This dissertation reports and discusses part of the results obtained during the multi partners experimental study: “Disordini di Movimento e Riabilitazione nella Parasili Cerebrale Infantile” proposed and developed in co-operation with the School of Exercise Science, the Department of Computer Science, the Department of Neurological and Visual Science of Verona University, the School of Medicine of Roma Cattolica University and the Don Calabria Institute. The project was funded with a grant assigned by the Fondazione Cariverona. During the three years of my PhD course I was mainly involved in the sub-project proposed by the School of Sport and Exercise Science. The aims of this project were to investigate: i) the economy of walking in children with cerebral palsy and: ii) their cardiovascular responses to exercise. In addition, we aimed to develop and propose a clinical protocol for the assessment in the clinical environment of the economy of locomotion and of the metabolic and cardiopulmonary responses to exercise of these patients. The competences and knowledge gained during this experimental campaign have been subsequently exploited in a study completed in collaboration with “E. Medea” Insitute, Associazione “La Nostra Famiglia” of Conegliano (Treviso, Italy), and for the assessment of a new type of walking aid. Therefore in the present Thesis, three different studies will be presented and discussed: • The first study is a product of the co-operation with the clinicians of the Don Calabria Institute and it mainly describes and discusses the economy of walking and the cardiovascular responses to exercise, of children with cerebral palsy compared with healthy children. • The second study is the product of the co-operation with the “E. Medea” institute and it deals with the differences in the economy of walking, among different clinical sub-groups of patients. • The third study has been accomplished by the collaboration with the Don Calabria institute, the “G. Rossi” Hospital, and the department of Computer Science. It describes the cardiovascualr and metabolic reponses of a child who walked with the aid of an actuated walker (single case study). FIRST STUDY Background. Cerebral palsy is a disorder of movement and posture due to a lesion of the brain occurring early in childhood or during the fetal development. In children with cerebral palsy (CP), compared with normal children, walking is less economical and efficient. Moreover, also the metabolic pathways and systems involved in muscular power production are impaired. For instance, maximal aerobic power is rather low in CP patients. For these reasons, children with CP become easily fatigued when exercising, even at moderate intensity. This leads them on a long term to reduce progressively their activity triggering a vicious circle that, in turn, causes a further reduction of physical fitness and daily independence. Aim: i) to determine energetic cost of locomotion (C) at different submaximal speeds, in healthy children and in cerebral palsy; ii) to study cardiovascular responses (V’O2, and O2 transport) to submaximal exercise. Population. 20 healthy subjects and 11 children with CP, aged between 6 and 14. Protocol. Oxygen consumption (V’O2; K4, Cosmed, Roma, Italy), heart rate (HR; Polar Electro, Finland), and arterial pressure profile (photopletismographic method, Portapres, FMS, Amsterdam, The Netherlands) were measured at rest and during walking at 1-2-3-4-5-6 Km/h, each speed was maintained for at least 4 minutes. Cardiac output was estimated by using arterial pulse analysis with Beatscope® software (FMS, Amsterdam, The Netherlands). Results. We confirmed that C and V’O2 are larger in CP children compare to healthy. Stroke volume (SV) was found to be significantly smaller then normal developing children at each speed. Conclusions. The main findings of this study: I) confirmed that the economy of locomotion in children with CP is lower than that of healthy mates; showed that the cardiovascular O2 transport was impaired especially because of the marked reduction od SV. The decrease of cardiac chamber volume is a clear marker of physical deconditioning and explains also the marked reduction of the maximal oxygen uptake usually found in this population. SECOND STUDY Background. Previous studies provided the evidence that energy cost of walking (C) of children with cerebral palsy (CP) tends to increase with their age, in contrast with what is observed in healthy children. In addition, children with CP of different clinical subtypes showed different values of C. Indeed, children with diplegia have a lower economy of walking than children with hemiplegia. However, the description of the trend of C, during their development remains unclear. Aim: i) to compare C among CP children and healthy children of overlapping age (4-7 years; 8-11 years; 