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Clinical usefulness of Adeli suit therapy for
improving gait function in children with spastic
cerebral palsy: a case study
Byoung-Hee Lee, PT, PhD1)
1) Department of Physical Therapy, College of Health Science, Sahmyook University: 815 Hwarang-ro,
Nowon-gu, Seoul 139-742, Republic of Korea
Abstract. [Pur pose] The purpose of this study was to determine the effects of Adeli suit therapy (AST) on gross
motor function and gait function in children with cerebral palsy. [Subjects and Methods] Two participants with
spastic cerebral palsy were recruited to undergo AST. AST was applied in 60-minute sessions, ve times per week,
with 20 sessions total over 4 weeks. Assessments of gross motor function, spatiotemporal parameters, and func-
tional ambulation performance for gait were conducted. [Results] Gross motor function, cadence, and functional
ambulation performance improved after the intervention in both cases. [Conclusion] Although additional follow-up
studies are required, the results demonstrated improved gross motor function and functional ambulation perfor-
mance in the children with cerebral palsy. These ndings suggest a variety of applications for conservative thera-
peutic methods that require future clinical trials in children with cerebral palsy.
Key words: Cerebral palsy, Adeli suit, Gait function
(This article was submitted Feb. 7, 2016, and was accepted Mar. 12, 2016)
INTRODUCTION
The Adeli suit was originally designed for the Russian space program in 1971. The suit was developed for the maintenance
of muscle tone in a weightless environment, such as that of a spaceship worker1). It was designed to create a normal frame-
work of forces on the body for stabilizing the torso to allow for more uent and coordinated movement of all limbs. It uses a
system of elastic bands and pulleys that create articial forces against which the body can work in order to prevent muscular
atrophy. The Adeli suit treatment (AST) has been proposed as an intensive exercise protocol for use in the management of
cerebral palsy (CP) and other neuromuscular disorders1). The suit is composed of a cap, a vest, shorts, knee pads, shoes with
attached auxiliary equipment, and a bungee cord to connect auxiliary equipment. The pieces are laced together with bungee-
type cords. The cords are adjustable for the application of varying degrees of tension to the child’s different muscle groups.
The bungee cords are positioned to keep the body properly aligned and to forcibly encourage movement within a normal
range of motion2). To reposition the limbs in order to correct for abnormal muscle alignment, the bungee cords are adjusted
by therapists to mimic normal exor and extensor patterns of the major muscle groups1).
The mechanism behind the Adeli suit is that through active movement therapy, the brain is stimulated and thus is retrained
to recognize, and eventually initiate, correct movement of the muscles. Once the body is in proper alignment, aggressive
movement therapy that will reeducate the brain to recognize correct movement of the muscles can be performed. The suit
enhances communication between the brain and peripheral muscles, particularly, the head and trunk control muscles, and the
locomotor functions of the legs1, 3). Rehabilitative gains in motor control through Adeli suit treatment are typically retained
after the intensive course is completed. Studies on groups of children with AST have shown long-term retention of skills after
the completion of the therapy program. AST is often used as part of a comprehensive physical therapy program and might
J. Phys. Ther. Sci. 28: 1949–1952, 2016
Corresponding author. Byoung-Hee Lee (E-mail: 3679@syu.ac.k r)
©2016 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access ar ticle distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd)
License <http://creativecom mons.org /licenses/ by-nc-nd/4.0/>.
Case Study
The Journal of Physical Therapy Science The Journal of Physical Therapy Science
J. Phys. Ther. Sci. Vol. 28, No. 6, 2016
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improve mechanical efciency without a corresponding gain in gross motor skills, especially in children with higher levels
of motor function4).
In this study, we compared changes in gross motor function, spatiotemporal parameters, and functional ambulation perfor-
mance score (FAPS) in children with CP who were assigned to receive AST and underwent training for a period of 4 weeks.
The results suggest the importance of the development of AST programs to improve gait ability in children with CP.
