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Utilizing Functional Electrical Stimulation and Exoskeletons in Pediatrics: a Closer Look at Their Roles in Gait and Functional Changes in Cerebral Palsy

  • Pediatric Rehabilitation Medicine (A Houtrow and M Fuentes, Section Editors)
  • Published:
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Abstract

Purpose of Review

A primary focus for many children with cerebral palsy (CP) is functional independence. However, due to neurologic insults that occur early in life, typical gait pattern development is impaired. Research has shown the importance of task-oriented movements in reorganizing the central nervous system in a functionally meaningful way. Advancements in technology, when used in conjunction with conventional strategies, have made it possible for therapists to utilize devices that provide repetitive patterning and feedback for gait retraining. This enables patients the opportunity to develop normal gait patterns and improve functional independence.

Recent Finding

Interventions such as functional electrical stimulation and exoskeletons can be utilized to assist patients with sequencing motor contractions of different muscles in more physiologic patterning. Children who suffer from neurologic insults may not only benefit from the restorative properties of these interventions, but also from the active engagement that is provided through the use of this technology. Therapists, utilizing these interventions, are able to encourage their patient’s interest and motivation while providing them with a repetitive goal-oriented task to assist with cortical reorganization.

Summary

This review focuses on current literature addressing the use of functional electrical stimulation and exoskeletons in pediatric rehabilitation. The results of these studies demonstrate the effectiveness of these devices when compared to conventional therapeutic interventions. This review shows that continued research is needed on specific dosage in order to determine optimal outcomes.

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References

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  1. Lepage C, Noreau L, Bernard PM. Association between characteristics of locomotion and accomplishment of life habits in children with cerebral palsy. Phys Ther. 1998;78(5):458–69.

    Article  CAS  Google Scholar 

  2. Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy. Jama. 2006;296(13):1602–8.

    Article  CAS  Google Scholar 

  3. Chruscikowski E, Fry NRD, Noble JJ, Gough M, Shortland AP. Selective motor control correlates with gait abnormality in children with cerebral palsy. Gait Posture. 2017;52:107–9.

    Article  Google Scholar 

  4. Fowler EG, Goldberg EJ. The effect of lower extremity selective voluntary motor control on interjoint coordination during gait in children with spastic diplegic cerebral palsy. Gait Posture. 2009;29:102–7.

    Article  Google Scholar 

  5. Sadowsky CL, McDonald JW. Activity-based restorative therapies: concepts and applications in spinal cord injury-related neurorehabilitation. Dev Disabil Res Rev. 2009;15(2):112–6.

    Article  Google Scholar 

  6. Grillner S. Neurobiological bases of rhythmic motor acts in vertebrates. Science (80- ). 1985;228(4696):143–9.

    Article  CAS  Google Scholar 

  7. Rossignol S, Debuc R, Gossard J-P. Dynamic sensorimotor interactions in locomotion. Physiol Rev. 2006;86(1):89–154.

    Article  Google Scholar 

  8. Hamacher DD, Herold F, Wiegel P, Hamacher DD, Schega L. Brain activity during walking: a systematic review. Neurosci Biobehav Rev. 2015;57:310–27.

    Article  Google Scholar 

  9. Dietz V, Sinkjaer T. Spastic movement disorder: impaired reflex function and altered muscle mechanics. Lancet Neurol. 2007;6(8):725–33.

    Article  Google Scholar 

  10. Stoykov ME, Madhavan S. Motor priming in neurorehabilitation. J Neurol Phys Ther. 2015;39(1):33–42.

    Article  Google Scholar 

  11. Dolbow DR, Holcomb WR, Gorgey AS. Improving the efficiency of electrical stimulation activities after spinal cord injury. Curr Phys Med Rehabil Rep. 2014;2(3):169–75.

    Article  Google Scholar 

  12. Reed B. The physiology of neuromuscular electrical stimulation. Pediatr Phys Ther. 1997;9:96–102.

    Article  Google Scholar 

  13. Merrill DR. Review of electrical stimulation in cerebral palsy and recommendations for future directions. Dev Med Child Neurol. 2009;51(SUPPL. 4:154–65.

    Article  Google Scholar 

  14. • Pool D, Elliott C, Bear N, Donnelly CJ, Davis C, Stannage K, et al. Neuromuscular electrical stimulation-assisted gait increases muscle strength and volume in children with unilateral spastic cerebral palsy. Dev Med Child Neurol. 2016;58(5):492–501. In this RCT, 32 subjects with spastic hemiplegic CP were examined to determine the effects of FES on gait, muscle volume and strength. It demonstrated sustained changed to muscle bulk and volume of the gastrocnemius muscle.

