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),

34 34 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),

35 Appendix A: Evidence Appraisal Worksheets 35

36 36 Citation (use AMA or APA format): Systematic Review Evidence Appraisal Worksheet 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 scale): 1a Does the design follow the Cochrane method? Step 1 formulating the question Do the authors identify the focus of the review A clearly defined question should specify the types of: people (participants), interventions or exposures, outcomes that are of interest studies that are relevant to answering the question Step 2 locating studies Should identify ALL relevant literature Did they include multiple databases? Was the search strategy defined and include: o Bibliographic databases used as well as hand searching o Terms (key words and index terms) o Citation searching: reference lists o Contact with experts to identify grey literature (body of materials that The authors do identify the focus of the review, A systematic review was conducted to evaluate the effectiveness of treadmill training for children with CP. People: Children with diagnosis of CP Intervention: Treadmill training as at least 80% of intervention treatment Outcome: Is it effective Of the 125 papers found only 5 met their inclusion criteria They first found 125 articles, but only 5 met their inclusion criteria. They searched the terms cerebral palsy, child, and treadmill training, in the following databases: the Cochrane Library, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PEDro, Medline, CINAHL, Embase, ERIC, PsychINFO, PubMed, AMED, Ausport Medical, and SPORT Discus Additional articles were found through a manual search of the reference lists of relevant articles and through citation tracking and key author

37 37 cannot be found easily through conventional channels such as publishers) o Sources for grey literature searches completed using the Web of Science. No reference of gray literature being found or sought out. Part 3:Critical Appraisal/Criteria for Inclusion Were criteria for selection specified? Did more than one author assess the relevance of each report Were decisions concerning relevance described; completed by non-experts, or both? Did the people assessing the relevance of studies know the names of the authors, institutions, journal of publication and results when they apply the inclusion criteria? Or is it blind? Part 3 Critically appraise for bias: Selection Were the groups in the study selected differently? Random? Concealed? Performance- Did the groups in the study receive different treatment? Was there blinding? Attrition Were the groups similar at the end of the study? Account for drop outs? Detection 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. 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 2 reviewers independently applied the inclusion and exclusion criteria Disagreements about the eligibility of articles were resolved by discussion between the 2 reviewers. The reviewers knew the names of the authors, institutions, journal o publication and results when they applied the inclusion criteria. The groups used in the systematic review were selected using the same inclusion criteria. The trial design were matched pairs, clinical controlled design, and 4 pre-post test intervention designs. 2 of the studies included a control or comparative group but did not conceal assignment. One study included 2 groups participating in training at separated venues but only the result from the outpatient group were used because inpatient group had a variety

38 38 Did the study selectively report the results? Is there missing data? of participant diagnoses. Only 1 study reported blinding of the assessors. The sample size was small in each study (6-19 participants), totaling 48 across the studies included in the review. The demographics of the participants varied. Most were males with mean years. The classification of the participants type and severity of CP varied bot within individual studies and between studies. Attrition: No attrition results were reported The review did not include the inpatient data on one of the studies because not enough of the participants had CP. Part 4 Collection of the data Was a collection data form used and is it included? Are the studies coded and is the data coding easy to follow? Were studies identified that were excluded & did they give reasons why (i.e., which criteria they failed). I did not see a collection form was used. The data was coded and put into a table format Yes there were studies that were identified that were excluded and they gave the reasons why they were excluded. Are the results of this SR valid? 1. Is this a SR of randomized trials? Did they limit this to high quality studies at the top of the hierarchies a. If not, what types of studies were included? b. What are the potential consequences of including these studies for this review s results? Yes. They only included studies that scored a PEDro score of 3 or higher. They really did try to include the most applicable studies of the highest level. This helps but does not solely eliminate the risk of getting a type 1 or type 2 error.

39 39 2. Did this study follow the Cochrane methods selection process and did it identify all relevant trials? a. If not, what are the consequences for this review s results? 3. Do the methods describe the processes and tools used to assess the quality of individual studies? a. If not, what are the consequences for this review s results? 4. What was the quality of the individual studies included? Were the results consistent from study to study? Did the investigators provide details about the research validity or quality of the studies included in review? 5. Did the investigators address publication bias Are the valid results of this SR important? Yes they follow Cochrane methods selection process and did a thorough search of the literature. They did not get a 3 rd party to settle disputes for if an article was included but came to a consensus between the 2 reviewers. Yes the methods describe both the processes and the tools used to assess the quality of the studies and also included an easy to read table about it. All the studies scored at least a 3 or higher on the PEDro scale. The results were pretty consistent from study to study, although some looked at different results. The investigators provided details about the research quality of the studies they used. No this was not addressed 6. Were the results homogenous from study to study? a. If not, what are the consequences for this review s results? 7. If the paper is a meta-analysis did they report the statistical results? Did they include a forest plat? What other statistics do they include? Are there CIs? 8. From the findings, is it apparent what the cumulative weight of the evidence is? No the results were not homogenous from study to study so a meta-analysis could not be used N/A From the findings, it is apparent that more research needs to be done in the area. However, these findings suggest that treadmill training is effective in increase gait speed. Can you apply this valid, important evidence from this SR in caring for your patient/client? What is the external validity?

