TREADMILL

TRAINING

IN

CHILDREN RECENT

ADVANCES

Contents Treadmill training

Need

TMT for preterm

TMT for CP

TMT for SCI

TMT for Downs

TMT for cerebellar disorders

Role of robotics

Recent trend

conclusion

The history of TMT-Begins

Barbeau H & Rossingnol S

1983-1986

Recovery of locomotion after chronic

spinalization in the adult cat

Brain Res 1987;412:84–95

Treadmill training

Task specific

Repetition training of whole gait cycle

Reduces the impact of poor balance on

the child’s ability to maintain weight

bearing during walking

Dynamic system approach for attainment

of locomotor skills in CP

SACKETT LEVEL OF EVIDENCE

PEDro Scale (Physiotherapy

Evidence Database)

Preterm infants

Enter this world with a disadvantage

Increases risk of neurodevelopmental

sequelae

Attains walking ability at older ages

Poorer quality of walking movement

Gait Posture 2008;27:340–346

Alternating steps

Full-term infants produces coordinated,

alternating steps by 7 months of age in

treadmill

preterm infants exhibited alternating steps

on a treadmill by 9 months of age

Early Hum Dev. 1994;39:211–223

Pre-term walking attainment

Tung et al (2009) longitudinally examines

the supported stepping in preterm and

full-term infants and to explore the step

parameters associated with walking

attainment

Phys Ther. 2009;89:1215–1225

Study description

Characteristic Intervention Outcome Result

SS-29/20

Pre-term - <37

weeks

Full-term - 38 to

42 weeks

children were

supported

under the arms

by an examiner

and stepped for

2 minutes at

0.2 m/s on a

treadmill

7 months –

walking/18 mo

GMF-AIMS

6 to 8 steps

during the 20-

second video

segments.

Phys Ther. 2009;89:1215–1225

Walking parameters

From the study

Tung et al (2009) conclude that preterm

infants had an increased risk of late

walking attainment compared to their

fullterm counterparts

Phys Ther. 2009;89:1215–1225

TMT for cerebellar ataxia

Locomotor training using BWS on a

treadmill in conjunction with overground

gait training may be an effective way to

improve ambulatory function in

individuals with severe cerebellar ataxia

Phys Ther. 2008;88:88–97

Case Description

Case Intervention outcome Result

• 13 yr old girl

• Post.fossa H

• Cerebellar &

brainstem Inf

• Ataxia

• Weakness

• Decreased

coordination

BWST-15 min

Overground

walking BWS-15

to 20 min

BWS-30% - 10%

TM speed-

0.18 m/s – 0.3

m/s

5 times / week

for 4 weeks

4 months

Gillette

Functional

Walking Scale

Pediatric

Functional

Independence

Measure

(WeeFIM)

No.of

unassisted steps

2-2-6

3-4-6

0-128-200

From this case report

Locomotor training using BWST is a

promising intervention for improving gait in

patients with severe cerebellar ataxia who

are non-ambulatory

Phys Ther. 2008;88:88–97 LOE-4, PEDro-2

PBWSTT

Special overhead structure supporting a

harness

Encircles the trunk of the child

Allows the child’s body weight to be partially

or fully supported to

Facilitates a normal gait pattern while

stepping on a treadmill

TRAINING PARAMETERS

Mean treadmill speed 0.23 m/sec - 0.34

m/sec

Net walking time 12.8 min - 18.6 min

BWS ranged from 20% to 40%

J Neurol Rehabil 2010;9:47-65

Duration of training

2-3 sessions of treadmill training per week

3-4 months of training

J Neurol Rehabil 2010;9:47-65

Traditional PT Vs PBWSTT

An intensive episode of physical therapy

that includes partial body weight treadmill

training may be effective in improving

gross motor skills of children with spastic CP

Statistically significant but not clinically

Pediatr Phys Ther 2007;19:11–19 LOE-4

Effects of PBSWTT

Walking velocity

Distance covered

Endurance – clinical significance but not

statistically

Balance – no significant difference

Effects of PBSWTT

Lower extremity strength improves

Functional improvements (standing,

transfers & rising)

Physiologically sound gait pattern

Intensive locomotor TMT

A systematic review by Katrin Mattern-

Baxter showed that TMT training was

effective but had longer duration of 4

weeks & above

Pediatr Phys Ther. 2009;21:12–22

No study compare the short term

intervention

Study description

Characteristic Intervention Outcomes Result

Inclusion criteria (1) a

diagnosis of

cerebral palsy, (2) age of 1 to

5 years, (3)

weight less

than

40 kg, (5)

parental ability to

provide

transportation

3 session/wk

4 wk

12 TM session

GMFM-66 item

version

PEDI 6 min walk test

10-Meter Walk

Test

Treadmill Walk

C (p=0.05)