    Article  Google Scholar 

  15. Pool D, Valentine J, Bear N, Donnelly CJ, Elliott C, Stannage K. The orthotic and therapeutic effects following daily community applied functional electrical stimulation in children with unilateral spastic cerebral palsy: a randomised controlled trial. BMC Pediatr. 2015;15(1):1–10.

    Article  Google Scholar 

  16. • El-Shamy SM, Abdelaal AAM. WalkAide efficacy on gait and energy expenditure in children with hemiplegic cerebral palsy. Am J Phys Med Rehabil. 2016;95(9):629–38. In this RCT of 34 subjects with spastic hemiplegic CP, the intervention group demonstrated improvement gait parameters (stride length, cadence, speed, cycle time, and stance phase percentage) after FES.

    Article  Google Scholar 

  17. Damiano D, Prosser L, AK CL. Muscle plasticity and ankle control after repetitive use of a functional electrical stimulation device for foot drop in cerebral palsy. Neurorehabil Neural Repair. 2013;27(3):200–7.

    Article  Google Scholar 

  18. Pool D, Valentine J, Blackmore AM, Colegate J, Bear N, Stannage K, et al. Daily functional electrical stimulation during everyday walking activities improves performance and satisfaction in children with unilateral spastic cerebral palsy: a randomized controlled trial. Arch Physiother. 2015;5(1):5.

    Article  Google Scholar 

  19. Pool D, Blackmore AM, Bear N, Valentine J. Effects of short-term daily community walk aide use on children with unilateral spastic cerebral palsy. Pediatr Phys Ther. 2014;26(3):308–17.

    Article  Google Scholar 

  20. • Moll I, Vles JSH, Soudant DLHM, Witlox AMA, Staal HM, Speth LAWM, et al. Functional electrical stimulation of the ankle dorsiflexors during walking in spastic cerebral palsy: a systematic review. Dev Med Child Neurol. 2017;59(1):1230–6. This article provides a meta-analysis of FES in spastic cerebral palsy that analyzes outcomes in a time frame that extends beyond the scope of this review.

    Article  Google Scholar 

  21. Hamid S, Hayek R. Role of electrical stimulation for rehabilitation and regeneration after spinal cord injury: an overview. Eur Spine J. 2008;17(9):1256–69.

    Article  Google Scholar 

  22. Chiu H-C, Ada L. Effect of functional electrical stimulation on activity in children with cerebral palsy: a systematic review. Pediatr Phys Ther. 2014;26(3):283–8.

    Article  Google Scholar 

  23. Kerr C, McDowell B, McDonough S. Electrical stimulation in cerebral palsy : a review of effects on strength and motor function. Dev Med Child Neurol. 2004;46(3):205–13.

    Article  Google Scholar 

  24. Sheffler LR, Chae J. Neuromuscular electrical stimulation in neurorehabilitation. Muscle Nerve. 2007;35(5):562–90.

    Article  Google Scholar 

  25. Comeaux P, Patterson N, Rubin M, Meiner R. Effect of neuromuscular electrical stimulation during gait in children with cerebral palsy. Pediatr Phys Ther. 1997;9:103–9.

    Article  Google Scholar 

  26. Seifart A, Unger M, Burger M. The effect of lower limb functional electrical stimulation on gait of children with cerebral palsy. Pediatr Phys Ther. 2009;21(1):23–30.

    Article  Google Scholar 

  27. Albany K. Physical and occupational therapy considerations in adult patients receiving botulinum toxin injections for spasticity. Muscle Nerve. 1997;20(S6):221–31.

    Article  Google Scholar 

  28. Sadowsky CL, Hammond ER, Strohl AB, Commean PK, Eby SA, Damiano DL, et al. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med. 2013;36(6):623–31.

    Article  Google Scholar 

  29. • Dolbow J, Stevens S, Gassler J. The gait restorative effects of robotic-assisted gait training for individuals with neurodegenerative disease : a review; 2016. p. 2–13. This article provides a review of other RAGT modalities that have been used for restorative gait therapy cerebral palsy and analyzes outcomes in a time frame that extends beyond the scope of this review.

    Google Scholar 

  30. • Contreras-Vidal JL, Bhagat NA, Brantley J, Cruz-Garza JG, He Y, Manley Q, et al. Powered exoskeletons for bipedal locomotion after spinal cord injury. J Neural Eng. 2016;13(3). This review article reviews 22 studies that utilize eight powered exoskeletons that were analyzed based on the protocol design, subject demographics, study duration, and primary/secondary outcome measures in patients with SCI. It highlights that selection criteria may be important on who and how patients may benefit from certain technologies into therapy protocols.