40 40 9. Is your patient different from those in this SR? 10. Is the treatment feasible in your setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 11. Does the intervention fit within your patient/client s stated values or expectations? a. If not, what will you do now? My patient is a male that falls between the mean age ranges of this review. He also has a diagnosis of CP. Yes, they have a pediatric treadmill on site and I have the skills and allotted time to administer the treatment. Yes my patient loves to move and I think the treadmill will help him do that. What is the bottom line? Summarize your findings and relate this back to clinical significance This systematic review suggests children with a diagnose of CP may benefit from a treadmill training program to increase walking speed over short distances and increase general gross motor skills. In addition treadmill training is found to be safe for this population. Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett Publishers, Sudbury, MA 2008 Citation (use AMA or APA format): Systematic Review Evidence Appraisal Worksheet 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 scale): 1a Does the design follow the Cochrane method?

41 41 Step 1 formulating the question Do the authors identify the focus of the review A clearly defined question should specify the types of: people (participants), interventions or exposures, outcomes that are of interest studies that are relevant to answering the question Yes. The researchers state the purpose of the review was to synthesize the current evidence from systematic reviews on the effectiveness of treadmill training with/without PBWS in children with motor impairments. Step 2 locating studies Should identify ALL relevant literature Did they include multiple databases? Was the search strategy defined and include: o Bibliographic databases used as well as hand searching o Terms (key words and index terms) o Citation searching: reference lists o Contact with experts to identify grey literature (body of materials that cannot be found easily through conventional channels such as publishers) o Sources for grey literature The researchers only included systematic reviews in their search. They used 10 electronic databases including AMED, CDSR, CINAHL, DARE, EMBASE, ERIC, MEDLINE, PEDro, PsychINFO, and SPORTDiscis. o The researchers did not write that they searched the literature by hand or sought out sources of gray literature. o The researchers also did not include what search terms they used. Part 3:Critical Appraisal/Criteria for Inclusion Were criteria for selection specified? Did more than one author assess the relevance of each report Were decisions concerning relevance described; completed by non-experts, or both? The researchers only included systematic reviews. In addition, the review had to have 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 More than one author assessed the relevance of the review and disagreements were settled by consensus.

42 42 Did the people assessing the relevance of studies know the names of the authors, institutions, journal of publication and results when they apply the inclusion criteria? Or is it blind? Part 3 Critically appraise for bias: Selection Were the groups in the study selected differently? Random? Concealed? Performance- Did the groups in the study receive different treatment? Was there blinding? Attrition Were the groups similar at the end of the study? Account for drop outs? Detection Did the study selectively report the results? Is there missing data? The researchers were not blinded to the assessment process. The articles chosen were based on the same inclusion criteria. Disagreements were settled by consensus among the researchers. Among the systematic reviews, there was variance between the intervention approaches, but none of the participants were blinded for the treatment they were receiving. This overview did not really talk about attrition The researchers only included systematic reviews published in English, so there is potential for missing data. Part 4 Collection of the data Was a collection data form used and is it included? Are the studies coded and is the data coding easy to follow? Were studies identified that were excluded & did they give reasons why (i.e., which criteria they failed). They used the AMSTAR scale to assess the methodological quality of the included SR. The studies are coded and the coding is easy to follow. The studies excluded were identified and the reasons why they were not used were described. Are the results of this SR valid? 12. Is this a SR of randomized trials? Did they limit this to high quality studies at the top of the hierarchies a. If not, what types of studies were included? This is a systematic review overview, so they only included SRs. This makes this a very high level of evidence, however, the reviews have quite a bit of variance in them. This

43 43 b. What are the potential consequences of including these studies for this review s results? 13. Did this study follow the Cochrane methods selection process and did it identify all relevant trials? a. If not, what are the consequences for this review s results? 14. Do the methods describe the processes and tools used to assess the quality of individual studies? a. If not, what are the consequences for this review s results? 15. What was the quality of the individual studies included? Were the results consistent from study to study? Did the investigators provide details about the research validity or quality of the studies included in review? 16. Did the investigators address publication bias Are the valid results of this SR important? could potentially cause a type 1 or type 2 error. It does seem like the researchers followed the Cochrane methods selection process. They did only review systematic reviews in English, potentially missing relevant data. This increases the risk of having a type 1 or type 2 error. Yes. The researchers went in quite a bit of detail on this. The researchers only included systematic reviews in their overview. The researchers did not discuss any publication bias. 17. Were the results homogenous from study to study? a. If not, what are the consequences for this review s results? 18. If the paper is a meta-analysis did they report the statistical results? Did they include a forest plat? What other statistics do they include? Are there CIs? 19. From the findings, is it apparent what the cumulative weight of the evidence is? There was positive tendencies between the studies, such as treadmill training helping increase gait speed and improve gross motor skills, but the degree to which were not the same between all the studies. A meta-analysis was not performed This overview provided a really great consolidation of the current evidence on the subject. However, the evidence out there is still pretty low

44 44 level and all of the studies had a pretty small sample size. Can you apply this valid, important evidence from this SR in caring for your patient/client? What is the external validity? 20. Is your patient different from those in this SR? 21. Is the treatment feasible in your setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 22. Does the intervention fit within your patient/client s stated values or expectations? b. If not, what will you do now? The majority of this overview included participants with a diagnosis with CP under the age of 21. My patient also has this diagnosis and falls in this age category. Yes, they have a pediatric treadmill on site and I have the skills and allotted time to administer the treatment Yes my patient loves to move and I think the treadmill will help him do that. What is the bottom line? Summarize your findings and relate this back to clinical significance This overview of systematic reviews indicates treadmill training is a safe intervention to use with children with CP. 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 GMFM score. Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett Publishers, Sudbury, MA 2008 Citation (use AMA or APA format):

45 45 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 scale): 1b Is the purpose and background information sufficient? Study Purpose Stated clearly? Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. Yes, the researchers conducted this study to evaluate the effect of a treadmill training intervention on gross motor function, walking speed, and spasticity for ambulatory adolescents with cerebral palsy. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Yes, the researchers presented a relatively thorough review of the current research and the current gap which need to be further examined. Describe the justification of the need for this study Does the research design have strong internal validity?

