Walking In Children Research Articles

Effects of mind-body exercise in children with cerebral palsy—A systematic review and meta-analysis

Background and purposeAn increasing number of studies have investigated the efficacy of mind-body exercise in the treatment of children with cerebral palsy (CP). However, the findings of these researches have produced inconsistent results. The objective of this study was to evaluate the effects of mind-body exercise on children with CP in order to provide more conclusive results. Materials and methodsA comprehensive search was conducted in PubMed, Cochrane, Embase, Web of Science, and Ovid databases from inception to May 2024. One researcher extracted the data, including first author, study type, country, year of publication, population, age, sample size, intervention details and outcomes, accuracy was verified by a second researcher. The included studies were analyzed using Review Manager 5.4 (RevMan 5.4) and StataNow/MP 18.5 software, with publication bias examined using funnel plots, and result stability assessed through sensitivity analysis. ResultsA total of six eligible studies, comprising 173 patients, were included in the meta-analysis. The results of the meta-analysis indicated that mind-body exercise can improve balance function in children with CP (SMD = 0.48, P = 0.006). There was no significant difference in the effect of mind-body exercise on walking function in children with CP (SMD = −0.23, P = 0.58). ConclusionCompared with routine care and rehabilitation, mind-body exercise may provide a safe and convenient approach to improving balance functions in children with CP, but showed no statistically significant beneficial effects on walking in children with CP. Prospero registration numberCRD42024534257.

Effects of motor and cognitive dual tasks on walking and balance in children with diparetic cerebral palsy

This study investigates the effects of motor and cognitive dual tasks on walking and balance in Children with diparetic cerebral palsy. The subjects of this study were 12 children (experimental group n = 6, control group n = 6) who were medical diagnosed with diparetic cerebral palsy. They aged 8–12 years. Experimental group was administered treatment for 30 min, 2 times a week for 8 weeks, with the experimental group performing motor and cognitive dual task, while the control group did not have such a training. Wilcoxon signed-rank test was performed to analyze changes in balance, gross motor function in the group, and the Mann–Whitney test was conducted to compare the differences between the two groups before and after intervention. In This study, the mean time for completing the Timed Up and Go Test in single and dual tasks and mean cognitive responses, there was a significant difference between the two groups (P < 0.05). Conclusion: Considering that many activities in daily life are dual tasks, these difficulties they experience in performing dual tasks show that children’s daily lives are also affected. Therefore, dual task evaluations are very important for individuals to be independent in daily life.

The Gait Outcomes Assessment List (GOAL) questionnaire: Test-retest reliability and validity in children with cerebral palsy in Türkiye

BackgroundMost questionnaires provide little information about children's or parents' views on functioning and do not attempt to understand their priorities or expectations. The Gait Outcomes Assessment List (GOAL) questionnaire was developed to fill this gap by identifying the most important goals of the patient and family for a gait intervention. Research questionTo investigate the test-retest reliability and concurrent and discriminant validity of the GOAL questionnaire in children with cerebral palsy (CP) in Türkiye. MethodsIn this study, we included 81 children with CP aged 5–18 years and their families. The parent and child version 5.0 of the GOAL was used. Standardized item, domain and total (across all domains) GOAL scores were calculated for each participant. Test-retest reliability was assessed with the intraclass correlation coefficient (ICC). The Gillette Functional Assessment Questionnaire (FAQ) was used for validation. ResultsThe mean age of the children was 10.4 ± 3.3 years (range 5–18), and 64.2 % were boys. The test–retest reliability was excellent for the GOAL-Child and GOAL-Parent total GOAL scores (ICC: 0.97 for the child and ICC: 0.96 for the parent). All standard errors of measurement (SEMs) for domain scores and total scores were fewer than 20 points. The children's total scores on the GOAL questionnaire showed a significant difference between the GMFCS levels (p <0.001). The parents’ total scores on the GOAL questionnaires also showed a significant difference between the GMFCS levels (p <0.001). There were moderate positive correlations between the GOAL child and parent questionnaire total scores and the FAQ walking level according to Spearman’s rho (GOAL child and FAQ walking rho: 0.66, p<0.001; GOAL parent and FAQ walking rho: 0.58, p<0.001). SignificanceThe results demonstrate that the child and parent versions of the GOAL 5.0 are valid and reliable for the comprehensive assessment of Turkish children with CP.

