Pediatric Balance Scale (PBS)- Article Summary
Article Title: Ankle Passive and Active Movement Training in Children with Acute Brain Injury Using a Wearable Robot
Purpose: This study aimed to evaluate the effectiveness of a wearable robotic device in promoting neuroplasticity and improving ankle motor control through forceful stretching and active movement in the pediatric population following acute TBI.
Study Population: Ten children (7 girls, 3 boys) with acute brain injury were asked to participate in this study. All participants were current patients at an inpatient rehabilitation facility. The ages of the participants ranged from 7-20 years old with a mean age of 13 years old. Each of the participants had impairment in at least one of their lower extremities and experienced varying amounts of voluntary ankle control ranging from minimal to flaccid paralysis.
Methods: The wearable rehabilitation robot was utilized with each of the ten participants to provide passive-active ankle movement and guided isometric torque generation into dorsiflexion and plantarflexion. Researchers provided participants with audiovisual feedback of their isometric joint torque generation and then used this information to guide participants with achieving an improved force-generation. The robotic device was equipped with a servomotor allowing the variables of the device to be manipulated by the researcher to better accommodate each participant’s motor ability.
Outcome Measures: Each participant received15-sessions of training with pre- and post-training evaluations utilizing clinical outcome measures. The clinical outcome measures included; Modified Ashworth Scale (MAS), Pediatric Balance Scale (PBS), Selective Control Assessment of the Lower Extremity (SCALE), Fugl-Meyer Lower Extremity (FMLE), 6-Minute Walk Test (6MWT), Timed Up-and- Go (TUG), and 10M Walk Test (10MWT). Researchers subsequently conducted biomechanical evaluations measuring each participant’s ankle PROM, AROM, and maximal voluntary contraction (MVC) for strength assessment before and after each session. Researchers evaluated ankle dorsiflexion PROM under a controlled velocity of 10°/s and peak resistance torque of 5 Nm.
Intervention: Participants received robotic therapy 3-5 times a week along with their respective conventional therapy provided by the inpatient rehabilitation facility. Each session consisted of ten minutes of passive ankle stretching, twenty minutes of assisted/resisted active movement using various computer games, followed by an additional ten minutes of stretching to conclude each session. Real-time feedback was provided guiding participants to reach their targeted goals, while incorporation of game play maintained participant engagement. The wearable rehabilitation robot was programmed to apply resistance and assistance tailored to the physical abilities of each participant. Biomechanical evaluations, outlined above, were assessed pre and post each session.
Results: Participants demonstrated biomechanical performance improvement over the 15 sessions of robotic therapy. In-session improvements included, median dorsiflexion AROM increased 2.73°, dorsiflexion MVC increased 0.87 Nm, and plantarflexion MVC increased 0.60 Nm. After 15 training sessions, median dorsiflexion AROM improved from -10.45° to 11.87° and dorsiflexion PROM improved from 20.0° to 25.0° post training. Mean dorsiflexion MVC improved from 0.21 Nm to 4.0 Nm with plantarflexion MVC improving from 8.33 Nm to 18.45 Nm. Reassessment of clinical outcome measures, status post robotic therapy, indicated significant reduction in patient spasticity according to MAS values (p value=0.004), and significant increases in PBS scores (p value=0.038) demonstrating marked improvement in functional balance. Participant’s subsequently demonstrated improvements with 6MWT, FMLE, TUG, and 10MWT although results did not indicate statistical significance.
Major Strengths: Researchers provided participants with early intensive and interactive robotic therapy, with objective feedback, during a time period where maximal recovery is known to occur following acute TBI. Researchers collected data in a consistent manner allowing easy replication for inter-session and post treatment assessment. Lastly, researchers utilized reliable test and measures validated by this sample population.
Major Limitations: The small sample size may lead to poor generalizability of the results to the population at large. Lack of a control group may lead to skepticism regarding how much of participant improvement can be designated to robotic therapy, given that conventional therapy was subsequently being provided by the inpatient rehabilitation facility. Lastly, no information was provided regarding how participants were selected or whether any exclusion criteria existed, which may negatively impact reproducibility of this research study.
Overall Conclusion: The wearable rehabilitation robot provided a useful tool for improving motor control, functional balance, and locomotion in children following acute TBI. The implementation of computer games during treatment sessions for assisted/resisted active movement provided real-time feedback which allowed for objective data to be collected, while subsequently increasing participant motivation to achieve improved force-generation. In conclusion, the use of robotics for acute rehabilitation following TBI demonstrates positive correlation with motor re-learning and improved ankle motor control in the pediatric population.
Reference: Kai CHEN, Bo XIONG, Yupeng REN, et al. Ankle Passive and Active Movement Training in Children with Acute Brain Injury Using a Wearable Robot. Journal of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation). 2018;50(1):30-36. doi:10.2340/16501977-2285.
2 responses to “Pediatric Balance Scale (PBS)- Article Summary”
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I was unaware that there was an adapted Berg for pediatrics. I think this is a great tool to use for children who are still developing and may not be able to complete the regular Berg. In your study I noticed that the oldest age was 20 years old and that the cut-off for the pediatric berg is school age children between 5-15. Did the article mention why they used someone that was older than 15? I would be interested in knowing at what point the standard Berg should be used.
This is a very interesting article. I would like to see this studied over a larger population as you discussed in your limitation section. I also agree with your comment about the lack of a control group. I would be interested to know whether their improvements were maintained in the weeks/months after the intervention was complete.