Effectiveness of Treadmill Training versus Overground Walking for Children with Cerebral Palsy

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1 Effectiveness of Treadmill Training versus Overground Walking for Children with Cerebral Palsy By: Davynne Atanasoff Doctoral Candidate University of New Mexico School of Medicine Division of Physical Therapy Class of 2016 Advisor: Tiffany Enache, DPT, DCE Printed Name of Advisor: Signature: Date: Approved by the Division of Physical Therapy, School of Medicine, University of New Mexico in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy.

2 2 Table of Contents ABSTRACT... 3 SECTION 1: Background and Purpose of PICO Question... 4 SECTION 2: Case Description... 5 EXAMINATION... 5 EVALUATION INTERVENTIONS SECTION 3: Evidence Based Analysis Reference Summaries Reference Table Discussion References Appendix A: Evidence Appraisal Worksheets... 35

3 3 Abstract Purpose: The aim of this literature review and case report was to answer the following PICO question via evidenced-based analysis: In children younger than 12 years old, with cerebral palsy, does full weight bearing treadmill training, compared to overground walking, result in greater gains in walking independence and endurance? Background: Treadmill training for children with cerebral palsy has been a popular topic in many pediatric physical therapy journals. However, many of these articles use partial body weight support (PBWS) devices, which are expensive and not very common in the clinical setting. Treadmills themselves are relatively common and are able to provide a lot of walking repetition as well as provide objective data on walking speed and distance. In addition, treadmills provide a safe walking environment, with no uneven surfaces or obstacles Case Description: : Carlos was a 4 year old male with a diagnosis of Cerebral Palsy (CP), currently receiving physical therapy services 1 hour a week, at a specialized school for the blind and visually impaired. He had very low tone, visual deficits, and had poor motor planning, making it difficult for him to meet his developmental milestones. Carlos was able to participant in 8 treadmill training sessions ranging from 5 to 15 minutes. Outcomes: The research comparing treadmill training to overground walking suggests treadmill training was significantly better at improving walking speed and gross motor development. Carlos was able to make substantial gains in his treadmill walking endurance and ability to increase his independent walking after treatment. Discussion: Treadmill training has been shown to improve various aspects of gait, however, treadmill protocols are still extremely variable. More research needs to be done to standardized treadmill training protocols to best fit this population.

4 4 SECTION 1: Background and Purpose of PICO question Cerebral Palsy (CP) is a condition describing a wide range of movement disorders and/or other disabilities, typically as a result of damage to the brain before or during birth. This disorder almost always results in developmental delays and decreased function. However, it is not a progressive disorder. CP is the most common cause of physical disability affecting children in developed countries, affecting 2 children out of every 1000 births. In addition to motor impairments, individuals may also have impairments in their cognition, behavior, communication, sensation, vision, and may have a seizure disorder (Campbell et al., 2006). Children with this disorder often reach their developmental milestones much later than their typically developing peers. Physical therapy is an intervention that is commonly prescribed for children with CP. The goal of physical therapy is to try to decrease this developmental gap as early as possible to allow these children to keep up with their peers. Children with CP often receive physical therapy both in their school and privately through outpatient services. In the school setting, physical therapy is used to increase the student s access to their learning environment, such as providing the student with the equipment they need to participate with their peers. In the private setting, the focus of physical therapy is to help the child reach their developmental milestones and help the child achieve the mobility goals set by the child/child s family. Motor learning theory suggests that when learning a new motor skill, the interconnected neurons are selected from a primary neuronal repertoire based on prior experience of the task (Willoughby et al., 2009). This suggests repetition of the skill will allow the neuronal pathways to become more efficient and thus allow the skill to be more easily performed. The use of the treadmill for children with cerebral palsy has been a popular topic in many pediatric physical

5 5 therapy journals. However, many of these articles use partial body weight support (PBWS) devices, which are expensive and not very common in the clinical setting. Treadmills themselves are relatively common and are able to provide a lot of walking repetition as well as provide objective data on walking speed and distance. In addition, treadmills provide a safe walking environment, with no uneven surfaces or obstacles, for a visually impaired individual. Overground walking is a common intervention used for many children with CP (Campbell et al., 2006). However, when walking overground, cadence is often inconsistent, especially for longer distances. In comparison, treadmills maintain a constant speed. The question arose if treadmill training was as effective as over ground walking. The aim of this literature review was to answer the question, In children younger than 12 years old with cerebral palsy, does full weight bearing treadmill training, compared to overground walking, result in greater gains in walking independence and endurance? SECTION 2: Case Description Introduction: Carlos was a 4 year old male with a diagnosis of CP, currently receiving physical therapy services 1 hour a week, at a specialized school for the blind and visually impaired, to increase his mobility independence at school. He had been making some progress since being seen in August 2015, but gains would need to be more substantial for him to meet his Individualized Educational Plan (IEP) goal by November EXAMINATION: History, Systems Review, and Tests & Measurements The following examination and evaluation findings were according to patient s school chart, including child s IEP. Information was also obtained via Carlos s current physical therapist who had been working with him for almost 2 years.

