August 2015

Robotic gait training doesn’t wow young patients with CP

Photo courtesy of William Suarez/Holland Bloorview Kids Rehabilitation Hospital

Photo courtesy of William Suarez/Holland Bloorview Kids Rehabilitation Hospital

Kids, parents differ on ‘normal’ gait

By Brigid Galloway

Although physical therapists and parents often strive for attaining “normal” gait in children with neuromotor disorders, a new study from researchers at the University of Alberta in Edmonton, Canada, indicates that children undergoing robotic gait training therapy may not share the same enthusiasm for this goal.

The qualitative study assessed the expectations and experiences of five children aged 8 to 11 years with cerebral palsy (CP, gross motor function classification system levels II or III), who underwent robotic gait training with a treadmill-based gait trainer, and their parents. The trainer provides upright support while using robotic orthoses to move the patient’s legs. Its adjustable body-weight support allows children to use a more vertical, physiologically typical gait pattern.

Over about 10 weeks, the children underwent 16 sessions of robotic gait training, which involved stepping over blocks, active hip extension against resistance, and playing with a ball while walking. The sessions also included video games in which children had to do specific movements to advance in play.

The study underscores the need for research that focuses on the opinion and voices of young patients, who often get mixed messages.

Researchers interviewed children and parents after the child’s last robotic training session. They asked parents about their expectations, experiences, and perceived outcomes with regard to the robotic trainer and walking goals for their child. Questions for children were designed to get their perspective on walking, as well as how they felt about using the trainer.

Parents generally expressed interest in continuing robotic gait training, felt it made their children more confident, and assumed their children found the games engaging and that they valued being able to walk like a typically developing child.

The children had more mixed impressions of the robotic trainer, finding it alternately “fun,” “boring,” and even “uncomfor­table/painful.” Young respondents also did not echo their parents’ point of view on “normal” gait, said lead author Shanon Phelan, PhD, assistant professor of occupational therapy at the University of Alberta. “They often equated normal walking with their typical gait, weren’t always sure whether the robot was helping them, and didn’t universally find it fun or engaging.”

Parents thought robotic training, which took place at Holland Bloorview Kids Rehabilitation Hospital in Toronto, boosted children’s confidence, but the children didn’t express this, and some felt anxiety about engaging the technology. Also a prominent problem for children was skin irritation caused by the trainer’s straps.

Both children and parents, however, said they valued the interactions with their therapists regardless of the technology.

“This study calls for critical reflection on why and how one might engage children in gait-related rehabilitation in ways that bring children’s desires and expectations to the forefront,” said Phelan. “This challenges clinicians to rethink how gait-related interventions are presented to children and families and how goals and outcomes are framed. For example, if a child is ambivalent about the quality of his or her gait, or [already] sees his or her gait pattern as ‘normal,’ one might consider presenting the benefits of an intervention in ways that highlight what is meaningful to the child and reinforce their abilities and positive self-identity.”

The study underscores the need for research that focuses on the opinion and voices of young patients, who often get mixed messages, she said.

“People in their lives often reinforce the idea of social acceptance. They hear, ‘there is nothing wrong with the way you walk,’ yet they participate in therapy to work on walking more like their same-aged, nondisabled peers,” she said. “When we focus solely on the physical aspects of walking/gait training, we can forget about the social and emotional implications for children.”

Disability and Rehabilitation epublished the study on April 9.

Theresa Sukal Moulton, PT, DPT, assistant research professor at Northwestern University in Evanston, IL, has worked extensively with children with CP using therapeutic robotic devices. Despite the inability to generalize the feelings, perceptions, and goals of this small cohort of patients onto all children with gait disorders, the study brings significant considerations to light, she said.

“The mismatch between a parent’s and child’s goals and perceptions about the effectiveness of therapeutic modalities is not uncommon in my clinical experience,” said Moulton. “Pediatric clinicians have the unique challenge of treating the whole family, so the perspective of both parents and patients must be considered and balanced, in an age-appropriate way.”

Brigid Galloway is a freelance journalist in Birmingham, AL.

Source:

Phelan SK, Gibson BE, Wright FV. What is it like to walk with the help of a robot? Children’s perspectives on robotic gait training technology. Disabil Rehabil 2015 Apr 9:1-10. [Epub ahead of print]

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