12-14 years); ii) to evaluate possible differences in C within the clinical CP subtypes: diplegia and hemiplegia (two of the more common clinical sub-types). Population: 43 CP children (32 with diplegia and 11 with hemiplegia) and 20 healthy children. Methods: Oxygen uptake (V’O2; K4, Cosmed, Roma, Italy), and heart rate (HR; Polar Electro, Finland) were measured at rest and at different walking speed (from 1 to 6 km.h-1). Then C (V’O2net.speed-1) was calculated at each speed. Results: V’O2 and C of diplegic children are significantly larger than in healthy children at all ages, whereas for hemiplegic children this holds true for the youngest groups (4-7 years) but not for the eldest groups (12-14 years). Interpretation: the economy of walking in children with hemiplegia tends to increase by increasing the age, unlike in diplegia where C is always significantly larger then in normal developing children. THIRD STUDY Background. Gait training with the help of assistive technological devices is an innovative field of research in neurological rehabilitation. Most of the available gait training devices do not allow free movement in the environment, which would be the most suitable natural and motivating condition for training children with neurological gait impairment. Aim. To evaluate the potential usefulness of a new robotic walking aid as a tool for gait training in non-ambulatory children with Cerebral Palsy. Population. A 11-years-old child unable to stand and walk independently as a result of spastic tetraplegic Cerebral Palsy. Methods. The experimental device was a newly actuated version of a dynamic combined walking and standing aid (NF-Walker®) available in the market, which was modified by means of two pneumatic artificial muscles driven by a foot-switch inserted in the shoes. The child was tested at baseline (while maintaining the standing position aided by the non-actuated NF-Walker®) and in the experimental condition (while using the actuated robotic aid). The outcome measures were 2-minutes walking test, 10-meters walking test, oxygen consumption (V’O2; K4, Cosmed, Roma, Italy), heart rate (HR; Polar Electro, Finland) and energy cost of locomotion (C). Results. At baseline, the child was unable to perform any autonomous form of locomotion. When assisted by the actuated aid (i.e. during the experimental condition), the child was successful in moving around in his environment. His performance was 9.63 m in the 2-minutes walking test and 64 s in the 10-meters walking test. V’O2 and HR were higher than healthy age-matched children both at baseline and in the experimental condition. C of gait, which was not valuable in the baseline condition, was significantly higher than C at optimal speed in healthy children. Conclusion. The new robotic walking aid may help children suffering from cerebral palsy with severe impairment of gait to move around in their environment. Clinical rehabilitation impact: This new robotic walking device may have a potential impact in stimulating the development and in training of gait in children with neurological gait impairment. Future studies are warranted in order to test this hypothesis.
This dissertation reports and discusses part of the results obtained during the multi partners experimental study: “Disordini di Movimento e Riabilitazione nella Parasili Cerebrale Infantile” proposed and developed in co-operation with the School of Exercise Science, the Department of Computer Science, the Department of Neurological and Visual Science of Verona University, the School of Medicine of Roma Cattolica University and the Don Calabria Institute. The project was funded with a grant assigned by the Fondazione Cariverona. During the three years of my PhD course I was mainly involved in the sub-project proposed by the School of Sport and Exercise Science. The aims of this project were to investigate: i) the economy of walking in children with cerebral palsy and: ii) their cardiovascular responses to exercise. In addition, we aimed to develop and propose a clinical protocol for the assessment in the clinical environment of the economy of locomotion and of the metabolic and cardiopulmonary responses to exercise of these patients. The competences and knowledge gained during this experimental campaign have been subsequently exploited in a study completed in collaboration with “E. Medea” Insitute, Associazione “La Nostra Famiglia” of Conegliano (Treviso, Italy), and for the assessment of a new type of walking aid. Therefore in the present Thesis, three different studies will be presented and discussed: • The first study is a product of the co-operation with the clinicians of the Don Calabria Institute and it mainly describes and discusses the economy of walking and the cardiovascular responses to exercise, of children with cerebral palsy compared with healthy