Practical Recommendations for Robot-Assisted Treadmill Therapy (Lokomat) in Children with Cerebral Palsy: Indications, Goal Setting, and Clinical Implementation within the WHO-ICF Framework

Abstract

Active participation and the highest level of independence during daily living are primary goals in neurorehabilitation. Therefore, standing and walking are key factors in many rehabilitation programs. Despite inconclusive evidence considering the best application and efficacy of robotic tools in the field of pediatric neurorehabilitation, robotic technologies have been implemented to complement conventional therapies in recent years. A group of experienced therapists and physicians joined in an “expert panel.” They compared their clinical application protocols, discussed recurring open questions, and developed experience-based recommendations for robot-assisted treadmill therapy (exemplified by the Lokomat, Hocoma, Volketswil, Switzerland) with a focus on children with cerebral palsy. Specific indications and therapeutic goals were defined considering the severity of motor impairments and the International Classification of Functioning, Disability and Health framework (ICF). After five meetings, consensus was found and recommendations for the implementation of robot-assisted treadmill therapy including postsurgery rehabilitation were proposed. This article aims to provide a comprehensive overview on therapeutical applications in a fast developing field of medicine, where scientific evidence is still scarce. These recommendations can help physicians and therapists to plan the child's individual therapy protocol of robot-assisted treadmill therapy.

Keywords

child - cerebral palsy - rehabilitation - robotics - International Classification of Functioning, Disability and Health