Auditory-motor synchronization in developmental coordination disorder: Effects on interlimb coordination during walking and running.

Developmental coordination disorder (DCD) presents challenges in motor control. DCD affects tasks such as walking and running and is characterized by poor interlimb coordination and increased spatiotemporal variability compared to typically developing children (TDC). While auditory rhythm synchronization has shown to have benefits for gait performance in adults, its impact on children with DCD during walking and running remains unclear. This study investigated auditory-motor synchronization and interlimb coordination during walking and running in children with and without DCD. Twenty-one DCD and 23 TDC participants aged 8-12 years walked and ran to two different auditory metronomes (discrete and continuous). Synchronization consistency was the primary outcome, with interlimb coordination and spatiotemporal variability as secondary outcomes. Results showed that children with DCD exhibited significantly lower synchronization consistency than TDC, particularly during running. The metronome structure did not influence synchronization ability. Additionally, interlimb coordination differed significantly between DCD and TDC during running and was not impacted by auditory-motor synchronization. Spatiotemporal variability was higher in DCD during both walking and running than in TDC, and accentuated during running. Variability of cadence was influenced by the use of continuous metronomes, which may offer potential benefits in reducing cadence variability.

Transcutaneous Spinal Cord Stimulation Enables Recovery of Walking in Children with Acute Flaccid Myelitis.

Limited research exists for use of transcutaneous spinal stimulation (TSS) in pediatric spinal cord injuries (SCI) to improve walking outcomes, especially in children diagnosed with SCI secondary to acute flaccid myelitis (AFM). This case series demonstrates the feasibility and efficacy of TSS paired with gait training in children diagnosed with AFM. A total of 4 participants diagnosed with incomplete SCI secondary to AFM completed 22, 2-h therapy sessions over 5-8 weeks. TSS paired with body weight-supported treadmill training (BWSTT) was provided for the first 30 min of each session. Changes in walking function were assessed through the 6 min walk test (6MWT), Timed Up and Go (TUG), 10 m walk test (10MWT), and walking index for spinal cord injury II (WISCI-II). To assess safety and feasibility, pain, adverse events, and participant and therapist exertion were monitored. All participants tolerated the TSS intervention without pain or an adverse response. Changes in the 6MWT exceeded the minimal clinically important difference (MCID) for three participants and WISCI-II exceeding the minimal detectable change (MDC) for two of the participants. These results demonstrate that TSS is a safe and clinically feasible intervention for pediatric patients with AFM and may supplement gait-based interventions to facilitate improvements in walking function.

Modeling impairments in predicitive simulations of walking in children with CP: A series of case studies

Modeling impairments in predicitive simulations of walking in children with CP: A series of case studies

Investigating impact of unilateral and bilateral femoral anteversion on lower extremity parameters during walking in hypermobile children: A pilot study

Investigating impact of unilateral and bilateral femoral anteversion on lower extremity parameters during walking in hypermobile children: A pilot study

Walking and running of children with decreased femoral torsion are compared to each other

Walking and running of children with decreased femoral torsion are compared to each other

Motor adaptation to continuous lateral trunk support force during walking improves trunk postural control and walking in children with cerebral palsy: A pilot study

PurposeTo determine whether the application of continuous lateral trunk support forces during walking would improve trunk postural control and improve gait performance in children with CP. Materials and methodsNineteen children with spastic CP participated in this study (8 boys; mean age 10.6 ± 3.4 years old). Fourteen of them were tested in the following sessions: 1) walking on a treadmill without force for 1-min (baseline), 2) with lateral trunk support force for 7-min (adaptation), and 3) without force for 1-min (post-adaptation). Overground walking pre/post treadmill walking. Five of them were tested using a similar protocol but without trunk support force (i.e., control). ResultsParticipants from the experimental group showed enhancement in gait phase dependent muscle activation of rectus abdominis in late adaptation period compared to baseline (P = 0.005), which was retained during the post-adaptation period (P = 0.036), reduced variability of the peak trunk oblique angle during the late post-adaptation period (P = 0.023), and increased overground walking speed after treadmill walking (P = 0.032). Participants from the control group showed modest changes in kinematics and EMG during treadmill and overground walking performance. These results suggest that applying continuous lateral trunk support during walking is likely to induce learning of improved trunk postural control in children with CP, which may partially transfer to overground walking, although we do not have a firm conclusion due to the small sample size in the control group.

