Evaluation of the Effectiveness of Robotic Gait Training and Gait-focused Physical Therapy Programs for Children and Youth With Cerebral Palsy: A Mixed Methods Randomized Controlled Trial
Trial Snapshot
- Phase
- Not Applicable
- Status
- Completed
- Sponsor
- University of Alberta
- Enrollment
- 68
- Locations
- 6
- Primary Endpoint
- Change in gross motor abilities using the Gross Motor Function Measure (GMFM-66) from 0-8 and 0-20 weeks
Study Overview
Brief Summary
Robot assisted gait training is seen as a promising intervention for improving the walking abilities of children with cerebral palsy, but research to support its effectiveness compared to best practice physical therapy is lacking. This research consists of a randomized controlled trial (RCT) and a qualitative descriptive study that is linked with the RCT. The goal of the RCT is to compare: 1) a walking training program with the Lokomat® robotic device (LOK), 2) a functional physical therapy program (fPT) that includes activities to enhance balance/co-ordination/endurance and advanced motor skills conducted over 'real ground', 3) a combined Lokomat® + functional physical therapy (LOK+fPT) program, and 4) a regular maintenance therapy condition (CONT) for ambulatory children and youth with CP (aged 5- 18 years). The three intervention programs will consist of sixteen 50-minute sessions given twice weekly over 8 to 10 weeks. The primary objective of the RCT is to compare the four groups with respect to walking-related motor skills as measured by the Gross Motor Function Measure. The secondary objectives are to compare each intervention's impact on walking abilities, individualized goals, fitness, balance, physical activity levels, child's belief in ability to do physical activity, participation and quality of life. The investigators will also evaluate the extent of carryover or progress 3 months after the intervention. The qualitative part of the study will consist of interviews of children and parents after they have finished the study intervention. The information from the interviews will assist us with interpretation of the outcome results (areas of impact and amount of change) from the RCT. In particular, the interviews will 1) provide insight into their experiences with the trial interventions, 2) identify the mobility-related outcomes that are important to families and the factors that influence their preferences, and 3) explain the family values, experiences and contextual factors that influenced participation in the study. This research will provide information needed to allow clinicians and families to make informed choices about Lokomat therapy and physical therapy options in relation to their child's functional goals and abilities.
Detailed Description
Cerebral palsy (CP) is the most common cause of childhood physical disability, affecting 2.0-2.5 in 1000 children. CP represents a group of disorders of movement and posture with impairments (e.g., muscle weakness, decreased selective motor control, alterations in muscle tone, and impairment of postural control) that collectively affect functional mobility. About 65% of children/youth with CP use minimal or no assistive devices (leg braces, walkers, and/or wheelchairs) to walk (i.e., Gross Motor Function Classification System (GMFCS) Levels I and II) while children in GMFCS Levels III - V require varying degrees of bracing, walkers and other walking devices, wheelchairs, or assistance from others for mobility.
Robotic Assisted Gait training devices are increasingly used with children with CP to improve their gait related motor skills. The Lokomat® (LOK) is a commercially available robot assisted gait training system that uses robotics to simulate walking. It facilitates inter-limb co-ordination and gait cycle timing and provides variable degrees of body weight support and guidance.
This study represents the first adequately powered RCT to evaluate the effectiveness of robot assisted gait training for children with CP. The qualitative aspect will give contextual information to assist with interpretation of the RCT and provide valuable information about families' experiences with the interventions.
The research questions for this study are:
i) What is the comparative effectiveness of robot assisted gait training (LOK) and fPT program for improving gait related motor skills of ambulatory children and youth with CP? ii) Does combining LOK and fPT result in greater improvements in gait related motor skills of ambulatory children and youth with CP than robot assisted gait training or fPT alone? iii) What are families' experiences with trial participation and what implications do they have for interpretation of the quantitative results and the use of robot assisted gait training and fPT in clinical settings?
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Factorial
- Primary Purpose
- Treatment
- Masking
- Single (Outcomes Assessor)
Eligibility Criteria
- Ages
- 5 Years to 18 Years (Child, Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Diagnosis of CP (any type), GMFCS Levels II and III
- •Able to follow GMFM testing instructions, and to participate in a minimum of 30 minutes of active PT (as judged by the child's PT or physician if not followed by a PT)
- •Able to reliably signal pain, fear and discomfort using verbal or nonverbal signals
- •Passive range of motion (ROM) of hips and knees within minimum range requirement for LOK (hip and knee flexion contracture < 10 degrees, and knee valgus < 40 degrees).