46 46 Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression Assignment: The participants were stratified according to GMFCS level and sex. Then they were randomly assigned to the experiment and control group. The participants were not aware of the group they were in. However, the students did all go to the same school. Attrition: All 22 students completed the 12 week problems. Some sessions were missed due to school activities. History: All the children participated in the study during the same time period. There was also a control group. Instrumentation: I feel the right measurement tools were selected for this study. I wish they would have had a strength measurement as well. Maturation: There was a control group and the children all did the intervention at the same time. Testing: The participants were randomized into the groups. However, a baseline test was given for both groups. Compensatory Equalization of treatments: The researchers were not blinded to which treatment the child was receiving. The treadmill group seemed to have relatively strict protocol. The control group had a set length of time for each participant, but it seemed more tailored to the student s needs. Compensatory rivalry: This was not really addressed in the article. However, I do not think the students would know which the treatment group was and which the control was. Statistical Regression: The results were reported with SD. No report of outliers being dropped.

47 47 Are the results of this therapeutic trial valid? 23. Did the investigators randomly assign subjects to treatment groups? a. If no, describe what was done b. What are the potential consequences of this assignment process for the study s results? 24. Did the investigators know who was being assigned to which group prior to the allocation? a. If they were not blind, what are the potential consequences of this knowledge for the study s results? 25. Were the groups similar at the start of the trial? Did they report the demographics of the study groups? a. If they were not similar what differences existed? b. Do you consider these differences a threat to the research validity? How might the differences between groups affect the results of the study? 26. Did the subjects know to which treatment group they were assign? a. If yes, what are the potential consequences of the subjects knowledge for this study s results Yes the participants were stratified and the randomly allocated into the two groups. The group sample sizes are still on the smaller side which runs the risk of a type 2 error The participants were stratified and then randomly assigned, a process led by a blinded Doctorate Student. But the researchers were not blinded to the treatment the participants were receiving. Because the researchers were not blinded, they could have pushed on group harder (or not as hard). This could skew their data. Yes, the groups were similar at the beginning of the trial and no statistical differences were found between the groups at the start of the clinical. The subjects were given their group assignments by a sealed envelope. However, all the participants went to the same small school. If they found out what treatment group they were in, it could skew the results. A participant might work harder because they know they are in the treatment group, or a participant might feel cheated and not work as hard because they are not in

48 Did the investigators know to which treatment group subjects were assigned? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 28. Were the groups managed equally, apart from the actual experimental treatment? a. If not, what are the potential consequences of this knowledge for the study s results? 29. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research? a. If not, what are the potential consequences of this knowledge for the study s results? 30. Did all the subjects originally enrolled complete the study? a. If not how many subjects were lost? b. What, if anything, did the authors do about this attrition? c. What are the implications of the attrition and the way it was handled with respect to the study s findings? the intervention group. However, I am not sure they would know if they were in the treatment or control group just by discussing what they were doing as both could be perceived as the intervention treatment. Yes, the investigators knew which treatment each participant was receiving. This could also skew their results because they could push one group more than the other. Although, they tried to use a strict protocol, the control treatment group was individualized to the participant (although they all worked on a set amount of skills). The groups received the same amount of treatment time. However, the protocol for the treadmill group was fairly strict for all of the group, whereas the control group was more individualized to the participant. This could skew their results because the therapist in the control group may have not pushed them as hard as they could go (because it is less objective compared to the treadmill). There was absolutely no follow-up for this study. Because of this, it is impossible to know if the results had any lasting effects. Yes all 22 participants completed the 12 week training program.

49 Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)? a. If not, what did the authors do with the data from these subjects? b. If the data were excluded, what are the potential consequences for this study s results? Are the valid results of this RCT important? All the participants were analyzed in the groups to which they were assigned. The study did not have any attrition so all participants data was analyzed. 32. What were the statistical findings of this study? a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences With p-values and CI c. Include effect size with p- values and CI d. Include ARR/ABI and RRR/RBI with p-values and CI e. Include NNT and CI f. Other stats should be included here 33. What is the meaning of these statistical findings for your patient/client s case? What does this mean to your practice? Gross Motor Function-Measure (D and E): o Treadmill group statically significantly improved more than the control group. Medium effect size was found (d=0.38) with a 95% confidence interval of to Meter Walk Test: o Treadmill group statically significantly improved more than the control group. Large effect size found (d=1.13) with a 95% confidence interval of 0.19 to Modified Ashworth Scale: o No statistical difference was found between the two groups. Although my student is a lot younger than the participants in the study, I still think he could benefit from a similar program. However, I do not think the amount of time (3 times a week for 12 weeks) would be appropriate for a preschool child. This would be a good protocol to use for a middle school group in an adaptive PE class, however.

