Cerebral palsy is the most common disability that starts in childhood, affecting about 50 million people worldwide.
Cerebral palsy can impact a person’s ability to move their body. This can result in mobility problems, muscle stiffness or weakness, and abnormal movements. There are often other neurological issues as well, such as epilepsy or visual impairment.
Physiotherapy can help people with cerebral palsy across the lifespan. It uses a range of interventions to improve mobility and function. Conventional physiotherapy includes treadmill training, strength training and task-specific training (such as practising getting in and out of a car).
But there’s another therapy tool that’s been showing promise – exoskeletons. These wearable devices support a person’s body from the outside, helping their posture and movements.
For two decades, lower limb robotic exoskeletons have been a major focus in neurological rehab for adults. The majority of research has been about people with stroke and spinal cord injury.
Can they help with cerebral palsy too? Published in Disability and Rehabilitation Journal, our new systematic review of robotic exoskeletons for cerebral palsy reports promising findings – and more questions to tackle.
From the lab to everyday life
The first exoskeletons to help people walk were developed in the 1960s. These were clunky, complex devices, and took several decades to leave the lab.
Over the past 60 years, exoskeletons have become much more streamlined. In Australia, several have been approved by the Therapeutic Goods Administration in recent years.
There are three main categories of medical exoskeleton. Two of them are essentially stuck in place – these are devices paired with treadmills, such as the Lokomat, and “end-effectors” (static devices similar to an elliptical machine), such as the Innowalk.
The third category are devices which can be used overground, such as the Atlas 2030. With overground devices, users can have more choice in where they move, and interact with their environment more.
They even show promise as longer term assistive devices – something the person might wear in everyday life.
What does the evidence say?
An advisory committee for Australia’s National Disability Insurance Scheme (NDIS) is currently reviewing various supports for people with disability, including robot-assisted gait training.
The results will advise Australia’s peak disability funding body on whether and how to fund therapy with this technology. So, it’s timely to look at the evidence. That’s exactly what our systematic review did.
We asked: what are the effects of wearable overground exoskeleton-assisted therapy on physical, functional, quality of life and participatory domains for people with cerebral palsy? “Participation” refers to being truly involved, rather than just present, in chosen activities.
We included 21 studies representing 241 people with cerebral palsy, with an average age of nine. Then, we extracted and analysed data for all clinical outcomes. This included walking speed, endurance, balance, high-level mobility (running and jumping), strength, goal attainment and more.
Robotic rehabilitation outperformed conventional therapies for four outcomes:
- walking speed
- walking endurance
- balance
- high-level mobility.
This means using exoskeletons could provide meaningful benefits in these areas for people with cerebral palsy.
For other outcomes, there was not enough data to make recommendations, or results were inconsistent. Skin irritation was reported in some studies, but never prevented ongoing use of the exoskeleton. Where mentioned, user experiences were generally positive, although most studies didn’t evaluate them.
More to discover
Despite our review showing some encouraging benefits of exoskeleton therapy for people with cerebral palsy, there’s much we still don’t know. Very few of the included studies reevaluated outcomes after the person stopped the therapy. So we can’t say whether benefits are sustained.
We also couldn’t categorise results by type or severity of cerebral palsy, or by age. And with only seven adult participants represented in this systematic review, results can be confidently applied to children, but not adults.
There’s some evidence this technology is beneficial, compared to conventional therapy. However, no studies explicitly compared the use of the exoskeleton with the next most equivalent, and more readily available intervention – bodyweight supported treadmill training.
Exciting is not enough
Recently, therapy with overground exoskeletons is becoming more available in Australia. Costs for these sessions with trained and experienced clinicians can be supported through NDIS funding. However, currently no scheme in Australia will fund a person to have an exoskeleton of their own.
It’s very common for families to want to “try it all”, particularly new and exciting therapy options. Exoskeletons are definitely exciting and attract significant interest.
However, it’s important that families don’t waste money and time on inappropriate therapies.
Our systematic review supports the use of overground exoskeletons for walking speed, walking endurance, balance and high-level mobility for people with cerebral palsy.
It’s crucial for clinicians to provide appropriate and evidence-based advice on the best treatment options. If someone with cerebral palsy wants to try robotic exoskeleton therapy, the clinician should set clear goals for what results to expect, and step forward with caution.
