Cerebral palsy is the most common cause of physical disability in childhood . In Australia, one child is born with cerebral palsy every 15 hours . It is a life long neurological condition that occurs early in life and with advances in medical care and improved neonatal survival rates, more children with cerebral palsy now live into adulthood . Not only does this have a lifelong impact regarding health, well-being and quality of life but also impacts economically with a reported financial cost of $1.47 billion in 2007(0.14% GDP), making cerebral palsy one of the top 5 most costly conditions in Australia .
As such, recommendations for future directions are focused on research evaluating treatment effectiveness to maximize service delivery in order to improve quality of life and functioning to minimize the impact of this life long condition .
Physiotherapy is an important patient focused healthcare delivery intervention that is necessary to improve functioning of muscles, walking and in the prevention of deformities. The life-long impact of cerebral palsy is higher than many conditions because of the early age onset. Hence physiotherapy needs to be provided from an early age to influence not only muscular structure (such as strength and flexibility) but also neurological structures such as the brain - which can learn and change when given the right stimulus to do so [8,9].
There has been a recent paradigm shift in how to train and promote walking in people with neurological conditions [8–10]. Activity and intensity of training are crucial and much of this has been drawn from neurological research and spinal cord injury research . It is increasingly recognised that teaching the pattern of walking is important to stimulate the central pattern generators – the intrinsic and reflexive pathways in our neurological system that guide movement .
This approach is not well understood in the area of cerebral palsy but given the theoretical foundation combined with our pilot work that has demonstrated feasibility and potential efficacy, a controlled larger scale study is necessary. This is particularly relevant because technology is now increasingly available in the community but is supported by limited evidence. Evidence based approaches are necessary to ensure ethical use of limited funds.
The significance of this research recognizes that one in three children with cerebral palsy cannot walk  and rely on equipment aides and physical support from carers. Hence programs focusing on walking will address known issues due to sedentary behaviour in children with cerebral palsy and in the prevention of obesity and pain [11,12]. Such interventions will improve independence and functioning hence reducing the burden of care, which is by far, accountable for the highest economic impact of this condition . Therefore training to walk at an early age actually translates to increasing and maintaining movement, strength, independence, function, participation and well-being to reduce the burden of care not just for short term gain but well into the future as children become adults.
The primary aims of this research are to determine if robotic assistive rehabilitation improves mobility in children with cerebral palsy who usually require assistance to walk.
In addition, the secondary aims are to also:
1. Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. Australian Journal of Physiotherapy. 2003;49(1):7–12.
2. ACPR. Report of the Australian Cerebral Palsy Register, Birth years 1993-2003. 2009.
3. Access Economics Ltd Pty. The economic impact of cerebral palsy in Australia 2007. 2008.
4. Novak I, Hines M, Goldsmith S, Barclay R. Clinical Prognostic Messages From a Systematic Review on Cerebral Palsy. Pediatrics. 2012;130(5):e1285–e1312.
5. Marder E, Bucher D. Central pattern generators and the control of rhythmic movements. Current Biology. 2001;11(23):986–996.
6. Dunlop S. Activity-dependent plasticity: implications for recovery after spinal cord injury. Trends in Neurosciences. 2008;31(8):410–418.
7. Brooks JC, Strauss DJ, Shavelle RM, Tran LM, Rosenbloom L, Wu YW. Recent trends in cerebral palsy survival. Part II: Individual survival prognosis. Developmental Medicine and Child Neurology. 2014:1065–1071.
8. Yang JF, Livingstone D, Brunton K, Kim D, Lopetinsky B, Roy F, Zewdie E, Patrick SK, Andersen J, Kirton A, et al. Training to enhance walking in children with cerebral palsy: are we missing the window of opportunity? Seminars in pediatric neurology. 2013;20(2):106–15.
9. Damiano D. Effects of motor activity on brain and muscle development in cerebral palsy. In: Shepherd RB, editor. Cerebral palsy in infancy. Targeted activity to optimize early growth and development. 1st Ed. Sydney: Churchill Livingstone Elsevier; 2014. p. 205–215.
10. Damiano DL. Activity, activity, activity: rethinking our physical therapy approach to cerebral palsy. Physical therapy. 2006;86(11):1534–1540.
11. Parkinson KN, Dickinson HO, Arnaud C, Lyons A, Colver A. Pain in young people aged 13 to 17 years with cerebral palsy: cross-sectional, multicentre European study. Archives of disease in childhood. 2013;98(6):434–40.
12. Butler JM, Scianni A, Ada L. Effect of cardiorespiratory training on aerobic fitness and carryover to activity in children with cerebral palsy: a systematic review. International journal of rehabilitation research. 2010;33(2):97–103.
Julie, an 8 year old girl who uses elbow crutches in the community and sometimes relies on a wheelchair for longer distances. Her goals were to improve her walking endurance and balance to reduce her falls. After 6 weeks, she improved her walking speed, decreased her reliance on walking aides and was falling over less. She is now able to walk more independently at school and in the community. Her mother Jennifer’s feedback was: The intensive therapy program was amazing. It allowed Julie to be 100% in charge of her therapy goals and achievements. She was motivated, enthusiastic and engaged. This resulted in her making exciting gains and improvement in her independent walking.
