Influence of commuting methods on low back pain and musculoskeletal function of the lower limbs in elementary school children: A cross-sectional study.

BACKGROUND: Lower limb flexibility is known to be decreased in those living in mountainous areas, and musculoskeletal growth is often influenced by lifestyle factors. The purpose of this study was to determine the relationship between the means of transportation to school and lower limb musculoskeletal function and low back pain. METHODS: During routine medical examinations conducted in two cities in a prefecture in 2016, a questionnaire was administered. The parents of 15,259 students who attended elementary school answered questions evaluating the following parameters: (1) anteflexion limit in the standing posture, (2) crouching failure, (3) one leg standing failure, (4) low back pain during lumbar extension, (5) lower limb alignment abnormalities, and (6) flat foot. Students were divided into a walking commuting group (13,569 students) and a vehicle commuting group (1690 students), and findings were compared between the two groups using chi-square tests. RESULTS: In the walking and vehicle commuting groups, anteflexion limit in the standing posture was present in 23.3% and 26.1% of students, respectively (p = 0.013). Crouching failure was present in 4.6% and 7.3% of students (p < 0.001); one leg standing failure in 5.3% and 8.5% of students (p < 0.001); low back pain in 5.0% and 7.1% of students (p < 0.001); positive leg alignment abnormalities in 7.3% and 8.0% of students (p = 0.260); and flat foot in 7.4% and 8.7% of students (p = 0.067), respectively. Significant differences were observed in all four of the failure measures. No significant differences were observed in the two methods evaluating morphological abnormalities. CONCLUSIONS: The decreased walking duration and increased sitting duration associated with vehicle commuting had little effect on lower limb morphology but could induce lower limb dysfunction and low-back pain in children. Thus, supplemental walking should be instated for children who commute by car.

The relationship between gluteus medius and minimus muscle volumes and hip development in developmental dysplasia of the hip.

BACKGROUND: Several studies in adult hips have revealed the role of the gluteus medius (Gmed) and gluteus minimus (Gmin) muscles in maintaining the stability and centripetal force of the hip joint. Hip centripetality in developmental dysplasia of the hip (DDH) patients contributes to subsequent healthy hip development later in life. The purpose of this study is to investigate the relationship between Gmed and Gmin volume and centripetality of the hip in infant DDH patients. METHODS: We retrospectively enrolled 41 unilateral DDH patients (4 males, 37 females) who were treated by closed reduction from 2006 to 2016 and underwent magnetic resonance imaging at around 2 years old. Gmed, and Gmin volume was measured in magnetic resonance imaging. We defined both Gmin and Gmed together as hip abductor gluteus muscles (GMs; Gmed + Gmin). The muscle volume ratio of the affected side was calculated by dividing the GMs volume of the affected side by the contralateral side. Relationships between center-head distance discrepancy (CHDD) at 2 years old, and at 4-6 years old and GMs volume ratio were investigated by Pearson's correlation coefficient within the same patients. RESULTS: Mean age of closed reduction was 0.8 years old and mean age at MRI was 2.2 years old with a mean follow-up period of 3.7 years. Mean GMs volume in the affected side, contralateral side, and muscle volume ratio were 25.3 cm3, 27.0 cm3, and 0.94, respectively. GMs volumes were significantly higher in the contralateral side (p < 0.001). GMs volume ratio at 2 years old significantly correlated with CHDD at 4-6 years old (p < 0.05). CONCLUSION: GMs volume at 2 years old was found to be associated with later hip afferents. Promoting the healthy development of GMs by properly maintaining the infant's natural hip movement is important for the healthy hip development. LEVEL OF EVIDENCE: Level III.

Effect of the Hybrid Assistive Limb on the Gait Pattern for Cerebral Palsy.