The Prevalence of Persistent Toe Walking in Children With and Without Autism Spectrum Disorder and the Odds of Subsequent Surgery

Persistent toe walking is associated with autism spectrum disorder. The true prevalence of persistent toe walking and odds of progression to surgery in children with and without autism remains unclear. This retrospective descriptive study identified patients ages 3 to 17 years who were enrolled in our healthcare system over a 2-year period. Using international classification of disease codes, we identified all children with autism and persistent toe walking, and excluded children with conditions that may independently cause toe walking. Data on Achilles lengthening surgeries, sex, race and body mass index was gathered. The toe walking prevalence amongst children with and without autism was calculated. Multivariable logistic regression analysis controlling for sex, race and body mass index was used to determine independent risk factors for persistent toe walking and surgery. Of the children who met inclusion criteria (N = 284,925), 4622 (1.6%) had persistent toe walking. Prevalence of persistent toe walking was higher amongst children with autism (6.3% vs 1.5%, p < .01), as were odds of persistent toe walking (OR 4.13, 95% CI 3.74 to 4.56, p < .01). Males and White patients had higher odds of persistent toe walking compared to females and patients of any other race, respectively (p < .01 for all). Although children with autism and toe walking had higher rates of surgery than their counterparts without autism (4.3% vs 2.6%, p = .04), this difference was not significant after controlling for sex, race and BMI (OR 1.59, 95% CI 0.95 to 2.69, p > .05).

Toe walking in children and adolescents with Autism Spectrum Disorder: Relationship with sensory and motor functions,language, cognition, and autism severity

BackgroundChildren and adolescents with Autism Spectrum Disorder (ASD) often present motor signs and symptoms, including toe walking (TW). The pathophysiology of TW in ASD is not fully understood. In particular, it is debated whether it may represent a persistent primitive walking pattern or the result of abnormal processing of sensory input from the lower limbs and feet. The present study is aimed at assessing the association between TW and cognitive, sensory, motor and language functions, as well as autism severity. MethodWe enrolled 112 children and adolescents with ASD, 61 with TW and 51 without TW. A complete psychodiagnostic assessment was performed, including ADOS-2, ADI-R, PEP-3, IQ testing or Griffiths Mental Developmental Scales, and Short Sensory Profile. ResultsChildren and adolescents with TW have significantly lower cognitive level, greater language and motor impairment, as well as greater autism severity. Instead, no difference in severity of sensory abnormalities or in sensory profile emerges between cases with and without TW. Conclusionsthe present data are most compatible with a model interpreting TW as a behavioral pattern resulting from the persistence of a primitive walking pattern (i.e. lack of heel strike, prior to the acquisition of plantar walking) or possibly of archaic tonic reflexes, rather than as a consequence primarily of abnormal sensory processing. Health practitioners should monitor the gait of autistic children and plan appropriate interventions, aimed at promoting the adoption of more mature plantar walking patterns.

Does botulinum neurotoxin A make walking easier in children with cerebral palsy? A randomized clinical trial.

To assess the effect of single botulinum neurotoxin A (BoNT-A) injectionsinto the calf muscles on the gross energy cost of walking in children with cerebral palsy (CP) and to evaluate the effect of BoNT-A on walking capacity, physical activity, perceived changes in mobility, and pain. This was an industry-independent, randomized, quadruple-blind, placebo-controlled, multicentre trial (ClinicalTrials.gov registration: NCT02546999). Sixty-one children (33 male, median age [range] = 8 years [4-16 years]) with spastic CP and classified in Gross Motor Function Classification System (GMFCS) levels I and II allocated to single injections of either BoNT-A or 0.9% saline into the calf muscles. The main outcome was gross energy cost (J/kg/m); secondary outcomes were walking capacity, habitual physical activity, perceived change in mobility tasks, and calf pain at baseline, 4 weeks (P1), 12 weeks (P2), and 24 weeks (P3) after the injection. The mean change in energy cost did not differ significantly between groups at the primary time point P2 (-0.27 J/kg/m, 95% confidence interval - 0.91 to 0.36, p = 0.404), nor at P1 or P3. Regarding the secondary outcomes, there was some evidence of a larger reduction in pain intensity in the group given BoNT-A (p = 0.043). One treatment with BoNT-A was not superior to placebo in making walking easier in children with CP classified in GMFCS levels I and II, at least in the short term. BoNT-A may have a pain-reducing effect.

