1
Perturbation-based Training on Compliant
Surfaces to Improve Balance in Children with
Cerebral Palsy: A Feasibility Study
Connor M. Phillips, Vu Phan, Kwanghee Jo, Omik Save, Joshua B. Russell, Kayla B Zeien, Megan C.
Eikenberry, Carolyn L. Kinney, and Hyunglae Lee*, Member, IEEE
Abstract— Children with cerebral palsy suffer from balance
deficits that may greatly reduce their quality of life. However,
recent advancements in robotics allow for balance rehabilitation
paradigms that provide greater control of the training
environment and more robust measurement techniques. Previous
works have shown functional balance improvement using standing
surface perturbations and compliant surface balancing. Visual
feedback during balance training has also been shown to improve
postural balance control. However, the combined effect of these
interventions has not been evaluated. This paper presents a robot-
aided rehabilitation study for children with cerebral palsy on a
side-specific performance-adaptive compliant surface with
perturbations. Visual feedback of the participant’s center of
pressure and weight distribution were used to evaluate successful
balance and trigger perturbations after a period of successful
balancing. The platform compliance increased relative to the
amount of successful balance during each training interval. Two
participants trained for 6 weeks including 10, less than 2 hours
long, training sessions. Improvements in functional balance as
assessed by the Pediatric Balance Scale, Timed 10 Meter Walk
Test, and 5 Times Sit-to-Stand Test were observed for both
participants. There was a reduction in fall risk as evidenced by
increased Virtual Time to Contact and an increase in dynamic
postural balance supported by a faster Time to Perturb, Time to
Stabilize, and Percent Stabilized. A mixed improvement in static
postural balance was also observed. This paper highlights the
feasibility of robot-aided rehabilitation interventions as a method
of balance therapy for children with cerebral palsy.
Index Terms— Cerebral palsy, postural balance, robot-aided
rehabilitation, robotic rehabilitation, balance training
I. INTRODUCTION
C EREBRAL PALSY (CP) is a class of non-progressive
neuromuscular disorders that affects movement and
posture, and it is caused by trauma to the developing brain at or
near the time of birth [1]. These deficits lead to balance and
Submitted for review on April 8, 2022. This work was funded by Arizona
Biomedical Research Centre (ABRC).
C. M. Phillips was with the School for Engineering of Matter, Transport,
and Energy, Arizona State University, Tempe, AZ 85287, USA. He is now with
the Rehabilitation Medicine Department of the National Institutes of Health,
Bethesda, MD, 20892 USA. (e-mail: cmphil13@asu.edu)
V. Phan, K. Jo, O. Save, and J. B. Russell are with the School for
Engineering of Matter, Transport, and Energy, Arizona State University,
coordination issues that can dramatically impede a child’s
ability to complete the tasks of daily life [2] and limit
participation in social activities that contribute to wellbeing and
emotional development [3], [4]. One primary contributor to this
is reduced postural balance control [5], particularly in the face
of balance threats [6].
Indeed, children with CP are less able to respond to balance
threats and have shown to have a reduced ability to time
neuromuscular responses to both physical [6], [7], [8] and
virtual balance perturbations [9]. This is due to a combination
of factors including an increase in coactivation of muscles
during postural balance tasks [7], [8], [10], [11], postural
misalignment [12], and sensory deficits [13], [14].
Traditionally, the balance deficits of CP are rehabilitated
through conventional physical therapy which focuses on gross
motor functions like walking, jumping, and improving range of
motion [15]. Less common, though still effective, is strength
training which aims to correct muscle imbalance and weakness
that limit efficient gross motor function [16]. Both methods
have been shown to improve balance [17], [18] and muscle
coordination [15], [19], [20] in children with CP. Although
these methods are effective, recent technological advancements
present possible supplementary rehabilitation methods that
allow for greater control of the training environment and can
assess the progress of the patient with higher resolution.
There are several studies that aim to improve balance in
children with CP using visual feedback-guided balance
training. The simplest of these technologies are static standing
surfaces that measure normal force and provide visual feedback
of the participant’s balance. A popular option is the low-cost
Wii Balance Board [21]‒[24] which gamifies balance training
through exercise-based modalities. A meta-review on the
efficacy of the Wii Balance Board for balance rehabilitation
found moderate evidence for improvement in functional
balance as measured by the Pediatric Balance Scale. The
Tempe, AZ 85287, USA. K. Zeien is with the School of Biological and Health
Systems Engineering, Arizona State University, Tempe, AZ 85287 USA.
M. C. Eikenberry is with the Department of Physical Therapy, Midwestern
University, Glendale, AZ 85308 USA.
C. L. Kinney is with the Department of Physical Medicine and
Rehabilitation, Mayo Clinic, Phoenix, AZ 85054 USA.
H. Lee is with the School for Engineering of Matter, Transport, and Energy,
Arizona State University, Tempe, AZ 85287, USA (e-mail:
hyunglae.lee@asu.edu; *corresponding author).
 2

improvement increased when combined with conventional TABLE I

physical therapy [21]. Other static surface interventions include
force plate systems that provide visual feedback of the center of
pressure (CoP, a measure frequently used to evaluate postural
balance control [25], [26]) to perform custom balance tasks.