SUBJECTS AND METHODS
The subjects consisted of a 6-year-old boy (height, 112 cm; weight, 18 kg; Gross Motor Function Classication System
[GMFCS], level II) and a 3-year-old boy (height, 89 cm; weight, 10 kg; GMFCS, level II) with spastic diplegic CP recruited
from an S rehabilitation center in Korea. The subjects with CP had no history of newly developed neurological problems,
musculoskeletal disorders, or botulinum toxin injections in the previous 6 months. The study was approved by the Sahmyook
University Institutional Review Board (SYUIRB2015-109). The objective of the study and its requirements were explained
to the subjects, and all of the participants’ parents provided written consent, in accordance with the ethical principles of the
Declaration of Helsinki.
AST was applied in two subjects for a period of 4 weeks, 5 times per week, in 60-minute sessions per day. AST included
intensive multiple movements combined with the wearing of a tted garment (Adeli suit), which provided resistance during
the multiple movements. This suit comprised a vest, shorts, knee pads, and specially designed shoes. It was connected by
hooks, rings, and elastic bands that could be adjusted to provide pressure and support to joints and muscle groups. The
bungee-like cords were adjusted by a physical therapist to mimic normal exor and extensor patterns of the major muscle
groups in an attempt to reposition limbs in order to correct abnormal muscle alignment. Each session included multiple
movements based on the children’s abilities and included standing up, sitting, playing with balls while standing, jumping on
the trampoline, walking on different geographical features, and climbing stairs or ladders5).
To assess gross motor function, we used the gross motor function measure (GMFM-88). GMFM is a tool for measuring
and recording changes in exercise level during the process of treatment or elapsed time. It is used to measure the level of a
child’s physical performance6). The GMFM-88 consists of 88 items grouped into ve domains as follows: domain A (lying
and rolling, 17 items), domain B (sitting, 20 items), domain C (crawling and kneeling, 14 items), domain D (standing, 13
items), and domain E (walking, running, and jumping, 24 items)7, 8). Each item is worth 3 points, and the points earned from
each domain are multiplied by 100 points to obtain a domain score. The nal score is obtained by adding each domain score
and dividing the sum by 5 to obtain a total score7).
To measure gait function, we used the GAITRite Walkway System (CIR system Inc., PA, USA), which consists of an
electronic walkway (90 × 460 cm). Data were sampled from the walkway at a frequency of 80 Hz. The spatiotemporal
characteristics of the GAITRite system have shown excellent reliability with an intraclass correlation coefcient of between
0.82 and 0.929). The procedure was explained and demonstrated to the child. The child was then instructed to walk barefoot at
a self-selected walking speed, with the head facing forward and the eyes looking straight ahead10). Data on spatial (step length
and stride length) and temporal gait parameters (walking speed and cadence) were obtained by using GAITRitever 3.2b9, 11).
Velocity was calculated by dividing the distance by the ambulation time and was expressed in centimeters per second. Stride
length was dened and measured on the line of progression between the heel points of two consecutive footfalls of the same
foot and was expressed in centimeters. Cadence was dened as the number of foot falls in 1 minute5).
The FAPS is integrated within the GAITRite walkway and is considered to be the gold standard for spatiotemporal gait
parameter analysis. The FAPS is commonly used for clinical evaluations. The measurement was performed 3 times, and to
eliminate the fatigue of walking, the subjects were allowed a 30-second rest after walking once12).
All measurements were performed twice, before intervention and after 4 weeks of intervention. The spatiotemporal gait
parameters and the FAPS for gait function were measured three times, and the average of the three measurements was used
in the analysis. All of the data were codied and analyzed with SPSS Statistics for Windows version 17.0.
RESU LT S
The gross motor function of case A as assessed by GMFM increased from 87.2% at pretest to 94.37% at post-test; for case
B, GMFM increased from 71.17% at pretest to 73.0% at post-test. The gait velocity of case A increased from 78.57 cm/s at
pretest to 80.705 cm/s at post-test, while the cadence increased from 135.63 to 136.97 steps/min, the right-sided step length
decreased from 39.01 to 37.03 cm, the left-sided step length increased from 31.76 to 37.27 cm, the right-sided stride length
increased from 70.08 to 77.52 cm, the left-sided stride length increased from 70.08 to 76.85 cm, and the FAPS increased
from 81 to 84 (Table 1).
