NeuroGame Therapy for the Improvement of Ankle Control in Ambulatory Children with Cerebral Palsy
Gilbertson, Torey J.
MetadataShow full item record
Background Cerebral palsy (CP) describes a group of permanent movement and posture disorders occurring from non-progressive injury to the fetal or developing brain. CP affects 3-4 per 1,000 children in the United States and the majority of those children have spasticity as a primary presentation. Though most children with CP are able to walk, with or without the help of an assistive device, many of them have trouble with toe clearance, which can lead to instability and increased fall risk. Learning new motor patterns is possible due to neuroplasticity, but requires a high number of repetitions with the proper challenge, and appropriate feedback. A NeuroGame Therapy (NGT) system was developed that utilizes surface electromyography (sEMG) as a biofeedback device that allows the participant to practice activation of any targeted muscle. The sEMG activation triggers a video game to make the practice enjoyable. Objectives The first objective was to determine valid and reliable outcome measures to assess walking children with CP. The second objective was to determine if a different method of assessing range of motion was valid and reliable. The final objective was to determine if using NGT to train the tibialis anterior muscles and pairing game play with immediate walking practice would affect balance, walking, and selective ankle movement in children with CP. Methods First, a scoping review was conducted to determine the most appropriate measures of gait in children with CP, based on the measures’ validity and reliability when used with children with CP. Second, a study was conducted on children with CP and those who were typically developing to determine if using video recording was a valid and reliable method of measuring ankle range of motion. Finally, an intervention study was conducted where nine children with CP used NGT at home for 6 weeks to train their tibialis anterior muscles bilaterally. Results The results of the review indicated that the 6-minute walk test possessed the strongest evidence for use on children with CP when directly measuring walking capacity. Though the review showed that the Edinburg Gait Scale had the greatest evidence of appropriate psychometric properties in children with CP for measuring movement quality, the gold standard of 3-dimensional kinematic analysis was chosen for the intervention study. The study to determine the validity and reliability of using video recording to measure ankle range of motion revealed high validity and reliability when comparing measurements from video recording to real-time goniometry. Children who participated in the NGT study all showed improvement in at least one outcome measure assessing body structure and function (e.g. sEMG outcomes, muscle contraction force, selective motor control, etc.). Most, but not all, participants showed at least slight improvement in activity level measures (i.e. 6-minute walk test or reported falls). NGT to train the tibialis anterior muscles is feasible in children with CP. More NGT play appeared to yield better results, especially with sEMG outcomes. Overall, NGT did not appear to have an effect on dorsiflexion during gait, but did have a positive influence on dorsiflexion muscle contraction force. The majority of results seen in the post-test were observed again at the follow-up testing. Limitations The suggested measures from the scoping review were based on psychometric properties rather than the intended or desired application of the outcome. The range of motion study was based on standardized marking of the leg and ankle and camera position, so is not generalizable to video recording of any other joint, or with recording without using the standardized set-up. The NGT study was subject to measurement error due to the technical nature of the data collection and the fact that children were assessed five times over 12 weeks, so natural variability was inevitable. There were also some technological limitations of the NGT system. Finally, the small sample size and mixed results make it difficult to generalize the results broadly to children with CP. Conclusions Of the direct measurements, the 6-minute walk test possessed the strongest evidence of psychometric properties when measuring walking capacity in children with CP. The Edinburg Gait Scale had the strongest evidence for use in assessing kinematic properties during gait. Other measures, however, may have clinical utility based on the goals for that child. The video recording assessment of ankle range of motion in children used within this study was supported as a standardized method with high validity and reliability. There is some promise for the NGT system to assist children with CP to improve muscle contraction force, however carry-over to changes in the children’s gait pattern was limited. Given that the children who showed the most change were those that played the longest, more practice may be needed to effect greater change.