The CoP is defined as the point where a person’s center of mass
(CoM) is cancelled out by the resultant normal force vector
created from the support of the standing surface [26]. Studies
implementing CoP-based visual feedback in children with CP
have shown improved neuromuscular coordination of involved
muscles, [27] and decreased postural sway leading to improved
walking symmetry in hemiplegic patients [28]. Despite their
benefits, the static nature of these systems does not address the
need for an improved response to external balance threats.
More advanced systems that employ robots have been used
to directly address CP children’s response to external
perturbations. Known as reactive balance control, these studies
employed physical perturbations both with [29], [30], and
without [31] visual feedback. Shumway-Cook et al. (2003)
showed an improved ability to recover stability following a high
repetition of un-anticipated (no visual feedback) lateral
perturbations [31], while El-Shamy et al. (2013) and El-Kafy et
al. (2014) showed an improvement in functional balance ability,
reduction in fall risk, and improved walking after balance
training with visual feedback on the compliant surface of the
Biodex Balance Training System [29], [30]. These systems
demonstrated the efficacy of reactive balance training to
improve functional and reactive balance control. However,
further emphasis can be made on addressing side-specific
ability which may benefit both uni- and bi-lateral CP patients.
A precursor to this study conducted by Hennington et al.
(2019) described a unilateral balance training study to improve
ankle function in hemiparetic stroke patients [32]. This
involved a single dual-axis robotic platform that could simulate
a compliant surface [33]. The participants placed their paretic
foot on the compliant platform and the other foot on solid
ground. Visual feedback challenged the participant to manage
their weight distribution and perform a target-reaching task by
manipulating the angle of the platform with their ankle. Post-
training, participants exhibited improved functional balance
and paretic ankle mobility. Although the purpose of this study
was to improve functional outcomes in hemiparetic stroke, we
observed the potential of this robotic balance platform for
improving postural balance in other populations with
neurological disorders like children with CP.
Similar to stroke, this cohort suffers from decreased motor
control and balancing ability. However, the causal trauma is
often near the time of birth which leads to life-long impairment.
We aimed to further develop a training protocol by combining
the compliant surface and perturbation elements of existing
balance training methods into a side-specific program using two
of these robotic platform systems. The inclusion of both
compliant surfaces and external perturbations allows us to more
closely mirror the balance threats experienced in daily life,
while the addition of a second platform accounts for the non-
symmetrical functional deficiencies present in cerebral palsy.
This study aimed to evaluate the feasibility of side-specific
PARTICIPANT INFORMATION
Subject Number 1 2
Pre-test age (yr) 14 11
Gender M M
Diagnosis Spastic Spastic Triplegic
Diplegic (Right arm affected)
Ambulation Status Independent Assisted
Assistive Device None Walker at school, cane
otherwise
Orthotics None Bilateral Solid AFOs
GMFCS level II III
Other therapy None Traditional PT 1 hr/week
perturbation-based compliant surface training on a set of
robotic platforms for the improvement of balance in cerebral
palsy.
II. METHODS
A convenience sample of two children with cerebral palsy
participated in this study (ages: 14, 11 years, height: 146.1,
146.4 cm, weight: 32.9, 42.5 kg) which was approved by the
Arizona State University Institutional Review Board
(STUDY00013754).
Participants were included in the study if they had a
physician’s diagnosis of spastic cerebral palsy, were between
the ages of 8-14, had a Gross Motor Function Classification
Score [34] of III or less, the ability to stand independently for 5
minutes, and the cognizance to understand experimental
procedures and give informed consent. More detailed
information on each participant’s functional status is included
in Table I.
A. Training Schedule
Ten training sessions occurred over 6 weeks, each lasting no
longer than 2 hours. The first session was used as a practice
session to tune experimental parameters and was not included
in the results. Each training session contained 3, 30 s long
blocks of quiet standing data collection before the training in
which the surface of the platforms were rigid and the
participants were asked to “stand as still as possible.” After this,
there were up to 12, 3-minute-long blocks of training in which
the platforms simulated a compliant surface and perturbed.
Participants were allowed break periods of 3 minutes in-
between each training block and were given an additional 3
minutes if needed. The training session ended early if the
participant expressed that they were too fatigued to continue or
if the total visit time reached 2 hours. Participants 1 and 2
completed 96% and 84% of the 108 possible training blocks,
respectively. Assessment sessions were conducted before the
first training session and after the last to evaluate the cumulative
effect of the training on functional balance ability (Fig. 1).
These sessions included both clinical and experimental
measures of postural balance (see Sections D and E respectively
for detailed information on the tests employed).
B. Training Apparatus
Participants balanced with one foot on each surface of the

Fig 1. A flowchart showing a breakdown of the experimental timeline. It
includes the pre- and post-training assessment sessions, the 10 training
sessions, and the final 3-month post-training survey to evaluate the
participants’ perceived functional improvement (as described by parents and
the participants).
twin dual-axis robotic platforms (Fig. 2A). The platforms can
rotate in the anteroposterior (AP) and mediolateral (ML)
directions and were controlled independently using MATLAB
and Simulink Real-time (MathWorks, MA, USA). Force plates
served as the point of contact with the participants’ feet and
were used to record bilateral CoP data (9260AA3, Kistler, NY,
USA). For each CoP measure, the weighted average of the right
and left CoP data (i.e., net CoP) was reported.