  31. • Wu M, Kim J, Gaebler-Spira DJ, Schmit BD, Arora P. Robotic resistance treadmill training improves locomotor function in children with cerebral palsy: a randomized controlled pilot study. Arch Phys Med Rehabil. 2017;98(11):2126–33. In this article, 23 children with spastic CP were assigned either controlled assistance or resistance loads using RAGT. Improvements in walking speed and distance were only demonstrated in the group that received resistance demonstrating active participation is important in achieving lasting outcomes.

    Article  Google Scholar 

  32. Howlett OA, Lannin NA, Ada L, Mckinstry C. Functional electrical stimulation improves activity after stroke: a systematic review with meta-analysis. Arch Phys Med Rehabil. 2015;96(5):934–43.

    Article  Google Scholar 

  33. Aurich Schuler T, Müller R, Van Hedel HJ. Leg surface electromyography patterns in children with neuro-orthopedic disorders walking on a treadmill unassisted and assisted by a robot with and without encouragement. J Neuroeng Rehabil. 2013;10(1):1–13.

    Article  Google Scholar 

  34. • Bailes AF, Caldwell C, Clay M, Tremper M, Dunning K, Long J. An exploratory study of gait and functional outcomes after neuroprosthesis use in children with hemiplegic cerebral palsy. Disabil Rehabil. 2017;39(22):2277–85. This study followed 11 subjects with hemiplegic CP and found improvement while using FES as a neuroprosthesis, but no carry over effect.

    Article  Google Scholar 

  35. • Mukhopadhyay R, Lenka PK, Biswas A, Mahadevappa M. Evaluation of functional mobility outcomes following electrical stimulation in children with spastic cerebral palsy. J Child Neurol. 2017;32(7):650–6. In this feasibility study, the effects of FES in combination with PT in comparison to PT alone. The FES/Therapy group demonstrated an improvement in walking speed, GMFM and Physiologic Cost Index.

    Article  Google Scholar 

  36. Harrington AT, McRae CGA, Lee SCK. Evaluation of functional electrical stimulation to assist cycling in four adolescents with spastic cerebral palsy. Int J Pediatr. 2012;2012:1–11.

    Article  Google Scholar 

  37. Trevisi E, Gualdi S, De Conti C, Salghetti AM, Martinuzzi A, Pedrocchi A, et al. Cycling induced by functional electrical stimulation in children affected by cerebral palsy: case report. Eur J Phys Rehabil Med. 2012;48(1):135–45.

    CAS  PubMed  Google Scholar 

  38. • Wallard L, Dietrich G, Kerlirzin Y, Bredin J. Effect of robotic-assisted gait rehabilitation on dynamic equilibrium control in the gait of children with cerebral palsy. Gait Posture. 2018;60(June 2016):55–60. In this study, 30 subjects with CP GMFCS II were evaluated by gait analysis after treatment with the Lokomat versus subjects that had traditional PT. The subjects who received RAGT demonstrated improvement in postural and locomotive parameters , especially balance.

    Article  CAS  Google Scholar 

  39. • Wallard L, Dietrich G, Kerlirzin Y, Bredin J. Robotic-assisted gait training improves walking abilities in diplegic children with cerebral palsy. Eur J Paediatr Neurol. 2017;21(3):557–64. In this study, 30 subjects with CP GMFCS II were evaluated by gait analysis after treatment with the Lokomat versus subjects that had traditional PT. The subjects who received RAGT demonstrated improvement in GMFM, demonstrating improvements in gait and balance.

    Article  CAS  Google Scholar 

  40. Druzbicki M, Rusek W, Snela S, Dudek J, Szczepanik M, Zak E, et al. Functional effects of robotic-assisted locomotor treadmill therapy in children with cerebral palsy. J Rehabil Med. 2013;45(4):358–63.

    Article  Google Scholar 

  41. Matsuda M, Iwasaki N, Mataki Y, Mutsuzaki H, Yoshikawa K, Takahashi K, et al. Robot-assisted training using hybrid assistive limb® for cerebral palsy. Brain and Development. 2018;40(8):642–8.

    Article  Google Scholar 

  42. • Bayón C, Martin-Lorenzo T, Moral-Saiz B, Ramirez Ó, Perez-Somarriba A, Lerma-Lara S, et al. A robot-based gait training therapy for pediatric population with cerebral palsy: goal setting, proposal and preliminary clinical implementation. bioRxiv (submitted to JNER). 2018;255448. In this pilot study, subjects with CP received 16 non -consecutive training sessions over an 8-week period of time with goals defined by ICF-CY guidelines. At the end of the session, the subjects showed improvement in strength, velocity, step length, and gait performance.

  43. • Lerner ZF, Damiano DL, Bulea TC. A lower-extremity exoskeleton improves knee extension in children with crouch gait from cerebral palsy. Sci Transl Med. 2017;9(404):1–11. In this pilot study, seven subjects with CP GMFCS I-II with crouch gait were trialed in an exoskeleton that provided powered knee extension. After training, subjects showed improvement in early stance, late stance and hip extension.