D(p=0.007)

E (p= 0.01)

P=0.018 P=0.029

P=0.011

P=0.009

Pediatr Phys Ther 2009;21:308–319 LOE-4, PEDro-4

The result of the study says

short-term intensive treadmill training

improves measures of gross motor

function, maximum and self-selected

walking speed, and walking distance in a

small sample of young children with CP

2.5 to 3.9 years of age

Pediatr Phys Ther 2009;21:308–319 LOE-4, PEDro-4

Quality of Life

HRQOL directly relates b/w physical

impairment & physical well being

Pediatric Quality of Life Inventory (PedsQL)

is used to evaluate HRQOL after PBWSTMT

Assessed HRQOL after intense BWSTMT

PedsQL

Three different age versions

- young children (5–7 years), children (8–12

years), and teen (13–18 years)

3 dimensions

- General fatigue - 0.90 0.60

- Sleep/rest fatigue - 0.83 0.82

- Cognitive fatigue - 0.92 0.65

Pediatr Phys Ther 2009;21:45–52 LOE-4, PEDro-4

HRQOL improves

Clinically & statistical sig. decrease in post

mean scores of PedsQL except sleep/rest

fatigue

Therapists must always consider the

impact of an intervention on the health,

well-being, and QOL of the client

Pediatr Phys Ther 2009;21:45–52 LOE-4, PEDro-4

PBWSTT vs overground walking

PBWSTT was found to be no more effective

for improving walking speed, endurance,

and walking function at school than

practicing overground walking

Arch Phys Med Rehabil 2010;91:333-9 LOE-1B

Controversies

This finding would appear to contrast with

findings from recently published systematic

reviews

Disabil Rehabil 2009;31:1971-9

Pediatric Neurorehabilitation 2009;33:27-44

Which suggest that many PBWSTT programs

designed to improve walking in children with

CP

Reasons

Poor quality

Small sample sizes

Lack of randomization, concealed

allocation, and blinded assessment

Overestimation of their effect

TMT for Downs

Down syndrome (DS) occurs approximately

1.36 times in every 1,000 live births

Infants with Down syndrome (DS) are

consistently late walkers

Dev Med Child Neurol. 2009;51:453–462

Delayed motor skills

Greater joint range of motion (ligamentous

Laxity)

Delayed development of postural reactions

and myelination

Low muscle tone all contribute to delayed

motor skills

Pediatr Clin North Am.1984;31:1331–1343

Reciprocal pattern

Infants with DS can produce coordinated

alternating steps when supported under

their arms on a small motorized treadmill by

11 months of age

Dev Med Child Neurol. 1992;34:233–239

Milestones

GROSS MOTOR FUNCTION MONTHS

Sit without support 11

Pull up to standing position 17

Supported standing 20

Standing without support 24

walking 26

Arch Phys Med Rehabil. 2001;82:494–500

Treadmill speed

0.15 m/s to 0.26 m/s for infants

0.23 m/s to 0.34 m/s for children

On development

Dale et al (2008) studied the effects of

individualized, progressively more intense

treadmill training on developmental

outcomes in infants with DS

Phys Ther. 2008;88:114–122

Study desciption

Characteristic Intervention Results

SS- 30 (16-HI & 14-

LI )

Age (mo) -

9.65±1.61

Height (m) -

0.69±0.02

Weight (kg) -

8.49±1.05

No significant

group

differences

Steps/min - 10-

≤40

Belt Speed

(m/s) – 0.15-0.3

Duration – 8-12

min

Ankle weight

(50%, 75%,

100%, and 125%)-

HI

Phys Ther. 2008;88:114–122 LOE-2B

Attain earlier milestones

HI Treadmill training of infants with DS is an

excellent supplement to regularly

scheduled physical therapy intervention

for the purpose of reducing the delay in

the onset of walking

Phys Ther. 2008;88:114–122 LOE-2B, PEDro-3

Obstacle negotiation

Dale et al (2008) along with Chad (2008)