Background and objectives: Cerebral palsy (CP) is the most frequent childhood motor disability. Achieving ambulation or standing in children with CP has been a major goal of physical therapy. Recently, robot-assisted gait training using the Hybrid Assistive Limb® (HAL) has been effective in improving walking ability in patients with CP. However, previous studies have not examined in detail the changes in gait pattern after HAL training for patients with spastic CP, including gait symmetry. This study aimed to evaluate the immediate effect of HAL training on the walking ability and the changes in gait pattern and gait symmetry in patients with spastic CP. Materials and Methods: We recruited 19 patients with spastic CP (13 male and six female; mean age, 15.7 years). Functional ambulation was assessed using the 10-Meter Walk Test and gait analysis in the sagittal plane before and after a single 20-min HAL intervention session. Results: The walking speed and stride length significantly increased after HAL intervention compared to the pre-intervention values. Two-dimensional gait analysis showed improvement in equinus gait, increase in the flexion angle of the swing phase in the knee and hip joints, and improvement in gait symmetry. Immediate improvements in the walking ability and gait pattern were noted after HAL training in patients with spastic CP. Conclusions: The symmetry of the joint angle of the lower limb, including the trunk, accounts for the improvement in walking ability after HAL therapy.

Use of malleoli as an indicator for flatfoot in patients with Down syndrome: development of a simple and non-invasive evaluation method through medial longitudinal arch.

[Purpose] Flatfoot often presents in patients with Down syndrome, and it can be diagnosed using a simple radiograph. Consequently, due to radiograph limitations, alternative non-invasive testing must be determined. Conventionally, arch height ratio can be used for evaluation of the medial longitudinal arch, where the foot is evaluated by detecting the navicular bone on the foot surface. However, detection of the navicular tuberosity is difficult and even though the detection is relatively straightforward for patients without intellectual disability, measuring navicular bone is more difficult in patients with intellectual disability, such as those who have Down syndrome and are uncooperative with a tester. Therefore, we evaluated arch height ratio using the malleoli instead of the navicular bone to determine whether malleoli testing was appropriate for patients with Down syndrome that have an intellectual disability. [Participants and Methods] We conducted a retrospective study of 16 pairs of feet in 16 patients with Down syndrome, diagnosed with flatfoot. The height to the centre of the talo-navicular joint and that of the malleoli from the sole were measured on radiographs using weight-bearing conditions. [Results] The age range was 5.2 to 25.3 years. There was a correlation between the height of the navicular bone and that of the medial and lateral malleoli. [Conclusion] We conclude that the medial and lateral malleoli can substitute navicular bone as a landmark diagnosis test for flatfoot. Considering the close physical distance between the medial malleolus and navicular bone, and the association between the tibia and medial longitudinal arch, the medial malleolus may provide a better landmark in patients with Down syndrome with it being potentially less invasive for uncooperative patients.

Screening for musculoskeletal problems in children using a questionnaire.

BACKGROUND: On April 1, 2016, the Ministerial ordinance was enforced, and musculoskeletal examination of the extremities was made mandatory. From 2008, the University of us started musculoskeletal direct examination. To expand the examination, from 2016, we started to use the marksheet-type questionnaire. This study aimed to report the results of a musculoskeletal examination and investigate the association between musculoskeletal examination and age/gender and reports the reliability of the collected questionnaire data. METHODS: Direct musculoskeletal examination was performed in K school by 7 orthopedic surgeons. A marksheet-type screening questionnaire was distributed to all the elementary and junior high school students in Tsukuba and Hitachiomiya cities. The rates of abnormal findings for scoliosis, standing flexion, full squatting with the heels on the floor, general joint laxity, and standing on one leg, torticollis, and flat feet were calculated. We compared the results of the questionnaire and direct examination and calculated sensitivity, specificity, and odds ratio. RESULTS: A total of 1844 students in K school had direct examination, and 22,494 questionnaires were able to correct in Tsukuba and Hitachiomiya cities. The rates of abnormal findings in direct examination/questionnaire in scoliosis, standing flexion, full squat, general joint laxity, standing on one leg, torticollis and flat foot were 18.7% (344/1842)/5.1% (1094/21441), 20.2% (372/1841)/26.6% (5817/22078), 6.2% (114/1832)/6.9% (1516/22101), 7.5% (1648/22252), 4.9% (1100/22077), 2.2% (31/1844)/1.2% (272/21687), and 12.5% (231/1842)/8.7% (1785/20871), respectively. Sensitivities of the questionnaire for scoliosis, stand flexion, full squatting, torticollis, and flat feet were 16.8% (53/316), 67.9% (250/368), 48.2% (55/114), 18.9% (7/37), and 32.2% (65/202), respectively. CONCLUSION: We reported the result of musculoskeletal examination. Accuracy and reliability of this questionnaire were not satisfactory. To perform high quality musculoskeletal examinations, we will aim to increase the quality of screening methods.

