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Effects of Intensive Locomotor Treadmill Training on Young Children

with Cerebral Palsy

Article in Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association · December 2009
DOI: 10.1097/PEP.0b013e3181bf53d9 · Source: PubMed

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 R E S E A R C H R E P O R T

Effects of Intensive Locomotor

Treadmill Training on Young
Children with Cerebral Palsy
Katrin Mattern-Baxter, PT, PCS, DPT, Sandra Bellamy, PT, DPT, PCS, and Jim K. Mansoor, PhD
Department of Physical Therapy, University of the Pacific, Stockton, California

Purpose: To examine whether an intensive, short-term locomotor treadmill training program helps children
with cerebral palsy (CP) younger than 4 years of age improve their gross motor skills related to ambulation,
walking speed, and endurance. Methods: Six children with cerebral palsy, ages 2.5 to 3.9 years, participated in
treadmill training 3 times per week for 1-hour sessions consisting of 2 individualized treadmill walks, for 4
weeks, and were tested before and after the intervention and at a 1-month follow-up. The outcome measures
included the Gross Motor Function Measure-66, the Pediatric Evaluation of Disability Inventory, a timed 10-m walk
test, and a 6-minute walk test. Results: Significant differences were found in the Gross Motor Function Measure-66
Dimensions D and E, the Pediatric Evaluation of Disability Inventory Mobility Scales, over-ground walking speed,
and walking distance. Conclusions: The results of this study provide preliminary evidence that children with CP
younger than 4 years of age can improve their gross motor function, walking speed, and walking endurance after
intensive locomotor treadmill training. (Pediatr Phys Ther 2009;21:308 –319) Key words: activities of daily living,
age factors, cerebral palsy/therapy, child/preschool, exercise therapy, gait, human movement system, physical
therapy modalities/instrumentation, treatment outcome, walking

INTRODUCTION dren with CP state ambulation as an explicit goal for their

Children with cerebral palsy (CP) show different motor child.5 Young children with CP achieve their motor mile-
patterns than children with typical development. Their move- stones at an accelerated rate compared with older children
ments are defined by excessive muscle cocontraction, altered with CP.6 In light of this, it is crucial to provide intensive
joint kinematics, and decreased postural reactions, resulting physical-therapy intervention for children with CP during the
in difficulty with ambulation for 90% of these children.1 Am- earlier years of childhood. In the past 10 years, locomotor
bulation with or without assistance is important for various training on a treadmill (LTT) has been used in the treatment
reasons. It has been shown that children who are ambulatory of children with CP in an attempt to maximize walking inde-
are more accomplished in their daily activities and peer inter- pendence, gait speed, and walking endurance. Locomotor
actions compared with children who use a wheelchair.2 The training is designed to provide task-specific training with
additional benefits of walking include increased bone mineral multiple repetitions of the walking task. Active participation
density, cardiopulmonary endurance, and obesity preven- of the child and explicit feedback in the form of verbal and
tion.3,4 Furthermore, the majority of parents of young chil- tactile reinforcement have been shown to aid in the achieve-
ment of new motor skills.7–9
Locomotor training has been studied in both ambulatory
0898-5669/109/2104-0308
and nonambulatory children with CP, with most studies hav-
Pediatric Physical Therapy
Copyright © 2009 Section on Pediatrics of the American Physical ing been conducted with children ages 5 to 18 years.10 –15 Im-
Therapy Association. provements in walking speed and endurance were shown in a
clinically controlled study of 14 school-age children ages 5.5
Address Correspondence to: Katrin Mattern-Baxter, PT, PCS, DPT, De- to 14.7 years with moderate to severe impairments (GMFCS
partment of Physical Therapy, University of the Pacific, 3601 Pacific
Avenue, Stockton, CA 95211. E-mail: [email protected] levels III and IV).14 In a study of 6 children ages 6 to 14 years
Grant Support: Part of the equipment used in this study was obtained with with mild impairments (GMFCS level I), significant improve-
a Scholarly/Artistic Activity Grant from the University of the Pacific,
Stockton, Calif.
ments were seen in the Energy Expenditure Index and gait
DOI: 10.1097/PEP.0b013e3181bf53d9
speed.12 When examining the effects of a 3-month LTT inter-
vention on gross motor function in 10 school-age children