6 6 History: General demographics: o Carlos was a visually impaired 4 year old, Hispanic male with a diagnosis of cerebral palsy, unspecified. Carlos was nonverbal but had started to learn sign language. He had a substantial vision impairment, seeing best out of his left eye peripheral. He was very low tone and had poor motor planning, making it difficult for him to meet his developmental milestones. History of Current Condition: o Carlos was referred to physical therapy due to his history of delayed gross motor skills including decreased ambulatory endurance, which impaired his ability to access his classroom environment. Past Medical History: o The pregnancy with Carlos was uncomfortable for mother throughout gestation. She had some urinary tract infections for which she took antibiotics for. She also had placenta previa with on and off bleeding. At 41 weeks, she was found to have protein in her urine and labor was induced. The delivery had no complications. Six hours after being born, it was determined Carlos had a very low glucose level, and parents are unsure what intervention Carlos had through the night. Parents report the next morning Carlos was started on an intravenous line until his blood sugars resolved. He was kept in the intensive care unit for 5 days, his blood glucose levels stabilized and he was discharged home.

7 7 o The first day Carlos was seen by this therapist, he was able to squat to the floor to pick something up off the ground with minimum assist to maintain balance. He was easily fatigued and required a rest after performing this task 10 times. He was consistently able to take 4 independent steps before falling down. He was able to walk 200 feet at an inconsistent speed, using his rear walker, with minimum assist for steering. Carlos was able to consistently balance for seconds at a time, before falling to the floor. His physical therapist had been working on a lot of lower extremity strengthening including squatting, sit to stands, and walking. She had also been working a lot with Carlos on his balance. The physical therapist reported he was not really able to use his rear walker when he first started school in August. Past Surgical history: Bilateral medial rectus resection for esotropia Medications: o Was taking an anti-seizure medication at home o Immunizations: Up to date Diagnostic Testing: o New born hearing screen: Passed o Vision: Cortical vision impairment o Lead and metabolic screen were negative o Early childhood education program (ECEP) evaluation revealed a 50% delay in all areas Precautions/Contraindications o Fall risk with static sitting, static standing, and ambulation

8 8 Past History of this Condition: o Prior to attending the school in 2014 (at age 3), Carlos received early intervention since he was 13 months of age. Prior Level of Function: o Prior to receiving physical therapy in the school setting, Carlos was first able to roll over at 9 months, sit by himself at 18 months, and started bunny hopping at around 19 months. Current Level of Function: o He used a modified form of crawling (bunny hopping) as his main way of accessing his classroom. He was able to walk up to 200 feet with an inconsistent speed, using his rear facing walker, but often fell to his knees during ambulation. He was able to consistently take 4 independent steps on his own before falling. Living Environment: o Carlos lived with his mother and father along with his 3 half older siblings. Social/Recreational History: o Carlos enjoyed participating with his classmates during music time and fine motor activities. General Health Status: o Carlos was a healthy young boy with seizures controlled by medication. Developmental and Family History: o Carlos had 4 half siblings who were developing normally. He also had another half-sister on paternal side who passed away at age 3 from complications of Arnold-Chiari malformations. There was no reported family history of learning or

9 9 developmental problems, fetal loss, strabismus, autism, mental health diseases, seizure disorder, or hearing loss in children. Patient s Goals: o Carlos s current physical therapy IEP goal was, In one year s time by November 2016, Carlos will demonstrate improved walking ability, balance, and motor planning as demonstrated by the following objectives: 1) pulling to stand to his rear walker, turning around in it appropriately and maneuvering around shelves, chairs, and through doorways; 2)no longer crawl in the classroom setting, either walking between stable surfaces for support or maneuvering a rear walker appropriately; 3) demonstrate independent static stance with feet shoulder width apart while accomplishing squat to retrieve object unsupported, or interacting with suspended balloon play for >10 second, as observed and documented by the physical therapist 4 out of 5 observations. Systems Review: Musculoskeletal: He was very low tone and wore ankle foot orthotics (AFOs) while at school. He was able to consistently take 4 steps independently before falling down. Neuromuscular: No evidence of spasticity or clonus Cardiopulmonary: No concerns seen at this time Integumentary: No concerns seen at this time Communication/Cognition: Carlos was nonverbal, but was able to shake his head yes and no to answer questions. He was able to signal Me or My turn by using his hand to pat his chest. He was also able to point to a communication picture on a non-cluttered board (array of 3 pictures) to communicate what he wanted.

10 10 Tests and Measures: Table 1: Tests and measures from first visit Activity Outcome: Range of Motion Within functional limits in all joints Rolling Able to roll both right and left independently Balance Able to long sit with no upper extremity support for time frames equal to that of typically developing peers. Able to consistently static stand for about 10 seconds and a max of 1 minute when focused on an activity before falling to the ground Sit to Stand Able to perform about 10 with tactile cuing for balance with extra time Crawling Able to hold 4 point stance for 10 seconds. Able to bunny hop 50 feet. Unable to coordinate crawling movements. Walking Able to walk 200 feet with rear walker in 2 minutes 58 seconds- Only verbal cues given were walk to the motor room. o Speed inconsistent and he often slid down to his knees when he became tired. Able to consistently take about 4 independent steps before falling down. Required 2 hand held assistance and moderate assistance to take 5 steps backwards or sideways both directions. Stairs Able to ambulate up and down stairs with step to gait pattern with

