Design and Investigation the Effectiveness of Gait Enhancer on Standing Ability and Walking Speed in Children With Cerebral Palsy

Objective: The purpose of this study was to design and investigate the effectiveness of gait training with Gait Enhancer on standing ability and walking speed in children with cerebral palsy. Materials and methods: We designed a new gait trainer according to Theo Jansen mechanism. Two separated Jansen linkages were placed on both sides of a frame and were connected to the lower limb at the ankle joint by 2 plates under feet. This experimental research organized in a single subject system (A-B-A design) in 4 children with spastic diplegic cerebral palsy who were receiving conventional occupational therapy sessions as outpatients. Inclusion criteria were: Diagnosis of spastic diplegia; aged 6 to 10 years; ability to walk independently with an assistive device; ability to follow simple verbal instructions according to SPARCLE questionnaire; belong to levels III of Gross Motor Function Classification System (GMFCS), written consent from their parents; no surgical operation or botulinum toxin injection during the last year. Exclusion criteria were: uncontrolled seizure; dislocation or subluxation of hip joints; true shortness of one of the lower limbs more than 2 cm. The average age of the participants was 7 year and 9 months and they all were boys. This method includes repetitive measures in three phases, baseline and intervention and then maintenance. Baseline or Phase (A1) lasted for 4 weeks; intervention phase (B) and maintenance phase (A2) each lasted for 6 weeks. All the participants received conventional occupational therapy during the study period. They had 18 gait training sessions, 3 times per week with Gait Enhancer for 30 minutes in intervention phase. Dimension D (standing) of GMFM-66 and 10-Mtere walk test were performed to evaluate standing ability and walking speed, respectively, before and after baseline Phase (A1) and every week during intervention (B) and maintenance (A2) phases. Findings were considered by visual graphs and statistically by measuring Nonoverlap indices and Cohen’s d. Visual analyses of the graphs indicated the effect of intervention. Results: When intervention phase was compared to baseline, all subjects showed significant changes in standing scores and walking speed. Nonoverlap indices for both variables indicate significant effect of Gait training on standing ability and walking speed between baseline and intervention phases. The effect size, measured by Cohen’s d, for standing ability were 1.95, 2.29,1.83 and 2.3 for subjcts1, 2, 3and 4 respectively. Regarding walking speed, the effect size for these children were 1.13, 3.37, 2.15 and 2.21. Cohen’s d, for calculating the effect size, was greater than 0.8 which means meaningful changes after intervention. Hedges g which reflects the effect size for small sample sizes was greater than 0.8 for all subjects in standing ability and walking speed. Conclusion: Standing ability and walking speed improved in children with cerebral palsy following gait training with Gait Enhancer in combination with conventional occupational therapy. The findings of this study suggest that the Gait Enhancer can be useful for children with spastic diplegia to increase their ability in standing and their speed of walking. Children using the gait trainer in combination with conventional therapy showed a significantly greater improvement in the investigated parameters compared with just conventional occupational therapy period. The present study was only a single subject study after designing a new gait trainer. Therefore, further studies like RCTs are needed in order to investigate the impact of this new gait trainer in children with CP.