308 Mattern-Baxter et al Pediatric Physical Therapy

from 6 to 18 years (GMFCS levels not specified), statistically needed for ambulation; (3) improve gross motor skills related
significant results in Gross Motor Function Measure to standing and walking; and (4) decrease the amount of care-
(GMFM) Dimensions D (standing) and E (walking, running, giver assistance for the children.
and jumping) were found.11 In another group of 6 children
ages 2.3 to 9.7 years with a mean age of 6.8 years and with the METHODS
GMFCS levels ranging from I to V, improvement in gross
motor function and endurance were found after an LTT pro- Study Participants
gram that was offered 3 to 4 times per week for 4 weeks.16 In Approval for the study was obtained from the Institu-
a study of 8 children ages 3.5 to 6.3 years with a mean age of tional Review Board of University of the Pacific, California.
4.5 years and GMFM levels II and III, who received LTT 2 to Written informed consent was obtained from the parents,
3 times per week for 36 weeks, significant improvements in and additional verbal assent was obtained from those chil-
gross motor function and stride length were found.17 dren who were old enough to understand the purpose of
Despite these encouraging results, there is still a relative the study. A convenience sample of 6 children with CP was
paucity of literature on LTT related to younger children with recruited from parent support groups, from referrals from
CP. In a case study, a 5-month-old infant with grade III intra- pediatric physical therapists in the community, and from
ventricular hemorrhage and at high risk for developmental Early Intervention Programs in the Northern California
disabilities was offered LTT for 23 weeks. This infant, who did region. The inclusion criteria included (1) a diagnosis of
not have a diagnosis of CP, made great improvement in gross cerebral palsy, (2) age of 1 to 5 years, (3) weight less than
motor function, including increased symmetry of gait, and 40 kg, (4) the ability to bear weight on legs with or without
eventually achieved independent ambulation.18 In an ex- support, and (5) parental ability to provide transportation.
tended study of 4 infants with CP who were nonambulatory The exclusion criteria included (1) a medical contraindi-
ages 1.7 to 2.3 years (mean age 2.0 years), LTT was provided cation for standing or walking, (2) history of untreated
3 to 4 times per week for 4 months as an adjunct to traditional cardiac problems, (3) history of uncontrolled seizures, (4)
physical therapy. All children showed improved gross motor history of orthopedic surgery, and (5) use of medication to
function, and 2 children attained independent walking.19 control spasticity, including a baclofen pump or Botox in-
Both studies, however, were carried out for several months jections in the past 6 months. Ten children were screened
and maturation effects could have played an important role. in their homes for participation in the study, with 6 chil-
The author of a recent systematic review concluded that there dren meeting the inclusion criteria. All children who were
was a lack of evidence regarding the effects of intensive, short- selected participated in the study, and 5 children attended
term LTT on young children with CP younger than the age of all scheduled sessions. Only 1 child missed 2 sessions be-
4 years.20 cause of respiratory illness.
Accordingly, we examined the effects of intensive LTT in The age of the children ranged from 2.5 to 3.9 years with
children younger than 4 years with different types and sever- a mean age of 3.1 years, with 3 boys and 3 girls. Among them,
ity of CP with respect to gross motor function, in particular, 1 was GMFCS level I, 2 were GMFCS level II, 1 was GMFCS
standing and walking function. We used a short-term, inten- level III, and 2 were GMFCS level IV; 3 children had spastic
sive intervention period of 4 weeks to limit gross motor diplegia, 1 had spastic quadriplegia, 1 had dystonic quadriple-
changes because of maturation. In particular, we were inter- gia, and 1 had hypotonic CP. Of them, 3 children were able to
ested in determining whether this short-term, intensive pro- ambulate with supervision and supporting devices at the start
gram would (1) increase the walking speed and the endur- of the study, with 1 child beginning to take independent steps.
ance in children who were ambulatory with or without The other 3 children used gait trainers with maximal assist
supporting devices; (2) decrease the amount of assistance (see Table 1 for subject characteristics).

TABLE 1
Characteristics of Participants at Entry into Study

GMFCS Height Weight

Subject Diagnosis Age (yr) Gender Race/Ethnicity Level Ambulatory Status Orthotics (cm) (kg)
1 Quadriplegic dystonic 2.8 F Multiracial IV Maximum assistance Bilateral solid 76 13.6
CP with gait trainer ankle AFOs
2 Spastic quadriplegic 3.3 M Multiracial IV Maximum assistance Bilateral solid 94 12.2
CP with gait trainer ankle AFOs
3 Hypotonic CP, cerebellar 2.9 M White III Maximum assistance with None 97 17.1
hypoplasia gait trainer
4 Spastic diplegic CP 3.9 F White II Supervision with reverse Bilateral solid 99 14.5
platform walker ankle AFOs
5 Spastic diplegic CP, 3.1 M Multiracial II Supervision with reverse None 86 10.9
chronic lung disease walker
6 Spastic diplegic CP 2.5 F White I Supervision with reverse Bilateral solid 74 11.8
walker ankle AFOs
CP indicates cerebral palsy; AFOs indicate ankle–foot orthoses.

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 309
Study Design and Outcome Measures The test was performed 2 consecutive times with a short
The intervention consisted of 12 treadmill training break between, and the faster time achieved was re-
sessions that were offered 3 times per week for a total of 4 ported. The children subsequently rested until resting
weeks, with 1 or 2 days of rest between sessions. The train- heart rate (HR) returned to pretest values, and then they
ing sessions consisted of 2 sets of treadmill walking with a proceeded to the 6-minute walk test.
small break between sets. The children were encouraged to Six-Minute Walk Test: This test is a reliable and valid
walk for as long as possible and as fast as possible during measure to assess walking endurance in children with
CP.25 The children were encouraged to walk at a self-
each set. All children were assessed at baseline within 10
selected walking speed but were discouraged from run-
days of the start of the intervention period. The post-
ning and were allowed to vary their pace or rest as
assessment was conducted within 7 days after completion
needed. The total walking distance in meters was mea-
of the intervention period, and a 1-month follow-up was con-
sured with a tape measure.
ducted 1 month after the post-assessment. All dimensions
Treadmill Walk: The third method of measuring walk-
of the Gross Motor Function Measure (GMFM) and 3 do-
ing ability was done by measuring the total distance and the
mains of the Pediatric Evaluation of Disability Inventory
speed walked on the treadmill during the 3 testing periods.
(PEDI) (Mobility-Functional Skills, Mobility-Caregiver
A pediatric weight-support harness system with a hydrau-
Assistance, and Self-Help-Caregiver Assistance) were used
lic lifting mechanism (LiteGait Walkable 100) was placed
as tests of gross motor function. Additionally, performance
over a treadmill with adjustable speed (GaitKeeper
on the timed 10-m walk test, the 6-minute walk test, a
18WST). The subjects were fitted into the harness and
treadmill walk test, and standing balance on 2 feet was mea-
lowered onto the treadmill and were encouraged to take as
sured. The walking tests were conducted at a local facility in
much weight as possible on their legs without buckling.
Davis, California, by the same Pediatric Certified Specialist
The percentage of weight support was calculated by weigh-
(PCS) to ensure the same conditions for each child. All chil- ing the children while in the harness and calculating the per-
dren used their customary lower extremity orthotics during centage in relation to their full body weight. All the children
the walking sessions. Four children wore bilateral lower ex- held on to an adjustable handle bar during the treadmill train-
tremity orthotics and shoes, and 2 children walked only in ing. The children received assistance with hand placement if
shoes (Table 1). they could not maintain their grasp during walking. The chil-
Tests of Gross Motor Function. GMFM: This a stan- dren were given 1 initial training session on the treadmill to
dardized clinical instrument, which is designed to evaluate determine optimal walking speed and harness support. The
6
changes in gross motor function in children with CP. The optimal walking speed was determined to be the speed at
GMFM has been shown to have high validity and reliabil- which the children were able to take continuous steps with-
ity.21 The GMFM-66 item version was used in this study. out dragging their feet for more than 5 seconds. The treadmill
All the GMFM dimensions (Dimension A: lying and roll- distance and the walking speed were measured at the first
ing; Dimension B: sitting; Dimension C: crawling and intervention training session and the last intervention train-
kneeling; Dimension D: standing; Dimension E: walking, ing session and at the 1-month follow-up.
running, and jumping) were measured in this study. The Balance. Children who were able to stand indepen-
children were videotaped in their homes during all 3 as- dently were asked to stand on both feet as long as pos-
sessments by a PCS with 22 years of pediatric experience. sible, without stepping or external support. Two consec-
The videotapes were analyzed, and the children were as- utive trials were given, and the longer of the 2 trials was
sessed for GMFM levels by a different blinded PCS with 9 recorded in seconds.
years of pediatric experience. Intervention Protocol. The training sessions were
PEDI: This is an instrument that provides a clinical scheduled 3 days per week for 4 weeks, with 1 or 2 rest days
assessment of a child’s current functional performance or after each training day. The intervention lasted for 1 hour per
status.22 The PEDI is designed to evaluate 3 domains: self- day. Five children completed all training sessions, and 1 child
care, mobility, and social function. These domains are eval- missed 2 training sessions because of respiratory illness. All
uated through parent interviews, direct observations, and children participated in their regularly scheduled physical
testing of the functional abilities of the children. The PEDI therapy sessions during the duration of the study. None of the
includes caregiver assistance scales for each domain. The children received additional treadmill training during the
Mobility-Functional Skills domain and the Caregiver As- study period. All children were allowed to engage in their
sistance domains for Mobility and Self-Help were used in normal everyday activities, including walking.
this study. PEDI administration was done in the children’s The starting treadmill speed was determined during
homes by the same PCS who videotaped the children for the initial training session and was increased as quickly as
the GMFM.23 possible throughout the sessions. The speed was increased
Walking Tests. Timed 10-Meter Walk Test: This is a when the children could move their feet independently,
valid and reliable measure to assess walking speed in children with verbal cues or minimal manual cues at the pelvis with-
with CP.24 It can be used to assess self-selected walking speed out dragging their feet for more than 5 seconds. The chil-
or maximum walking speed. The children walked as fast dren walked on the treadmill for as many minutes as pos-
as possible without running and were timed for 10 m. sible to the point of fatigue. During all treadmill walking,