Improvement and sustainability of walking ability with hybrid assistive limb training in a patient with cerebral palsy after puberty: a case report.

[Purpose] Cerebral palsy is one of the most common causes of childhood physical disability affecting motor development. Gait training with a wearable-robot, such as the Hybrid Assistive Limb, has been reported to improve gait ability in patients with chronic motor disabilities; however, there are no reports concerning the sustained improvement of walking ability with its use in patients with cerebral palsy. We present our observations for the use of Hybrid Assistive Limb gait training in a postpubescent cerebral palsy patient. [Participant and Methods] A 17-year-old male with spastic cerebral palsy could only ambulate slightly using a crouch gait posture and with the aid of a walker. Hybrid Assistive Limb training was performed thrice weekly for 4 weeks (total of 12 sessions) along with concurrent daily physical therapy. The follow-up period was 7 months after the intervention. [Results] The intervention resulted in improvements in the patient's gait speed, proportion of the stance phase in a gait cycle, step length, and the flexion angle of the knees at initial contact and during late stance phase, which was sustained for 7 months following the intervention. [Conclusion] Our observations suggest that Hybrid Assistive Limb training may effectively improve and sustain walking ability even among postpubescent cerebral palsy patients who have a decreased walking ability.

Newly developed hybrid assistive limb for pediatric patients with cerebral palsy: a case report.

[Purpose] The effect of fitness training on improving walking ability in cerebral palsy is controversial. However, gait training with a wearable robot (hybrid assistive limb) has been reported to improve gait ability in patients with cerebral palsy. For pediatric patients, a smaller, lighter-weight hybrid assistive limb has been newly developed. We describe the immediate effect of this newly developed smaller hybrid assistive limb on the gait ability of a pediatric patient with cerebral palsy and examine its safety and feasibility. [Participant and Methods] An 11-year-old male with spastic cerebral palsy (height, 130 cm; weight, 29.0 kg) who could ambulate using an elbow crutch participated in this study. A single session of hybrid assistive limb training comprising pre-exercise of the hip and knee joints and walking for 20 minutes was conducted. [Results] The intervention immediately improved his gait speed, stride length, and cadence according to the 10-m walking test. Co-contraction of agonist/antagonist muscles during walking improved, and the flexion angle of the right hip during the swing phase increased, which resulted in symmetry of movement of both legs. [Conclusion] Gait training using the new, smaller hybrid assistive limb for a pediatric patient was safe and feasible, and the newly developed hybrid assistive limb has the potential to immediately improve walking ability even among young children with cerebral palsy.

Long-term sustained effect of gait training using a hybrid assistive limb on gait stability via prevention of knee collapse in a patient with cerebral palsy: a case report.

[Purpose] The hybrid assistive limb was developed to improve the kinematics and muscle activity in patients with neurological and orthopedic conditions. The purpose of the present study was to examine the long-term sustained effect of gait training using a hybrid assistive limb on gait stability, kinematics, and muscle activity by preventing knee collapse in a patient with cerebral palsy. [Participant and Methods] A 17 year-old male with cerebral palsy performed gait training with a hybrid assistive limb 12 times in 4 weeks. After completion of 12 sessions of hybrid assistive limb training, monthly follow-up was conducted for 8 months. The improvement was assessed on the basis of joint angle and muscle activity during gait. [Results] The degree of knee collapse observed at baseline was improved at 8-month follow-up. Regarding muscle activity, electromyography revealed increased activation of the vastus lateralis at 8-month follow-up. Moreover, the hip and knee angles were expanded during gait. In particular, the knee extension angle at heel contact was increased at 8 months after follow-up. [Conclusion] Gait training with a hybrid assistive limb provided improvement of gait stability such as kinematics and muscle activity in a patient with cerebral palsy. The improved gait stability through prevention of knee collapse achieved with hybrid assistive limb training sustained for 8 months.

