Stop Tip-toeing Around Toe-walking

Study Overview
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Brief Summary
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The purpose of this study is to explore the interplay among nervous-, musculoskeletal-, and psychological systems and how they impact toe-walking behavior, and vice versa. Sub-Project 1 is to analyze the feasibility of the developed virtual reality (VR) environment, in 10 TD and sCP children respectively. It is assess the effects of VR immersion on predefined static and dynamic stability parameters. Sub-Project 2: After adjustments have been made following Sub-Project 1 regarding the study procedure, technical factors or the parameters of interest etc., the optimized study procedure is implemented in Sub-Project 2 (20 to 25 TD will be included). Sub-Project 3: After adjustments have been made following Sub-Project 1 regarding the study procedure, technical factors or the parameters of interest etc., the optimized study procedure is implemented in Sub-Project3 (20 to 25 sCP will be included)

Detailed Description
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The interplay between the nervous-, musculoskeletal-, and psychological systems and their impact on resulting walking patterns are poorly understood. Children that toe-walk often show poorer levels of static and dynamic stability, leading to a lower quality of life compared to typically develop-ing children (TD). Current research suggests multifactorial adaptations in central and/or peripheral nervous as well as the musculoskeletal system contribute to and result from toe-walk-ing. The purpose of this study is to explore the interplay among nervous-, musculoskeletal-, and psychological systems and how they impact toe-walking behavior, and vice versa. The effect of psychological factors (via the use of a custom-designed virtual reality environment) on static vs. dynamic stability, motor control, coordination (indirect assessment of central nervous system function) as well as reflex control (Hoffmann-reflex, H-reflex, performance of peripheral nervous system) is investigated.

Official Title
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Stop Tip-toeing Around Toe-walking: Towards a Better Understanding and More Effective Treatment of Toe-walkers With Cerebral Palsy

Conditions
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Spastic Cerebral Palsy (sCP)

Intervention / Treatment
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* Diagnostic Test: Static stability measurement
* Diagnostic Test: Dynamic stability measurement


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for TD children: between the age of 7 and 18 years who are typically developing able to stand and walk alone without using assistance or assistive devices able to place their feet flat on the force platforms with enough German language skills to follow the instructions Inclusion Criteria for sCP children: between the age of 7 and 18 years with the diagnosis of spastic CP or CP similar (both unilateral and bilateral), functionally classified level I or II according to the Gross Motor Function Classification System (GMFCS) being able to stand and walk alone without assistance or assistive devices able to place their feet flat on the force platforms with enough German language skills to follow the instructions Exclusion Criteria for TD children: severe visual, cognitive, or auditory impairments that would interfere with the study instructions and the VR immersion any vestibular problems (e.g. severe motion sickness) history of epilepsy, pace-marker or/and electrical pumps (due to possible interference with electrical stimulation) prior experience of VR to ensure a comparable baseline between subjects Exclusion Criteria for sCP children: severe visual, cognitive, or auditory impairments that would interfere with the study instructions and the VR immersion severe knee flexion gait (>45°) walking capacity <50m botulinum toxin type A treatment (past 6 months) orthopedic surgery of upper or lower extremities (past 12 months) any vestibular problems (e.g. severe motion sickness or dizziness) history of epilepsy, pace-marker or/and electrical pumps (due to possible interference with electrical stimulation) prior experience of VR as they may already be adapted to VR.