    Article  Google Scholar 

  44. Ambrosini E, Ferrante S, Ferrigno G, Molteni F, Pedrocchi A. Cycling induced by electrical stimulation improves muscle activation and symmetry during pedaling in Hemiparetic patients. IEEE Trans Neural Syst Rehabil Eng. 2012;20(3):320–30.

    Article  Google Scholar 

  45. • Peri E, Ambrosini E, Pedrocchi A, Ferrigno G, Nava C, Longoni V, et al. Can FES-augmented active cycling training improve locomotion in post-acute elderly stroke patients? Eur J Transl Myol. 2016;26(3):6063. This is a single-blinded randomized control trial that compared FES-augmented cycling to traditional physiotherapy. The subjects that received FES-augmented cycling showed a higher percentage of change and results that were higher than the minimally clinical difference.

    Article  Google Scholar 

  46. • Carvalho I, Pinto SMSM, Das D, Chagas V, Praxedes JL, Santos D, et al. Robotic gait training for individuals with cerebral palsy: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2017;98(11):2332–44. This study is a meta-analysis evaluating different forms of RAGT on subjects of CP. The conclusion is there is benefit to this population by increasing walking speed, increasing endurance and improving GMFCM.

    Article  Google Scholar 

  47. Knaepen K, Mierau A, Swinnen E, Tellez HF, Michielsen M, Kerckhofs E, et al. Human-robot interaction: does robotic guidance force affect gait-related brain dynamics during robot-assisted treadmill walking? PLoS One. 2015;10(10):1–19.

    Article  Google Scholar 

  48. • Wu M, Kim J, Arora P, Gaebler-Spira DJ, Zhang Y. Effects of the integration of dynamic weight shifting training into treadmill training on walking function of children with cerebral palsy: a randomized controlled study. Am J Phys Med Rehabil. 2017;96(11):765–72. Twenty-three children with CP were randomly assigned to RAGT versus BWSTT. There were significant changes in walking speed and endurance in the group that received RAGT.

    Article  Google Scholar 

  49. • Van Hedel HJA, Severini G, Scarton A, O’Brien A, Reed T, Gaebler-Spira D, et al. Advanced robotic therapy integrated centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies. J Neuroeng Rehabil. 2018;15(1):1–16. This is a study that provided a meta-analysis of patients from 14 clinical practices with various neurological and gait deficits who used the Lokomat. The goal of this study is to assess the application and changes in function in real clinical practice.

    Article  Google Scholar 

  50. • Mazzoleni S, Battini E, Rustici A, Stampacchia G. An integrated gait rehabilitation training based on functional electrical stimulation cycling and overground robotic exoskeleton in complete spinal cord injury patients: preliminary results. Int Conf Rehabil Robot. 2017;2017:289–93. In this study both exoskeleton training and FES-cycling are used in the rehabilitative training of 20 SCI patients. Significant changes were found in spasticity, 6MWT, TUG, standing time and number of steps. This demonstrates that the uses of multiple technology modalities may provide more benefit than a single intervention.

  51. • Laursen CB, Nielsen JF, Andersen OK, Spaich EG. Feasibility of using Lokomat combined with functional electrical stimulation for the rehabilitation of foot drop. Eur J Transl Myol. 2016;26(3):268–73. This study integrates both Lokomat training with FES in patients with brain injury. The subjects showed an increase in the level of tibialis anterior muscle activation and dorsiflexion in swing phase when comparing pre and post intervention evolutions.

    Article  Google Scholar 

  52. Rossi S, Colazza A, Petrarca M, Castelli E, Cappa P, Krebs HI. Feasibility study of a wearable exoskeleton for children: is the gait altered by adding masses on lower limbs? PLoS One. 2013;8(9):1–9.

    Article  Google Scholar 

  53. Fasoli SE, Ladenheim B, Mast J, Krebs HI. New horizons for robot-assisted therapy in pediatrics. Am J Phys Med Rehabil. 2012;91(11 SUPPL.3):280–9.

    Article  Google Scholar 

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Authors and Affiliations

  1. Physical Medicine and Rehabilitation, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Road, Atlanta, GA, 30342, USA

    Joshua A. Vova

  2. Department of Rehabilitation, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Road, Atlanta, GA, 30342, USA

    Erin M. Eggebrecht

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  1. Joshua A. Vova
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Correspondence to Joshua A. Vova.

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Vova, J.A., Eggebrecht, E.M. Utilizing Functional Electrical Stimulation and Exoskeletons in Pediatrics: a Closer Look at Their Roles in Gait and Functional Changes in Cerebral Palsy. Curr Phys Med Rehabil Rep 7, 57–66 (2019). https://doi.org/10.1007/s40141-019-00215-w

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