Paul, a 5 year old boy who mainly relies on a wheelchair wanted to be able to walk in his walking frame at home. His mother Sally wanted him to be able to stand more on his own to reduce the amount of lifting she had to do. Sally summarised their experience: I as a mother, who has tried out intensive therapy overseas and NAPA therapy was a complete sceptic. I didn’t really understand how Paul would benefit from a few hours per week of walking and cycling in a machine would help. It was hard to watch my son try and walk 10 metres in over 6mins in his walker. Something that took seconds for abled children to complete….I was pleasantly surprised that after 3 weeks of the therapy he was able to do this in not half the time but quarter of the time! This program by far has been the only program to give him so much more confidence, more belief in himself, have less fear and most importantly, wanted to be more upright and on his feet more. I couldn’t be happier with the results. Paul has matured in this time and has been walking more and more in his walker…the program has been remarkable and exceeded all my expectations. This program should be available to all children like Paul, the proof and evidence is clearly there, its a life changing program!
Alison, a 5 year old girl who is reliant on a wheelchair for all settings and faces further complications from significantly impaired vision. She wanted to be able to walk in her walking frame indoors but muscle stiffness prevents her left leg to bend. After 6 weeks, she was able to bend her leg and can now walk independently in her frame indoors, by up to 50m. Her heart rate response demonstrates that she is doing the equivalent of interval fitness training, providing the opportunity to exercise when it was not possible to do so before. “Just to see her walking so freely in her walker is amazing. She could only do 1 step before. She loves it and is very enthusiastic about walking”
a locomotor training program for children with cerebral palsy
Functional electrical stimulation for children with cerebral palsy
Clinical application from results from the Walk Aide Study.
Cerebral Palsy is a movement disorder that affects 2.7 per 1000 live births in Western Australia. Muscle weakness and tightness are common in people with cerebral palsy. Its effects are varied but lifelong.
Spastic hemiplegia is a type of cerebral palsy, which means that muscle weakness and muscle tightness (spasticity) affect one (right or left) side of the body including the arm and the leg. This can make walking a challenge because one side of the body is more difficult to move. When walking, the foot sometimes “catches” on the ground. This is because the muscles are not strong enough to bend the ankle and lift the foot up when taking a step. The person appears to be limping. This “catching” of the foot on the ground is called “foot drop”. It can cause frequent tripping or even falling over which can greatly impact a child or teenager’s confidence and ability to keep up with their peers.
The Walk Aide ® is a small device that is simply strapped to the leg just below the knee on the weak side of the body. It provides electrical impulses each time the person takes a step. The electrical impulses stimulate the muscles to lift the foot up during walking so that the person with hemiplegia does not “catch” or trip over their foot, so it is very useful in preventing tripping and falling.
We have now established that the Walk Aide ® is accepted and well tolerated by children in this age range with notable changes in their strength, tightness as well as reductions in tripping and falling. The next crucial step is to conduct a more comprehensive study involving a greater number of children with spastic hemiplegia to truly and conclusively understand what these changes are and why they are occurring.
Understanding this is important so that we can not only establish guidelines for which children may best benefit from using such a device, but also determine if there is an age it should be implemented for maximum benefit. If the use of the Walk Aide ® demonstrates effectiveness, it may be a very efficient treatment technique as the child will be doing their physiotherapy with each and every step.
Children and adolescents with cerebral palsy often have problems with their ability to walk. Weak leg muscles make it difficult or even impossible for the children and youth to control how they move their ankle and toes. Without this ability, tripping and falling is inevitable making walking very difficult. This can severely impact daily life, limiting the ability to walk safely. This is usually managed by a rigid brace that helps to hold the foot at an angle that reduces trips and falls. However, for some children, using the brace can be met with difficulty as it can be quite restrictive on their movement.
Technology is always evolving and this presents as an exciting opportunity to find new and innovative ways to provide treatments to children and adolescents with physical disabilities. The Walk Aide® is one such device that uses electrical impulses to lift the toes up at the exact time when walking to prevent trips and falls. Over the past 4 years, with the support of the PMH Foundation, our research team has conducted and published numerous studies to establish the effect of the Walk Aide® on a range of outcomes in children with physical disabilities. We have shown that it is effective in improving walking ability, strength, balance and even muscle size. It was well tolerated and described to be preferable to braces.
The Walk Aide® studies have also made several clinical recommendations which take into consideration both our results as well as children and parent feedback. It is time now for the Next Steps Project – a time to take all that we have learnt from the Walk Aide® studies into clinical practice to ensure that more children with physical disabilities can access this treatment. We have developed a clear knowledge translation plan to ensure the knowledge from our Walk Aide® studies will get translated into clinical practice. This plan has been developed with the involvement of all project partners including consumers, researchers, clinicians and management.
A number of evidence based knowledge translation strategies will be employed including small group training for clinicians, educational outreach, multi-professional collaboration, combined interventions, educational material champions and performance feedback. The outcome of this could have the potential to change and improve how a child participates or in other words, how they get involved in day to day activities.