Andreas Meyer-Heim

Spontaneous intracranial haemorrhage in children: aetiology, presentation and outcome.

We are aware of only few reports addressing spontaneous intracranial haemorrhage (SICH) in non-selected series of children. This is a retrospective analysis of clinical presentation and outcome in 34 children with SICH seen in the period 1990-2000 in our hospital. Traumatic, neonatal and subdural haemorrhages were excluded. The majority (47%, 16/34) of SICH was caused by an arteriovenous malformation (AVM). SICH was presented as an acute event in 53% (17/32) of patients. Forty-seven percent (15/32) of the cases had protracted courses, which made the diagnosis difficult. In our series, younger children had less specific symptoms. Mortality (25%, 8/32) and morbidity were considerable, particularly in infratentorial haemorrhages, in aneurysms, in children younger than 3 years and in those with underlying haematological disorders.

Feasibility of robotic-assisted locomotor training in children with central gait impairment.

Intensive, task‐specific training enabled by a driven gait orthosis (DGO) may be a cost‐effective means of improving walking performance in children. A paediatric DGO has recently been developed. This study was the first paediatric trial aimed to determine the feasibility of robotic‐assisted treadmill training in children with central gait impairment (n=26; 11 females, 15 males; mean age 10y 1mo [SD 4y]; range 5y 2mo‐19y 5mo). Diagnoses of the study group included cerebral palsy (n=19; Gross Motor Function Classification System Levels I–IV), traumatic brain injury (n=1), Guillain‐Barré syndrome (n=2), incomplete paraplegia (n=2), and haemorrhagic shock (n=1), and encephalopathy (n=1). Sixteen children were in‐patients and 10 were outpatients. Twenty‐four of the 26 patients completed the training which consisted of a mean of 19 sessions (SD 2.2; range 13–21) in the in‐patient group and 12 sessions (SD 1.0; range 10–13) in the outpatient group. Gait speed and 6‐Minute Walking Test increased significantly (p<0.01). Functional Ambulation Categories and Standing dimension (in‐patient group p<0.01; outpatient group p<0.05) of the Gross Motor Function Measure improved significantly. DGO training was successfully integrated into the rehabilitation programme and findings suggest an improvement of locomotor performance.

Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy

Objective: To measure functional gait improvements of robotic-assisted locomotion training in children with cerebral palsy (CP). Design: Single-case experimental A-B design. Settings: Rehabilitation Centre Affoltern am Albis, Children’s University Hospital Zurich, Switzerland (inpatient group) and Neurology Department of the Dr von Haunersches Children’s Hospital Munich, Germany (outpatient group). Participants: 22 children (mean age 8.6 years, range 4.6–11.7) with CP and a Gross Motor Function Classification System level II to IV. Interventions: 3 to 5 sessions of 45–60 minutes/week during a 3–5-week period of driven gait orthosis training. Main outcome measures: 10-metre walk test (10MWT), 6-minute walk test (6MinWT), Gross Motor Function Measure (GMFM-66) dimension D (standing) and dimension E (walking), and Functional Ambulation Categories (FAC). Results: The mean (SD) maximum gait speed (0.78 (0.57) to 0.91 (0.61) m/s; p<0.01) as well as the mean (SD) dimension D of the GMFM-66 (40.3% (31.3%) to 46.6% (28.7%); p<0.05) improved significantly after the intervention period. The mean (SD) 6MinWT (176.3 (141.8) to 199.5 (157.7) m), the mean FAC (2.6 (1.7) to 3.0 (1.6)) and the mean (SD) dimension E of the GMFM-66 (29.5% (30.3%) to 31.6% (29.2%)) also showed an increase, but did not reach a statistically significant level. Conclusion: These results suggest that children with CP benefit from robotic-assisted gait training in improving functional gait parameters.