The platforms were programmed to employ a 2nd order
admittance controller which may simulate various compliant
surfaces through the modulation of their assigned stiffness
value. The range of stiffnesses used for this experiment was
300-1500 Nm/rad. The upper and lower limits of this range
were chosen based on preliminary experimentation with healthy
participants.
Visual feedback was displayed during the training sessions
to provide real-time information on the participant’s balance.
Left and right CoP were shown on the corresponding sides, and
the participant’s weight distribution was shown in the center
(Fig. 2B). Each visual feedback measure had an associated
boundary that established the criteria for “successful balance”.
Successful balance occurred when all visual feedback measures
were within their respective boundaries at the same time. CoP
boundaries were determined through the average of the 95
percentiles for 5, 30 s trials of quiet-standing CoP data in the
AP and ML directions separately. During these trials, platforms
were set at the middle value of stiffness (900 Nm/rad). The CoP
boundaries were calculated in the first session and then
recalculated before the 2nd session after tuning the experimental
parameters (the 1st training session was not included in the data
analysis). The CoP boundaries on the visual feedback were
circular and appeared the same on both sides. However, the
3
Fig. 2. (A) A participant standing on the platform, and (B) a representation
of the visual feedback used during the training, with a post-training block
score shown. This example shows successful CoP modulation and
unsuccessful weight modulation.
virtual scale of the visual was side- and direction-specific. If a
patient was more disabled on one side, meaning they have more
impaired motor control, the 95 percentiles of the CoP data in
AP and ML directions for that side will likely be larger. This
would decrease the scale of the impaired side to make
movement of the cursor on that side proportionally smaller
(essentially zoomed out). However, this boundary still occupies
space as the less impaired side. The weight distribution
boundary was calculated as 20% of the participant’s total
weight at the beginning of every training session. CoP
calibration occurred every time the participant stepped on the
platforms, while weight distribution was calibrated once at the
beginning of every training session. In both cases, the mean
value was calculated from 15 s of quiet standing data and
subtracted from the input to the visual feedback. An outline of
the participant’s foot position was drawn on the paper fixed to
the platforms’ top surfaces to ensure participants’ feet were
placed consistently. This same outline was used for all
subsequent uses of the platform by that participant. Participants
wore shoes and any ankle-foot orthoses that would normally be
worn during athletic activities. Additionally, participants
always wore a harness when standing on the platforms to
prevent falling. The harness was adjusted such that no weight
support was provided unless a fall was imminent. To ensure
participant safety and comfort, a spotter was present behind the
participant at all times.
C. Training Mechanics
The goal during each training session was for the participant
to maintain successful balance (defined by the visual feedback
boundaries) for as long as possible. A boundary is considered
“passed” when the center of the user’s cursor moves beyond the
boundary. If the visual feedback was satisfied for 2 s
consecutively, the platforms would rotationally perturb +/- 3°
in one of the four directions (forwards, backward, left, right,
named by the direction normal to the upper face of the force
plate) starting from the platform angle at which the visual
feedback criteria were satisfied.
The platforms perturbed synchronously and in the same
direction then returned to the zero-angle position in the
perturbed plane. This process occurred over a combined 1.5 s
(1 s for the +/- 3° perturbation, and 0.5 s for the return to the
 4

zero-angle position). At this point, the perturbed plane of the

platforms was held at the zero-angle position for 2 s. This
allowed us to investigate the effects of the perturbation on the
participant’s balance in this plane. Throughout all these events,
the non-perturbed plane remained compliant. Following the
recovery period, the perturbed direction of both platforms
switched back to the admittance controller and simulated the
same compliant environment. At all points during the
experiment, the simulated compliance of both platforms was the
same. Two seconds of data were removed following the
recovery period (and at the beginning of the block) to account
for a potential jerking movement that occurred when switching
between perturbation and admittance controllers. This was due Fig. 3. The platform angle in a single plane of rotation for one platform
following 2 s of consecutively satisfying the visual feedback criteria.
to differences in the participant’s preferred balance angle and
Note that the maximum angle may be greater than >3 due to the non-
the neutral position. This discrepancy was determined to be of zero angle of perturbation.
little significance because of the near-zero angle position that is
required for the participants to satisfy the criteria for successful
balance. Fig. 3 shows the angle of the platform in a single plane
during the events surrounding a perturbation. The process was
repeated following the switch to compliance after the
participant balanced successfully for 2 s consecutively. A score
between 0-1000 (10 times the participant’s percentage of
successful balance) was shown on the visual feedback at the end
of each training session to motivate the participants. If they
scored over 500 (50% of successful balancing) “Great Work!”
was displayed.