50 Do these findings exceed a minimally important difference? Was this brought up or discussed? a. If the MCID was not met, will you still use this evidence? Yes these finding exceed minimally importance differences. This was not directly said in the article but was hinted at. Can you apply this valid, important evidence about an intervention in caring for your patient/client? What is the external validity? 35. Does this intervention sound appropriate for use (available, affordable) in your clinical setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 36. Are the study subjects similar to your patient/ client? a. If not, how different? Can you use this intervention in spite of the differences? 37. Do the potential benefits outweigh the potential risks using this intervention with your patient/client? 38. Does the intervention fit within your patient/client s stated values or expectations? a. If not, what will you do now? I do think the time commitment might not be appropriate for the school setting for a young child (below the age of 10). I was able to see my student for 2 hours a week, but that was pushing my limits. The therapist s caseloads are just too large to commit 3 hours a week for 12 weeks to one child, in the school setting. My student is a lot younger than the participants in the study. In addition, he does not have spasticity which all the participants had. Although he has some key differences, I do believe he could benefit from a similar program. Yes, this treatment seems to be low risk and potentially high reward. Yes my patient really enjoys walking on the treadmill. 39. Are there any threats to external validity in this study? Yes, the sample size is on the lower end, but they exceeded to the calculated participants to meet the effect size. There was also little standardization on the control group s protocol, which may affect the external validity. However, I think overall this is a well put together study and is generalizable.

51 51 What is the bottom line? PEDRO score (see scoring at end of form) 9 Summarize your findings and relate this back to clinical significance 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.

52 52 Intervention Evidence Appraisal Worksheet Citation (APA format): 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 scale): 1b Is the purpose and background information sufficient? Study Purpose Stated clearly? Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. Yes, the researchers conducted this study was 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. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Describe the justification of the need for this study Yes, the researchers presented a relatively thorough review of the current research and the current gap which need to be further examined, including the fact that there are not any studies looking at the effect of treadmill training on balance for children with CP.

53 53 Does the research design have strong internal validity? Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression Assignment: 15 participants with CP were randomly allocated to either the experiment group or the control group. Randomization was performed at central office using a randomization table. Sealed envelopes were then given to the participants. 1 member of the control group had to drop out due to a respiratory illness, making 7 children in each group. Attrition: One member of the control group dropped out due to a respiratory illness. His data was not included in the study. History: All the individuals participated in the study during the same time period. There was also a control group. Instrumentation: I think the researchers picked very good outcome measures for balance. Maturation: There was a control group and the individuals all did the intervention at the same time. Testing: The participants were randomized into the groups and received similar treatments. However, it was impossible to measure the speed of the control group. Compensatory Equalization of treatments: The researchers were not blinded to which treatment the child was receiving. Compensatory rivalry: This was not really addressed in the article, but they report allocation was concealed. Statistical Regression: The results were reported with SD. No report of outliers being dropped.

54 54 Are the results of this therapeutic trial valid? 40. Did the investigators randomly assign subjects to treatment groups? a. If no, describe what was done b. What are the potential consequences of this assignment process for the study s results? 41. Did the investigators know who was being assigned to which group prior to the allocation? a. If they were not blind, what are the potential consequences of this knowledge for the study s results? 42. Were the groups similar at the start of the trial? Did they report the demographics of the study groups? a. If they were not similar what differences existed? b. Do you consider these differences a threat to the research validity? How might the differences between groups affect the results of the study? 43. Did the subjects know to which treatment group they were assign? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 15 participants with CP were randomly allocated to either the experiment group or the control group. Randomization was performed at central office using a randomization table. Sealed envelopes were then given to the participants. 1 member of the control group had to drop out due to a respiratory illness, making 7 children in each group. The group sample sizes are still on the smaller side which runs the risk of a type 2 error. No. Randomization was performed at central office using a randomization table. Yes, the groups were similar at the beginning of the trial but there were some differences between them. The control group had 6 boys and only one girl, whereas the treatment group had 3 boys and 4 girls. I do not think this difference will really affect the research validity. GMFCS level, Age, body mass, height, and BMI were all about the same between the two groups. The subjects were randomly allocated. The children did not know which group they were assigned to. However, all the children go to the same physical therapy clinic. If they did find out which group they were in, it could skew their results. A participant in the

55 Did the investigators know to which treatment group subjects were assigned? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 45. Were the groups managed equally, apart from the actual experimental treatment? a. If not, what are the potential consequences of this knowledge for the study s results? 46. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research? a. If not, what are the potential consequences of this knowledge for the study s results? 47. Did all the subjects originally enrolled complete the study? a. If not how many subjects were lost? b. What, if anything, did the authors do about this attrition? c. What are the implications of the attrition and the way it was handled with respect to the study s findings? 48. Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)? a. If not, what did the authors do with the data from these subjects? b. If the data were excluded, what are the potential control group may feel cheated and not work as hard. A participant knowing they are in the experiment group may work harder (be more motivated). Yes, the investigators knew which treatment each participant was receiving. This could also skew their results because they could push one group more than the other. There also did not seem to be much a protocol for the control group. The groups received the same protocol, except one group was on the treadmill and the other was walking on the ground. However, it was impossible to determine the walking speed for the control group. There was absolutely no follow-up for this study. Because of this, it is impossible to know if the results had any lasting effects. 1 child in the control group dropped out due to respiratory illness. His data was not included in the study. This may skew the data and possible result in a type 2 error. All the participants were analyzed in the groups to which they were assigned.