children. • The second study is the product of the co-operation with the “E. Medea” institute and it deals with the differences in the economy of walking, among different clinical sub-groups of patients. • The third study has been accomplished by the collaboration with the Don Calabria institute, the “G. Rossi” Hospital, and the department of Computer Science. It describes the cardiovascualr and metabolic reponses of a child who walked with the aid of an actuated walker (single case study). FIRST STUDY Background. Cerebral palsy is a disorder of movement and posture due to a lesion of the brain occurring early in childhood or during the fetal development. In children with cerebral palsy (CP), compared with normal children, walking is less economical and efficient. Moreover, also the metabolic pathways and systems involved in muscular power production are impaired. For instance, maximal aerobic power is rather low in CP patients. For these reasons, children with CP become easily fatigued when exercising, even at moderate intensity. This leads them on a long term to reduce progressively their activity triggering a vicious circle that, in turn, causes a further reduction of physical fitness and daily independence. Aim: i) to determine energetic cost of locomotion (C) at different submaximal speeds, in healthy children and in cerebral palsy; ii) to study cardiovascular responses (V’O2, and O2 transport) to submaximal exercise. Population. 20 healthy subjects and 11 children with CP, aged between 6 and 14. Protocol. Oxygen consumption (V’O2; K4, Cosmed, Roma, Italy), heart rate (HR; Polar Electro, Finland), and arterial pressure profile (photopletismographic method, Portapres, FMS, Amsterdam, The Netherlands) were measured at rest and during walking at 1-2-3-4-5-6 Km/h, each speed was maintained for at least 4 minutes. Cardiac output was estimated by using arterial pulse analysis with Beatscope® software (FMS, Amsterdam, The Netherlands). Results. We confirmed that C and V’O2 are larger in CP children compare to healthy. Stroke volume (SV) was found to be significantly smaller then normal developing children at each speed. Conclusions. The main findings of this study: I) confirmed that the economy of locomotion in children with CP is lower than that of healthy mates; showed that the cardiovascular O2 transport was impaired especially because of the marked reduction od SV. The decrease of cardiac chamber volume is a clear marker of physical deconditioning and explains also the marked reduction of the maximal oxygen uptake usually found in this population. SECOND STUDY Background. Previous studies provided the evidence that energy cost of walking (C) of children with cerebral palsy (CP) tends to increase with their age, in contrast with what is observed in healthy children. In addition, children with CP of different clinical subtypes showed different values of C. Indeed, children with diplegia have a lower economy of walking than children with hemiplegia. However, the description of the trend of C, during their development remains unclear. Aim: i) to compare C among CP children and healthy children of overlapping age (4-7 years; 8-11 years; 12-14 years); ii) to evaluate possible differences in C within the clinical CP subtypes: diplegia and hemiplegia (two of the more common clinical sub-types). Population: 43 CP children (32 with diplegia and 11 with hemiplegia) and 20 healthy children. Methods: Oxygen uptake (V’O2; K4, Cosmed, Roma, Italy), and heart rate (HR; Polar Electro, Finland) were measured at rest and at different walking speed (from 1 to 6 km.h-1). Then C (V’O2net.speed-1) was calculated at each speed. Results: V’O2 and C of diplegic children are significantly larger than in healthy children at all ages, whereas for hemiplegic children this holds true for the youngest groups (4-7 years) but not for the eldest groups (12-14 years). Interpretation: the economy of walking in children with hemiplegia tends to increase by increasing the age, unlike in diplegia where C is always significantly larger then in normal developing children. THIRD STUDY Background. Gait training with the help of assistive technological devices is an innovative field of research in neurological rehabilitation. Most of the available gait training devices do not allow free movement in the environment, which would be the most suitable natural and motivating condition for training children with neurological gait impairment. Aim. To evaluate the potential usefulness of a new robotic walking aid as a tool for gait training in non-ambulatory children with Cerebral Palsy. Population. A 11-years-old child unable to stand and walk independently as a result of spastic tetraplegic Cerebral Palsy. Methods. The experimental device was a newly actuated version of a dynamic combined walking and standing aid (NF-Walker®) available in the