Immediate effects of a single session of robot-assisted gait training using Hybrid Assistive Limb (HAL) for cerebral palsy.

[Purpose] Robot-assisted gait training (RAGT) using Hybrid Assistive Limb (HAL, CYBERDYNE) was previously reported beneficial for stroke and spinal cord injury patients. Here, we investigate the immediate effect of a single session of RAGT using HAL on gait function for cerebral palsy (CP) patients. [Subjects and Methods] Twelve patients (average age: 16.2 ± 7.3 years) with CP received a single session of RAGT using HAL. Gait speed, step length, cadence, single-leg support per gait cycle, hip and knee joint angle in stance, and swing phase per gait cycle were assessed before, during, and immediately after HAL intervention. [Results] Compared to baseline values, single-leg support per gait cycle (64.5 ± 15.8% to 69.3 ± 12.1%), hip extension angle in mid-stance (149.2 ± 19.0° to 155.5 ± 20.1°), and knee extension angle in mid-stance (137.6 ± 20.2° to 143.1 ± 19.5°) were significantly increased immediately after intervention. Further, the knee flexion angle in mid-swing was significantly decreased immediately after treatment (112.0 ± 15.5° to 105.2 ± 17.1°). Hip flexion angle in mid-swing also decreased following intervention (137.2 ± 14.6° to 129.7 ± 16.6°), but not significantly. Conversely, gait speed, step length, and cadence were unchanged after intervention. [Conclusion] A single-time RAGT with HAL improved single-leg support per gait cycle and hip and knee joint angle during gait, therapeutically improving gait function in CP patients.

Safety and immediate effect of gait training using a Hybrid Assistive Limb in patients with cerebral palsy.

[Purpose] This study aimed to determine the safety and immediate effect of a single training session with the Hybrid Assistive Limb (CYBERDYNE) on walking ability in patients with cerebral palsy. [Participants and Methods] This study included 20 patients with cerebral palsy (15 males, 5 females, mean age 15.0 ± 6.3 years; 19 with spastic cerebral palsy, 1 with athetoid cerebral palsy; Gross Motor Function Classification System level I: 4, II: 3, III: 9, and IV: 4). Participants completed a single 20-minute gait training session using the Hybrid Assistive Limb. The safety and immediate effect were evaluated. The immediate outcomes were gait speed and mean step length, and cadence before and after training. [Results] Two participants were excluded because they were not tall enough to use the Hybrid Assistive Limb. Eighteen participants performed the training. There were no serious adverse events during the training. Since 14 participants were able to walk on their own, walking evaluations were performed before and after training. Statistically significant improvements were observed in gait speed and mean step length. [Conclusion] Gait training using the Hybrid Assistive Limb is safe for patients with cerebral palsy and can produce immediate effects on walking ability in ambulatory patients with cerebral palsy.

A Multidisciplinary Rehabilitation Approach for a Patient With Diffuse Large B-cell Lymphoma and Bone Metastasis: A Case Report.

Cancer is often accompanied by bone metastasis, which may lead to skeletal-related events (SREs), such as pain, hypercalcemia, pathological fractures, spinal cord compression, orthopedic surgical intervention, and palliative radiation directed at the bone. Herein, we report the case of a 75-year-old female patient diagnosed with diffuse large B-cell lymphoma (DLBCL) with bone metastasis and a pathological fracture of the right iliac bone. The management strategy and follow-up were determined by a multidisciplinary cancer board comprising physicians, physiatrists, orthopedic surgeons, radiologists, and rehabilitation therapists. A conservative approach was chosen, incorporating a bone-modifying agent and weight-bearing restrictions for the right leg, along with rehabilitation therapy and post-discharge support. A multidisciplinary rehabilitation approach for two months enabled the patient to walk independently upon discharge. She maintains her activities of daily living (ADL) for over six months after discharge without any skeletal issues. This case highlights the effectiveness of a multidisciplinary approach in managing bone metastasis or involvement in patients with lymphoma.

Benefits of a Wearable Cyborg HAL (Hybrid Assistive Limb) in Patients with Childhood-Onset Motor Disabilities: A 1-Year Follow-Up Study.