310 Mattern-Baxter et al Pediatric Physical Therapy

the children were monitored with a HR monitor (Polar Self-Help Scale. The post hoc analysis of the Functional
Monitor Model 515), and the HR was recorded at 1-minute Skills Mobility Scale showed a significant difference between
intervals. The maximum allowable HR was 80% of the age- pre-intervention and 1-month follow-up but not between pre-
predicted maximum HR. None of the children reached the intervention and post-intervention. The post hoc analysis of
80% maximum HR. The HR was also continuously moni- the Caregiver Assistance Mobility Scale revealed significant
tored after the treadmill walk until it returned to resting differences between pre-intervention and post-intervention
levels, at which point a second treadmill walk was initiated. and between pre-intervention and 1-month follow-up. This
The children were not allowed to walk for more than a total indicates that the children increased their independence in
of 40 minutes per training session. The amount of weight the functional mobility tasks and relied less on their caregiv-
support was decreased as quickly as possible over the du- ers for assistance (Fig. 2).
ration of the study determined by their ability to take con-
tinuous steps without dragging their feet for more than 5 Walking Tests
seconds. By week 2 of the intervention period, 5 of 6 chil- Timed 10-Meter Walk Test. Three children were able
dren did not require weight support anymore. The parents to complete the 10-m walk test at the pre-intervention as-
were present during all the sessions. sessment; 4 children were able to complete the test at post-
The same physical therapist provided facilitation at intervention assessment, whereas all 6 children were able
the pelvis when the child stumbled or stopped stepping. to complete this test at the 1-month follow-up. Of the chil-
The facilitation was not intended to correct the gait pattern dren who learned to propel their gait trainers during the
of the child. The children were allowed to make mistakes in study period, the steering wheels had to be locked during
step length and height but were encouraged with verbal the test because of their inconsistent ability to walk in a
and tactile cues to take symmetrical steps. The children straight line. Statistically significant changes were found
were encouraged to look up during walking and were mo- in the primary analysis (p ⫽ 0.011). Although all the
tivated with singing, favorite toys, or stuffed animals. children improved their walking speed between pre-in-
tervention and post-intervention, the post hoc test
Data Analysis showed a significant difference only between pre-inter-
Nonparametric statistics were used in all analyses be- vention and 1-month follow-up (Fig. 3A).
cause of the lack of a normal population distribution. For Six-Minute Walk Test. Three children were able to
the primary analysis of all data, a Friedman analysis of ambulate for 6 minutes during the pre-intervention testing.
variance (pre-intervention versus post-intervention versus By the 1-month follow-up, all the children were able to take
1-month follow-up) was performed. Post hoc analysis for steps in their gait trainers independently and were thus
pairwise comparisons was performed using the minimum able to participate in the 6-minute walk test. The primary
significant difference.26 An alpha level of ⱕ0.05 was used in analysis showed statistically significant differences (p ⫽
all analyses. For tests that the subjects were unable to com- 0.029), with nonsignificant improvements occurring be-
plete (eg, the 10-m and 6-minute walk tests), they were tween pre-intervention and post-intervention but signifi-
assigned the worst ranks for data analysis purposes. The cant improvements occurring between pre-intervention
data are presented as means plus or minus standard devia- and 1-month follow-up (Fig. 3B).
tions, unless otherwise indicated. Statistical analyses were Treadmill Walk. Statistically significant differences
performed using SPSS version 16.0 for the MAC. were found in the primary analysis for the total distance
walked (p ⫽ 0.009) and walking speed (p ⫽ 0.002). The
RESULTS post hoc analysis was significant for both variables between
pre-intervention and post-intervention and between pre-
Tests of Gross Motor Function intervention and 1-month follow-up. Some children re-
GMFM. GMFM Dimensions A and B showed no sta- quired partial weight support during this activity. The
tistically significant changes between pre-intervention and mean walking speed was 0.08 m/sec during the first train-
post-intervention. Statistically significant changes were ing session with a range of 0.04 to 0.13 m/sec. The mean
found in the GMFM Dimensions C (p ⫽ 0.05), D (p ⫽ walking speed during the last training session was 0.25
0.007), and E (p ⫽ 0.01) in the primary analysis. The post m/sec with a range of 0.13 to 0.45 m/sec. The mean dis-
hoc analysis revealed a significant difference between tance walked during the first training session was 46.3 m
pre-intervention and post-intervention and between with a range of 4.0 to 79.0 m, and the mean distance walked
pre-intervention and 1-month follow-up, for both Di- at the last training session was 151.8 m with a range of 36.0
mensions D and E, indicating that the children improved to 434.0 m (Table 2).
their functional standing and walking abilities (Fig. 1). In addition to these results, 1 child who was ambula-
PEDI. The analysis of the Functional Skills Mobility tory with a walker at the beginning of the study achieved
Scale, the Caregiver Assistance Mobility Scale, and the independent walking during the intervention period.
Caregiver Assistance Self-Help Scale of the PEDI revealed Three children who used gait trainers with maximal assist
statistically significant changes in the Functional Skills at the beginning of the study improved to intermittent as-
Mobility Scale (p ⫽ 0.022) and the Caregiver Assistance sistance by the end of the study. This intermittent support
Mobility Scale (p ⫽ 0.018) but not the Caregiver Assistance was for steering of the gait trainer and for occasional help