A randomized cross-over study protocol to evaluate long-term gait training with a pediatric robotic exoskeleton outside the clinical setting in children with movement disorders.

Individuals with neuromuscular disorders display a combination of motor control deficits and lower limb weakness contributing to knee extension deficiency characterized by exaggerated stance phase knee flexion. There is a lack of evidence for long-term improvement of knee extension deficiency with currently available clinical treatment programs. Our previous work testing a wearable robotic exoskeleton with precisely timed assistive torque applied at the knee showed immediate increases in knee extension during walking for children with cerebral palsy, which continued to improve over an acute practice period. When we applied interleaved assistance and resistance to knee extension, we observed improvements in knee extension and increased muscle activation indicating the potential for muscle strengthening when used over time. There is a need for additional, high-quality trials to assess the impact of dosage, intensity and volume of training necessary to see persistent improvement in lower limb function for these patient populations. This randomized crossover study (ClinicalTrials.gov: NCT05726591) was designed to determine whether 12 weeks of overground gait training with a robotic exoskeleton outside of the clinical setting, following an initial in clinic accommodation period, has a beneficial effect on walking ability, muscle activity and overall motor function. Participants will be randomized to either complete the exoskeleton intervention or continue their standard therapy for 12 weeks first, followed by a crossover to the other study component. The primary outcome measure is change in peak knee extension angle during walking; secondary outcome measures include gait speed, strength, and validated clinical scales of motor function and mobility. Assessments will be completed before and after the intervention and at 6 weeks post-intervention, and safety and compliance will be monitored throughout. We hypothesize that the 12-week exoskeleton intervention outside the clinical setting will show greater improvements in study outcome measures than the standard therapy.

Variable gearing at the ankle during walking in adults and young children: implications for foot development and evolution

Introduction: The human foot has evolved over the past seven million years from a relatively mobile, grasping appendage to a highly derived structure with a heel pad and longitudinal arch that can absorb shock at heel strike and weight-bearing yet also function as a powerful lever at toe-off. It has been proposed that the modern human foot evolved to allow our species to use “variable gearing” during walking and running. In this model, the gears of the human foot are defined relative to the ankle center of rotation as R, the distance from the ground reaction resultant vector, and r, the distance from the calf muscle vector. The gear ratio defines the torque generated to propel the body or stretch the triceps surae muscles. We test the hypothesis that variable gearing is associated with modern human pedal anatomy and a heel-to-toe rollover that allows a shift from “low gear” to “high gear” during stance.Methods: Using force plate and video analysis, we examined variable gearing in adults and children engaging in adult heel strike (AHS = 35), flat foot contact (FFC = 39), or initial heel contact (IHC = 26).Results and Discussion: Our hypothesis was partly supported. Although variable gearing was observed in IHC steps and was greater than in FFC steps, it was not as developed as in AHS steps. This may be related to anatomical and motor control differences between juvenile and adult feet, suggesting that adult anatomy, including a high arch, and neural control are critical for full use of variable gearing and that this feature would have evolved in later hominins around two million years ago with the appearance of a fully modern foot.

Investigation of joint contact forces during walking in the subjects with toe in gait due to increasing in femoral head anteversion angle.