The gait velocity of case B decreased from 71.26 cm/s at pretest to 62.27 cm/s at post-test, while the cadence increased
from 152.9 to 157.6 steps/min, the right-sided step length decreased from 28.70 to 28.55 cm, the left-sided step length
decreased from 23.50 to 22.11 cm, the right-sided stride length decreased from 52.18 to 51.25 cm, the left-sided stride length
increased from 52.27 to 52.94 cm, and the FAPS increased from 75 to 84 (Table 1).
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DISCUSSION
The current neurodevelopmental treatment of CP focuses on maintaining or improving function in patients with CP. Vari-
ous treatments may help children with CP to hold an upright body alignment, strengthen muscles, prevent complications, and
improve their daily functions. Although several treatments of CP exist, adjustments to existing and new treatments are still
needed. AST has been used recently to treat and facilitate active movement in CP. Many families and clinicians are interested
in the outcomes of treatment using the Adeli suit, but the rehabilitation community does not have adequate scientic support
for its use as a generally accepted treatment of CP1).
This study focused on children with CP who received AST for a period of 4 weeks, in order to examine changes in GMFM,
spatiotemporal parameters, and the FAPS. An important nding is improvement in gross motor function, as assessed by
GMFM, in both cases. The applied AST involved multiple movements based on the children’s abilities and included standing
up, sitting, playing with balls while standing, jumping on the trampoline, walking on different geographical features, and
climbing stairs or ladders. Proprioceptive stimulation by multiple movements has a profound effect in the treatment of CP
because proprioception stimulates the nervous system at the onset of damage, thus creating a better basis for successful
rehabilitation. For this reason, gross motor function was increased in both cases. Regarding gait function, the cadence and
FAPS improved after the intervention in both cases. Step length increased on the left side and decreased on the right side in
case A, resulting in a decreasing tendency of asymmetries in step length after the intervention.
Studies on the effect of AST for rehabilitation of CP are scarce. However, AST has been proposed as a treatment of CP.
The results of previous studies on AST suggest that the subject relies on changes in proprioceptive information from muscles,
tendons, and joints. An increase in the input of proprioception and signicant information from the vestibular organs can
affect body position, balance, and posture tension. Through active movement therapy with AST, the brain is stimulated and,
thus, is retrained to recognize, and eventually initiate, the correct movement of the muscles, resulting in the improvement of
body alignment through trunk stability, along with improved walking patterns1, 5).
Body deformation due to a disability prevents patients from maintaining good posture or weight support in comfortable
standing positions. The location of the elastic bands in the Adeli suit is similar to the position of antagonistic muscle pairs.
Motor improvement of the joints in the lower extremities in antigravity situations was associated with resistance to the
muscles that occurred when patients moved each part of their body that is connected to a bungee cord. AST controls each
movement in response to the constantly acting gravitational force, particularly for the head, trunk, and locomotor functions
of the legs.
A limitation of this study is that only two children with CP participated in the study. However, the results show that AST
improved gross motor function and functional ambulation performance in these subjects. These ndings suggest that AST
should be recommended for treatment of CP, as a properly executed intervention would bring more benets, particularly for
functional improvements in CP.
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Tab le 1. Gross motor function and gait function scores
Parameter Case A Case B
Pretest Posttest Pretest Posttest
GMFM (%) 87. 2 94.4 71. 2 73.0
Velo cit y (c m /s) 78.6 80 .7 71.3 62.3
Cadence (step/min) 135.6 13 7.0 152 .9 157.6
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Stride length
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Right side 70.1 77. 5 52.2 51.3
Left side 70.1 76.9 52.3 52.9
FAPS (s cor e) 81 84 75 84
Values represent means.
GMFM: gross motor function measure, FAPS: functional ambulation performance score
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