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 311
 A
100
pre-intervention
post-intervention
1-month follow-up
80

GMFM Dimension D percent score

60

40

20

B
100
GMFM Dimension E percent score

80

60

40

20

0
1 2 3 4 5 6
Subject

Fig. 1. Individual GMFM Scores for Dimensions D and E. Subject 2 had scores of 0 for pre-intervention Dimension D and for pre-intervention,
post-intervention, and 1-month follow-up for Dimension E. Means were statistically different between pre-intervention and post-intervention
for Dimensions D and E.

when getting stuck, but all 3 children were able to self- improved by intensive treadmill training in children
propel their gait trainers, which they had previously been with CP. In this study, young children of ages 2.5 to 3.9
unable to do. years with various types of CP and different functional
levels were able to make significant improvements in
Balance their walking ability, as measured by walking distance
Because of their young age and the functional level of and gait speed. They also showed improvement in func-
the children, standing balance on 1 foot could not be at- tional gross motor skills related to standing and walking.
tained by any of the children. Therefore, standing balance These changes, in general, were greater in children with
on 2 feet was used as a measure of balance, which could higher GMFCS levels compared to children with lower
only be attained by 2 of the children. Both the children GMFCS levels at study onset. Additionally, no adverse
approximately doubled their standing balance time from effects such as excessive fatigue or harness discomfort
pre-intervention to post-intervention and continued to from the intensive LTT training program used in this
show gains at the 1-month follow-up. study were observed.
Five of the 6 children were able to improve in their
DISCUSSION functional standing skills as measured by Dimension D
The findings of this study add to the body of knowl- and were able to maintain those skills at the 1-month
edge that functional standing and walking skills can be follow-up. The child who did not show any changes in

312 Mattern-Baxter et al Pediatric Physical Therapy

 A
35
pre-intervention
30 post-intervention
functional skills mobility standard score

1-month follow-up
25

20

15

10

B
40

35
care giver assist mobility standard score

30

25

20

15

10

C
45
care giver assist self-help standard score

40

35

30

25

20

15

10

0
1 2 3 4 5 6
subject

Fig. 2. Individual PEDI Standard Scores for Functional Skills Mobility Scale, Caregiver Assistance Mobility Scale, and Caregiver Assistance
Self-Help Scale. Means were statistically different for the Functional Skills Mobility Scale between pre-intervention and 1-month follow-up
and for the Caregiver Assistance Mobility Scale between pre-intervention and post-intervention, and between pre-intervention and
1-month follow-up.

Dimension D was ambulatory with a walker at the onset improve in this dimension. This child, who was nonambu-
of the study but had a diagnosis of chronic lung disease latory GMFCS level IV, and dependent in all gravity-de-
causing him to miss 2 training sessions because of respira- pendent positions, had to use partial weight support on the
tory illness. This child did, however, make improvements treadmill throughout the entire study, and had strong
in his functional walking skills as measured by Dimension lower extremity spasticity. Schindl et al11 found that after a
E of the GMFM. An additional 4 children showed improve- 3-month intensive treadmill-training program a decrease
ment in Dimension E. One child with spastic CP did not in assistance was required for ambulation in 3 of 6 children

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 313
 A
200
pre-intervention
post-intervention
1-month follow-up

10 M walk time (sec) 150

100

50

B
250

200
distance walked in 6 min (m)

150

100

50

0
1 2 3 4 5 6
subject

Fig. 3. Individual scores for the 10-m walk test (A) and 6-minute walk test (B). Subjects 1, 2, and 3 were not able to complete the 10-m walk
test and the 6-minute walk test for some of the conditions. Means were statistically different for the 10-m walk test between pre-
intervention and 1-month follow-up and for the 6-minute walk test between pre-intervention and 1-month follow-up.