Robotic-assisted treadmill therapy improves walking and standing performance in children and adolescents with cerebral palsy

OBJECTIVE Task-specific body-weight-supported treadmill therapy improves walking performance in children with central gait impairment. The aim of the study was to investigate the effect of robotic-assisted treadmill therapy on standing and walking performance in children and adolescents with cerebral palsy and to determine parameters influencing outcome. METHODS 20 Patients (mean age 11.0 ± 5.1, 10 males and 10 females) with cerebral palsy underwent 12 sessions of robotic-assisted treadmill therapy using the driven gait orthosis Lokomat. Outcome measures were the dimensions D (standing) and E (walking) of the Gross Motor Function Measure (GMFM). RESULTS Significant improvements in dimension D by 5.9% (± 5.2, p=0.001) and dimension E by 5.3% (± 5.6, p<0.001) of the GMFM were achieved. Improvements in the GMFM D and E were significantly greater in the mildly affected cohort (GMFCS I and II) compared to the more severely affected cohort (GMFCS III and IV). Improvement of the dimension E but not of D correlated positively with the total distance and time walked during the trial (r(s)=0.748, p<0.001). CONCLUSIONS Children and adolescents with bilateral spastic cerebral palsy showed improvements in the functional tasks of standing and walking after a 3-week trial of robotic-assisted treadmill therapy. The severity of motor impairment affects the amount of the achieved improvement.

Improved Gait Parameters After Robotic-Assisted Locomotor Treadmill Therapy in a 6-Year-Old Child with Cerebral Palsy

Task‐specific body‐weight‐supported treadmill therapy improves walking performance in children with central gait impairment. Modulation of spinal networks and improvement of muscle energy consumption are thought to contribute to this effect. Robotic‐assisted treadmill therapy enabled by a driven gait orthosis (DGO) has been established for adults and shown to provide significant improvements in individuals with spinal cord injury and stroke. Recently a pediatric DGO has been developed. Here, we report the results of a 3‐week trial of robotic‐assisted treadmill therapy of a 6‐year‐old boy with bilateral spastic cerebral palsy. The boy tolerated the trial very well and showed improved function, speed, and endurance of walking. Introducing methods of robotic medicine to pediatrics may help children with central gait impairment to regain motor function.

Virtual reality-based paediatric interactive therapy system (PITS) for improvement of arm and hand function in children with motor impairment—a pilot study

Objective: Rehabilitation of upper-limb sensorimotor function in children with motor dysfunctions is primarily based on movement training. This study developed a virtual-reality based, paediatric interactive therapy system (PITS) that allows children to practice specific movements of the upper limbs with immediate feedback about their motor performance. Methods: The system was tested on five children with motor dysfunctions over 3 weeks of training. Pre- and post-assessment was conducted before and after the training period. Results: Results of the pilot study show improvements of hand function in the test scores (except one patient). Patient motivation was high and maintained over the course of the therapy sessions. Conclusion: PITS is an applicable VR-system which can be feasibly applied during the rehabilitation of children with upper limb motor dysfunctions. Further investigation is necessary to determine if the system provides significantly improved results compared to conventional therapies, both in terms of motor function outcomes and patient motivation.

Cervical myelomeningocele—follow-up of five patients

Only a few series of patients with cervical myelomenigocele (cMMC) and cervical meningocele (cMC) have been published. Interventions as well as the neurologic, orthopaedic, urologic and intellectual outcomes were analysed in this retrospective description of five patients with cMMC and cMC diagnosed in the period 1984-1999. Four patients suffered from cMMC, one from cMC. The average duration of follow-up was 9.5 years. None of the patients had periconceptual prevention with folic acid. Three had a Chiari II malformation and two a hydrocephalus. Tethering of the cervical cord was demonstrated in three patients at follow-up. All children achieved an independent ambulatory function and urinary continence. Incomplete sensorimotor hemiparesis was present in two children, and a mild unilateral arm paresis in one. Two of five patients had age appropriate cognitive functions. Three patients with mild mental retardation or behavioural problems had to be placed in special classes. The outcome of patients with cMMC is favourable regarding to the neurologic, orthopaedic and urologic problems compared with lower neural tube defects. However, the burden of repeated examinations and therapies is considerable and induces high costs, therefore prevention with periconceptual folic acid is a crucial issue also in cMMC. Spinal cord dysfunction has to be considered in growing children due to persistent tethering or re-tethering, therefore regular neurologic and urodynamic investigations are of particular importance.