market, which was modified by means of two pneumatic artificial muscles driven by a foot-switch inserted in the shoes. The child was tested at baseline (while maintaining the standing position aided by the non-actuated NF-Walker®) and in the experimental condition (while using the actuated robotic aid). The outcome measures were 2-minutes walking test, 10-meters walking test, oxygen consumption (V’O2; K4, Cosmed, Roma, Italy), heart rate (HR; Polar Electro, Finland) and energy cost of locomotion (C). Results. At baseline, the child was unable to perform any autonomous form of locomotion. When assisted by the actuated aid (i.e. during the experimental condition), the child was successful in moving around in his environment. His performance was 9.63 m in the 2-minutes walking test and 64 s in the 10-meters walking test. V’O2 and HR were higher than healthy age-matched children both at baseline and in the experimental condition. C of gait, which was not valuable in the baseline condition, was significantly higher than C at optimal speed in healthy children. Conclusion. The new robotic walking aid may help children suffering from cerebral palsy with severe impairment of gait to move around in their environment. Clinical rehabilitation impact: This new robotic walking device may have a potential impact in stimulating the development and in training of gait in children with neurological gait impairment. Future studies are warranted in order to test this hypothesis.
Energetic Cost of Walking and Cardiovascular Responses to Exercise in Healthy Children and in Children with Cerebral Palsy
MARCONI, Valeria
2011-01-01
Abstract
This dissertation reports and discusses part of the results obtained during the multi partners experimental study: “Disordini di Movimento e Riabilitazione nella Parasili Cerebrale Infantile” proposed and developed in co-operation with the School of Exercise Science, the Department of Computer Science, the Department of Neurological and Visual Science of Verona University, the School of Medicine of Roma Cattolica University and the Don Calabria Institute. The project was funded with a grant assigned by the Fondazione Cariverona. During the three years of my PhD course I was mainly involved in the sub-project proposed by the School of Sport and Exercise Science. The aims of this project were to investigate: i) the economy of walking in children with cerebral palsy and: ii) their cardiovascular responses to exercise. In addition, we aimed to develop and propose a clinical protocol for the assessment in the clinical environment of the economy of locomotion and of the metabolic and cardiopulmonary responses to exercise of these patients. The competences and knowledge gained during this experimental campaign have been subsequently exploited in a study completed in collaboration with “E. Medea” Insitute, Associazione “La Nostra Famiglia” of Conegliano (Treviso, Italy), and for the assessment of a new type of walking aid. Therefore in the present Thesis, three different studies will be presented and discussed: • The first study is a product of the co-operation with the clinicians of the Don Calabria Institute and it mainly describes and discusses the economy of walking and the cardiovascular responses to exercise, of children with cerebral palsy compared with healthy children. • The second study is the product of the co-operation with the “E. Medea” institute and it deals with the differences in the economy of walking, among different clinical sub-groups of patients. • The third study has been accomplished by the collaboration with the Don Calabria institute, the “G. Rossi” Hospital, and the department of Computer Science. It describes the cardiovascualr and metabolic reponses of a child who walked with the aid of an actuated walker (single case study). FIRST STUDY Background. Cerebral palsy is a disorder of movement and posture due to a lesion of the brain occurring early in childhood or during the fetal development. In children with cerebral palsy (CP), compared with normal children, walking is less economical and efficient. Moreover, also the metabolic pathways and systems involved in muscular power production are impaired. For instance, maximal aerobic power is rather low in CP patients. For these reasons, children with CP become easily fatigued when exercising, even at moderate intensity. This leads them on a long term to reduce progressively their activity triggering a vicious circle that, in turn, causes a further reduction of physical fitness and daily independence. Aim: i) to determine energetic cost of locomotion (C) at different submaximal speeds, in healthy children and in cerebral palsy; ii) to study cardiovascular responses (V’O2, and O2 transport) to submaximal exercise. Population. 