11 11 use of 2 rails, tactile cueing, verbal cueing, and moderate assistance for weight shift. Jumping Required maximum assistance for any activities requiring this skill Tone Demonstrated low upper extremities, lower extremities, and trunk tone as shown by difficulty holding himself erect in both sitting and standing positions. Attention Able to consistently perform a gross motor task for 30 seconds in busy environment or 5 minutes in a low stimulation environment. Motor Planning Required moderate assistance to perform sequencing to approach and sit in a chair. EVALUATION: Diagnosis: Medical Diagnosis: Cerebral Palsy, Unspecified (ICD-10-CM G80.9) Physical Therapy Diagnosis: Difficulty in walking, not elsewhere stated (ICD-10-CM R26.8) Narrative Assessment: Carlos is a 4 year old boy with cerebral palsy and a substantial visual impairment. He has very low tone and demonstrates decreased muscle strength, decreased postural control, and poor motor planning. These impairments inhibit from reaching his developmental milestones. Barriers include patient being easily distracted and inability to verbally communicate. Barriers will be addressed during physical therapy sessions. Carlos would benefit from skilled PT to improve strength, increase cardiovascular endurance, and help increase his independence.

12 12 Clinical Judgments and Problem List: Impairments: o Hypotonic upper and lower extremities and trunk o Decreased LE strength Activity limitations: o Inability to walk with rear walker for 200 feet without falling to knees o Inability to take more than 10 independent steps o Inability to ambulate up and down steps without moderate assistance Participation Restrictions: o Inability to access all of the playground equipment, including climbing structure with large slide o Inability to walk with class during fieldtrips Goals, Plan of Care, and Prognosis: Goals: o Long Term Physical Therapy Goal: IEP Goal: In one year s time by November 2016, Carlos will demonstrate improved walking ability, balance, and motor planning as demonstrated by the following objectives: 1) pulling to stand to his rear walker, turning around in it appropriately and maneuvering around shelves, chairs, and through doorways; 2)no longer crawl in the classroom setting, either walking between stable surfaces for support or maneuvering a rear walker

13 13 appropriately; 3) demonstrate independent static stance with feet shoulder width apart while accomplishing squat to retrieve object unsupported, or interacting with suspended balloon play for >10 second, as observed and documented by the physical therapist 4 out of 5 observations o Short Term Physical Therapy Goal: In 3 weeks, Carlos will be able to walk on the treadmill for 10 minutes, to increase his strength and cardiovascular endurance, as observed by the physical therapist. In 3 weeks, Pt will be able to take greater than 10 independent steps, to access his classroom, as observed by the physical therapist. Plan of care: Carlos will receive an hour of physical therapy a week until the end of the school year in May. Interventions will include treadmill training, therapeutic exercises, gross motor development exercises, functional exercises, neuro-re-education, and gait training. o Patient related instruction: Importance of staying safe when walking Instructed on how to stay upright when standing and walking o Coordination and communication with classroom staff, Occupational therapist, orientation and mobility specialist, and speech language pathologist: Discussed the importance of Carlos wearing his orthotics when weight bearing Discussed the importance of Carlos walking to all classroom activities with rear walker, 1 hand held assist, or independently.

14 14 Instructed classroom staff how to work with Carlos on squatting to stand to pick up his toys. o Direct interventions: Treadmill training Conventional physical therapy including strengthening exercises, balance exercises, and gait training. Prognosis: Carlos has great potential to meet expected goals due to his supportive classroom and therapy staff. INTERVENTIONS: o Carlos received two, 30 minute physical therapy sessions each week for 6 weeks. Sessions involved walking on the treadmill, gait training with rear walking, independent walking, independent standing, balance activities, and lower extremity strengthening activities. Carlos s ability varied day to day. Factors for performance included how well he slept the night before and if he had a seizure during the day. There were no records of this data written in the notes or the chart as to which days these occurred. In addition, some days Carlos really enjoyed walking on the treadmill and other days he had to be motivated by watching Elmo s world on therapist s phone while walking. After about 10 minutes patient would step off the treadmill signaling he was finished. The treadmill training program was variable, depending on Carlos s ability/motivation that day. He was encouraged to walk as long as possible and the therapist adjusted the speed to comfortably challenge the patient.

15 15 Outcomes: Carlos was able to make substantial gains during the 6 weeks of therapy. He was able to increase his ability to walk of the treadmill from less than 5 minutes to 15 minutes by the end of the 6 weeks. He was able to achieve all of his short term goals and was making progress towards his long term goals. Carlos would benefit from continuing skilled physical therapy to further increase his walking ability, meet his developmental milestones, and increase overall independence. Section 3: Evidence Based Analysis Search Methodology: The following search methodology sought to answer the PICO question, In children younger than 12 years old, with cerebral palsy, does full weight bearing treadmill training, compared to overground walking, result in greater gains in walking independence and endurance? The following major databases and journal collections were searched: PubMed, CINAHL, and Web of Knowledge. Search terms were uniform for each database searched and included the following terms: treadmill training, children, and cerebral palsy. See Table 2 for details of the search and articles included/excluded. Table 2: Systematic Literature Review Process Search Terms # of Articles Included/Excluded PubMed Treadmill training, children, cerebral palsy CINAHL Treadmill training, children, cerebral palsy Web of Knowledge Treadmill training, children, cerebral palsy excluded based on irrelevance of title. 14 included based on relevance of title excluded based on relevance of abstracts; 5 Included based on relevance of abstracts. 5 Relevant articles (Articles, 1,2,3,5, and 7) excluded based on irrelevance of title; 5 excluded due to being duplicates to the relevant articles found in PubMed; 1 included due to relevance of title 1 Relevant article (Article 6) 41 Language Filter: English 37 articles in English