• References

• 1 Barbeau H, Rossignol S. Recovery of locomotion after chronic spinalization in the adult cat. Brain Res 1987; 412 (1) 84-95
• 2 Lovely RG, Gregor RJ, Roy RR, Edgerton VR. Effects of training on the recovery of full-weight-bearing stepping in the adult spinal cat. Exp Neurol 1986; 92 (2) 421-435
• 3 Dobkin B, Apple D, Barbeau H , et al; Spinal Cord Injury Locomotor Trial Group. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology 2006; 66 (4) 484-493
• 4 Lum PS, Burgar CG, Shor PC, Majmundar M, Van der Loos M. Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Arch Phys Med Rehabil 2002; 83 (7) 952-959
• 5 Mayr A, Kofler M, Quirbach E, Matzak H, Fröhlich K, Saltuari L. Prospective, blinded, randomized crossover study of gait rehabilitation in stroke patients using the Lokomat gait orthosis. Neurorehabil Neural Repair 2007; 21 (4) 307-314
• 6 Werner C, Von Frankenberg S, Treig T, Konrad M, Hesse S. Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients: a randomized crossover study. Stroke 2002; 33 (12) 2895-2901
• 7 Mehrholz J, Elsner B, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev 2013; 7: CD006185
• 8 Tefertiller C, Pharo B, Evans N, Winchester P. Efficacy of rehabilitation robotics for walking training in neurological disorders: a review. J Rehabil Res Dev 2011; 48 (4) 387-416
• 9 Damiano DL, DeJong SL. A systematic review of the effectiveness of treadmill training and body weight support in pediatric rehabilitation. J Neurol Phys Ther 2009; 33 (1) 27-44
• 10 Dodd KJ, Foley S. Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial. Dev Med Child Neurol 2007; 49 (2) 101-105
• 11 Willoughby KL, Dodd KJ, Shields N, Foley S. Efficacy of partial body weight-supported treadmill training compared with overground walking practice for children with cerebral palsy: a randomized controlled trial. Arch Phys Med Rehabil 2010; 91 (3) 333-339
• 12 Prosser LA. Locomotor training within an inpatient rehabilitation program after pediatric incomplete spinal cord injury. Phys Ther 2007; 87 (9) 1224-1232
• 13 DeLuca PA. Gait analysis in the treatment of the ambulatory child with cerebral palsy. Clin Orthop Relat Res 1991; (264) 65-75
• 14 World Health Organisation ICoF. Disability and Health, Child & Youth Version: ICF-CY. Geneva, Switzerland: WHO; 2007
• 15 Schiariti V, Klassen AF, Cieza A , et al. Comparing contents of outcome measures in cerebral palsy using the International Classification of Functioning (ICF-CY): a systematic review. Eur J Paediatr Neurol 2014; 18 (1) 1-12
• 16 Westbom L, Hagglund G, Nordmark E. Cerebral palsy in a total population of 4-11 year olds in southern Sweden. Prevalence and distribution according to different CP classification systems. BMC Pediatr 2007; 7: 41
• 17 Himpens E, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, distribution, and severity of cerebral palsy in relation to gestational age: a meta-analytic review. Dev Med Child Neurol 2008; 50 (5) 334-340
• 18 Smania N, Bonetti P, Gandolfi M , et al. Improved gait after repetitive locomotor training in children with cerebral palsy. Am J Phys Med Rehabil 2011; 90 (2) 137-149
• 19 Drużbicki M, Rusek W, Snela S , et al. Functional effects of robotic-assisted locomotor treadmill thearapy in children with cerebral palsy. J Rehabil Med 2013; 45 (4) 358-363
• 20 McNevin NH, Coraci L, Schafer J. Gait in adolescent cerebral palsy: the effect of partial unweighting. Arch Phys Med Rehabil 2000; 81 (4) 525-528
• 21 Meyer-Heim A, Borggraefe I, Ammann-Reiffer C , et al. Feasibility of robotic-assisted locomotor training in children with central gait impairment. Dev Med Child Neurol 2007; 49 (12) 900-906
• 22 Meyer-Heim A, Ammann-Reiffer C, Schmartz A , et al. Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy. Arch Dis Child 2009; 94 (8) 615-620
• 23 Borggraefe I, Schaefer JS, Klaiber M , et al. Robotic-assisted treadmill therapy improves walking and standing performance in children and adolescents with cerebral palsy. Eur J Paediatr Neurol 2010; 14 (6) 496-502
• 24 Borggraefe I, Kiwull L, Schaefer JS , et al. Sustainability of motor performance after robotic-assisted treadmill therapy in children: an open, non-randomized baseline-treatment study. Eur J Phys Rehabil Med 2010; 46 (2) 125-131
• 25 Dietz V, Nef T, Rymer WZ. Neurorehabilitation Technology. London, United Kingdom: Springer Verlag; 2012
• 26 Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997; 39 (4) 214-223
• 27 Schroeder AS, Von Kries R, Riedel C , et al. Patient-specific determinants of responsiveness to robot-enhanced treadmill therapy in children and adolescents with cerebral palsy. Dev Med Child Neurol 2014; 56 (12) 1172-1179
• 28 Zwicker JG, Mayson TA. Effectiveness of treadmill training in children with motor impairments: an overview of systematic reviews. Pediatr Phys Ther 2010; 22 (4) 361-377
• 29 Schroeder AS, Homburg M, Warken B , et al. Prospective controlled cohort study to evaluate changes of function, activity and participation in patients with bilateral spastic cerebral palsy after Robot-enhanced repetitive treadmill therapy. Eur J Paediatr Neurol 2014; 18 (4) 502-510
• 30 Palisano RJ, Cameron D, Rosenbaum PL, Walter SD, Russell D. Stability of the gross motor function classification system. Dev Med Child Neurol 2006; 48 (6) 424-428
• 31 Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol 2008; 50 (10) 744-750
• 32 Borggraefe I, Klaiber M, Schuler T , et al. Safety of robotic-assisted treadmill therapy in children and adolescents with gait impairment: a bi-centre survey. Dev Neurorehabil 2010; 13 (2) 114-119
• 33 Heinen F, Desloovere K, Schroeder AS , et al. The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol 2010; 14 (1) 45-66
• 34 Bax M, Goldstein M, Rosenbaum P , et al; Executive Committee for the Definition of Cerebral Palsy. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol 2005; 47 (8) 571-576