20 healthy subjects and 11 children with CP, aged between 6 and 14. Protocol. Oxygen consumption (V’O2; K4, Cosmed, Roma, Italy), heart rate (HR; Polar Electro, Finland), and arterial pressure profile (photopletismographic method, Portapres, FMS, Amsterdam, The Netherlands) were measured at rest and during walking at 1-2-3-4-5-6 Km/h, each speed was maintained for at least 4 minutes. Cardiac output was estimated by using arterial pulse analysis with Beatscope® software (FMS, Amsterdam, The Netherlands). Results. We confirmed that C and V’O2 are larger in CP children compare to healthy. Stroke volume (SV) was found to be significantly smaller then normal developing children at each speed. Conclusions. The main findings of this study: I) confirmed that the economy of locomotion in children with CP is lower than that of healthy mates; showed that the cardiovascular O2 transport was impaired especially because of the marked reduction od SV. The decrease of cardiac chamber volume is a clear marker of physical deconditioning and explains also the marked reduction of the maximal oxygen uptake usually found in this population. SECOND STUDY Background. Previous studies provided the evidence that energy cost of walking (C) of children with cerebral palsy (CP) tends to increase with their age, in contrast with what is observed in healthy children. In addition, children with CP of different clinical subtypes showed different values of C. Indeed, children with diplegia have a lower economy of walking than children with hemiplegia. However, the description of the trend of C, during their development remains unclear. Aim: i) to compare C among CP children and healthy children of overlapping age (4-7 years; 8-11 years; 12-14 years); ii) to evaluate possible differences in C within the clinical CP subtypes: diplegia and hemiplegia (two of the more common clinical sub-types). Population: 43 CP children (32 with diplegia and 11 with hemiplegia) and 20 healthy children. Methods: Oxygen uptake (V’O2; K4, Cosmed, Roma, Italy), and heart rate (HR; Polar Electro, Finland) were measured at rest and at different walking speed (from 1 to 6 km.h-1). Then C (V’O2net.speed-1) was calculated at each speed. Results: V’O2 and C of diplegic children are significantly larger than in healthy children at all ages, whereas for hemiplegic children this holds true for the youngest groups (4-7 years) but not for the eldest groups (12-14 years). Interpretation: the economy of walking in children with hemiplegia tends to increase by increasing the age, unlike in diplegia where C is always significantly larger then in normal developing children. THIRD STUDY Background. Gait training with the help of assistive technological devices is an innovative field of research in neurological rehabilitation. Most of the available gait training devices do not allow free movement in the environment, which would be the most suitable natural and motivating condition for training children with neurological gait impairment. Aim. To evaluate the potential usefulness of a new robotic walking aid as a tool for gait training in non-ambulatory children with Cerebral Palsy. Population. A 11-years-old child unable to stand and walk independently as a result of spastic tetraplegic Cerebral Palsy. Methods. The experimental device was a newly actuated version of a dynamic combined walking and standing aid (NF-Walker®) available in the market, which was modified by means of two pneumatic artificial muscles driven by a foot-switch inserted in the shoes. The child was tested at baseline (while maintaining the standing position aided by the non-actuated NF-Walker®) and in the experimental condition (while using the actuated robotic aid). The outcome measures were 2-minutes walking test, 10-meters walking test, oxygen consumption (V’O2; K4, Cosmed, Roma, Italy), heart rate (HR; Polar Electro, Finland) and energy cost of locomotion (C). Results. At baseline, the child was unable to perform any autonomous form of locomotion. When assisted by the actuated aid (i.e. during the experimental condition), the child was successful in moving around in his environment. His performance was 9.63 m in the 2-minutes walking test and 64 s in the 10-meters walking test. V’O2 and HR were higher than healthy age-matched children both at baseline and in the experimental condition. C of gait, which was not valuable in the baseline condition, was significantly higher than C at optimal speed in healthy children. Conclusion. The new robotic walking aid may help children suffering from cerebral palsy with severe impairment of gait to move around in their environment. Clinical rehabilitation impact: This new robotic walking device may have a potential impact in stimulating the development and in training of gait in children with neurological gait impairment. Future studies are warranted in order to test this hypothesis.
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