ages 6 to 18 years with spastic tetraparesis who were pre- in this study who were nonambulatory and who com-
viously nonambulatory. This suggests that improvements pletely relied on their caregivers’ ability to provide mobility
in gross motor skills related to ambulation might necessi- because none of the children had access to independent
tate a prolonged intensive treadmill training program for power mobility devices. Although these 3 children used
children with lower GMFCS levels and higher levels of gait trainers, they required maximum assistance for ambu-
spasticity. lation and were usually in adaptive strollers or carried by
In an effort to assess the children’s functioning in so- their parents during community outings. It might be de-
cietal roles according to the International Classification of batable whether the significant results in the caregiver por-
Functioning, Disability, and Health Model of the World tion of the Mobility Scale represented increased participa-
Health Organization,27 we used the PEDI Caregiver Assis- tion in societal roles in these children, but it clearly
tance Scale.22 Caregiver assistance is an important factor reflected a decreased burden on caregivers. Indeed, the
that contributes to a child’s ability to participate in society PEDI is a reliable and valid assessment tool that reflects
at this young age. Parents and guardians play a central role caregivers’ perceptions of the performance of their child
in the child’s ability to fulfill social roles at this age and are and is sensitive to change over time.29
often the sole providers of support during outings in the The primary emphasis of this study was to enable
community.28 This was particularly true for the 3 children young children with CP to take independent steps on the

314 Mattern-Baxter et al Pediatric Physical Therapy

 treadmill with as little support or facilitation as possible.

Pre-intervention Post-intervention Follow-up

0.3 ⫾ 0.2
1-Month

0.18
0.13
0.13
0.45
0.18
0.45
This invariably led to more mistakes during LTT, and a
chance for the children to self-correct before outside
correction was provided. Although the children received

Treadmill Speed (m/sec)

ongoing explicit verbal feedback, tactile feedback was

0.3 ⫾ 0.2
kept to a minimum, and the children were not corrected

0.18
0.13
0.13
0.45
0.18
0.45
regarding step height or step length. This is in contrast
to other studies in which facilitation was provided at the
hips, knees, and feet by 1, 2, and, in some instances, 3
therapists.11,14,15,17,19 Furthermore, the amount of weight

0.1 ⫾ 0.0
support was decreased, and the treadmill speed was in-
0.09
0.04
0.04
0.13
0.09
0.09
creased as quickly as possible throughout the interven-
tion period. Three of 4 children who required weight
support at study onset no longer required weight sup-
152.0 ⫾ 143.9* 122.2 ⫾ 87.1†
Follow-up

port at the end of the intervention period. All children

1-Month

97
89
37
106
113
291

increased their treadmill speed by at least 100%, and 1

child increased her speed by 500% by the end of the
Total Distance Walked (m)

4-week intervention period. Increases in treadmill speed

Pre-intervention Post-intervention

have been previously reported in school-age children

with CP12,16 and in studies with adults after stroke30 but
86
89
36
106
160
434

were not as large as in this sample of young children

with CP. Begnoche and Pittetti16 reported increases in
treadmill speed of 50% to 80% over 4 weeks in a study of
5 children with a mean age of 6.7 years. Provost et al12 pro-
46.2 ⫾ 31.2
Progression of Treadmill Ambulation

gressed the treadmill speed by 61% to 65% in 6 children with

43
15
4
79
68
69

a mean age of 10.5 years. However, the starting speeds in our

study were lower than those in other studies because of the
young age and the inexperience of our subjects in walking on
TABLE 2

564.5 ⫾ 241.6* 492.2 ⫾ 142.2†

a treadmill. It was observed initially that the children with

Follow-up
1-Month

lower GMFCS levels tended to sit in the harness during tread-

451
540
224
600
539
599

mill training and seemed unsure how to move their legs—a

Total Time Walked (seconds)

trend that was reversed with the training at progressively

higher treadmill speeds and decreased weight support. This
Subject Pre-intervention Post-intervention Follow-up Pre-intervention Post-intervention

finding is consistent with studies of school-age children when

weight support was decreased as quickly as possible to allow
393
548
215
600
736
895

maximal active involvement of the children.12,16 This im-

provement in stepping ability with decreased weight support
might have been triggered by an increase in proprioceptive
372.0 ⫾ 223.9

†Indicates p ⱕ 0.05 from pre-intervention to 1-month follow-up.

input from the increased joint pressure throughout the ki-

*Indicates p ⱕ 0.05 from pre-intervention to post-intervention.

netic chain.31 Similar increases in stepping ability with de-

352
185
49
441
605
600

creased weight support over time have been observed in pe-

diatric patients with Down syndrome when the children
received additional proprioceptive input by use of ankle
1-Month

weights during treadmill walking.32–34 Additionally, improved

0
0
0
0
0
0

stepping ability at faster treadmill speeds may have been due

to a greater stretch of the hip flexors, leading to an increased
activation of central pattern generators mediated at the spinal
% Weight Support

level.35
0
17
0
0
0
0

We saw significant decreases in the 10-m walk test

Mean ⫾ SD

times and significant increases in the 6-minute walk test

distance in our young subjects. In contrast to other studies
in which the timed 10-m walk test was used to assess com-
fortable walking speed,12,14,16 we used it to examine maxi-
42
40
45
20
0
0

mum walking speed over 10 m. Although other investiga-

tors have observed improvements in self-selected walking
speed over 10 m in children of ages 5 to 18 years,12,14,16 our
study is the first to show improvements in maximal walk-
1
2
3
4
5
6

