was synthesized into a human-machine interface (HMI) that enabled poststroke and incomplete spinal cord injury patients to voluntarily control multiple joints in a multifunctional robotic exoskeleton in real time. RESULTS: We demonstrated patients' control accuracy across a wide range of lower-extremity motor tasks. Remarkably, an increased level of exoskeleton assistance always resulted in a reduction in both amplitude and variability in muscle activations as well as in the mechanical moments required to perform a motor task. Since small discrepancies in onset time between human limb movement and that of the parallel exoskeleton would potentially increase human neuromuscular effort, these results demonstrate that the developed HMI precisely synchronizes the device actuation with residual voluntary muscle contraction capacity in neurologically impaired patients. CONCLUSIONS: Continuous voluntary control of robotic exoskeletons (i.e. event-free and task-independent) has never been demonstrated before in populations with paretic and spastic-like muscle activity, such as those investigated in this study. Our proposed methodology may open new avenues for harnessing residual neuromuscular function in neurologically impaired individuals via symbiotic wearable robots.

A robot-based gait training therapy for pediatric population with cerebral palsy: goal setting, proposal and preliminary clinical implementation.

BACKGROUND: The use of robotic trainers has increased with the aim of improving gait function in patients with limitations. Nevertheless, there is an absence of studies that deeply describe detailed guidelines of how to correctly implement robot-based treatments for gait rehabilitation. This contribution proposes an accurate robot-based training program for gait rehabilitation of pediatric population with Cerebral Palsy (CP). METHODS: The program is focused on the achievement of some specifications defined by the International Classification of Functioning, Disability and Health framework, Children and Youth version (ICF-CY). It is framed on 16 non-consecutive sessions where motor control, strength and power exercises of lower limbs are performed in parallel with a postural control strategy. A clinical evaluation with four pediatric patients with CP using the CPWalker robotic platform is presented. RESULTS: The preliminary evaluation with patients with CP shows improvements in several aspects as strength (74.03 ± 40.20%), mean velocity (21.46 ± 33.79%), step length (17.95 ± 20.45%) or gait performance (e.g. 66 ± 63.54% in Gross Motor Function Measure-88 items, E and D dimensions). CONCLUSIONS: The improvements achieved in the short term show the importance of working strength and power functions meanwhile over-ground training with postural control. This research could serve as preliminary support for future clinical implementations in any robotic device. TRIAL REGISTRATION: The study was carried out with the number R-0032/12 from Local Ethical Committee of the Hospital Infantil Niño Jesús. Public trial registered on March 23, 2017: ISRCTN18254257 .

Medial gastrocnemius structure and gait kinetics in spastic cerebral palsy and typically developing children: A cross-sectional study.

To compare medial gastrocnemius muscle-tendon structure, gait propulsive forces, and ankle joint gait kinetics between typically developing children and those with spastic cerebral palsy, and to describe significant associations between structure and function in children with spastic cerebral palsy.A sample of typically developing children (n = 9 /16 limbs) and a sample of children with spastic cerebral palsy (n = 29 /43 limbs) were recruited. Ultrasound and 3-dimensional motion capture were used to assess muscle-tendon structure, and propulsive forces and ankle joint kinetics during gait, respectively.Children with spastic cerebral palsy had shorter fascicles and muscles, and longer Achilles tendons than typically developing children. Furthermore, total negative power and peak negative power at the ankle were greater, while total positive power, peak positive power, net power, total vertical ground reaction force, and peak vertical and anterior ground reaction forces were smaller compared to typically developing children. Correlation analyses revealed that smaller resting ankle joint angles and greater maximum dorsiflexion in children with spastic cerebral palsy accounted for a significant decrease in peak negative power. Furthermore, short fascicles, small fascicle to belly ratios, and large tendon to fascicle ratios accounted for a decrease in propulsive force generation.Alterations observed in the medial gastrocnemius muscle-tendon structure of children with spastic cerebral palsy may impair propulsive mechanisms during gait. Therefore, conventional treatments should be revised on the basis of muscle-tendon adaptations.

Prolonged stretching of the ankle plantarflexors elicits muscle-tendon adaptations relevant to ankle gait kinetics in children with spastic cerebral palsy.

Tissue related ankle hyper-resistance has been reported to contribute to equinus gait in children with spastic cerebral palsy. Hence, ankle plantarflexor stretching programs have been developed in order to restore passive ankle dorsiflexion. Despite high quality evidence on the limited effects of stretching on passive joint mobility, further muscle-tendon adaptations have been reported which may impact gait performance. As such, children with spastic cerebral palsy subject to long-term manual static stretching achieved dorsiflexion gains through the reduction of muscle and fascicle strain whilst preserving tendon strain, and prolonged use of ankle-foot orthoses achieved similar dorsiflexion gains through increased tendon strain whilst preserving muscle and fascicle strain. The latter concurred with normalization of early stance plantarflexor moment yet reductions in push-off plantarflexor moment given the increase in tendon compliance. Therefore, similar limited gains in passive ankle joint mobility in response to stretching may be achieved either by preserving/restoring optimal muscle-tendon function, or at the expense of muscle-tendon function and thus contributing gait impairments. The largest increase in ankle passive joint mobility in children with SCP has been obtained through prolonged plantarflexor stretching through ankle casting combined with botulinum neurotoxin type A. However, to our knowledge, there are no published studies on muscle-tendinous adaptations to ankle casting combined with botulinum toxin type A and its effect on ankle joint gait kinetics. Therefore, we hypothesized that ankle casting elicits muscle-tendon adaptations which concur with altered ankle joint kinetics during the stance phase of gait in children with SCP. More information is needed about the relationships between muscle structure and function, and the effect of specific interventions designed to alter muscle properties and associated functional outcomes in children with spastic cerebral palsy.