- •Parent/child agrees to attend 16 study intervention sessions (given within two 10-week periods), a LOK fitting/acclimatization session or fPT acclimatization session and the three assessment sessions during the course of the study.
- •Parent agrees to contact of their primary PT (if not already involved by parent in the screening process) and their paediatrician or physiatrist to confirm eligibility.
- •Parent agrees that regular PT (and other gross motor mobility therapies such as conductive education and MEDEK) will be discontinued from the time of the baseline assessment through the 8 to 10 weeks of the active intervention or control group. Note that home programs such as stretching and strengthening and treadmill and exercise bike riding (no more than 10 minutes total per day) will be permitted in all groups.
Exclusion Criteria
- •Botulinum Toxin injection within the past 4 months or planned within the next 6 months
- •Fixed knee contracture > 10 degrees, knee valgus >40 degrees such that orthosis will not be adaptable to lower limbs.
- •Hip instability/subluxation as demonstrated by a migration percentage > 45%
- •Orthopaedic surgery (soft tissue releases) within the last 9 months, or lower limb bony surgery within the last 18 months
- •Severe spasticity may be a contraindication as determined in Lokomat trial session using L-FORCE assessment.
- •Any weightbearing restrictions.
- •Seizure disorder unless fully controlled by medication and no evidence of seizure in the last 12 months and physician provides singed approval to enter the study
- •Open skin lesions or vascular disorder of lower extremities
- •Not able to co-operate or be positioned adequately within the LOK as shown during the fitting/acclimatisation session. -
Arms & Interventions
Gait focused physical therapy (fPT)
Two 50-minute sessions per week. Each weekly fPT session consists of 50 minutes of active treatment, a 'dose' equivalent to time spent in active treatment in the LOK arm. Techniques that focus on body structure changes will be not be permitted (e.g., inhibitive casting, kinesiotaping, functional electrical stimulation).
Intervention: Gait focused physical therapy (fPT) (Procedure)
LOK + fPT
Two 50-minute sessions per week. Children will receive both the LOK and the fPT protocols (content as described above for each) for the duration of the 8 to 10 week intervention phase. These will be given as two sessions of LOK one week alternating with two sessions of fPT the next week. The fPT will build on motor learning principles because the activities will allow the child to practice motor skills in a variety of different activities. Techniques focusing on body structure changes will be prohibited.
Intervention: LOK + fPT (Procedure)
Lokomat (LOK)
Two 50-minute sessions per week. The manualized LOK walking protocol provides methods for progressing/tracking including a 5-minute overground walking session after the LOK to facilitate transfer of motor learning from the LOK to usual walking devices. The goal-based LOK program uses a standardized approach to progressing LOK body weight and guidance support and includes upper body activities while walking to encourage dual tasking and improved posture, and motor imagery practice.
Intervention: Lokomat (LOK) (Procedure)
Maintenance therapy
Consists of maintenance therapy and a weekly email from the centre's research assistant to monitor any co-interventions. Maintenance may include range of motion/stretching and basic isometric strength home program as well as up to 10 minutes per day of exercise bicycle or treadmill or general walking practice.
Outcomes
Primary Outcomes
Change in gross motor abilities using the Gross Motor Function Measure (GMFM-66) from 0-8 and 0-20 weeks
Time Frame: Baseline, 8 weeks, 20 weeks
A standardized measure of gross motor function for children with cerebral palsy
Secondary Outcomes
- Change in individual goal attainment using the Canadian Occupational Performance Measure (COPM) performance ratings from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in walking distance using the 6-Minute walk test from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in Quality FM from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in quality of life using the Life Satisfaction Scale from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in individual goal attainment using Goal Attainment Scaling (GAS) from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in anaerobic capacity using the Adapted Shuttle Run Test from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in confidence in performing ambulatory abilities as measured by the Activities Balance Confidence Scale from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in Pediatric Berg Balance Scale from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in the participation measured using the Participation and Environment Measure for Children and Youth (PEM-CY) from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in functional abilities as measured by the PEDI-CAT from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks)
- Change in # of steps/day from 0-8 and 0-20 weeks as measured with an accelerometer.(Baseline, 8 weeks, 20 weeks)
- Change in self-efficacy for physical activity as measured by the Physical Activity Self-efficacy scale(Baseline, 8 weeks, 20 weeks)
- Change in quality of life using the Kidscreen from 0-8 and 0-20 weeks(Baseline, 8 weeks, 20 weeks-up)