Rehabilitation robots have shown promise in improving the gait of children with childhood-onset motor disabilities. This study aimed to investigate the long-term benefits of training using a wearable Hybrid Assistive Limb (HAL) in these patients. Training using a HAL was performed for 20 min a day, two to four times a week, over four weeks (12 sessions in total). The Gross Motor Function Measure (GMFM) was the primary outcome measure, and the secondary outcome measures were gait speed, step length, cadence, 6-min walking distance (6MD), Pediatric Evaluation of Disability Inventory, and Canadian Occupational Performance Measure (COPM). Patients underwent assessments before the intervention, immediately after the intervention, and at 1-, 2-, 3-month and 1-year follow-ups. Nine participants (five males, four females; mean age: 18.9 years) with cerebral palsy (n = 7), critical illness polyneuropathy (n = 1), and encephalitis (n = 1) were enrolled. After training using HAL, GMFM, gait speed, cadence, 6MD, and COPM significantly improved (all p < 0.05). Improvements in GMFM were maintained one year after the intervention (p < 0.001) and in self-selected gait speed and 6MD three months after the intervention (p < 0.05). Training using HAL may be safe and feasible for childhood-onset motor disabilities and may maintain long-term improvements in motor function and walking ability.

Robot-Assisted Ankle Rehabilitation Using the Hybrid Assistive Limb for Children after Equinus Surgery: A Report of Two Cases.

After equinus corrective surgery, repetitive exercises for ankle dorsiflexion and plantar flexion are crucial during rehabilitation. The single-joint Hybrid Assistive Limb (HAL-SJ) is an advanced exoskeletal robotic device with a control system that uses bioelectrical signals to assist joint motion in real time and demonstrates joint torque assistance with the wearer's voluntary movement. We present two cases of robot-assisted ankle rehabilitation after equinus surgery using the HAL-SJ in children. Case 1 was an 8-year-old boy, whereas case 2 was a 6-year-old boy. When they were allowed to walk without braces, training with the HAL-SJ was performed postoperatively for 20 min per session a total of eight times (2-4 sessions per week). Assessments were performed before and after HAL-SJ training. During gait analysis, case 1 had improved joint angles during the stance phase on the operated side; however, case 2 had improved joint angles during the stance and swing phases. The co-activation index values of the medial gastrocnemius and tibialis anterior muscles, which were high before training, decreased after training and approached the standard value. The HAL-SJ may provide systematic feedback regarding voluntary ankle dorsiflexion and plantar flexion and is considered to have motor learning effects.

Short-Term Outcome of Rehabilitation Program with Hybrid Assistive Limb after Tendon Lengthening in Patients with Cerebral Palsy.

In this study, we aimed to evaluate the short-term outcomes of a rehabilitation program with the Hybrid Assistive Limb® after soft tissue lengthening in young patients with cerebral palsy. We assessed six patients with cerebral palsy who underwent soft tissue surgery followed by gait training using the Hybrid Assistive Limb®. Clinical assessments were conducted preoperatively, before, immediately after, and at 1, 2, and 3 months after gait training. Gross Motor Function Measure was improved 5.93 ± 6.11% (mean ± standard deviation, p < 0.05), Canadian Occupational Performance Measure performance was improved 3.12 ± 1.53 points, and satisfaction was improved 3.80 ± 2.14 points (p < 0.05). The knee extension strength on the operated side was changed 7.75 ± 4.97 Nm after the intervention (p = 0.07). In ambulatory patients, gait speed was changed 8.37 ± 1.72 m/min, stride length was changed 10 ± 6.16 cm, and 6 min walking distance was changed 52 ± 16 m after the intervention. Training with the Hybrid Assistive Limb® may improve walking ability and clinical outcomes in young patients with cerebral palsy after soft tissue lengthening.

Voluntary-assisted Upper Limb Training for Severe Cerebral Palsy Using Robotics Devices and Neuromuscular Electrical Stimulation: Three Case Reports.