The stimulated compliance of the platforms was adapted
between blocks of training based on the performance of the
participant during the previous block. This performance-
adaptive component training was meant to challenge the
Fig. 4. A graphical example of the function used to determine the stiffness
participant as much as possible and thus maximize the training value for a block of training. The initial value and the block 1 value based
benefit. The initial stiffness of the platform was set to a on the participant percent success are bisected to yield the new stiffness
conservative value of 1500 Nm/rad since it was not known how value.
well the children with CP would perform on a challenging
(which is likely given the lack of compliance), the next value
compliant surface. Then, a linear function was employed that
would otherwise be the lowest possible simulated stiffness.
related the stiffness of the platform to the percent of successful
balancing during the most recent block of training. The slope of D. Clinical Balance Metrics
-12 creates a line that runs through 1500 Nm/rad at 0% In each assessment session, the Pediatric Balance Scale
successful balance and 300 Nm/rad at 100% successful balance: (PBS, [35]), Timed 10 Meter Walk Test (10MWT, [36]), and 5
Times Sit-to-Stand Test (5XSTS, [37]) were performed by a
𝑘!"# = −12 ∗ 𝑃$%&&"$$ + 𝑘'() (1) licensed physical therapist according to established protocols.
Each of these measures have been shown to be valid and
,!"##$%& -,%$'
𝑘!")* = (2) reliable tests for assessing children with CP and other
.
neuromuscular disorders. The test-retest reliability intra-class
where 𝑘!"# is the new value of stiffness calculated from the correlation coefficients (ICC) for the PBS, 10MWT, and
percent of successful balancing from the most recent block of 5XSTS are 0.998 [35], 0.81 [36], and 0.97 [37], respectively.
training; 𝑃$%&&"$$ is the percentage of successful balancing from These tests evaluate functional balance ability, walking speed,
the most recent training block; 𝑘'() is the maximum value of and lower extremity strength, respectively. It should be noted
simulated stiffness (1500 Nm/rad); 𝑘&%//"!* is the current that Participant 2 had limited unassisted ambulation and self-
simulated value of stiffness; and 𝑘!")* is the bisected value of selected to use their walking cane during the 10MWT, but was
the current stiffness and 𝑘!"# that will be the stiffness the not allowed to use it during the PBS.
platforms simulate in the next training block. E. Experimental Balance Metrics
A linear relationship was chosen to simplify the stiffness An additional compliant balancing test was completed in
adaptation as much as possible (Fig. 4). The use of the bisection each assessment session to evaluate a participant’s dynamic
method prevents rapid change in the stiffness value, without balance without the use of visual feedback [38]. Participants
this if the participant scored 100% at the highest stiffness value stood on the platform during 3 different levels of compliance:

Fig 5. Representations of the training metrics, including A) Time to
Perturb, B) Time to Stabilize, and C) Percent Stabilized. The final value
for each example is shown in green.
rigid (10,000 Nm/rad), compliant (500 Nm/rad), highly
compliant (300 Nm/rad) and with their eyes either opened (EO)
or closed (EC). Three 45 s trials were collected for each of the
6 conditions and the middle 30 s of each trial were analyzed.
This removed the effect of the platform switching to and from
compliance mode on the CoP data.
The CoP data of the compliant balancing test (recorded
before and after the training) was quantified with Virtual Time
to Contact (VTC), also known as Virtual Time to Collision,
which is an effective measure for dynamic balance conditions
[38], [39]. To understand this metric, it is important to know
that the goal of postural control is to keep the vertical projection
of a person’s center of mass (CoM) within their boundary of
support (BoS, an area formed by the connected outline of their
feet). If the CoM moves beyond the BoS, a person will fall [40].
It is thought that the CoP represents the neuromuscular
influence of the CoM, and beyond the BoS compensatory
movements (e.g., stepping) would be triggered to avoid falling
[39]. The VTC takes the instantaneous kinematics of the CoP at
every time point of data and extrapolates this trajectory to the
BoS (assuming no intermediate postural adjustment). The
amount of time it would take to cross the BoS at every point is
recorded and the minima are averaged. The VTC provides an
outcome-based method of quantifying CoP characteristics, and
increased VTC demonstrates a reduction in fall risk [39], [41].
The quiet standing CoP data (recorded before each training
session) were quantified using CoP velocity and area, two
common measures for the evaluation of static balance in CP [5],
[42], [43]. If the participant has greater postural control, a lower
net CoP velocity and a smaller CoP area are expected [25]. CoP
area was defined as the area of an ellipse that encompassed 95%
of the CoP data.
5
F. Training Session Metrics
The training data was analyzed using several metrics to
quantify the progression of the participants’ ability to complete
the balance task. The first measure was the simulated stiffness
over the course of the training. A decreasing trend in system
stiffness would represent an ability to balance successfully in
an increasingly challenging environment.
The other metrics were created in accordance with the events
surrounding the perturbation. Data in the compliance period
were evaluated using the Time to Perturb, which represented
the time following the switch to compliance until the next
perturbation (Fig. 5A). This measured the participant’s ability
to balance stably in a compliant environment with the use of
visual feedback. The recovery period was quantified using the
Time to Stabilize (Fig. 5B) and Percent Stabilized (Fig. 5C).
Time to Stabilize represented the amount of time that it took to
balance successfully for 0.5 s consecutively following the
return to the zero-angle position. This measured how quickly
the participant recovered their balance. Percent Stabilized
quantified the percentage of the recovery period during which
the participant maintained successful balance. This
encompassed the speed of recovery, but also accounted for
whether the participant lost successful balance after stabilizing.