56 56 consequences for this study s results? Are the valid results of this RCT important? 49. What were the statistical findings of this study? a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences With p-values and CI c. Include effect size with p- values and CI d. Include ARR/ABI and RRR/RBI with p-values and CI e. Include NNT and CI f. Other stats should be included here 50. What is the meaning of these statistical findings for your patient/client s case? What does this mean to your practice? Berg Balance Scale: o Both groups improved following treatment o Treadmill group statically improved more than overground group (p=0.01) Stabiliometry performed on a Tekscan MatScan System pressure platform: o No statistically difference between group for COP displacement in AP direction with either eyes open or eyes closed. o Statistically difference was found in oscillations in the AP direction between eyes open and eyes closed in both the experimental group (p=0.03) and the control (p=0.01). No statistical difference was found between the groups. o Treadmill group: 6 children showed less oscillation in the ML direction with eyes open (mean of 2.0 cm less oscillation p=0.04) o Control group: 3 children showed less oscillation in ML direction with eyes open (mean of 0.34 cm less oscillation p=0.63) No raw values were reported in this article My student meets all the eligibility requirements except one (he has an visual impairment. However, I think this study is still very applicable to him.

57 Do these findings exceed a minimally important difference? Was this brought up or discussed? a. If the MCID was not met, will you still use this evidence? Yes these finding exceed minimally importance differences. Can you apply this valid, important evidence about an intervention in caring for your patient/client? What is the external validity? 52. Does this intervention sound appropriate for use (available, affordable) in your clinical setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 53. Are the study subjects similar to your patient/ client? a. If not, how different? Can you use this intervention in spite of the differences? 54. Do the potential benefits outweigh the potential risks using this intervention with your patient/client? 55. Does the intervention fit within your patient/client s stated values or expectations? a. If not, what will you do now? Yes, the treadmill is very accessable and the 2, 30 minutes sessions a week are fit within the child allotted physical therapy time. My student meets almost all the inclusion criteria. However, he has a visual impairment, which is one of the exclusion criteria for this study. However, I think he would still be able to complete the treadmill training protocol of this study. Yes, this treatment seems to be low risk and potentially high reward. Yes my patient really enjoys walking on the treadmill. 56. Are there any threats to external validity in this study? Yes, the sample size is on the lower end. In addition, the sample was one of convenience (all from the same clinic) which might affect the generalizability of the study. What is the bottom line? PEDRO score (see scoring at end of form) 9

58 58 Summarize your findings and relate this back to clinical significance 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.

59 59 Intervention Evidence Appraisal Worksheet Citation: 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 scale): 1b Is the purpose and background information sufficient? Study Purpose Stated clearly? Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Yes, assess the effect of treadmill training without partial weight support on functional mobility in (gait velocity) in children with CP, through a comparative analysis of training with overground walking, and determine whether the effects last after the interruption of the interventions. The secondary aim was to compare the effects of treadmill training and overground training on the motor abilities of the participants (functional performance, gross motor function and both static and functional balance." Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Yes. The researchers did talk about the recent systematic reviews on the topic, and showed to need for evidence with larger sample sizes. They also discussed the need to compare treadmill training to overground walking.

60 60 Describe the justification of the need for this study Does the research design have strong internal validity? Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression Assignment: The patients were randomly assigned to either the treatment group or the overground group. No statistically significant difference between the groups were found. Attrition: 3 children dropped out of the study due to respiratory problems and administrating of botulinum toxin in LE. History: This study had a control (overground walking group). Instrumentation: I feel the right measurement tools were selected for this study. The person conducting the test was also blinded as to what treatment the child was receiving. Maturation: There was a control group and the children all did the intervention at the same time. Testing: The participants were randomized into the groups. However, a baseline test was given for both groups. Compensatory Equalization of treatments: The researchers were not blinded to which treatment the child was receiving. They did seem to have pretty strict protocols, but it was impossible to determine the overground participants walking speed. Compensatory rivalry: This was not really addressed in the article. Statistical Regression: The results were reported with SD. No report of outliers being dropped.

61 61 Are the results of this therapeutic trial valid? 57. Did the investigators randomly assign subjects to treatment groups? a. If no, describe what was done b. What are the potential consequences of this assignment process for the study s results? 58. Did the investigators know who was being assigned to which group prior to the allocation? a. If they were not blind, what are the potential consequences of this knowledge for the study s results? 59. Were the groups similar at the start of the trial? Did they report the demographics of the study groups? a. If they were not similar what differences existed? b. Do you consider these differences a threat to the research validity? How might the differences between groups affect the results of the study? 60. Did the subjects know to which treatment group they were assign? a. If yes, what are the potential consequences of the subjects knowledge for this study s results Yes, participants were randomly distributed into an experimental group and overground walking group. Randomization was performed at a central office using a randomization table. The group sample sizes are still on the smaller side which runs the risk of a type 2 error. The participants were randomly assigned through a central office. But the researchers were not blinded to the treatment the participants were receiving. Yes, the groups were similar at the beginning of the trial and no statistical differences were found between the groups at the start of the clinical. o The treatment group had more females, but I do not think this would interfere with the validity of the study. The subjects did know what treatment they were receiving. This could skew the results. A participant might work harder because they know they are in the treatment group, or a participant might feel cheated and not work as hard because they are not in the intervention group.