ing speed over 10 m in children younger than 4 years of age

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 315
with CP as a consequence of locomotor training. Three walking speeds of 0.86 to 0.99 m/sec, whereas mean self-
children with GMFCS levels I and II were able to complete selected walking speed increases to 1.12 and 1.16 m/sec by
the timed 10-m walk test and the 6-minute walk test as part kindergarten age and school age, respectively.36,37 The chil-
of the pretest. By the posttest, 1 additional child at dren in our study who were ambulatory showed self-se-
GMFCS level III was able to complete the 10-m walk test by lected walking speeds of 0.14, 0.55, and 0.59 m/sec by the
independently moving his gait trainer. At the 1-month 1-month follow-up, which is still considerably slower than
follow-up, 2 additional children at GMFCS level IV were those of peers with typical development. However, their
able to walk 10 m with their gait trainers. However, the 3 maximum walking speeds by the 1-month follow-up were
children who used gait trainers for locomotion continued 0.24, 0.86, and 1.34 m/sec, indicating that, with effort,
to need assistance for steering and were able to move their these children could temporarily keep up with their
gait trainers only on level, smooth ground. Although these peers.38
gains were only functional in an optimal environment There were significant improvements in the distance
without barriers, they were reported as major improve- walked during the 6-minute walk test between preassess-
ments by these young children’s parents. Similar results ment and 1-month follow-up in our study. The lack of
have been found after a 4-month LTT intervention proto- significance between preassessment and postassessment
col in 4 toddlers ages 1.7 to 2.3 years.19 However, these (immediately after the intervention period) might indicate
toddlers were younger than the subjects in our study, and that a period longer than 4 weeks is necessary to make
the intervention period spanned a 4-month period, indicat- significant physiological changes in endurance in young
ing that maturation may have been responsible for some of children with CP. These results are similar to those of 2
the positive changes. Although some degree of maturation other studies that did not find significant improvements in
cannot be ruled out in the 2-month period between pre- the 6- or 10-minute walk test after a 6-week LTT interven-
intervention assessment and 1-month follow-up, the great- tion that was offered 2 times per week to children with CP
est gains in our study were made immediately after the aged 5 to 14 years.12,14 These findings indicate that pro-
4-week intervention period, probably indicating that the longed, more intensive LTT programs might be necessary
children improved because of intervention rather than to make physiological changes in endurance.
maturation. Moreover, we cannot discount the role of con- An additional interesting finding was the significant cor-
tinued practice after the intervention period, which may relation (r ⫽ 0.98; p ⫽ 0.004) between self- selected walking
have played an important role in the improvements seen at speed in the 6-minute walk test and walking speed on the
the 1-month follow-up. treadmill. We determined treadmill walking speed based on
Our self-selected walking speed was calculated from the children’s ability to step without dragging their feet for
the 6-minute walk test, and all our subjects showed im- more than 5 seconds. This indicates that the criterion for
provements attributable to the LTT. These improvements selecting treadmill speed in this study was a good reflection of
in self-selected walking speed were similar to those found the child’s self-selected over-ground walking speed. This find-
by Provost et al,12 who reported significant improvements ing suggests that a reliable, clinical estimate of a child’s gait
in self-selected walking speed in children who were ambu- speed could be made by observing the ability to advance the
latory ages 5 to 18 years after 6 weeks of LTT. However, in legs on the treadmill without dragging the feet for more than
2 other studies on school-age children,14,16 improvements 5 seconds. This might prove a useful approach for practitio-
in self-selected walking speed did not reach statistical sig- ners when selecting treadmill walking speed for children with
nificance. The 3 children in our study who were ambula- CP (Table 3).
tory with supporting devices at study onset made relatively
larger gains than did those who were nonambulatory. LIMITATIONS
Their ages were 2.5, 3.1, and 3.9 years. Children who de- A limitation of this study is the lack of a control group
velop typically in this age range achieve self-selected mean for this convenience sample of children with CP. Because

TABLE 3
Comparison of Walking Speed Across Tests (m/sec)

Treadmill Walk 6-Minute Walk Test at Self-Selected Walk 10-m Walk Test at Maximum Walk
Speed (m/sec) Speed (m/sec) Speed (m/sec)
1-Month 1-Month 1-Month
Subject Pre-intervention Post-intervention Follow-up Pre-intervention Post-intervention Follow-up Pre-intervention Post-intervention Follow-up
1 0.09 0.18 0.18 Unable Unable Unable Unable Unable 0.15
2 0.04 0.13 0.13 Unable Unable 0.05 Unable Unable 0.05
3 0.04 0.13 0.13 Unable 0.03 0.18 Unable 0.1 0.75
4 0.13 0.45 0.45 0.22 0.46 0.59 0.6 0.8 1.34
5 0.09 0.18 0.18 0.09 0.15 0.14 0.1 0.3 0.24
6 0.09 0.45 0.45 0.33 0.54 0.55 0.4 0.7 0.86
Mean treadmill walking speeds were significantly different between pre-intervention and post-intervention and between pre-intervention and
1-month follow-up.