G. Statistical Analysis
Where applicable, results from the remaining 9 sessions of
training were presented in 3 groups (early, mid, and late) each
including the average of 3 sessions worth of data. This was done
to delineate trends more clearly across the training.
Each of the training measures was processed for statistical
significance between groups (early, mid, and late). The
Shapiro-Wilks normality test was used to evaluate whether the
data for each group could be considered normally distributed.
If both groups were normally distributed, a dependent t-test was
run to evaluate significance. If one or more of the groups being
compared was non-normally distributed, then the Wilcoxon
signed-rank test was used. The other data sets (clinical,
dynamic, and static balancing) were not evaluated for statistical
significance because of their low sample size.
III. RESULTS
Results (excluding the change in stiffness) are sectioned into
functional postural balance, static postural balance, and
dynamic postural balance. The functional postural balance
section includes the results of the clinical tests, the static
postural balance section includes the quiet standing data
collected before each training session, and the dynamic postural
balance includes the results of the dynamic balance test and the
training data. The training data were quantified by pooling the
training block averages of each metric for all blocks within a
group. All training results except the change in stiffness are
shown with the group means and the average of the worst 25%
of the data for each group. Statistical tests were run on the group
means only.
A. Functional Postural Balance
The results of the clinical assessment are shown in Table II.
Both participants improved across all 3 clinical tests
administered. Participant 1 improved by 7 points in the PBS,
 6

TABLE II
CLINICAL RESULTS
Subject Initial Final Percent
TEST
Number Assessment Assessment Change
Pediatric Balance
45 52**↑ 15.6
Scale
Timed 10 Meter SS: 1.06 SS: 1.56↑ 47.2
1 Walk Test (m/s) Fast: 1.57 Fast: 2.31↑ 47.1
5 Times Sit-to-
0.35 0.66*↑ 86.9
Stand Test (rep/s)
Pediatric Balance
Scale 40 44*↑ 10.0

Timed 10 Meter SS: 0.90 SS: 1.06↑ 17.8

2
Walk Test (m/s) Fast: 1.17 Fast: 1.27↑ 8.5
5 Times Sit-to-
0.15 0.31*↑ 110.3
Stand Test (rep/s)
** Results that satisfy the reported criteria for minimally clinically
important difference (MCID). * Results that satisfy the reported criteria
for minimum detectable change (MDC) or that there were no reported
criteria for MCID. No symbol means no significance, or no criteria
reported for MDC. SS means self-selected. Fig. 6. The results of the quiet standing data taken before each training
session. Data are represented in box whisker plot format. Means are
which is above the threshold for a minimal clinically important represented as x’s. The 2D CoP velocity for participants 1 and 2 are
shown in the top row (A & B), while CoP area is shown in the bottom
difference (5.83 points, MCID) [44]. This participant also row (C & D). A decrease in CoP Velocity represents greater postural
improved by 0.31 rep/s (86.9%) in the 5XSTS which is far stability. The same is true for CoP Area.
above the threshold for minimum detectable change (MDC)
(0.11 rep/s, no MCID reported) in this population [37].
Participant 1 showed a 0.50 and 0.74 s improvement in self-
selected and fast walking speeds, respectively, representing a
~47% improvement for both measures (no MCID reported).
Participant 2 showed a 4-point improvement in PBS score
(which is above the 1.59-point criteria for an MDC) [44], a 0.16
rep/s (110.3%) improvement in the time to complete 5XSTS,
and a 0.16 (17.8%) and 0.10 s (8.5%) improvement in the
10MWT for self-selected and fast walking speeds, respectively.
B. Static Postural Balance
The results of the quiet-standing data taken before each
training session are shown in Fig. 6. Participant 1 showed a
decrease in mean CoP velocity of 0.32 ± 0.50 m/s (26.6%)
between the early-late groups. There was a decrease in
maximum value of 0.18 m/s (12.1%) and interquartile range
(IQR) of 0.10 m/s (29.2%) (Fig. 6A). Participant 1 showed a
decreasing trend in CoP area with a difference in mean of 3.05
± 2.78 cm2 (72.3%), maximum of 4.88 cm2 (65.0%), and IQR
of 2.07 cm2 (82.0%) (Fig. 6C) between early-late groups.
Participant 2 showed a decreasing trend in only the CoP area
(Fig. 6D), with a decrease in mean of 2.14 ± 5.86 cm2 (28.2%),
maximum of 6.90 cm2 (47.8%), and IQR of 2.86 cm2 (46.3%)
between early and late groups.