62 Did the investigators know to which treatment group subjects were assigned? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 62. Were the groups managed equally, apart from the actual experimental treatment? a. If not, what are the potential consequences of this knowledge for the study s results? 63. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research? a. If not, what are the potential consequences of this knowledge for the study s results? 64. Did all the subjects originally enrolled complete the study? a. If not how many subjects were lost? b. What, if anything, did the authors do about this attrition? c. What are the implications of the attrition and the way it was handled with respect to the study s findings? 65. Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)? a. If not, what did the authors do with the data from these subjects? b. If the data were excluded, what are the potential consequences for this study s results? Yes, the investigators knew which treatment each participant was receiving. This could also skew their results because they could push one group more than the other. Although, they tried to use a strict protocol, the speed of the overground walking could not be determined during treatment sessions. I think they were. Both groups essentially had the same protocol, except one was on the treadmill and one was on the ground. Yes, I think there was adequate followup No not every participant completed the study o 3 were lost o The authors did not do anything about the attrition. o It is unclear what they did with their data. There was an intention to treat analysis. o I am unsure what the researchers did with the data of the 3 subjects they lost. They obviously couldn t use their data in the results because they did not complete the ending tests. This could potentially skew their data.

63 63 Are the valid results of this RCT important? 66. What were the statistical findings of this study? a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences With p-values and CI c. Include effect size with p- values and CI d. Include ARR/ABI and RRR/RBI with p-values and CI e. Include NNT and CI f. Other stats should be included here Both the treadmill group and the control group significantly improved in the: 6 Minute Walk Test: o Experiment group from SD 49.4 to SD 93.0 o Overground group from SD 42.6 to SD 45.0 Timed Up and Go: o Experiment group from: 14.3 SD 2.9 to SD 2.2 o Overground group from: 12.8 SD 2.2 to 10.5 SD 2.5 Pediatric Evaluation Disability Inventory o Experiment group from: SD 19.9 to SD 18.4 o Overground group from: SD 19.0 to SD 12.2 Gross Motor Function-Measure 88: o Experiment group from: 81.6 SD 8.7 to 93.0 SD 5.7 o Overground group from: 77.3 SD 7.0 to 80.8 SD 7.2 Berg Balance Test: o Experiment group from: 34.9 SD 8.5 to 46.7 SD 7.6 o Overground group from: 31.9 SD 7.0 to SD 6.8 TT group showed greater improvement compared to overground group both after treatment and during follow-up (p<0.05)

64 What is the meaning of these statistical findings for your patient/client s case? What does this mean to your practice? 68. Do these findings exceed a minimally important difference? Was this brought up or discussed? a. If the MCID was not met, will you still use this evidence? No RAW data was given in the article TT training may be more effective at increasing my patients walking endurance, gait speed, balance, and gross motor development compared to overground training. Yes these finding exceed minimally importance differences. This was not directly said in the article but was hinted at. Can you apply this valid, important evidence about an intervention in caring for your patient/client? What is the external validity? 69. Does this intervention sound appropriate for use (available, affordable) in your clinical setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 70. Are the study subjects similar to your patient/ client? a. If not, how different? Can you use this intervention in spite of the differences? 71. Do the potential benefits outweigh the potential risks using this intervention with your patient/client? 72. Does the intervention fit within your patient/client s stated values or expectations? a. If not, what will you do now? This intervention does sound appropriate. The facility has a treadmill and I have the skill level to perform the treatment. Yes he is for the most part. My patient is in the age range and has a diagnosis of CP. However, he has unspecified CP and is on the younger side of the age range. In addition, one of the exclusion criteria was visual impairment, which is something my patient has. I do not think this will affect the results of treadmill training, because it will be a pre and post measure. Yes, this treatment seems to be low risk and potentially high reward. Yes my patient really enjoys walking on the treadmill. 73. Are there any threats to external validity in this study? Yes, the sample size is on the lower end, but they exceeded to the calculated participants to meet the effect size. There was also little

65 65 standardization on the control group s walking speed, which may affect the external validity. However, I think overall this is a well put together study and has generalizable. What is the bottom line? PEDRO score (see scoring at end of form) 7 Summarize your findings and relate this back to clinical significance TT training may be more effective at increasing my patients walking endurance, gait speed, balance, and gross motor development compared to overground training.

66 66 Intervention Evidence Appraisal Worksheet Citation (APA format): 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), Level of Evidence (Oxford scale): 2b Is the purpose and background information sufficient? Study Purpose Stated clearly? Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Yes, 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. Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Yes, the researchers presented a relatively thorough review of the current research and the current gap which need to be further examined, including the fact that there are not any studies looking at the effects of treadmill without body weight support for adults with CP. Describe the justification of the need for this study

67 67 Does the research design have strong internal validity? Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression Assignment: 21 participants 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. Attrition: The researchers did not report any attrition. History: All the individuals participated in the study during the same time period. There was also a control group, although the control group was half the size. Instrumentation: This was difficult to understand in the article. I do agree with the use of the 6 minute walk test and the O2 consumption, however, I think they needed to spend more time explaining the outcome measures. Maturation: There was a control group and the individuals all did the intervention at the same time. Testing: The participants were randomized into the groups. However, the control group was half the size of the treatment group. Compensatory Equalization of treatments: The researchers were not blinded to which treatment the child was receiving. Compensatory rivalry: This was not really addressed in the article. If participants did find out what group they were in, this might skew the results. Statistical Regression: The results were reported with SD. No report of outliers being dropped.