Ages Eligible for Study
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Minimum Age: 7 Years
Maximum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Cross sectional, age-matched-controlled and monocentric study with an exploratory approach.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Typically Developing (TD) children<br>Static stability and Dynamic stability measurement in children with: 1) between the age of 7 and 18 years, 2) who are typically developing, 3) able to stand and walk alone without using assistance or assistive devices, 4) able to place their feet flat on the force platforms, and 5) with enough German language skills to follow the instructions. | Diagnostic Test: Static stability measurement<br>* The child stands barefoot on dual force platforms in two (CP: three) different conditions: barefoot and with shoes (CP: and with orthosis). Each condition is recorded three times each lasting for 30s, and 30s rest between them. Both conditions are recorded with and without wearing a headset. The order of conditions (within each Virtual Reality (VR)-condition) is randomized. For each condition, the child rests in a comfortable position for 20s with the heels on the same level and arms hanging at their sides. Between both VR-conditions, the child rests for 120 s.<br>Diagnostic Test: Dynamic stability measurement<br>* The child walks at their normal walking speed on a 10-m walkway in two (CP: three) different conditions: barefoot and with shoes (CP: and with orthosis). For each condition, at least six error-free trials are recorded. Errors in data may occur due to hidden or lost markers during walking or software interruptions. Both conditions are recorded with and without wearing a headset. The order of conditions (within each VR-condition) is randomized.<br>|
| Experimental: Spastic Cerebral Palsy (sCP) children<br>Static stability and Dynamic stability measurement in children with: 1) between the age of 7 and 18 years, 2) with the diagnosis of spastic CP or CP similar (both unilateral and bilateral), functionally classified level I or II according to the Gross Motor Function Classification System (GMFCS) [98], 3) being able to stand and walk alone without assistance or assistive devices, 4) able to place their feet flat on the force platforms, and 5) with enough German language skills to follow the instructions. | Diagnostic Test: Static stability measurement<br>* The child stands barefoot on dual force platforms in two (CP: three) different conditions: barefoot and with shoes (CP: and with orthosis). Each condition is recorded three times each lasting for 30s, and 30s rest between them. Both conditions are recorded with and without wearing a headset. The order of conditions (within each Virtual Reality (VR)-condition) is randomized. For each condition, the child rests in a comfortable position for 20s with the heels on the same level and arms hanging at their sides. Between both VR-conditions, the child rests for 120 s.<br>Diagnostic Test: Dynamic stability measurement<br>* The child walks at their normal walking speed on a 10-m walkway in two (CP: three) different conditions: barefoot and with shoes (CP: and with orthosis). For each condition, at least six error-free trials are recorded. Errors in data may occur due to hidden or lost markers during walking or software interruptions. Both conditions are recorded with and without wearing a headset. The order of conditions (within each VR-condition) is randomized.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Static stability assessed by Center of Pressure (COP) shifts in anterior-posterior and mediolateral directions under each limb | COP shifts in anterior-posterior and mediolateral directions under each limb are assessed via the use of two force plates embedded in the floor (Kistler Instrumente AG, Winterthur, Switzerland, sample rate 1500 Hz) (mean value of three repetitions) | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Static stability assessed by Visual Analogue Scale (VAS) | Self-perceived degree of safety during walking in the VR environment will be assessed using a Visual Analogue Scale (VAS) ranging from 0 (feeling completely safe) to 10 (feeling completely unsafe) | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Static stability assessed by Ratio between H-reflex and M-wave amplitude | Ratio between H-reflex and M-wave amplitude, measured through soleus muscle in affected side of hemiplegic sCP and in none-dominant side for diplegic CP and TD (recruitment curve of the H-reflex and the M-wave of the Soleus elicited by stimulating the tibial nerve while standing) | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability assessed by COP shifts in combination with base of support trajectory | COP shifts in combination with base of support trajectory assessed via the use of four force plates embedded in the floor (mean value of three repetitions) | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability assessed by number of muscle synergies | Number of muscle synergies assessed via the use of a sixteen-channel surface electromyography system | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability assessed by interlimb coordination | Interlimb coordination will be calculated by using kinematic data from lower and upper extremities | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability assessed by Self-perceived degree of safety during walking in the VR environment using a Visual Analogue Scale (VAS) | Dynamic stability assessed by Self-perceived degree of safety during walking in the VR environment using a Visual Analogue Scale (VAS) ranging from 0 (feeling completely safe) to 10 (feeling completely unsafe) | one time assessment at baseline (complete baseline assessments up to 3 hours) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Dynamic stability measurement assessed by kinematic data of upper & lower extremities (joint angles in degree) | Dynamic stability measurement assessed by kinematic data of upper & lower extremities (joint angles in degree) | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability measurement assessed by spatiotemporal parameters: walking speed (normalized to leg length) [m/(s*mm)] | Dynamic stability measurement assessed by spatiotemporal parameters: walking speed (normalized to leg length) [m/(s*mm)] | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability measurement assessed by spatiotemporal parameters: stride width [s] | Dynamic stability measurement assessed by spatiotemporal parameters: stride width [s] | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability measurement assessed by spatiotemporal parameters: double support time [s] | Dynamic stability measurement assessed by spatiotemporal parameters: double support time [s] | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability measurement assessed by spatiotemporal parameters: cadence [steps/min] | Dynamic stability measurement assessed by spatiotemporal parameters: cadence [steps/min] | one time assessment at baseline (complete baseline assessments up to 3 hours) | 
| Dynamic stability measurement assessed by spatiotemporal parameters: step length [m] | Dynamic stability measurement assessed by spatiotemporal parameters: step length [m] | one time assessment at baseline (complete baseline assessments up to 3 hours) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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tip-toeing, toe-walking, gait cycle, heel-strike, Static stability, Dynamic stability, Virtual Reality, Cerebral Palsy (CP)