Elizabeth G. Condliffe

Background: School-based implementation of robot-assisted walking may support increased physical and social participation for children with physical disabilities, but evidence from an adequately powered trial is needed. This pilot study evaluated implementation strategies and study procedures to inform a future definitive trial. Methods: Participants were randomized to 12-weeks of robot-assisted walking or control, with subsequent crossover to the other condition. In the intervention arm, targeted dose was 75 minutes of robot-assisted walking, spread across three days/week. Implementation strategies for the child’s classroom team included educational materials, centralized technical assistance, school champions, and on-going training. Implementation strategy evaluation focused on intervention protocol feasibility (i.e., weekly device use, troubleshooting) and fidelity (documentation of implementation strategy modifications). Preliminary estimates participation goal changes were obtained using the Canadian Occupational Performance Measure (COPM) ‘Performance’ scale (/10). Results: Eight children with neurodevelopmental physical disabilities participated (mean age 3.5, SD 0.5 years). Device use varied from 2.1 to 4.3 days/week (median 3.3) with a range of 48 to 96 minutes/week (median 80). Target use of ≥ 3 days/week was achieved for 66% of weeks and met the ≥75-minute target for 33% of weeks. Troubleshooting occurred in 18.5% of sessions. Two implementation strategies were modified to improve feasibility. COPM mean change was 3.56 (SD 1.07) for robot-assisted walking and 2.11 (SD 2.41) for control (d _z =0.74). Conclusions: This pilot study provided preliminary evidence regarding both the feasibility of robot-assisted walking implementation in schools and its potential effectiveness for children with physical disabilities. Findings support progression to a definitive trial.

Purpose: To explore how 12-weeks of robotic walking impacts physical function and sequelae of inactivity for individuals with pediatric-onset neuromotor impairments. Methods: A single-arm mixed-methods interventional study examined robotic walking for 12-weeks in home and community settings, with 12-week follow-up. Outcomes included family goals (Goal Attainment Scale (GAS)) and perspectives (Interviews), postural control (Early Clinical Assessment of Balance), physical activity (Actigraphy, Habitual Activity Estimation Scale, Patient Reported Outcome Measurement Information System (PROMIS) Physical Activity) and sequelae of inactivity (PROMIS Sleep Disturbances, Bowel Function Diary). GAS was collected pre-training, post-training, and 12-week follow-up. All other quantitative outcomes were collected every 4-weeks. Quantitative data are described with median (25 ^th -75 ^th percentile) and analyzed using a Skillings-Mack test with post-hoc Wilcoxon Signed-Rank. Qualitative interviews were conducted before and after training and analyzed thematically. Results: 15 participants aged 4-23 completed this study. Participants had cerebral palsy (10/15) or rare genetic conditions (5/15), and most used a wheelchair in community settings. Postural control improved (test-statistic = 23.0, p 50) after training. Exploratory analyses suggest improvements in sleep disturbance immediately after training (p=0.025) and 4-weeks after (p=0.047). All measures of physical activity did not improve. Parents reported improvements in walking, activities of daily living, and sequelae of inactivity (i.e., bowel function, appetite, and sleep). Conclusions: Improvements were seen across a range of measures and notably postural control improvements were maintained at the follow-up. Parents perceived improvements in physical function and activities of daily living. Future research is warranted to further understand the impacts of robotic walking for children and small adults with mobility impairments.

Importance: There are very few interventions designed for individuals with the most severe mobility impairments. Robotic walking may be an effective way to facilitate exercise in this population. Objective: To examine how robot-assisted walker’s physical parameters and user characteristics moderate the exercise intensity achieved by individuals with neuromotor disorders causing mobility impairments. Design: A prospective study. Intervention: A single-session intervention involving an overground robot-assisted walker that can be used in an “endurance” mode requiring no voluntary movement or a “strength” mode during which voluntary movement could impact the gait pattern. Participants: Individuals with pediatric-onset mobility impairments Main Outcome Measures: Participants were characterized based on their age, sex, diagnosis, and Gilette Functional Assessment Ǫuestionnaire (FAǪ) levels. Heart rate during the final minute of four 5-minute walking conditions: “strength” mode at fast speed, “strength” mode at slow speed, “endurance” mode at fast speed and “endurance” mode at slow speed was expressed as a percentage of each participant’s heart rate reserve (%HRR). Linear mixed-effects models were used to evaluate the impact of speed, device mode and user characteristics on the level of exercise achieved. Results: 29 individuals (aged 2-26 years) with mobility impairments (FAǪ levels 1-6) completed this study. Fast speeds were associated with a higher %HRR (β= 2.11, SE = 1.03, p = 0.044). Participants in FAǪ class 1 exhibited significantly higher %HRR compared with those in FAǪ classes 2 and 3 (β =18.6, SE=7.31, p=0.017; β= 16.9, SE = 8.13, p = 0.047, respectively). No other device or participant characteristics were associated with exercise intensity. Conclusions: To facilitate higher exercise levels, users of robot-assisted walkers can increase their speed. Individuals who cannot take steps due to their neuromotor impairments experience the highest levels of exercise. Relevance: The findings in this study highlight the promise of robot-assisted walkers to improve health, particularly in those who often face the greatest barriers to exercise.