16 excluded due to irrelevance of titles or being duplicates of relevant articles found in PubMed or CINAHL 2 Relevant articles (Articles 4 and 8) Articles included for analysis: 1. Willoughby, K., Dodd, K., & Shields, N. (2009). A systematic review of the effectiveness of treadmill training for children with cerebral palsy. Disability & Rehabilitation TIDS, 31(24), Zwicker, J. G., & Mayson, T. A. (2010). Effectiveness of Treadmill Training in Children with Motor Impairments. Pediatric Physical Therapy, 22(4), Chrysagis, N., Skordilis, E. K., Stavrou, N., Grammatopoulou, E., & Koutsouki, D. (2012). The Effect of Treadmill Training on Gross Motor Function and Walking Speed in Ambulatory Adolescents with Cerebral Palsy. American Journal of Physical Medicine & Rehabilitation, 91(9), Grecco, L. A., Tomita, S. M., Christovão, T. C., Pasini, H., Sampaio, L. M., & Oliveira, C. S. (2013). Effect of treadmill gait training on static and functional balance in children with cerebral palsy: A randomized controlled trial. Revista Brasileira De Fisioterapia Rev. Bras. Fisioter., 17(1), Grecco, L. A., Zanon, N., Sampaio, L. M., & Oliveira, C. S. (2013). A comparison of treadmill training and overground walking in ambulant children with cerebral palsy: Randomized controlled clinical trial. Clinical Rehabilitation, 27(8), Kim, O., Shin, Y., Yoon, Y. K., Ko, E. J., & Cho, S. (2015). The Effect of Treadmill Exercise on Gait Efficiency During Overground Walking in Adults With Cerebral Palsy. Ann Rehabil Med Annals of Rehabilitation Medicine, 39(1), Mattern-Baxter, K., Bellamy, S., & Mansoor, J. K. (2009). Effects of Intensive Locomotor Treadmill Training on Young Children with Cerebral Palsy. Pediatric Physical Therapy, 21(4), Crowley, J. P., Arnold, S. H., Mcewen, I. R., & James, S. (2009). Treadmill Training in a Child with Cerebral Palsy: A Case Report. Physical & Occupational Therapy In Pediatrics, 29(1),

17 17 Reference # 1: Willoughby, K., Dodd, K., & Shields, N. (2009). A systematic review of the effectiveness of treadmill training for children with cerebral palsy. Disability & Rehabilitation TIDS, 31(24), Level of Evidence: Oxford: 1a Pedro: N/A Purpose: The purpose of this systematic review is to assess the effectiveness of treadmill training for children with Cerebral Palsy. Method: The researchers conducted an electronic search in 13 different electronic databases, using the terms cerebral palsy, child, and treadmill training as their search terms. Additional articles were found through a manual search of the reference lists of relevant articles. Two reviewers independently applied the inclusion and exclusion criteria and disagreements about the eligibility of articles were resolved by discussion between the two reviewers. Articles were included if 1) Participants were younger than 18 years old, 2) Greater than 80% of the participants had a diagnosis of CP, 3) treadmill training compromised at least 80% of the treatment. Articles were excluded if 1) participants had concurrent physical or cardiorespiratory disorder that may have impacted on their ability to participate in training, 2) where a treadmill was used for assessment purpose only, 3) if articles scored less than 3 on the PEDro scale, and 4) if only an abstract was available. Results: The researchers first identified 125 articles, but only 5 met their inclusion criteria. Their results found treadmill training was safe to use with children with CP across a large range of ages and functional abilities. Their results also indicate the treatment may help increase walking speed for short distances and improve overall gross motor function. Critique/Bottom Line: This study indicates treadmill training is a low risk intervention strategy for children with a diagnoses of CP, and may help increase their walking speed and their overall gross motor development.

18 18 Reference # 2: Zwicker, J. G., & Mayson, T. A. (2010). Effectiveness of Treadmill Training in Children with Motor Impairments. Pediatric Physical Therapy, 22(4), Level of Evidence: Oxford: 1a Pedro: N/A Purpose: An overview of systematic reviews was conducted to synthesize the current evidence on the effectiveness of treadmill training with/without PBWS in children with motor impairments. Method: Two researchers conducted an electronic search in 10 different electronic databases. The search terms used were not included in the overview. The researchers only included systematic reviews in the overview. In addition, the review had to include all of the following: 1) either PBWS and/or treadmill training as an intervention, 2) children from birth-21, and 3) a diagnosis consistent with having a motor impairment to be included in the overview. The researchers were not blinded to the assessment process. Results: The majority of the participants used in this study had a diagnosis of CP (248 out 412 participants). The results were also broken down into the medical diagnostic categories. Specifically in the Cerebral Palsy category, full weight bearing treadmill training showed statistically significant improvements in stride/step length, sit-to-stand ability, lateral step test, motor assessment scale, and Gross Motor Functional Measure (GMFM) score. Critique/Bottom Line: This overview of systematic reviews indicates treadmill training is a safe intervention to use with children with CP, with no complaints from participants with CP other than some exhaustion. In addition, treadmill training may offer some positive benefits for children with CP in terms of their gait pattern and gross motor skills. There seems to be very little risk with this intervention and potentially great gains. This intervention is also very low cost if the facility already has a treadmill.