Strategy used in obstacle negotiation by

studying the the percentage of the fall,

crawl, and walk strategies used by each

group

Exp Brain Res (2008) 186:261–272

Higher walk strategy

HI group produced a significantly higher

percentage of walk strategy and a lower

percentage of crawl strategy than the LG

group

Exp Brain Res (2008) 186:261–272 LOE-2B, PEDro-4

Follow up – the gait cycle

Dale et al (2008) extended his study along

with Rosa and Jianhua to find whether 2

treadmill interventions would have

different influences on the development

of joint kinematic patterns in infants with

DS – 1yr follow up study

Phys Ther. 2010;90:1265–1276

Phys Ther. 2010;90:1265–1276 LOE-2B

Inference from the study

The timing of peak ankle plantar flexion

(before toe-off) in the HI group implies

further benefits from the HI intervention

HI group may use mechanical energy

transfer better at the end of stance and

may show decreased hip muscle forces

and moments during walking

Joint kinematic pattern improves

HI intervention can accelerate the

development of joint kinematic patterns

in infants with DS within 1 year after

walking onset

Phys Ther. 2010;90:1265–1276 LOE-2B, PEDro-3

TMT in SCI

Treadmill helps in practice stepping

Believed to trigger and enhance intrinsic

plasticity of the spinal cord central pattern

generators for locomotion

Helps in neurotrophin expression serve as

inherent potential for neural circuit

reorganization

J Appl Physiol. 2004;96:1954–1960

Why not in children? Intense locomotor training after

incomplete spinal cord injury (SCI) have

been described in adults with acute and

chronic injuries and with various levels of

ambulatory function

Laura et al & Robert et al explains about

motor improvement & neuroplasticity in

Children with SCI

Case description

Case Examination Intervention Outcome

measures

Result

Age-

5yr10mo

GCS-13/15

C4 level

ASIA-A

ASIA-B (5D)

LEMS score-

4/50

UEMS score-

8/50

ASIA-C

(1mo)

60-90 min

3–5 d/wk

20–30 min

6 month

BWS-80%-

10%

ASIA

WeeFIM II

WISCI II

Mobility in

home,

school, and

community

UE-8/50 to

31/50

LE-4/50 to

29/50

WeeFIM II 5/35 to 21/35

in mobility

and from

8/54 to 34/54

in

self-care

WISCI-II – 0

to 12

Phys Ther. 2007;87:1224–1232 LOE-4

Activity-dependent plasticity

Activity-dependent plasticity within spinal

circuitry may play a role in behavioral

response to training

Supraspinal changes in response to

locomotor training

Phys Ther. 2007;87:1224–1232 LOE-4

Neuroplasticity in child ?

Clinical literature does not indicate how

neuroplasticity in the young central

nervous system might be exploited by

newer rehabilitation strategies

Treadmill and over-ground settings – a

case report by Robert et al

Case description case Examination Locomotor

training

result

• Age-3.5 yrs

• Bullet entered

at T3 and

lodged near

C6–7

• ASIA – A

• 3 mo-IP ASIA-

A to ASIA-C

• Non-Amb.,

not ind. Std

• ASIA-LE – 4/50

MAS

Clonus

Reflexes

ROM of LE

7.01-

calculated gait

speed

WISCI-II

Accelerometer

-step F

Step train-20 to

30 min in BWSTMT

0.8-1.2 m/s

10-20 min over

ground Train

5 session/wk

76 sessions

Reciprocal,

Rhy.stepping P

Phys Ther. 2008;88:580–590 LOE-4

Conclusion

Independet standing

with a rolling walker,

but he could not stand

without external

support or

independently move

from a sit-to-stand

position

Evidence - Neuroplasticity

Cortico-brain-stem-spinalsystem

(mesencephalic locomotor), such as the

reticulospinal tract, could support voluntary

activation of the SPGL without recovery of

isolated voluntary leg movements

Phys Ther. 2008;88:580–590

Gait training orthosis

The Lokomat –

Robotic gait-training

orthosis

Developed by A G

Hocoma in 19__ at

Volketswil,

Switzerland

The Lokomat

Lokomat was developed in late 90s to

help automate manual-assisted BWSTMT

The device is an exoskeleton that

attaches to the outside of the subjects leg

Assists the subjects as he/she ambulates in

TM

Lokomat (Pediatric Version)

Provide assistance ranges from full passive

mode to complaint mode

Recently a pediatric Lokomat version was

released to public that allows children

approx. 4-12 yrs of age to participate in

gait training

Role of Robotics

Automated locomotor training can be

given by commercially-available DGO

Lokomat

DGO – A promising tool

DGO Lokomat provides higher intensity

gait therapy to regain or improve walking

capacity

Reduces more effort & more therapist LOE-4

conclusion

Condition Level of

Evidence

Result

Pre-term infant

Cerebral Palsy 1A

Downs syndrome 2B,2B,2B Facilitates early

walking

Cerebellar

disorder

4

SCI 4

Role of Robotics

Take home message-I

Efficacy of treadmill training in

accelerating walking development in

Down syndrome has been well-

demonstrated

J Neurol Phys Ther. 2009 March ; 33(1): 27–44

Take home message-II

Evidence supporting the efficacy or

effectiveness of BWSTT in pediatric

practice for improving gait impairments

and level of activity and participation in

those with cerebral palsy, spinal cord

injuries, and other central nervous system

disorders remains insufficient

J Neurol Phys Ther. 2009 March ; 33(1): 27–44