Cerebral palsy (CP) is the most prevalent severe pediatric motor disability and often leads to compromised bone health due in part to limitations in functional mobility. While moderate-tovigorous physical activity (MVPA) positively influences bone health, its relationship with bone parameters in adolescents with CP remains understudied. Our primary objective was to identify whether bone mineral content (BMC) and density (BMD) differ between ambulatory adolescents with CP and sex and maturity-status (years from peak height velocity) matched typically developing (TD) adolescents. Our secondary objective evaluated the association between MVPA and bone parameters. We conducted a secondary analysis on data from 64 adolescents (32 CP, 32 TD) and examined BMC and areal BMD (aBMD) using total body dual X-ray absorptiometry scans. MVPA was assessed using waist-worn accelerometers. Height-adjusted bone Z-scores accounted for differences in body size. Linear-mixed effects models revealed no significant differences in total body BMC (β:-0.34, 95% CI: -0.74 to 0.06, p = 0.097) or aBMD (-0.30, 95% CI: -0.76 to 0.17, p = 0.203) Z-scores between adolescents with CP and TD peers.MVPA was positively associated with height-adjusted BMC Z-scores, regardless of group (β:0.01, 95% CI: 0.00 to 0.02, p = 0.023). These findings suggest that the greater functional ability of ambulatory adolescents with CP may play a protective role in bone accrual, and highlight the importance of physical activity for bone health in adolescents with and without CP.

Many youth with cerebral palsy (CP) experience challenges generating the muscle force required for efficient and effective movement due to impaired development of movement and posture. These impair...

Robotic walkers are a new and novel technology with growing evidence of benefits for children living with mobility impairments. However, little is known about how using these devices at home impacts families. This study aims to explore parents' perceptions of home-based robotic walking and the impacts on their family and their child living with a mobility impairment. Qualitative interviews were conducted with seven parents who have a child who used a robotic walker in their home for at least six months. Thematic analysis was used to analyse all interviews. Themes were then mapped to the F-words for child development. Using a robotic walker at home led to family bonding and created new ways for parents and siblings to interact with the child living with a mobility impairment. Many children enjoyed using the robotic walker. This, combined with being able to direct its use in their own environments, contributed to less parental stress than was associated with other rehabilitation interventions. However, some parents discussed an increase in parental stress due to certain logistical aspects, getting their child in and out and transporting the robotic walker. Finally, parents discussed that obtaining the device was a financial burden for them. Robotic walking in the home environment impacts family relationships and parental stress. Understanding families' experiences can inform decision-making by families and practitioners around the appropriateness of robotic walker use for a child living with a disability.

To evaluate the feasibility, impacts, and perspectives of a family-led robotic walking intervention. This single-arm interventional study recruited participants aged ≥4 years with neuromotor impairments. Participants were lent a robotic walker and recommended to use at least 150 min/week for 12-weeks. Robotic walking use, acceptability, practicality and adverse events were tracked. Family goals were measured before and after training period using Canadian Occupational Performance Measure (COPM). Quality of life was examined using EQ-5D-Y, Carer-QoL, and CP-CHILD. Quantitative data were analyzed using descriptive statistics (median (25^th-75^th percentile)) and Wilcoxon signed-rank tests. Qualitative interviews captured family perspectives and were analyzed using thematic analysis. 15 participants aged 4-23 completed this study. Participants trained 5 (3.5-6) times for 150(82-181) minutes and took 7,544(4,640-9,575) steps each week. Adverse events occurred in p ≤ 0.001) and satisfaction (3.3(3.0-5.0), p ≤ 0.001) of goals increased. Parents described positive changes in social experiences and family interactions and difficulties with the logistics of robotic walking. This family-led robotic walking intervention resulted in improvements in individual goals, though families did struggle with some logistics of robotic walking.