19 19 Reference # 3: Chrysagis, N., Skordilis, E. K., Stavrou, N., Grammatopoulou, E., & Koutsouki, D. (2012). The Effect of Treadmill Training on Gross Motor Function and Walking Speed in Ambulatory Adolescents with Cerebral Palsy. American Journal of Physical Medicine & Rehabilitation, 91(9), Level of Evidence: Oxford: 1b Pedro: 9 Purpose: This study was conducted to evaluate the effect of a treadmill training intervention on gross motor function, self-selected walking speed, and spasticity for ambulatory adolescents with spastic cerebral palsy. Method: 22 students met the eligibility requirements and participated in the study. The participants were stratified according to Gross Motor Function Classification System (GMFCS) level and sex. Then they were randomly assigned to the experiment and control group. The experiment group followed a specific treadmill program, where speed was gradually progressed. The control group received conventional physical therapy focusing on balance, gait training, and gross motor function. Both groups had three 45 minute sessions a week for 12 weeks. The GMFM (sections D and E), 10 meter walk test, and the Modified Ashworth Scale (MAS) were used as outcome measures. Results: The treadmill training group significantly improved in the GMFM and 10 meter walk test compared to the control group. There was no significant difference in the MAS score between the two groups. Critique/Bottom Line: This study indicates treadmill training may be more effective than standard physical therapy on gross motor function and self-selected walking speed for adolescent children with spastic CP. Although my student is a lot younger and does not have spastic CP, I believe he would benefit from a modified version of this treadmill training program.

20 20 Reference # 4: Grecco, L. A., Tomita, S. M., Christovão, T. C., Pasini, H., Sampaio, L. M., & Oliveira, C. S. (2013). Effect of treadmill gait training on static and functional balance in children with cerebral palsy: A randomized controlled trial. Revista Brasileira De Fisioterapia Rev. Bras. Fisioter., 17(1), Level of Evidence: Oxford: 1b Pedro: 9 Purpose: This randomized controlled trial was conducted to compare the effects of gait training on a treadmill and gait training on the ground on the functional and static balance in functionally ambulatory children with CP. Method: 14 children with cerebral palsy met the inclusion criteria and were randomly allocated into an experiment treadmill training group or a control overground walking group. Outcome measures included Berg balance scale and determination of oscillations from the center of pressure. Assessments were performed by a blinded evaluator both before and after treatment. The intervention consisted of two 30-minute sessions per week for 7 weeks in their assigned group. Results: Both the treatment group and the experiment group showed about the same improvement in static balance. However, the treadmill training group showed a statistically greater improvement in functional balance (Berg balance scores) and less mediolateral oscillation displacement compared to the control group. Critique/Bottom Line: This study indicates that while both treadmill training and overground walking improve static balance about the same, treadmill training results in significantly greater functional balance improvements and mediolateral oscillation with eyes open in children with CP.

21 21 Reference # 5: Grecco, L. A., Zanon, N., Sampaio, L. M., & Oliveira, C. S. (2013). A comparison of treadmill training and overground walking in ambulant children with cerebral palsy: Randomized controlled clinical trial. Clinical Rehabilitation, 27(8), Level of Evidence: Oxford: 1b Pedro: 7 Purpose: This RCT was performed to assess the effect of treadmill training, without partial weight support, on gait speed and gross motor development, in children with CP, compared to training with overground walking. The researchers also wanted to determine if there was a lasting effect after a 4 week period of no intervention. Method: Participants were recruited for the study if they met the following inclusion criteria: 1) between the age of 3-12 years old, 2) absent of cognitive or visual impairment, and 3) Level 1, 2, or 3 on the GMFCS. Participants were excluded if they had any (or indication for) surgical or neuromuscular procedures performed within the last 12 months prior to training sessions. The participants were then randomly assigned to either the treadmill group or the overground walking group. The following outcome measures were used: 6 minute walk test, Timed Up and Go test (TUG), Pediatric Evaluation, Disability Inventory (PEDI), GMFM-88, and Berg Balance Scale. Testing was performed by a single examiner, blinded to the allocation of the participants. Results: Both the treadmill group and the control group significantly improved in the: 6 Minute Walk Test, TUG Test, PEDI, GMFM-88, and the Berg Balance Test. However, the treadmill training group demonstrated statistically greater improvement compared to the overground walking group both after treatment and during follow-up (p<0.05). Critique/Bottom Line: Although Carlos is not identical to the participants selected for the study, mainly due to his visual impairment, I do feel the results of this study are applicable to him. This study indicates treadmill training may be more effective than training with over ground walking in all the listed outcome measures both after treatment and during follow up.