68 68 Are the results of this therapeutic trial valid? 74. Did the investigators randomly assign subjects to treatment groups? a. If no, describe what was done b. What are the potential consequences of this assignment process for the study s results? 77. Did the investigators know who was being assigned to which group prior to the allocation? a. If they were not blind, what are the potential consequences of this knowledge for the study s results? 78. Were the groups similar at the start of the trial? Did they report the demographics of the study groups? a. If they were not similar what differences existed? b. Do you consider these differences a threat to the research validity? How might the differences between groups affect the results of the study? 79. Did the subjects know to which treatment group they were assign? a. If yes, what are the potential consequences of the subjects knowledge for this study s results participants 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. 76. The group sample sizes are still on the smaller side which runs the risk of a type 2 error. In addition because the control group was ½ the size of the experiment group, this could skew their results and cause a type 1 error. The participants were randomly assigned using a central telephone randomization service. Yes, the groups were similar at the beginning of the trial and no statistical differences were found in age, sex, height, weight, body mass index, systolic blood pressure, or diastolic pressure between the groups at the start of the clinical. The subjects were randomly allocated, but there was no concealment once they were in their group. Although it is unlikely they were told specifically they were in the experiment or control group. If they did find out which group they were in, it could skew their results. A participant in the control group may feel cheated and not work as hard. A participant knowing they are in the experiment group may work harder (be more motivated).

69 Did the investigators know to which treatment group subjects were assigned? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 81. Were the groups managed equally, apart from the actual experimental treatment? a. If not, what are the potential consequences of this knowledge for the study s results? 82. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research? a. If not, what are the potential consequences of this knowledge for the study s results? 83. Did all the subjects originally enrolled complete the study? a. If not how many subjects were lost? b. What, if anything, did the authors do about this attrition? c. What are the implications of the attrition and the way it was handled with respect to the study s findings? 84. Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)? a. If not, what did the authors do with the data from these subjects? b. If the data were excluded, what are the potential consequences for this study s results? Yes, the investigators knew which treatment each participant was receiving. This could also skew their results because they could push one group more than the other. There also did not seem to be much a protocol for the control group. The groups received the same amount of treatment time. However, the protocol for the treadmill group was fairly strict for all of the group, whereas the control group protocol was not well outlined. This could skew their results because the therapist in the control group may have not pushed them as hard as they could go (because it is less objective compared to the treadmill). There was absolutely no follow-up for this study. Because of this, it is impossible to know if the results had any lasting effects. The researchers did not report any attrition. This makes me think all 21 participants completed the study. All the participants were analyzed in the groups to which they were assigned. The study did not have any attrition so all participants data was analyzed.

70 70 Are the valid results of this RCT important? 85. What were the statistical findings of this study? a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences With p-values and CI c. Include effect size with p- values and CI d. Include ARR/ABI and RRR/RBI with p-values and CI e. Include NNT and CI f. Other stats should be included here 86. What is the meaning of these statistical findings for your patient/client s case? What does this mean to your practice? 87. Do these findings exceed a minimally important difference? Was this brought up or discussed? a. If the MCID was not met, will you still use this evidence? 6 Minute Walk test: o Treadmill Group Gait significantly increased from ±91.79 to ± Gait velocity significantly increased from ± to ± o Control No significant change was seen KB1-C Oximeter: o Overground walking O2 cost significantly improved from 0.56 ± 0.36 to 41 ± 0.18 ml/kg(m) O2 rate did not significantly improve after treadmill walking. o Control No significant changes were seen No raw values were reported in this article My student is a lot younger than the participants in the study. The mean age of the participants is around 28 and my student is almost 4. I do not think he could tolerate the assigned protocol. However, I think he could benefit from a modified version and hopefully achieve similar results. Yes these finding exceed minimally importance differences. This was not directly said in the article but was hinted at.

71 71 Can you apply this valid, important evidence about an intervention in caring for your patient/client? What is the external validity? 88. Does this intervention sound appropriate for use (available, affordable) in your clinical setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 89. Are the study subjects similar to your patient/ client? a. If not, how different? Can you use this intervention in spite of the differences? 90. Do the potential benefits outweigh the potential risks using this intervention with your patient/client? 91. Does the intervention fit within your patient/client s stated values or expectations? a. If not, what will you do now? I do think the time commitment might not be appropriate for the school setting for a young child. I was able to see my student for 2 hours a week, but that was pushing my limits. The therapist s caseloads are just too large to commit 3 hours a week for 12 weeks to one child, in the school setting. I also do not think the oximeter is a very assessable tool in the school setting. My student is a lot younger than the adult participants in the study. Although he has some key differences, I do believe he could benefit from a similar program. Yes, this treatment seems to be low risk and potentially high reward. Yes my patient really enjoys walking on the treadmill. 92. Are there any threats to external validity in this study? Yes, the sample size is on the lower end. In addition, the control group was ½ size of the treatment group which could potentially skew the results. What is the bottom line? PEDRO score (see scoring at end of form) 6 Summarize your findings and relate this back to clinical significance This study indicates treadmill exercise may improve the gait efficiency by decreased energy expenditure during

72 overground walking for adults with cerebral palsy, allowing adults to walk further before fatiguing. 72

73 73 Intervention Evidence Appraisal Worksheet Citation (use AMA or APA format): 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 scale): 2b Is the purpose and background information sufficient? Study Purpose Stated clearly? Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. Yes, the researchers conducted this study to determine if an intensive, 4 week treadmill program helps children with CP younger than 4 in their gross motor development, their walking speed and endurance, and the amount of assistance they require. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Yes, the researchers presented a relatively thorough review of the current research and the current gap which need to be further examined. Describe the justification of the need for this study

74 74 Does the research design have strong internal validity? Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression Assignment: There were only 6 children and they all received the same intervention (pre and post tested). Attrition: 5 of the 6 children completed all 12 training sessions and 1 child completed 10 sessions (missed 2 due to respiratory illness). History: All the children participated in the study during the same time period. However, there was no control group in the study. Instrumentation: I feel the right measurement tools were selected for this study. I am impressed they chose to use the GMFM-66, which provides a lot more detail of the difficulty of the task compared to the GMFM-88. Maturation: The participants all performed the intervention at the same time. However, there was no control group. Testing: The participants all received the same treatment (pre and post-test). Compensatory Equalization of treatments: The researchers were not blinded to which treatment the child was receiving, because all the children were receiving the same one. They did seem to have a decently strict protocols, and the intervention was performed by the same people for all the children. Compensatory rivalry: Not really relevant because all the children received the same treatment. Statistical Regression: The results were reported with SD. No report of outliers being dropped.