Fig. 7. The results of the dynamic postural balance test, showing the Virtual
C. Dynamic Postural Balance Time to Contact (VTC) in (A, B) rigid, (B, C) compliant, and (E, F) highly
The results of the dynamic postural balance test quantified compliant conditions, each with eyes-open and eyes-closed. A higher VTC
using VTC are shown in Fig. 7. As expected, all values of VTC means greater postural stability. These data were collected before and after
the 6-weeks of training. Data is represented as mean +/- STD.
decreased with higher platform compliance. However, there
was a positive increase in VTC after training for both 0.26 ± 0.48 s (14.4%). The greatest improvement for Participant
participants within each compliance level and both the visual 2 occurred in the highly compliant EC condition (Fig. 7F) with
conditions (EO and EC). The greatest improvement for an increase in mean VTC of 0.84 ± 0.17 s (105.0%), while the
Participant 1 was in the highly compliant EO condition (Fig. worst improvement occurred in the compliant EO condition
7E) with an increase in mean VTC of 0.91 ± 0.09 s (57.0%), (Fig. 7D) with a mean increase of only 0.24 ± 0.44 s (14.0%).
and the worst improvement occurred in the highly compliant Additionally, the mean VTC values for Participant 1 were
EC condition (also Fig. 7E) with an increase in mean VTC of

Fig. 8. The trend of simulated platforms stiffness for participants (A) 1
and (B) 2. Stiffness of each block shown in orange and the mean +/- STD
of each group shown in blue. * for p < 0.5, ** for p < 0.01, and *** for p
< 0.001. Lower platform stiffness demonstrates improved performance
and competency with the experimental paradigm.
Fig. 9. The Time to Perturb metric for participants (A) 1 and (B) 2. The
worst 25% of the data for each group are shown in orange and total group
means are in blue, both are represented as mean +/- STD. * for p < 0.5, **
for p < 0.01, and *** for p < 0.001. A lower Time to Perturb indicates
greater postural stability.
consistently higher than Participant 2 both before and after the
training.
D. Training Results
1) Platform Stiffness Over Training
A progressive decrease in the platform stiffness over the
training for both participants was observed (Fig. 8). Participants
1 and 2 demonstrated statistically significant (p < 0.001)
decreases in platform stiffness of 30.2% and 22.4%,
respectively, between the early-mid groups of training and a
smaller, but still significant decrease of 3.8% (p < 0.05) and
13.6% (p < 0.001) between the mid-late groups.
2) Time to Perturb
There was a decreasing trend of Time to Perturb for both
participants throughout the training (Fig. 9). Participants 1 and
2 showed a 27.7% (p < 0.01) and 18.2% (p < 0.05) mean
decrease in Time to Perturb between early-mid groups, and a
7.4% (p = 0.18) and 27.2% (p < 0.001) decrease between mid-
late groups, respectively. The worst 25% of the data showed a
total decrease of 47.4% and 52.2%, respectively (Fig. 9A & B).
7
Fig. 10. The time required to stabilize for 0.5 s consecutively following the
return of the platforms to the zero-angle position. A lower Time to Stabilize
means greater postural stability. The results are separated by perturbation
direction. The worst 25% of the data s for each group are shown in orange
and total group means are in blue, both are represented as mean +/- STD. *
for p < 0.5, ** for p < 0.01, and *** for p < 0.001.
3) Time to Stabilize
There was a generally positive trend of decreasing Time to
Stabilize (Fig. 10), with a lesser decrease in the left perturbation
for both participants (Fig. 10 C and G). In the forward and
backward directions, there was a significant difference (p <
0.01) for both participants between the early-mid groups.
Participant 1 showed significance (p < 0.05) between early-late
groups in all but the left direction perturbations (Fig. 10C),
while Participant 2 showed a significant difference (p < 0.001)
between early-late in all but the left direction perturbations (Fig.
10G). Significance was shown between mid-late groups in only
one direction for both participants. Group means for the
forward and backward perturbations were generally higher than
the left and right perturbations.
4) Percent Stabilized
There was a general trend of stability improvement across all
perturbation directions for both participants (Fig. 11). All
except the left perturbation condition of Participant 1, show
significant (p < 0.01) improvement between the early-late
groups.

Fig. 11. The percentage of time the participant was successfully balanced
during the recovery period. A higher Percent Stabilized means greater
postural stability. The results are separated by perturbation direction. The
worst 25% of the data for each group are shown in orange and total group
means are in blue, both are represented as mean +/- STD. * for p < 0.5, **
for p < 0.01, and *** for p < 0.001.
IV. DISCUSSION
The main purpose of this study was to determine the
feasibility of side-specific perturbation-based balance training
on compliant surfaces using a set of robotic platforms.
Additionally, we aimed to provide preliminary results on its
effectiveness for improving balance in two children with CP of
varying ability (GFMCS II and III). Upon completion of the
training, both participants demonstrated improved performance
in functional, dynamic, and some static, postural balance
metrics.
A. Functional Postural Balance
Both participants showed improvement in all clinical
measures demonstrating various levels of improvement in
functional balance, lower limb strength, and walking ability.
These results suggest that the combination of compliant
balancing with perturbations is an effective modality for
improving overall balance in children with CP. This increased
their score above the reported threshold for high fall risk (45.5
points) [45]. Participant 2 demonstrated a 4-point improvement
8
in PBS score, which is not considered a clinically meaningful
difference, nor does it pass the threshold for high fall risk.
However, it does surpass the threshold for minimal detectable
change (1.59 points) [44], suggesting an improvement in
response to the training.