22 22 Reference # 6: Kim, O., Shin, Y., Yoon, Y. K., Ko, E. J., & Cho, S. (2015). The effect of treadmill exercise on gait efficiency during overground walking in adults with cerebral palsy. Annals of Rehabilitation Medicine, 39(1), Level of Evidence: Oxford: 2b Pedro: 6 Purpose: The researchers conducted this study to evaluate the effect of a treadmill walking exercise as a treatment method to improve the energy expenditure of walking and gait efficiency in adults with CP. A secondary aim was to determine if there was any improvement in parameters such as gait speed, distance, and energy expenditure from such exercise. Method: 21 adults with CP were randomly allocated to either the experiment group or the control group. At a 2:1 ratio, using a central telephone randomization service. The experiment group participated in 20 treadmill walking sessions over 1-2 month span. The control group received conventional physical therapy treatment. Gait distance, velocity, and O2 rate were assessed at the beginning and end of the treadmill walking. Results: The treadmill walking group statistically improved in their gait distance and velocity. They also decreased in their O2 consumption. The control group did not significantly improve in any of these measures. Critique/Bottom Line: This study indicates treadmill exercise may improve the gait efficiency by decreasing energy expenditure during overground walking for adults with cerebral palsy, allowing adults to walk further before fatiguing.

23 23 Reference # 7: Mattern-Baxter, K., Bellamy, S., & Mansoor, J. K. (2009). Effects of intensive locomotor treadmill training on young children with cerebral palsy. Pediatric Physical Therapy, 21(4), Level of Evidence: Oxford: 2b Pedro: 4 Purpose: The purpose of this study was to determine if an intensive, 4 week treadmill program for children below the age of 4, with a diagnosis of CP, improved gross motor development, walking speed, walking endurance, and decreased the amount of assistance they required. In addition, the researchers wanted to analyze if the children maintain these results 1 month later. Method: 6 children met the eligibility requirement for this study. They were tested using the GMFM-66, 3 domains of the PEDI, 10 meter test, 6 minute walk test, treadmill walk test, and 2 foot standing balance test. The tests were performed before, after, and 4 weeks following the cessation intervention. The intervention consisted of 3 one hour sessions a week for 4 weeks. The children were allowed to go to regularly scheduled physical therapy appointments and walk throughout the day. Results: Significant differences were found in GMFM-66 (D & E), 2 of the 3 domains of the PEDI, overground walking speed, and walking distances. This was also the case at follow-up. Critique/Bottom Line: The lack of a control and small sample size really hurts the external validity of this study. The results indicated some tests lacked statistically significant improvement between the pre and post-intervention test, yet with some of those same tests, significant improvement was found between the pre-intervention and 1 month follow-up. This may suggests the children statistically improved based on maturation. In addition, the amount of time required to perform this intervention in the school setting is not very realistic. All of this aside, the results indicate this intervention is safe and the child s walking speed, endurance, and gross motor development may improve from this type of intervention.

24 24 Reference # 8: Crowley, J. P., Arnold, S. H., Mcewen, I. R., & James, S. (2009). Treadmill training in a child with cerebral palsy: a case report. Physical & Occupational Therapy In Pediatrics, 29(1), Level of Evidence: Oxford: 3b Pedro: N/A Purpose: The purpose of this case study was to describe the effect of treadmill training, without body weight support, on a child with diplegic cerebral palsy s walking speed. Method: The student was assisted on to the treadmill and stationed in the middle of the treadmill belt. She was told to hold on to the treadmill hand rails. She received 30 minute treadmill training sessions, 3 times per week for 6 weeks. The goal was to have the student walk longer each session than she did on her previous session. Results: After the 6 week treadmill training period, the student was able to decrease her 50 feet walking time, using her posterior walker, from seconds to seconds. After 3 weeks post-intervention, she walked it in seconds. This was faster than the average walking speed of typical developing kindergarteners 13.5 seconds. She also decreased her 458 feet walking time from 4 minutes 27 seconds to 2 minutes 55 seconds. Her average speed after the 3 week follow-up was 3 minutes 1 second. Lastly, she demonstrated small gains in her GMFM score. Critique/Bottom Line: This study shows a positive indication that treadmill training, without partial weight bearing, can be used to greatly increase a child with cerebral palsy s walking speed for both 50 feet and 450 feet distances. Furthermore, this intervention did not increase the student s fatigue or seem to decrease her ability to participate at the school. This case report indicates treadmill training for this population may provide great benefits with very little risk.

25 25 # Author(s) Oxford Level 1 Willoughby, K., Dodd, K., & Shields, N. (2009) 2 Zwicker, J. G., & Mayson, T. A. (2010) Pedro Level 1a N/A 1 A systematic review was conducted to evaluate the effectiveness of treadmill training for children with CP 2. 1a N/A 1 An overview of systematic reviews was conducted to synthesize the current evidence on the effectiveness of treadmill training with/without PBWS 3 in children with motor impairments. Reference Table Purpose Outcome Measures Results Relevant to PICO Question 10 meter walk test 10 minute walk test 6 minute walk test Gross Motor Function Measure (E) Gross Motor Function Measure(D) Functional ambulation category Energy efficiency index Cadence Stride/Step length Treadmill speed Walking endurance Over ground speed Gross Motor Function Classification System 10 meter walk test 50 others for CP 2. The review suggests that treadmill training is safe and feasible for children with CP 2 and indicates that it may be beneficial to increase walking speed and improve general gross motor skills. This overview of systematic reviews indicates treadmill training is a safe intervention to use with children with CP 2. In addition, treadmill training showed statistically significant improvements in stride/step length, sit-tostand ability, over ground speed, lateral step test, motor assessment scale, treadmill speed, 10 meter walk test, and gross motor function measure score. Yes Yes