Purpose: Robotic walkers are a new and novel technology with growing evidence of benefits for children living with mobility impairments. However, little is known about how using these devices at home impacts families. This study aims to explore parents’ perceptions of home-based robotic walking and the impacts on their family and their child living with a mobility impairment. Materials and Methods: Qualitative interviews were conducted with seven parents who have a child who used a robotic walker in their home for at least six months. Thematic analysis was used to analyze all interviews. Themes were then mapped to the F-words for child development. Results: Using a robotic walker at home led to family bonding and created new ways for parents and siblings to interact with the child living with a mobility impairment. Many children enjoyed using the robotic walker. This, combined with being able to direct its use in their own environments, contributed to less parental stress than was associated with other rehabilitation interventions. However, some parents discussed an increase in parental stress due to certain logistical aspects, getting their child in and out and transporting the robotic walker. Finally, parents discussed that obtaining the device was a financial burden for them. Conclusion: Robotic walking in the home environment impacts family relationships and parental stress. Understanding families’ experiences can inform decision-making by families and practitioners around the appropriateness of robotic walker use for a child living with a disability.

Background: Cerebral palsy (CP) is a neurodevelopmental disability in which 75% of youth with CP report experiencing pain. Caregiver mental health, parenting style (e.g., authoritarian) and protective responses to pain (i.e., responses that reinforce pain behaviours and avoidance) have been linked to child pain outcomes. Although caregivers of children with neurodevelopmental disabilities experience heightened stress, little is known about the influence of caregiver mental health and parenting style on pain outcomes in youth with CP. Objectives: The present study investigated if caregiver mental health symptoms (i.e., depression and anxiety) and general parenting style (i.e., authoritarian, authoritative and permissive) were associated with child‐reported pain (i.e., pain intensity and pain interference), and whether protective responses to pain mediated these proposed associations. Methods: Forty‐three pairs of youth with CP and their caregiver were recruited from Canadian agencies, organizations and social media advertisements. Participants completed cross‐sectional measures of child‐reported pain and caregiver‐reported mental health, parenting style and protective responses to pain. Results: Caregiver mental health and authoritarian parenting style were significant predictors of youth pain interference ( p 's ≤ 0.05); however, unexpectedly, protective responses to pain did not mediate these associations (confidence intervals containing 0). Conclusions: These findings highlight the need for future investigations of family‐based interventions targeting general parenting style and caregiver mental health and their potential to reduce symptoms associated with secondary conditions, such as pain, that youth with CP experience.

Purpose: To evaluate the feasibility, impacts, and perspectives of a family-led robotic walking intervention. Materials & Methods: This single-arm interventional study recruited participants aged ≥4 years with pediatric-onset neuromotor disorders. Participants were lent a robotic walker and recommended to use at least 150min/week for 12-weeks. Robotic walking use, acceptability, practicality and adverse events were tracked. Family goals were measured before and after training period using Canadian Occupational Performance Measure (COPM). Quality of life was examined using EQ-5D-Y, Carer-QoL, and CP-CHILD. Quantitative data were analyzed using descriptive statistics (median (25 ^th -75 ^th percentile)) and Wilcoxon signed-rank tests. Qualitative interviews captured family perspectives and were analyzed using thematic analysis. Results: 15 participants aged 4-23 completed this study. Participants trained 5 (3.5-6) times for 150(82-181) minutes and took 7,544(4,640 – 9,575) steps each week. Adverse events occurred in <1% (16 minor, 1 moderate) of robotic walking sessions. Performance (3.5 (1.9-4.5), p=<0.001) and satisfaction (3.3(3.0-5.0), p=<0.001) of goals increased. Parents described positive changes in social experiences and family interactions and difficulties with the logistics of robotic walking. Conclusions: This family-led robotic walking intervention resulted in improvements in individual goals, though families did struggle with some logistics of robotic walking, such as; transport and difficulties with the device.