Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications
Abstract
:1. Introduction
2. Materials and Methods
3. Results
3.1. Trunk Control and Balance Robotic Training
3.2. Robotic Gait Training: A Biomechanical Perspective
4. Discussion
- CP patients with levels I and/or II of GMFCS are characterized by fatigue over long walking distances with mild limitations in gait and balance. They, therefore, could benefit from a treadmill (with or without BWS) and/or Alter G for gait training to improve endurance and gait velocity. VR exercises may further stimulate motivation and longer rehabilitation sessions. In fact, virtual gaming platforms could enhance postural stability, also in patients with ataxic CP.
- In level III, CP patients need more support to walk, especially outside. In this context, wearable exoskeletons, such as the Ekso-GT (Figure 2a), are useful to promote overground walking and autonomy in ambulation (when possible). The motor function can also be improved using the Lokomat, one of the most adaptable robotic tools in neurorehabilitation, thanks to its characteristics (Figure 3) that allow training patients with moderate to severe motor alterations. In addition, Lokomat equipped with a VR screen can provide more challenging training sessions, thus further increasing concentration but also enjoinment.
- CP children between III and IV GMFCS levels present more balance and gait limitations, and the active achievement of an upright position is not always possible. This is why they could benefit from gait training with Innowalk Pro, which supports the patients from sitting to verticalization, in addition to a BWS system. Moreover, exoskeletons like the Lokomat and/or Robogait may help in guaranteeing gait movements in a more passive modality, also reducing efforts for little patients.
- CP patients with level IV present important motor impairments, which tend to confine them to wheelchairs. Then, they could benefit from passive robotic gait training using exoskeletons equipped with BWS (i.e., Lokomat and Robogait), providing constant assistance and monitoring vital signs (blood pressure and oxygen saturation). In addition, the use of HRS with or without VR can be a valid instrument to improve balance functions, postural reactions and abduction hip ROM.
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Reference n° | Robotic Device | Clinical Evaluation | Biomechanical Parameters |
---|---|---|---|
Robotic balance training | |||
16 | TruST—cable-driven robot which provides assist-as-needed forces. | SP&R-co; BBT; MFRT; | Lower-thorax orientation during sitting (flexion–extension plane) |
17 | RAGT (authors not specified the robotic system) | GMFM and TIS | Sitting balance |
18 | Lokomat—(description focused on balance) a fixed gait rehabilitation exoskeleton which facilitates a bilateral symmetrical gait, as the individual actively tries to advance each limb, during walking. | BBS, TUG, RMI, mEFAP, MM, PASS, POMA-B, SPPB, RMA | Walking speed and covered distance. |
19 | AlterG—it is a treadmill which enables patients to walk/run at low percentage of their body weight, thanks to its microgravity envinronment. | Romberg test and DTI evaluation | Center of Pressure (CoP) |
20 | AlterG—mentioned above | BBT, TUG, DTI evaluation | Balance and posture |
22 | HRS—is a robotic device with a dynamic saddle. | Stabilometric platform, GMFM, Sitting assessment scale (SAS), BBS, B-POMA, SATCo, Romberg test | Balance, pelvic torsion, and pelvic tilt |
23 | Horseback riding simulator JOBA–robotic simulator of horse movement. | NA | Spinal posture: trunk imbalance, pelvic torsion, and pelvic tilt |
27 | Robotic HPOT system (FORTIS-102)—This robotic system simulates live horse movements (I.e. walk, trot, and gallop) and the partecipant is instructed to the different patterns of movement. | Ultrasound imaging of EO, IO, TrA, LM. | CoP, CoM |
28 | horse riding simulator U-Gallop—indoor exercise equipment, which uses the oscillatory action of the seat to simulate the horse riding experience. | MAS and PROM in hip abduction | NA |
Robotic assisted gait training evidence | |||
13 | Lokomat—(description focused on gait) robotic exoskeleton with active hip–knee actuation and passive ankle control during the swing phase, in addition to a variable level of assistance. | GMFM and Cerebral Palsy Quality of Life Questionnaire (CP QOL) | NA |
33 | Lokomat—mentioned above | Clinical gait analysis and GMFM | COP, COM, propulsive forces in anteroposterior and Medio lateral directions |
34 | RAGT (authors not specified the robotic devices) | GMFM, 6MWT | Walking speed, |
35 | Innowalk Pro—it is an end-effector that supports the user from sitting into a standing position, and provides assisted, guided and repetitive movements in a safe upright, weight-bearing position. | GMFM, 10MWT, 6MWT, standing on one leg test, PBBS, FAQ-WL | Walking speed and endurance, balance, |
36 | Robogait— is a fixed lower body hip-knee exoskeleton. The user’s weight is supported by a combination of an overhead attached harness and the support from the exoskeleton. | GMFM and 6MWT | Walking covered distance and gait velocity |
38 | tethered knee exoskeleton, pediatric knee exoskeleton (P.REX), untethered ankle exoskeleton, WAKE-Up ankle module, WAKE-Up ankle & knee module and unilateral ankle exosuit— It is not a passive robot but the device can interact actively with patients, correcting also the motor actions on the joint motion; in this way the subject is assisted or less only when requested. | EMG | Walking cadence, stride length and/or step length, gait symmetry, stride to stride vaiability |
39 | wearable joint-torque-assisting exoskeletal robot called the Angel Legs M20—wearable walking device that induce proper gait and support of the lower limbs. | GMFM, 6MWT,10MWT, Oxygen consumption | Walking speed |
40 | HWA (exoskeleton that assists hip flexion and extension of both limbs during gait)—it detects the gait cycle by the potentiometers (set beside the actuators) and produces flexion and extension torques on swing and stance phases, respectively. | MAS, ROM and MVC of hip flexion, hip extension, knee flexion, knee extension, dorsiflexion, and plantar flexion, GMFM (D and E dimensions), PEDI | Walking speed and gait symmetry |
41 | Lokomat—mentioned above. | hand-held dynamometer to test strength of lower limb muscles | Walking speed, cadence, stride length and sagittal joint kinematic gait parameters: pelvis, hip, knee and ankle minimum and maximum angles, as well as range of motion (ROM) during the stance phase. |
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Share and Cite
Bonanno, M.; Militi, A.; La Fauci Belponer, F.; De Luca, R.; Leonetti, D.; Quartarone, A.; Ciancarelli, I.; Morone, G.; Calabrò, R.S. Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications. J. Clin. Med. 2023, 12, 3278. https://doi.org/10.3390/jcm12093278
Bonanno M, Militi A, La Fauci Belponer F, De Luca R, Leonetti D, Quartarone A, Ciancarelli I, Morone G, Calabrò RS. Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications. Journal of Clinical Medicine. 2023; 12(9):3278. https://doi.org/10.3390/jcm12093278
Chicago/Turabian StyleBonanno, Mirjam, Angela Militi, Francesca La Fauci Belponer, Rosaria De Luca, Danilo Leonetti, Angelo Quartarone, Irene Ciancarelli, Giovanni Morone, and Rocco Salvatore Calabrò. 2023. "Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications" Journal of Clinical Medicine 12, no. 9: 3278. https://doi.org/10.3390/jcm12093278