Toe-in gait is a pathology in which the child walks and turns the foot inward instead of pointing straight ahead. The alignment of the lower limb structure changes in this disease, increasing the incidence of knee and hip osteoarthritis. This study aimed to determine the kinematic and joint loading in subjects walking with a toe-in gait pattern. This study selected two groups of subjects: normal subjects and those with toe-in gait due to an increased femoral head anteversion angle (each group consisted of 15 subjects). A Qualisys motion analysis system and a Kistler force plate were used to record the motions and forces applied to the leg while walking. OpenSim software (version 3.3) was used to analyze the range of motion, moments, muscle forces, and joint contact forces in both groups of subjects. The mean values of stride length for normal subjects (1.1 ± 0.141 m) and those with toe-in gait (0.94 ± 0.183 m) differed significantly. The mediolateral component of the ground reaction force decreased significantly in the toe-in gait group compared to normal subjects (p-value = 0.05). The peak force of most of the hip joint muscles increased significantly in those with toe-in gait compared to normal subjects (p-value < 0.05). The results of this study showed that those with toe-in gait, due to an increase in femoral head anteversion angle, only had a change in rotation of the pelvic and hip joint. There was no significant difference between walking speed and most ground reaction force components between normal subjects and those with toe-in gait. As the peaks of most of the hip joint muscles increased significantly in the toe-in gait group, this increased joint contact forces (especially the anteroposterior component of the hip joint and the mediolateral component of the knee joint), which may ultimately increase the incidence of hip and knee joint osteoarthritis.

Robot-assisted gait training improves walking and cerebral connectivity in children with unilateral cerebral palsy.

Robot-assisted gait training (RAGT) is promising to help walking rehabilitation in cerebral palsy, but training-induced neuroplastic effects have little been investigated. Forty unilateral cerebral palsy children aged 4-18 years were randomly allocated in a monocentric study to ten 20-minute RAGT sessions with the G-EO system, five days a week (n = 20) or to a control group (who continued conventional care with six 30-minute physiotherapy sessions, three days a week) (n = 20), two weeks running, from September 2020 to December 2021. Clinical and MRI outcomes were compared before and one month after therapy. The primary outcome was gait speed. Secondary outcomes were a 6-minute walking test distance, Gross Motor Function Measure-88 (GMFM-88) dimensions D and E, Patient Global Impression of Improvement, resting-state functional connectivity within the sensorimotor network, and structural connectivity in the corticospinal tracts. Gait speed and the 6-minute walking test distance improved more after RAGT. Resting-state functional connectivity increased after RAGT but decreased in controls between superior and lateral healthy or lateral injured sensorimotor networks. GMFM-88 and structural connectivity in corticospinal tracts were unchanged. Impression of improvement in children was better after RAGT. Short-term benefit of repetitive RAGT on walking abilities and functional cerebral connectivity was found in unilateral cerebral palsy children. Short-term repetitive robot-assisted gait training improves gait speed and walking resistance and increases cerebral functional connectivity in unilateral cerebral palsy. GMFM dimensions D and E were unchanged after short-term repetitive robot-assisted gait training in unilateral cerebral palsy.

Efficacy of neuromuscular electrical stimulation and interrupted serial casting in children with spastic diplegia

ObjectivesThis research was aimed at comparing the effects of neuromuscular electrical stimulation (NMES) combined with interrupted serial casting (SC) versus SC alone on various aspects of lower limb function in children with diplegic cerebral palsy. SC is a clinical technique used to increase passive range of motion (ROM), decrease hypertonicity, and improve walking in children with cerebral palsy (CP). MethodsThis randomized comparative trial involved 33 children with diplegic CP, who were randomly assigned to group A or group B at recruitment. Group A received SC along with a customized physical therapy program, whereas group B received the same interventions as group A along with NMES applied through cast windows during casting. Evaluations were based on ROM, the Modified Tardieu Scale, handheld dynamometer measurements, and the Observational Gait Scale. Assessments were conducted before and after 8 weeks of intervention. ResultsBoth groups exhibited significant improvements in dorsiflexion ROM, popliteal angle, gastrocnemius dynamic spasticity, and hamstring dynamic spasticity after the intervention (P = 0.0001 for all). However, significant differences (P < 0.05) in dorsiflexor strength, knee extensor strength, and observational gait scale score were observed between groups after the intervention, favoring group B. ConclusionsThe use of NMES during SC may help overcome the substantial decrease in strength resulting from casting, thus achieving less reduction of tone, improving ROM without significantly decreasing strength, and attaining greater improvements in gait function.

