Robotic Systems for the Physiotherapy Treatment of Children with Cerebral Palsy: A Systematic Review

 

Cerebral palsy is a neurological condition that is associated with multiple motor alterations and dysfunctions in children. Robotic systems are new devices that are becoming increasingly popular as a part of the treatment for cerebral palsy. A systematic review of the Pubmed, Web of Science, MEDLINE, Cochrane, Dialnet, CINAHL, Scopus, Lilacs and PEDro databases from November 2021 to February 2022 was conducted to prove the effectiveness of these devices for the treatment of motor dysfunctions in children who were diagnosed with cerebral palsy. Randomized clinical trials in Spanish and English were included. In total, 653 potential manuscripts were selected but only 7 of them met the inclusion criteria.

Introduction

According to a 2007 report, “Cerebral palsy is a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain”.

The most common treatments that have traditionally been used have tended to focus on physiotherapy and botulinum toxin; however, advances in new technologies have offered up a wide range of possibilities for the treatment of this pathology. New techniques have recently appeared for the rehabilitation and treatment of the motor conditions that are caused by cerebral palsy. One of them involves a virtual reality and has demonstrated improvements in the gross motor function of the lower limbs and the fine motor function of the upper limbs in children with cerebral palsy. Additionally, it is worth mentioning other new robotic system technologies, of which the Lokomat or Innowalk devices are the most significant. The objective of robotic systems is to help patients to achieve correct motor function, based on the repetition of tasks with their assistance. They can provide high intensity, repetitive, task-specific and interactive training. Robotics systems can focus on several strategies, such as assistive (similar to the exercises that are implemented by physiotherapists), haptic stimulation (related to the practice of daily life activities), coaching (help, motivation and promotion of motor skills learning) or challenge-based (exercises that involve more difficult tasks or challenges). The main benefits that could be obtained from the use of these devices are a decrease in spasticity and improvement in
joint amplitudes, autonomy, muscle tone and strength, etc. ; however, as these are such new techniques, their feasibility and effectiveness in the treatment of this condition and within this population are not entirely clear.

Therefore, the objectives of this study were to systematically review the evidence that  is available on the effectiveness of robotic systems either as a therapy by themselves or in combination with the physiotherapy treatments of children who have been diagnosed with cerebral palsy in improving their autonomy and quality of life.

Selection Criteria

This systematic review included randomized clinical trials with the following inclusion criteria:

(1) children aged between 4 and 14 years old with a cerebral palsy diagnosis;
(2) all forms and utilizations of robotic systems that are used for this population; 
(3) randomized clinical trials with at least 20 patients.

The exclusion criteria were:

(1) a combination of treatments;
(2) medical or pharmacological treatment at the same time as treatment with robotic systems or any other treatment other than robotic systems;
(3) other types of publication, such as cases, editorials or letters to editors.

Results

Regarding effectiveness, the present review yielded contradictory evidence. Some authors showed the superior effectiveness of the use of a robotic system (Walkbot-K) compared to the control group after a 6-week treatment program, which achieved improvements in function and ability to perform daily activities. After 12 weeks of treatment, the use of Innowalk also presented a clear superiority compared to the control group for Yazici et al., which improved muscular fitness, balance, gait speed and peripheral O2 saturation and the results were maintained up to 3 months after the end of the treatment.
Wallard et al. demonstrated an improvement in gait in their two studies, which improved upper limb control, as well as producing better postural control and an improved gait pattern. Druzbicki et al. concluded that the Lokomat, despite producing a slight improvement in gait, did not provide a significant improvement in the sample parameters after 4 weeks of treatment. Finally, Petrarca et al. postulated that they had inconclusive results after the implementation of a 4-week treatment program with Lokomat and hysiotherapy and that the results were not conclusive. Yasar et al. stated that there was no difference between the two treatment groups, but both groups improved in functional independence, balance and gait with the established treatment.