Background: Constraint-induced movement therapy (CIMT) improves the motor function of paralyzed upper limbs of adults after stroke. However, in patients with severe spastic cerebral palsy (CP), the use of CIMT is not warranted. Our aim was to investigate the feasibility and effectiveness of repetitive voluntary-assisted upper limb training (VAUT) for three patients with severe CP using a combination of robotics [Hybrid Assistive Limb (HAL)] and functional electrical stimulation [Integrated Volitional Control Electrical Stimulation (IVES)]. Case: Three patients with CP were enrolled. Patients 1, 2, and 3 were 8-, 19-, and 18-year-old males, respectively. Patient 1 had spastic hemiplegia, while patients 2 and 3 had spastic quadriplegia. VAUT using single-joint HAL was performed for 1 or 2 sessions/month for 50 min/session over an 8-month period for 9-13 sessions in total. One patient's voluntary hand movement was insufficient, affecting his upper limb exercise performance; therefore, IVES was required in addition to HAL. Outcome measures included motor function of the upper limbs and use of paralyzed hands, which were measured before and after intervention. No adverse events were observed during VAUT. After intervention, the Action Research Arm Test scores showed improvements in all three patients. The Children's Hand-use Experience Questionnaire showed improvements in two patients. Discussion: The use of VAUT, together with new systems such as HAL and IVES, for severe CP is safe and may be effective. Our study suggested that upper limb function can be improved for patients with severe CP.

Progressive age and other factors affecting scoliosis severity in cerebral palsy patients.

Objective: This study aimed to investigate the age at which scoliosis progresses to a severe condition and identify the factors related to severe scoliosis in patients with cerebral palsy. Patients and Methods: This retrospective study included 51 patients aged ≥15 years. The Cobb angle was measured over time using radiographs. Patients were divided into the following groups according to their final Cobb angle: <60°, 60°-100°, and ≥100°. The age at which the Cobb angle was ≥20° in the patients was compared among the groups. Moreover, the age at which a significant difference in the Cobb angle occurred in the groups was considered the age at which the scoliosis worsened. Association of the final Cobb angle with factors such as the location of curve, Gross Motor Functional Classification System (GMFCS), capability of turning over, orthosis use, hip dislocation, tracheotomy, and gastric fistula was examined. Results: The mean age at which the Cobb angle was ≥20° was significantly lower in the ≥100° group. From 9 years of age, a significant difference was noted in the Cobb angle between the <60° group and ≥100° group. Between 13-19 years, a significant difference in the Cobb angle was observed among the three groups. Furthermore, GMFCS, capability of turning over, hip dislocation, and gastric fistula were the factors showing a significant difference among the three groups. Conclusion: Scoliosis progressed to the severe form (Cobb angle ≥100°) at 9 years of age. Moreover, scoliosis is aggravated during the growth period. Severe cerebral palsy with low motor function levels and problems with internal functions was considered the cause of scoliosis deterioration.

A new tendon-lengthening technique using a tendon stripper for knee flexion contracture in a cerebral palsy patient.

Knee flexion contracture in a patient with cerebral palsy was treated by a new tendon-lengthening technique using a tendon stripper. The patient was a 10-year-old girl with mixed types of cerebral palsy related to a chromosomal anomaly. She was classified as level IV in the Gross Motor Functional Classification System with a bilateral 30° knee flexion contracture. The semitendinosus and gracilis muscle tendons were released from distal to proximal using a tendon stripper. The pulled-out muscle tendons were placed along and on their muscle portions. In addition, the semimembranosus tendon and the tendon of the biceps femoris were lengthened by an intramuscular lengthening until the contracture was released. After three weeks of casting, a long leg brace was made, and rehabilitation was started with full weight-bearing standing exercises. One year after the surgery, the improvement in maximum knee flexion contracture was maintained at 10° or less without severe progression or any complication. This new technique of using the tendon stripper on knee flexion contracture for a patient with cerebral palsy can be safe, feasible, and effective.

Determining the relationship between physical status and musculoskeletal injuries in children: a cohort study.