Regarding task-specific changes, Participant 1 showed
notable improvements in tandem stance (3+ points) and
alternate stepping to a stool (2+ points). This change may
represent an improved ability to intentionally shift the CoM
within the BoS and manipulate the BoS while making
appropriate anticipatory postural adjustments in response to the
training. Participant 2 did not improve their tandem stance but
did improve their alternate stool stepping by 1 point. The
participant’s use of AFOs might limit the ability to effectively
recruit hip strategies to maintain the CoM within the BoS in the
anteroposterior direction and limited the amount of ankle
mobility allowed in the inversion/eversion plane, thus reducing
the postural control in this position. However, Participant 2 did
improve in the ability to reach forward (2+ points) which
demonstrates improved confidence in translating their CoM
within the BoS and getting back to a “safe space” after moving
towards the end of limits of stability. The fact that both
participants improved in skills related to CoM control is both
positive and expected as this is trained directly in our
experimental paradigm. This is opposed to an increase in
muscle strength, which could be an indirect outcome of our
training.
The improvement in the 10MWT implies an increased
walking ability. This may demonstrate improved confidence in
balance and weight shifting. Although there are no reported
values for MCID in children with CP, Participant 1 showed a
dramatic improvement of a ~47% (+0.5 m/s) increase in both
fast and self-selected walking speeds. This is greater than 3
times the margin for clinical improvement in adults with stroke
(0.16 m/s) [46]. Participant 2 demonstrated less improvement
in the 10MWT with a 17.8% (+0.07 m/s) increase in self-
selected walking speed and an 8.5% (+0.1 m/s) increase in fast
walking speeds. However, it is important to consider that this
participant wore AFOs during ambulation and was unable to
ambulate efficiently without an assistive device (Table I). He
self-selected to use the cane within the walking assessments at
both the pre- and post-assessment. This required him to exert
much more effort to ambulate and dramatically reduced his
walking speed overall. Consequently, the use of cane may have
limited our ability to see meaningful clinical improvement in
this participant.
In the 5XSTS, both participants demonstrated an
improvement (0.31 and 0.16 rep/s for participants 1 and 2,
respectively) greater than the reported threshold for a minimum
detectable change (0.11 rep/s) [37]. This suggests that the
balance training was effective at improving lower extremity
strength in these children. Although the training protocol did
not specifically address lower extremity strength, patients did
have to stand for long periods of time which requires antigravity
muscular involvement, and they practiced reactive postural
control throughout the intervention. Furthermore, the 5XSTS
requires that participants intentionally translate their center of

mass from a lower, larger BoS to a higher, smaller BoS which
requires anticipatory postural adjustments combined with
adequate timing and force production of the lower extremities.
An improved score suggests improvement in these areas.
Interestingly, the baseline values were 0.35 rep/s and 0.15 rep/s
for Participants 1 (GMFCS II) and 2 (GMFCS III), respectively.
However, it was Participant 2 who showed a greater
improvement, meaning that their increased impairment did not
limit their functional gains in this area. Our training was
designed to be difficult, and the success of this patient
highlights the potential benefit of including children with
higher GFMCS levels if proper safety precautions are taken
(i.e., the inclusion of a body-weight harness). All existing
studies in this area do not include children with GMFCS level
III or higher [28-31], which may contribute to the perception
that these children cannot benefit from intensive balance
training.
B. Static Postural Balance
Although it was not possible to evaluate statistical
significance, Participant 1 showed a decreasing trend in mean
CoP velocity and CoP area (Fig. 6A and C). They also showed
a decrease in maximum values and IQR. This supports the
conclusion of improved postural control during quiet standing
for this participant. Participant 2 showed a decreasing mean,
maximum, and IQR trend for the CoP area, but there was no
change in CoP velocity (Fig. 6B and D). Although there are
clear trends in some of these static postural balance metrics, it
is important to highlight the high variability in the mean
differences. For Participant 1’s CoP velocity and Participant 2’s
CoP area, the cumulative precision error of the early and late
conditions is larger than the difference in means. This is likely
a function of intentional movement during the standing balance
test, and inherent variability in postural control caused by more
advanced CP. Indeed, when comparing the two participants, we
see that the median values for Participant 2’s CoP area were at
least 2 times greater than Participant 1’s, while their CoP
velocity values were ~20-50% larger. This reflects Participant
2’s decreased postural control during quiet standing as a
function of their GFMCS level, a result that has been previously
replicated in the CoP area between GFMCS levels I and II [43].
C. Dynamic Postural Balance
Both participants showed clear improvement in VTC for both
eyes-open and eyes-closed conditions (Fig. 7). This suggests
that our training methodology may improve dynamic postural
balance and reduce fall risk for children with CP. Furthermore,
the improvement is consistent despite increasing levels of
compliance throughout the training.
D. Training Measures
An improvement of balancing ability is supported by
statistical improvement in nearly all training measures. Both
participants showed a statistically significant reduction in the
Time to Perturb which represents a greater ability to stabilize
on compliant surfaces (Fig. 9). Participants also demonstrated
statistically significant improvement in Time to Stabilize and
percent stabilize throughout the training (Fig. 10 and 11). This
represents an improved ability to recover from external
perturbations. What’s more, these improvements in stability
9
and reactive balance control occurred despite a continuously
increasing level of platform surface compliance (Fig. 8). This
supports the effectiveness of dynamic training methods that
incorporate compliant surfaces and perturbations.