316 Mattern-Baxter et al Pediatric Physical Therapy

our study occurred over a 2-month period, history and Davis, Calif, and Seth Mailloux and Kyleigh Short from
maturation effects cannot be ruled out; however, none of Sacramento State University, Sacramento, Calif. Part of
the children engaged in other intensive interventions dur- the equipment used in this study was obtained with a
ing the study, except for their regularly scheduled physical Scholarly/Artistic Activity Grant from the University of
therapy sessions. Additional limitations are the small sam- the Pacific, Stockton, Calif. The treadmill was provided
ple size and the lack of homogeneity in our group, with on loan from Mobility Research, Tempe, Ariz. Most im-
children having different types of CP and GMFCS levels I portantly, the authors thank the children and their par-
through IV. The results of this study are preliminary for ents who participated in this study.
this small sample of young children, limiting external va-
lidity. Although a blinded assessor scored the GMFM from REFERENCES
videotapes of the children at preassessment, postassess- 1. Leonard CT, Hirschfeld H, Forssberg H. The development of inde-
ment, and 1-month follow-up, the walking and balance pendent walking in children with cerebral palsy. Dev Med Child Neu-
tests were conducted by the same nonblinded assessor. rol. 1991;33:567–577.
Although these tests were measured objectively by timing 2. Lepage C, Noreau L, Bernard P. Association between characteristics
of locomotion and accomplishment of life habits in children with
the children and measuring the walking distance, the chil-
cerebral palsy. Phys Ther. 1998;78:458 – 469.
dren might have performed better because they were more 3. Wilmshurst S, Ward K, Adams JE, et al. Mobility status and bone
comfortable with the assessor, the facility, or both. The density in cerebral palsy. Arch Dis Child. 1996;75:164 –165.
parents of the children in this sample were motivated to 4. Chien F, DeMuth S, Knutson L, et al. The use of the 600 yard walk-
drive to a facility 3 times per week and were able to take run test to assess walking endurance and speed in children with
cerebral palsy. Pediatr Phys Ther. 2006;18:86 – 87.
time out of their week to participate in the intervention.
5. Hutton JL, Pharoah P. Effects of cognitive, motor, and sensory
This type of intensive training might be limited to children disabilities on survival in cerebral palsy. Arch Dis Child. 2002;86:
whose parents are able to provide time and transportation. 84 –90.
Outside the research setting, it may be difficult to obtain 6. Rosenbaum P, Walter S, Hanna S, et al. Prognosis for gross motor
funding for this type of intensive treadmill training, creat- function in cerebral palsy: creation of motor development curves.
ing a socioeconomic advantage to those families who can JAMA. 2002;288:1357–1363.
7. Schmidt RA, Young DE, Swinnen S, et al. Summary knowledge of
afford it. results for skill acquisition: support for the guidance hypothesis.
J Exp Psychol Learn Mem Cogn. 1989;15:352–359.
CONCLUSIONS 8. Newell KM. Motor skill acquisition. Annu Rev Psychol. 1991;42:213–
The results of this study provide preliminary evi- 237.
dence that short-term intensive treadmill training im- 9. Hadders-Algra M. Early brain damage and the development of motor
behavior in children: clues for therapeutic intervention? Neural Plast.
proves measures of gross motor function, maximum and 2001;8:31– 49.
self-selected walking speed, and walking distance in a 10. Unnithan V, Kenne E, Logan L, et al. The effect of partial body weight
small sample of young children with CP 2.5 to 3.9 years support on the oxygen cost of walking in children and adolescents
of age. These changes were maintained after a 1-month with spastic cerebral palsy. Pediatr Exerc Sci. 2006;17:11–21.
11. Schindl MR, Forstner C, Kern H, et al. Treadmill training with partial
follow-up period, potentially indicating long-term changes.
body weight support in nonambulatory patients with cerebral palsy.
Although the results of this study are encouraging, this Arch Phys Med Rehabil. 2000;81:301–306.
type of intensive intervention at a facility requires a large 12. Provost B, Dieruf K, Burtner P, Phillips J, et al. Endurance and gait in
time commitment for parents and children and may be children with cerebral palsy after intensive body weightsupported
difficult to fund outside the research setting. Other re- treadmill training. Pediatr Phys Ther. 2007;19:2–10.
13. McNevin NH, Coraci L, Schafer J. Gait in adolescent cerebral palsy:
searchers have found home-based intervention on small
the effect of partial unweighting. Arch Phys Med Rehabil. 2000;81:
portable treadmills feasible and beneficial in children with 525–528.
Down syndrome.33 Although one study exists to date that 14. Dodd KJ, Foley S. Partial body-weight-supported treadmill training
showed the feasibility of LTT in an infant at high risk for can improve walking in children with cerebral palsy: a clinical con-
developmental disabilities,18 future research should exam- trolled trial. Dev Med Child Neurol. 2007;49:101–105.
15. Day J, Fox EJ, Lowe J, et al. Locomotor training with partial body
ine whether home-based treadmill training is feasible for
weight support on a treadmill in a nonambulatory child with spastic
young children with CP and whether it can lead to a more tetraplegic cerebral palsy: a case report. Pediatr Phys Ther. 2004;16:
convenient and cost-effective delivery model for intensive 106 –113.
intervention. 16. Begnoche D, Pitetti K. Effects of traditional treatment and partial
body weight treadmill training on the motor skills of children with
ACKNOWLEDGMENTS spastic cerebral palsy: a pilot study. Pediatr Phys Ther. 2007;19:
11–19.
The authors thank Physical Edge, a private physical 17. Cherng R, Liu C, Lau T, Hong R. Effect of treadmill training with
therapy practice in Davis, Calif, for providing their space body weight support on gait and gross motor function in children
and support during the intervention period. They thank with spastic cerebral palsy. Phys Med Rehabil. 2007;86:548 –555.
the parent groups, physical therapists, and other early in- 18. Bodkin AW, Baxter RS, Dobkin BH. Treadmill training for an infant
born preterm with a grade III intraventricular hemorrhage. Phys Ther.
tervention providers in the community who referred chil-
2003;83:1107–1118.
dren to this study. They also thank the student volun- 19. Richards CL, Malouin F, Dumas F, et al. Early and intensive treadmill
teers Jennifer Reynolds, Erin Turner, Marina Nguyen, locomotor training for young children with cerebral palsy: a feasibil-
and Jessica Johnson from the University of California, ity study. Pediatr Phys Ther. 1997;9:158 –165.