Background: In Japan, in 2016, the School Health and Safety Act was revised and examination of extremities in addition to scoliosis became mandatory. Musculoskeletal examinations were subsequently started using a mark sheet-type questionnaire. In the present study, we aimed to analyze the relationship between physical findings and musculoskeletal problems and propose a preventive strategy for musculoskeletal injuries. Methods: In 2017, a total of 4,073 elementary and middle school students underwent direct musculoskeletal examination. In a direct examination, the following elements were included: torticollis; scoliosis; stiffness of the shoulder, elbow, hip, knee, and ankle; flexion and extension in standing position; flat foot; hallux valgus; and alignment of the upper and lower extremities. Of the 4,073 students who underwent direct examination in early 2017, only 3,754 were able to complete the mark sheet-type questionnaires in early 2018. A prospective longitudinal analysis of the data gathered was performed. Results: A total of 396 (11%) students had injuries. The ankle sprain/non-ankle sprain group comprised 119 (3%)/3,635 (97%) students, while the fracture/non-fracture group comprised 105 (2.8%)/3,650 (97.2%) students, respectively. Comparing the sprain group with the non-sprain group, ankle stiffness significantly correlated with ankle sprain in the univariable and multivariable analyses. Injuries occurred more frequently among boys, older students, students with stiff bodies, and students who were involved in sports activities of longer duration. Conclusion: Ankle stiffness was assumed to be a risk factor for ankle sprain. Stretching of the ankle might be effective for preventing ankle sprain. However, further interventional studies are needed to confirm this finding.

Robot-assisted gait training using a very small-sized Hybrid Assistive Limb® for pediatric cerebral palsy: A case report.

PURPOSE: Gait parameters and gross motor function improve after 12 sessions of small-sized Hybrid Assistive Limb® (S-HAL) training in adult cerebral palsy (CP) patients. However, there are no reports on repetitive robot-assisted gait training using the newly developed very small-sized HAL (2S-HAL). This study aimed to examine the effect of using 2S-HAL on a pediatric CP patient. METHODS: The subject was an 11-year-old boy (height = 138 cm, weight = 30 kg) with spastic quadriplegia due to periventricular leukomalacia, with Gross Motor Function Classification System level IV. HAL training was performed for 2-4 sessions/week for 20 min/session (i.e., 4-week period with 12 sessions). Outcome measures were walking ability, gross motor function, Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, after, and at 1, 2, and 3 months after HAL-assisted gait training. RESULTS: After HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), Gross Motor Function Measure (GMFM), and COPM increased and physiological cost index (PCI) declined compared to those before intervention. The peaks of gait speed, step length, and cadence were 2 month, 1 month, and 3 month, respectively. 6MD, PCI, and GMFM at 1-3 months post-intervention were maintained. COPM peaked at 1 month post-intervention but remained higher than that before intervention. CONCLUSION: This is the first report of repetitive intervention using 2S-HAL in a pediatric CP patient. Gait training using 2S-HAL may be effective in CP patients as it improves post-training walking ability and gross motor function.

Safety and immediate effects of Hybrid Assistive Limb in children with cerebral palsy: A pilot study.

PURPOSE: Early intervention is effective for developing motor ability and preventing contractures and deformities in patients with cerebral palsy (CP). Gait training using the newly developed Hybrid Assistive Limb (HAL) shows promise as an intervention to prevent deterioration in walking ability and deformities in pediatric CP patients. The purpose of this pilot study was to examine the safety and immediate effects on walking ability after gait training using the HAL in pediatric CP patients. METHODS: Nineteen patients (six females, 13 males; mean age 8.5 years; mean height 120.5 cm; mean weight 23.2 kg) were enrolled. The Gross Motor Functional Classification Scale level was I in two patients, II in two, III in eight, and IV in seven. The HAL was used for a single session of gait training. The primary outcome was safety of the HAL for use in pediatric CP patients. The secondary outcome was the immediate effect after gait training with HAL, evaluated by passive range of motion (ROM) and gait parameters, including gait speed (m/s), step length (cm), and cadence (step/min). RESULTS: All 19 patients were able to carry out the gait training without any severe adverse events. Significant improvements were observed for mean internal/external rotation and abduction angles of the hip joint, and ankle dorsiflexion angles (n = 19). Significant improvements were observed for mean gait speed and step length based on expansion of the hip flexion-extension range (n = 11). CONCLUSION: Gait training using the HAL is safe and can produce immediate improvements in ROM and walking ability in pediatric patients with CP.