26 26 3 Chrysagis, N., Skordilis, E. K., Stavrou, N., Grammatopoulou, E., & Koutsouki, D. (2012). 4 Grecco, L. A., Tomita, S. M., Christovão, T. C., Pasini, H., Sampaio, L. M., & Oliveira, C. S. (2013). 5 Grecco, L. A., Zanon, N., Sampaio, L. M., & Oliveira, C. S. (2013). 1b 9 This study was conducted to evaluate the effect of a treadmill training intervention on gross motor function, walking speed, and spasticity for ambulatory adolescents with cerebral palsy. 1b 9 This RCT 4 was conducted to compare the effects of gait training on a treadmill and gait training on the ground on the functional and static balance in functionally ambulatory children with CP 2. 1b 7 This RCT 4 was performed to assess the effect of treadmill training without partial weight support on gait speed and gross motor development, in children with CP 2, compared to training with overground walking, and determine Gross Motor Function Measure (D & E) 10 m walk test Modified Ashworth scale Berg balance scale Stabiliometry performed on a Tekscan MatScan System pressure platform 6 minute walk test Timed Up and Go test Pediatric Evaluation Disability Inventory Gross Motor Function Classification System -88 Berg Balance Scale. This study indicates treadmill training may be more effective than standard physical therapy on gross motor function and self-selected walking speed for adolescent children with spastic CP 2. This study indicates that while both treadmill training and overground walking improve static balance about the same, treadmill training results in significantly greater functional balance improvements and mediolateral oscillation with eyes open in children with CP 2. Treadmill training proved more effective than training with over ground walking in all the listed outcome measures both after treatment and during follow up. Yes Yes Yes

27 27 6 Kim, O., Shin, Y., Yoon, Y. K., Ko, E. J., & Cho, S. (2015). if there was a lasting effect. 2b 6 The researchers conducted this study to evaluate the effect of a treadmill walking exercise as a treatment method to improve the energy expenditure of walking and gait efficiency in adults with CP 2. A secondary aim was to determine if there was any improvement in parameters such as gait speed, distance, and energy expenditure from such exercise. 6 minute walk test Oximeter This study indicates treadmill exercise may improve the gait efficiency by decreased energy expenditure during overground walking for adults with cerebral palsy, allowing adults to walk further before fatiguing. Yes 7 Mattern-Baxter, K., Bellamy, S., & Mansoor, J. K. (2009). 2b 4 The researchers conducted this study to determine if an intensive, 4 week treadmill program helps children with CP 2 younger than 4 in their gross motor development, their walking speed and endurance, and the amount of assistance they require. Gross Motor Function Measure-66 3 domains of Pediatric Evaluation Disability Inventory o Mobility functional skills o Mobility caregiver assistance This study indicates that a high intensity treadmill training program for children with CP 2, below the age of 4, could increase their walking speed, walking distance, standing balance, and decrease their need of assistance in their functional mobility. Yes

28 28 8 Crowley, J. P., Arnold, S. H., Mcewen, I. R., & James, S. (2009). Footer: 3b N/A 1 The purpose of this case study was to describe the effect of treadmill training, without body weight support, on a child with diplegic cerebral palsy s walking speed. o Self-help assistance) 10 meter test 6-minute test Treadmill walk test Standing balance of 2 feet test 50 feet walking speed 458 feet walking speed Gross Motor Function Measure -88 In addition, these results seem to last even a month after treatment. This case study found a 6 week treadmill training intervention help double the student s 50 feet and 458 feet walking speed. She also made small gains in her gross motor function measure score. These results continued to be the case 3 weeks after the intervention. Yes 1 Not Applicable (N/A) 2 Cerebral Palsy (CP) 3 Partial body weight support (PBWS) 4 Randomized controlled trial

29 29 Discussion: The most important question a therapist should ask themselves before administering an intervention is, Will this intervention be safe for my patient? In research, safety can be deduced from attrition, injury, or side effects. According to Willoughby et al. (2009), none of the 48 participants included in their systematic review dropped out. This nominal attrition was seen throughout the literature. In addition, there was no report of a participant experiencing an injury in any of the 8 articles analyzed. Fatigue was the most severe symptom reported. This symptom was often seen in interventions that challenge cardiovascular endurance. Based on this literature review, fatigue did not prevent the participants from continuing the treatment. Motor theory suggests the best way to improve a motor skill is to specifically practice the skill over and over (Willoughby et al., 2009). One of the benefits of treadmill training is that it provides the participant a lot of repetition at a consistent speed. The treadmill provides an objective measurement of speed and a precise measurement of distance, which can objectively be progressed. Although overground walking allows the participant to practice the target skill, it is difficult for the individual to maintain a consistent speed over longer distances (Crowley et al., 2009). Furthermore, it is difficult to objectively progress the individual s walking speed during overground walking treatment. Partial body weight support devices (PBWS) are expensive and not commonly found in the clinical setting. However, treadmills are common equipment found at many schools and almost all physical therapy clinics. Treadmill training protocols can be tailored to each individual patient to fit into the allotted time frame for physical therapy. Lastly, it is an intervention that can be performed all year long, regardless of the weather. These factors make treadmill training a feasible intervention for many physical therapists.

