Robotic exoskeletons have been developed to assist locomotion and address gait abnormalities in children with cerebral palsy (CP). These wearable assistive devices provide powered assistance to the lower-extremity joints, as well as support and stability. Does exoskeleton-assisted walking improve gait in children with CP? The PRISMA guidelines were used to conduct this systematic review. Articles were obtained in a search of the following electronic databases: Embase, CINAHL Complete, PubMed, Web of Science and MEDLINE. Studies investigating spatiotemporal, kinematic, kinetic, muscle activity and/or physiological parameters during exoskeleton-assisted walking in children with CP were included. All articles were assessed for methodological quality using an adapted version of the Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group, provided by the National Institutes of Health (NIH). Thirteen studies were included. They involved the use of the following exoskeletons: tethered knee exoskeleton, pediatric knee exoskeleton (P.REX), untethered ankle exoskeleton, WAKE-Up ankle module, WAKE-Up ankle & knee module and unilateral ankle exosuit. Methodological quality varied, with key limitations in sample size and allocated time to adapt to the exoskeleton. There was a consensus that robotic exoskeletons improve gait given careful optimisation of exoskeleton torque and sufficient exoskeleton practice time for each participant. Improvements in gait included reduced metabolic cost of walking, increased walking speed, and increased knee and hip extension during stance. Furthermore, exoskeletons with an actuated ankle module were shown to promote normal ankle rocker function. Robotic exoskeletons have the potential to improve the mobility of CP children and may therefore increase community participation and improve quality of life. Future work should involve larger controlled intervention studies utilising robotic exoskeletons to improve gait in children with CP. These studies should ensure sufficient exoskeleton practice time for each participant.

Background: In order to classify the gait of children with spastic cerebral palsy (sCP), the “gait pattern classification system for children with sCP” (GaP-CP) has been developed, based on a systematic review and complemented by an additional class of “mild deviations”. The objective of the current study was to examine the content and construct validity of the GaP-CP. Methods: Statistical non-parametric comparisons identified the differences between the kinematics (N = 270) and kinetics (N = 208) of children with sCP and children with typically developing gait (N = 56) (content validity—aim 1), and between neighboring patterns (construct validity—aim 2a). Pattern-specific clinical phenotypes were explored based on the differences between all gait patterns (Kruskal–Wallis comparisons with post hoc Mann–Whitney U tests) in patient- and impairment-specific characteristics (construct validity—aim 2b). Results: The apparent and true equinus were the most and least prevalent patterns, respectively. The majority of the original classification rules were confirmed by the patient data, indicating good content validity of the GaP-CP. Its construct validity was strengthened by distinguishing between gait deviations of neighboring patterns and differentiating between gait patterns based on patient-specific characteristics, leading to pattern-specific phenotypes. Yet, pattern-specific phenotypes could not be clearly defined based on the impairment-specific comparisons. Conclusions: The current results support the validity of the GaP-CP. Refined classification rules, using more precise terminology, establish a roadmap for its clinical implementation. The pattern-specific clinical phenotypes enable its use in a clinical context and may aid clinical decision-making.

Objectives Three-dimensional gait analysis is the ‘gold standard’ for measurement and description of gait. Gait variability can arise from intrinsic and extrinsic factors and may vary between walking conditions. This study aimed to define the inter-trial and inter-session repeatability in gait analysis data of children with cerebral palsy (CP) who were walking in four conditions, namely barefoot or with ankle-foot orthosis (AFO), and overground or treadmill. Design Test-retest repeatability study. Setting Rehabilitation facility with a human motion analysis laboratory. Participants Ten ambulatory children with spastic CP (age=5-15years). In addition, two control datasets (N=56; N=18) of typically developing children were used as a reference. Interventions Not applicable. Main Outcome Measures Inter-trial and inter-session variability was measured using intra-class correlations (ICC’s) with accompanying confidence intervals, standard error of measurement (SEM), as well as the SEM expressed as percentage (%SEM) of the total joint-range-of-motion of typically developed children. Results Overall we found good to excellent ICC-values and favourable SEM-values for the inter-session Gait Profile Score (ICC=0.85-0.98, SEM=0.45°-0.91°) and Gait Variable Scores (ICC=0.85-0.99, SEM=0.22-1.11°) for the lower-limb joints. The %SEM was the highest for the ankle joint (%SEM=0.8%–3.0%). For the continuous waveform data, only in the ankle joint, differences were observed. Namely, smaller SEM-values for the AFO-condition (mean inter-trial=0.14°; mean inter-session=1.121°) in comparison to the barefoot-condition (mean inter-trial= 0.55°; mean inter-session=2.22°). For all the kinetic parameters, the treadmill conditions showed smaller SEM-values in comparison to the overground condition. Conclusions All conditions proved to be repeatable, showing good to excellent ICC-values. The ankle kinematics were more repeatable when the participants were walking with their AFOs in comparison to barefoot walking. Taking the total joint-range-of-motion into account, the knee joint showed the most repeatable motion, while ankle motions showed the lowest repeatability. For kinetics, treadmill conditions showed better repeatability than the overground conditions.

Ankle–foot orthoses (AFOs) are commonly prescribed to children with cerebral palsy (CP). The conventional AFO successfully controls the first and second ankle rocker, but it fails to correct the third ankle rocker, which negatively effects push-off power. The current study evaluated a new powered AFO (PAFO) design, developed to address the shortcomings of the conventional AFO. Eight children with spastic CP (12.4 ± 3.4 years; GMFCS I-III; 4/4-♂/♀; 3/5-bi/unilateral) were included. Sagittal kinematic and kinetic data were collected from 20 steps during barefoot walking, with conventional AFOs and PAFOs. In the PAFO-condition, an actuation unit was attached to a hinged AFO and through push–pull cables to a backpack that was carried by the child and provided patient-specific assistance-as-needed. SnPM-analysis indicated gait cycle sections that differed significantly between conditions. For the total group, differences between the three conditions were found in ankle kinematics (49.6–66.1%, p = 0.006; 88.0–100%, p = 0.011) and angular velocity (0.0–6.0%, p = 0.001; 45.1–51.1%, p = 0.006; 62.2–73.0%, p = 0.001; 81.2–93.0%, p = 0.001). Individual SnPM-analysis revealed a greater number of significant gait cycle sections for kinematics and kinetics of the ankle, knee, and hip. These individual results were heterogeneous and specific per gait pattern. In conclusion, the new PAFO improved the ankle range-of-motion, angular velocity, and power during push-off in comparison to the conventional AFO.