Safety of robotic-assisted treadmill therapy in children and adolescents with gait impairment: A bi-centre survey

Objective: The aim of the present study was to report on adverse events encountered with robotic-assisted treadmill therapy in children and adolescents with gait disorders. Methods: Eighty-nine patients who underwent a trial of robotic assisted treadmill therapy in the two participating centres were analysed. Demographic data and safety data of the patients were analysed using descriptive statistics. Results: In 38 (42.7%) out of 89 patients, adverse events were documented. Most commonly, mild skin erythema at the sites of the cuffs of the device and muscle pain were encountered. In five patients (5.6%), open skin lesions (n = 2), joint pain (n = 2) or tendinopathy (n = 1) limited the continuation of the therapy with the Lokomat. No severe side-effects emerged. Conclusions: Robotic assisted treadmill therapy is a safe method to enable longer periods of gait therapy in children and adolescents with gait disorders.

Constraint-induced movement therapy for children with obstetric brachial plexus palsy: two single-case series.

The objective of this pilot study was to investigate the feasibility of constraint-induced movement therapy (CIMT) in children with obstetric brachial plexus palsy and receive preliminary information about functional improvements. Two patients (age 12 years) with obstetric brachial plexus palsy were included for a 126-h home-based CIMT intervention (3 and 4.5 weeks) and weekly monitored with the Melbourne Assessment of Unilateral Upper Limb function and the Nine-hole Peg Test. The Assisted Hand Assessment was performed 3 weeks before the beginning of intervention, preintervention, postintervention, and at 3 weeks follow-up (ABA single-case design). Tests were analyzed descriptively, visually, and where possible, using a time series analysis with C statistic. Results revealed changes of arm function in both patients between preintervention and follow-up test as follows: Assisted Hand Assessment from 85 to 92% in patient A and 80 to 89% in patient B, in the Melbourne Assessment of Unilateral Upper Limb function from 87 to 90% (C=0.578, z=1.876, P<0.05) in patient A and 72 to 80% (C=0.827, z=2.68, P<0.005) in patient B. There was no improvement in the Nine-hole Peg Test in both patients. Improvements as a result of CIMT found in this pilot study may not be considered substantial. However, they justify further research as some findings indicate relationship to the CIMT intervention in the ‘B’ phase. To enhance motivation and to plan a controlled, randomized clinical trial, child-friendly applications of the CIMT concept and adequate measures to monitor compliance are being discussed.

A Paediatric Interactive Therapy System for arm and hand rehabilitation

Paediatric rehabilitation using virtual reality systems pose unique usability challenges distinct from those in adult rehabilitation. These challenges relate to the different epidemiology and aetiology of childrenpsilas disorders requiring rehabilitation and the physical design of interactive virtual reality hardware for children of varying sizes. Just as importantly, children need highly entertaining interactive scenarios that suit their differing levels of cognitive development and thus their differing abilities to comprehend gaming scenarios. In this paper we present our virtual reality-based Paediatric Interactive Therapy System (PITS) designed specifically for upper arm rehabilitation in children aged from five years of age upwards. It incorporates a range of interchangeable position sensing devices (compass, bend sensor, pressure sensor and camera tracking) that can be adjusted to a large range of different hand sizes, and interactive gaming scenarios specifically designed for maximum entertainment value for children. We describe the neuroscientific principles behind our system, the technical details of the hardware components and the design of the interactive scenarios. An initial usability and patient acceptance pilot study has been conducted at the Rehabilitation Centre Affoltern of the University Childrenpsilas Hospital Zurich. To date all patients have accepted the system, and trained in reaching and grasping tasks at a far higher rate than in conventional occupational therapy. The system thus promises to be a valuable complement to conventional therapeutic programs offered in rehabilitation clinics.