30 30 Across the literature, treadmill training was either equal to or better than overground walking. This was true across all age groups from 3 years old to adulthood. More than half the studies analyzed showed an increase in GMFM scores, indicating an increase in gross motor development (Chrysagis et al., 2012; Crowley et al., 2009; Grecco, Zanon et al., 2013; Mattern- Baxter et al., 2009; Willoughby et al., 2009; Zwicker & Mayson, 2010). An overview of systematic reviews indicated full weight bearing treadmill training effectively improved participants 10 meter walking speeds (Zwicker & Mayson, 2010). In Grecco, Zanon et al. (2013), both the treadmill training group and the overground walking group significantly improved between their pre and post intervention scores. However, treadmill training proved significantly more effective in all tested outcome measures both after treatment and during follow-up. This begs the question, if treadmill training proves more effective even in one outcome, why is it not part of standard treatment for this population? Some limitations of the studies involved small sample sizes and lack of specific CP diagnosis, such as spastic diplegia CP. There are many types of CP and they present very differently. Studying one specific type may increase the generalizability of the results for the targeted population. Conclusion/Bottom Line: Full body weight supported treadmill training is a safe intervention and it is effective at increasing walking speed, walking endurance, and gross motor development for a wide range of ages (Willoughby et al., 2009). In addition, treadmills are accessible and protocols can be tailored to individuals. One of the limitations to this intervention is that participants need to be able to fully support their weight during walking, making the intervention only appropriate to individuals with cerebral palsy with the ability to walk short distances

31 31 independently or with an assistive device (Gross Motor Function Classification Scale, or GMFCS, level of I, II, or III for children between the ages 2-6). Carlos was a 4 year old with a diagnosis of cerebral palsy, nonspecified. He had a GMFCS level of III and was able to walk short distances with a rear walker. Based on the findings of the literature review, a treadmill training program trial was implemented. The parameters of the study were set by Carlos s available IEP time of 1 hour of physical therapy a week. This was broken down into two, 30 minute treatments a week to allow two treadmill training sessions a week. The treadmill speed was adjusted per session to comfortably challenge walking speed and Carlos was encouraged to walk as long as possible on the treadmill. Carlos had a unique presentation of cerebral palsy and had very low tone and no obvious spasticity. This was a major difference between him and the participants in the studies. The majority of the participants in the studies had spasticity. In addition, the participants in the literature review ranged from 3 years old to adulthood, with the median age around 12. This was a significant difference due to the differences of neuroplasticity at each age. Lastly Carlos had a substantial visual impairment. However, none of the participants in the study had a recorded visional impairment and some of the studies even used it as an exclusion criteria. Carlos participated in seven treadmill training sessions, four of which lasted approximately 10 minutes or more. After the first 10 minute session, Carlos took 15 independent steps, the most he had ever taken. However, this high of a number was not seen after the three other long sessions. The treadmill training challenged Carlos s walking endurance and he was often fatigued after the sessions. However, he was able to complete all his school activities after the session, and did not require taking a nap at school.

32 32 Some gains in terms of independent walking ability, treadmill walking endurance, and independent standing were noted after 4 treadmill training sessions. Carlos began taking more independent steps in the classroom and even shook the therapist s hand away so he could walk by himself down the hallway-something he had never done before. However, these gains were inconsistent and not significant. Independent walking steps was the main outcome measure used. In hindsight, the 10 meter walk test, 6 minute walk test, and vital signs should have been used as well to assess if Carlos s walking speed, walking endurance, and cardiopulmonary endurance respectively. Carlos benefited from this intervention as shown by his marked increase in walking time on the treadmill. I would use this intervention again on a child with a similar diagnosis if they were able to ambulate with or without an assistive device and were medically stable enough to perform the intervention. In conclusion, the evidence based literature review suggests treadmill training for children younger than 12 years old, with cerebral palsy, results in greater gains in walking independence and endurance when compared to overground walking.?

33 33 References Campbell, S. K., Palisano, R. J., & W., V. L. (2006). Physical therapy for children. St. Louis, MO: Elsevier Saunders. Chrysagis, N., Skordilis, E. K., Stavrou, N., Grammatopoulou, E., & Koutsouki, D. (2012). The effect of treadmill training on gross motor function and walking speed in ambulatory adolescents with cerebral palsy. American Journal of Physical Medicine & Rehabilitation, 91(9), Crowley, J. P., Arnold, S. H., Mcewen, I. R., & James, S. (2009). Treadmill training in a child with cerebral palsy: a case report. Physical & Occupational Therapy In Pediatrics, 29(1), Grecco, L. A., Tomita, S. M., Christovão, T. C., Pasini, H., Sampaio, L. M., & Oliveira, C. S. (2013). Effect of treadmill gait training on static and functional balance in children with cerebral palsy: a randomized controlled trial. Revista Brasileira De Fisioterapia Rev. Bras. Fisioter., 17(1), Grecco, L. A., Zanon, N., Sampaio, L. M., & Oliveira, C. S. (2013). A comparison of treadmill training and overground walking in ambulant children with cerebral palsy: Randomized controlled clinical trial. Clinical Rehabilitation, 27(8), Kim, O., Shin, Y., Yoon, Y. K., Ko, E. J., & Cho, S. (2015). The effect of treadmill exercise on gait efficiency during overground walking in adults with cerebral palsy. Annals of Rehabilitation Medicine, 39(1), Mattern-Baxter, K., Bellamy, S., & Mansoor, J. K. (2009). Effects of intensive locomotor treadmill training on young children with cerebral palsy. Pediatric Physical Therapy, 21(4),

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