Lower extremity inter-joint coupling angles and variability during gait in pediatric hypermobility spectrum disorder

Complex musculoskeletal complications in children with hypermobility spectrum disorder (HSD) include pain, proprioception deficits, and joint instability, which may result in movement dysfunction during walking. However, no studies have explored the inter-joint coordination deficits in children with HSD. The purpose of this study was to determine the lower extremity inter-joint coupling angles, patterns, and variability during walking in children with HSD compared to children without HSD (non-HSD). Ankle, knee, and hip kinematics during the stance phase of walking in 18 children with HSD and 18 children without HSD were measured using three-dimensional motion analysis. Coupling angles, patterns, and variability of hip-knee, hip-ankle, and knee-ankle were quantified in the sagittal, frontal, and transverse planes using vector coding techniques. Statistical modeling of coupling angles on sine and cosine scales and bootstrapped standard errors were used to compare coupling angles between HSD and non-HSD groups. Permutational multivariate analysis of variance and statistical non-parametric mapping two-sample t-tests were used to compare the coupling patterns and variability between HSD and non-HSD groups, respectively. Our results indicated that coupling angles, patterns, and variability were not significantly different between the groups. These findings suggest that lower extremity inter-joint coordination and its variability during walking might not be a promising area for further research or intervention in children with HSD. Further research could use other biomechanical methods to investigate coordination deficits in pediatric patients with HSD, and how aging and disease progression are associated with coordination deficits in individuals with HSD.

Wearable Sensor‐Based Multi‐modal Fusion Network for Automated Gait Dysfunction Assessment in Children with Cerebral Palsy

Gait, fundamental to human movement, becomes compromised in cerebral palsy (CP), a childhood‐onset central nervous system motor disorder. Precise assessment of patients’ gait is crucial for tailored rehabilitation interventions. Currently, clinical scales assessing CP gait dysfunction mostly, while valuable, rely on subjective clinician observations. To enhance objectivity and efficiency in CP diagnosis and rehabilitation, there is a need for more objective assessment procedures. This study introduces a multi‐modal and multi‐scale feature fusion (MMFF) framework, a new framework for automating gait dysfunction assessment in children with CP. By utilizing surface electromyography and acceleration signals recorded during children's walking, MMFF generates a feature vector enriched with adaptively refined feature maps, cross‐mode correlations, and both local and global information. Validation of MMFF's effectiveness is evident through an accomplished classification accuracy of 99.13%. The mean values for precision, recall, and F1‐score in Gross Motor Function Classification System (GMFCS)‐1, GMFCS‐2, and GMFCS‐3, reaching 99.00%, 99.00%, and 98.33%, respectively, further reflect the accuracy of functional assessments at each level. This study underscores MMFF's potential as an objective, streamlined tool for clinicians, promising improved gait assessment and well‐informed rehabilitation strategies for children with CP.

Efficacy of hinged and carbon fiber ankle-foot orthoses in children with unilateral spastic cerebral palsy and drop-foot gait pattern.

In children with unilateral spastic cerebral palsy (USCP), ankle-foot orthoses (AFOs) are widely used to correct common gait deviations such as a drop-foot pattern. Most studies on this topic have investigated specific time points while omitting other parts of the gait cycle. This study investigated the separate effects of prefabricated carbon fiber AFOs and custom-made hinged AFOs compared with barefoot walking in children with USCP with a drop-foot gait pattern using statistical parametric mapping. Retrospective, cross-sectional, repeated measures study. Twenty ambulatory children (9.9 ± 2.5 years) with USCP and a drop-foot gait pattern were included. Kinematics, kinetics, and spatiotemporal parameters assessed during 3-dimensional gait analysis were compared between barefoot and AFO walking. Statistical parametric mapping was used to compare joint angles and moment waveforms. Kinematics, kinetics and spatiotemporal parameters assessed during 3-dimensional gait analysis were compared between barefoot and AFO walking for each AFO type but not between the 2 AFO types. Compared with barefoot walking, there was a steeper sole angle at initial contact, corresponding to a heel strike pattern, and an increased ankle dorsiflexion in swing with the use of both AFOs. The ankle plantar flexion moment during loading response increased. Ankle power generation during pre-swing decreased in the carbon fiber AFO group when walking with AFOs. Both AFOs were beneficial for improving a drop-foot gait pattern in these small patient groups and can, therefore, be recommended to treat this gait deviation in patients with unilateral cerebral palsy. However, the reduction in ankle power generation during push-off and additional goals targeted by AFOs, such as correction of structural or flexible foot deformities, should be considered for prescription.