One interesting observation is that Participant 2 (GMFCS
level III) improved their performance more in the training
measures (i.e., lower time to perturb and final platform
stiffness) than the clinical measures as compared to Participant
1 (GMFCS II). This may reflect our perturbation method, which
is a very specific mode of balance improvement compared to
traditional physical therapy. Participant 2 was significantly
more impaired than the other participant, meaning it was likely
much easier for them to improve at the training itself than to see
improvement in functional tasks assessed by the clinical tests.
If this trend were to persist in a larger sample size, we would
assume it is because the training cannot address other
biomechanical deficiencies caused by cerebral palsy (muscle
weakness, spasticity, and limited range of motion) [1].
E. Limitations and Future Research Directions
The secondary purpose of this study was to perform a
preliminary evaluation of balance improvement on two children
with CP. The functional improvement of both participants,
although very positive, must be scrutinized. Motivation is a
very important consideration when dealing with child
participants, particularly disabled populations, who must
overcome significant barriers to complete functional
movements. These children are often more likely to experience
difficulties with motivation for tasks that challenge their
physical limitations (i.e., our clinical tests) [47] especially when
failure to complete a task may cause a negative psychological
response [48] or reinforce existing negative thought patterns
around their level of ability. This effect may be pronounced in
the initial assessment when participants are unfamiliar with the
test protocol and experimenters, leading to a dramatic increase
in testing scores when the participants wish to perform well
after developing a rapport with research personnel. A future
study, including multiple CP groups of varied impairment
compared against a control group, will help account for this and
other extraneous effects which prevent us from drawing firm
conclusions on the efficacy of our approach.
There are several other important limitations of this study.
Firstly, as shown in Fig. 8, the change in stiffness is
significantly reduced when comparing early-mid and mid-late
groups. This is likely due to a bottoming-out effect of the
bisection method used to calculate the experimental stiffness.
As the performance increases, participants will need to perform
much better over a longer period to achieve the same change.
This asymptote limits the potential for increasing training
difficulty, and thus the potential benefit for participants. Future
studies aiming to include a component of adaptive stiffness may
opt for a recalibration of the stiffness function when participants
exhibit a consistently high level of performance. A simple
example would be shifting the stiffness function to the left so
that a lesser performance would be needed to access the lower
stiffness values.
Another limitation of the study is the uniform nature of the
perturbations, for simplicity +/- 3° perturbations were applied
in all directions. Participants are required to occupy a natural
lateral stance which provides extra stability against the left and

right direction perturbations. The effect of this can be seen in
the early group values for Time to Stabilize and Percent
Stabilized metrics (Fig. 10 & 11); the values for the left and
right perturbations in the early group are generally much closer
to the metric limit (0.5 s and 100%, respectively) compared to
the forward and backward directions. For future perturbation-
based balance training, the magnitude of perturbations in the
left and right directions should be increased to mirror the
instability caused by perturbations in the other plane.
The benefit from the training may also be improved by
incorporating a performance adaptive component to the
perturbation magnitude. Metrics in the recovery period (Fig. 10
& 11) show a decreased improvement between the mid-late
groups. This means that the participant grew accustomed to the
magnitude of the perturbations. Improvement in reactive
balance control could be maximized if the perturbation
magnitude was set initially based on some limits of stability
(i.e., an average of 1 s to stabilize or less than 50% stabilized)
and recalibrated at the halfway point through the training.
The duration of balance improvements cannot be described
due to the absence of a follow-up study. Shumway-Cook et al.
(2003) showed a retainment of fall-risk reduction after 1 month;
however, the dosage of their regimen is different enough (100
lateral, i.e., non-rotational, perturbations per day for 5 days) to
prevent a meaningful comparison [31]. Despite this, the length
of our protocol (6 weeks) is much shorter than the standard
course of PT treatment for CP and thus the improvements
reported are still of note, even with a sample of two participants.
A longer study with more frequent clinical assessments and
follow-up is necessary to clearly elucidate the benefits of our
described training method. However, when participants were
surveyed approximately ~3 months following the conclusion of
the study, both reported a noticeable improvement in balance.
Then, when asked to rate this improvement on a scale of 1-10
(with 1 being a very small improvement and 10 being a
significant improvement), both participants answered 7.
Participant 1 (GFMCS II) reported improved balance while
boxing, and Participant 2 (GFMCS III) reported that it was
easier to move on uneven surfaces and that they experienced
less falling.
V. CONCLUSION
This paper presents the first side-specific perturbation-based
balance training on compliant surfaces aimed at improving
balance in children with CP. Over the 6-week robotic balance
training period, both participants demonstrated significant
improvement in functional balance, and dynamic balance, with
mixed improvement in static balance. This includes an
improved ability to stabilize in challenging environments and
quicker recovery from external perturbations. At the conclusion
of the study, both participants reported an improvement in
balance during activities of their daily life. The results of this
study support the feasibility of robot-aided rehabilitation as a
supplementary method for balance improvement in children
with CP.
ACKNOWLEDGMENT
The authors thank Varun Nalam for his contributions to this
project.
10
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