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 317
20. Mattern-Baxter K. Effects of partial body weight supported treadmill 29. Nichols D, Case-Smith J. Reliability and validity of the pediatric eval-
training on children with cerebral palsy. Pediatr Phys Ther. 2009;21: uation of disability inventory. Pediatr Phys Ther. 1996;8:15–24.
12–22. 30. Sullivan K, Brown D, Klasses T, et al. Effects of taskspecific locomotor
21. Russell DJ, Avery LM, Rosenbaum PL, et al. Improved scaling of the and strength training in adults who were ambulatory after stroke: results
gross motor function measure for children with cerebral palsy: evi- of the STEPS randomized clinical trial. Phys Ther. 2007:1580 –1600.
dence of reliability and validity. Phys Ther. 2000;80:873– 885. 31. Lam T, Pearson K. The role of proprioceptive feedback in the regula-
22. Feldman A, Haley S, Coryell J. Concurrent and construct validity tion and adaptation of locomotor activity. Adv Exp Med Biol. 2002;
of the pediatric evaluation of disability inventory. Phys Ther. 1990; 508:343–355.
70:602– 610. 32. Ulrich B, Ulrich D, Collier D, et al. Developmental shifts in the ability
23. Tieman BL, Palisano RJ, Gracely EJ, et al. Gross motor capability and of infants with Down syndrome to produce treadmill steps. Phys Ther.
performance of mobility in children with cerebral palsy: a compari- 1995;75:14 –23.
son across home, school, and outdoors/community settings. Phys
33. Ulrich DA, Lloyd MC, Tiernan C, et al. Effects of intensity of treadmill
Ther. 2004;84:419 – 429.
training on developmental outcomes and stepping in infants with
24. Boyd R, Fantone S, Rodda J, et al. High- or low-technology measure-
Down syndrome. Phys Ther. 2008;88:114 –122.
ments of energy expenditure in clinical gait analysis? Dev Med Child
34. Behrman AL, Nair PM, Bowden MG, et al. Locomotor training re-
Neurol. 1999;41:676 – 682.
stores walking in a nonambulatory child with chronic, severe, incom-
25. Li AM, Yin J, Yu CCW, et al. The six minute walk test in healthy
children: reliability and validity. Eur Respir J. 2005;25:1057–1060. plete cervical spinal cord injury. Phys Ther. 2008;88:580 –590.
26. Portney L, Watkins M. Foundations of Clinical Research. 3rd ed. Upper 35. Dimitrijevic MR, Gerasimenko Y, Pinter MM. Evidence for a spinal
Saddle River, NJ: Prentice Hall; 2009. central pattern generator in humans. Ann NY Acad Sci. 1998;860:
27. Rosenbaum P, Stewart D. The world health organization interna- 360 –376.
tional classification of functioning, disability, and health: a model to 36. David KS, Sullivan M. Expectations for walking speeds: standards
guide clinical thinking, practice and research in the field of cerebral for students in elementary school. Pediatr Phys Ther. 2005;17:
palsy. Semin Pediatr Neurol. 2004;11:5–10. 120 –127.
28. Østensjø S, Brogren E, Carlberg E, et al. Everyday functioning in 37. Waters R, Lunsford BR, Perry J, et al. Energy-speed relationship of
young children with cerebral palsy: functional skills, caregiver assis- walking: standard tables. J Orthop Res. 1988;6:215–222.
tance, and modifications of the environment. Develop Med Child Neu- 38. Sutherland DH, Olshen RA, Biden EN, et al. The Development of Ma-
rol. 2003;45:603– 612. ture Walking. London: MacKeith Press; 1988.

318 Mattern-Baxter et al Pediatric Physical Therapy

 CLINICAL BOTTOM LINE
Effects of Intensive Locomotor Treadmill Training on Young Children with Cerebral Palsy

“How should I apply this information?”

Canchild’s motor growth study has shown that young children with cerebral palsy (CP) achieve their motor milestones
at an accelerated rate compared with that of older children with CP.1 From these data, it seems crucial to provide intensive
physical therapy intervention at a young age to children with CP. One of these interventions is the use of locomotor
treadmill training (LTT) in an attempt to maximize walking independence, walking endurance, and gait speed. LTT
differs from body weight–supported treadmill training in that LTT uses as little weight support as possible. LTT fits in
current rehabilitation opinions for providing task-specific training with multiple repetitions to children with CP. LTT has
been studied in children with CP, both ambulatory and nonambulatory. Despite encouraging results, relatively few studies
have been performed in the younger age group. To fill this gap in the literature, the effects of an intensive LTT intervention were
examined in children younger than 4 years with different types and severity of CP on functional standing and walking skills.
Young children with CP were enabled to take independent steps on the treadmill with as little support or facilitation as possible.
The possible adverse effects of LTT such as excessive fatigue or other forms of discomfort were also studied. The study provided
preliminary evidence that intensive LTT in this small sample of preschoolers with CP improved gross motor function, maximum
and self-selected walking speed, and walking endurance, with no harmful side effects.
“What should I be mindful about in applying this information?”
The findings of this study add to the body of knowledge that functional standing and walking skills can be improved by
intensive treadmill training in preschool children with CP. This study is important in that it describes an intensive
physical therapy program for young children, which can be easily adapted to the child’s level of skill.
The next 3 factors were beyond the scope of this study, but these should be considered when applying the results. First,
it is crucial that preschoolers develop competence in movement skills, which are the basis for more complex movement
tasks later in life. Because locomotor training for preschoolers with CP is designed to provide task-specific training, it can
be questioned whether intensive walking is the best intervention for all children with CP. For children classified under
Gross Motor Function Classification System (GMFCS) levels IV and V, intensive therapy on a bicycle or wheelchair seems
to be more task specific. At an older age, these children may continue to walk for only short distances with physical
assistance at home, relying more on wheeled mobility.
Second, the authors note that for preschoolers a program longer than 4 weeks might be necessary to make significant
physiological changes in endurance. A minimum of 6 weeks with 3 training sessions per week seems to be more
appropriate and might lead to better results.
Third, the authors also note that intensive LTT requires a large time commitment for parents and children and is
difficult to continue outside a research setting. They suggest that home-based treadmill training might be beneficial and
cost-effective for this population. However, a weight-support harness system with hydraulic lifting mechanism is expen-
sive, not easy to use, and needs supervision. Moreover, home treadmills, which have been growing steadily in popularity,
pose a specific hazard to preschoolers, and safety is always a concern while supervision is necessary. Additional home
treadmill safety guidelines must be established.
Although long-term effects of intensive physical training at a young age are not known, one can only assume that an
early introduction to a lifestyle that includes intensive exercise would be beneficial for the future health and physical
activity of children with CP. The pediatric physical therapist is a key player in educating parents about their role in giving
their children a healthy start. An intensive intervention, such as LTT, early in life may help boost levels of physical activity,
which may have a more influential impact on obesity and other health risks later in life.
REFERENCE
1. Rosenbaum P, Walter S, Hanna S, et al. Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA.
2002;288:1357–1363.

Olaf Verschuren, PT, PhD, PCS

Centre of Excellence, Rehabilitation Center ‘de Hoogstraat’, Utrecht, The Netherlands
Paul J.M. Helders, PT, PhD, MSc, PCS
Faculty of Medicine, Division of Pediatrics, Utrecht University, Child Development and Exercise Center,
University Medical Center and Children’s Hospital, Utrecht, The Netherlands

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 319

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