75 75 Are the results of this therapeutic trial valid? 93. Did the investigators randomly assign subjects to treatment groups? a. If no, describe what was done b. What are the potential consequences of this assignment process for the study s results? 94. Did the investigators know who was being assigned to which group prior to the allocation? a. If they were not blind, what are the potential consequences of this knowledge for the study s results? 95. Were the groups similar at the start of the trial? Did they report the demographics of the study groups? a. If they were not similar what differences existed? b. Do you consider these differences a threat to the research validity? How might the differences between groups affect the results of the study? 96. Did the subjects know to which treatment group they were assign? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 97. Did the investigators know to which treatment group subjects were assigned? No all the children received the same intervention. The group sample sizes are very small which runs the risk of a type 2 error. No all the children received the same intervention. The group sample sizes are very small which runs the risk of a type 2 error. There was only one group and the individuals were all under the age of 4. The individuals varied greatly in the specific CP diagnosis and their ability level. o I do think it jeopardizes the research validity, even though a pre and post- test were done on each individual, because one child could have the potential to improve more on their tests because they started lower. Yes all the individuals received the same treatment intervention. I don t think there is any consequences of them knowing their treatment because there was no other group. Yes all the individuals received the same treatment intervention. I don t think there is any consequences of them

76 76 a. If yes, what are the potential consequences of the subjects knowledge for this study s results 98. Were the groups managed equally, apart from the actual experimental treatment? a. If not, what are the potential consequences of this knowledge for the study s results? 99. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research? a. If not, what are the potential consequences of this knowledge for the study s results? 100. Did all the subjects originally enrolled complete the study? a. If not how many subjects were lost? b. What, if anything, did the authors do about this attrition? c. What are the implications of the attrition and the way it was handled with respect to the study s findings? 101. Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)? a. If not, what did the authors do with the data from these subjects? b. If the data were excluded, what are the potential consequences for this study s results? Are the valid results of this RCT important? knowing their treatment because there was no other group. There was only one group but all the participants seemed to be managed the same. The follow up time was 1 month, which I the same amount of time the children performed the treatment for. I think this is an adequate amount of time for follow-up. o 5 of the 6 children completed all the training sessions. o The 6 th child missed 2 of the 12 training sessions due to a respiratory illness. All the participants performed the pre and post-tests, including the child who missed two treatment sessions What were the statistical findings of this study? Gross Motor Function-Measure 66:

77 77 a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences With p-values and CI c. Include effect size with p- values and CI d. Include ARR/ABI and RRR/RBI with p-values and CI e. Include NNT and CI f. Other stats should be included here o Showed statistical difference in dimensions C (p=0.05), D (p=0.007) and E (p=0.01) in the primary analysis. o Post hoc analysis showed significant difference between pre-intervention and post intervention in dimensions D and E and after 4 week followup. (Indicating children improved in their standing and walking abilities). Pediatric Evaluation Disability Inventory o Statistical difference was found in: Functional Skills Mobility Scale (p=0.022) Caregiver Assistance Mobility Scale (p=0.018) o No statistical difference found in: Caregiver Assistance Self-Help Scale o Post hoc results Functional Skills Mobility Scale: Significant difference between pre- and follow-up No significant difference between pre and post intervention. Caregiver Assistance Mobility Scale (p=0.018) Significant difference between pre- and post-intervention. Significant difference between preintervention and

78 78 1 month followup. Indicates children increased their independence in functional mobility and relied less on caregivers for assistance. 10 Meter Walk Test: o 3 out of 6 children were able to complete the test at preintervention o 4 out of 6 children were able to complete the test and postintervention o 6 out 6 children were able to complete the test at follow-up. o Statistically significant difference in primary analysis (p=0.011) o Post hoc test: No significant difference between pre and postintervention Significant difference between pre-intervention and follow-up. 6 Minute Walk Test: o 3 children could complete this test at pre-intervention. All 6 could complete the test at post intervention o Primary analysis: Significant difference (p=0.029) between preintervention and 1 month follow-up No significant difference between pre and postintervention. Treadmill Walk Test: o Primary analysis: Significant difference for distance walked (p=0.009) and walking speed (p=0.002)

79 What is the meaning of these statistical findings for your patient/client s case? What does this mean to your practice? 104. Do these findings exceed a minimally important difference? Was this brought up or discussed? a. If the MCID was not met, will you still use this evidence? o Post Hoc Significant difference in walking distance and walking speed between pre and post-intervention and between preintervention and followup. Standing Balance Test with 2 feet: o This could only be completed by 2 children. These children doubled their standing time between pre and postintervention and continued to make gains 1 month later. Some raw data included (about the above treadmill speed and distances). Tables not appropriate to fill out due to the lack of control group. I think my patient could really benefit from this type of intervention. However, I do not think a therapist in the school setting could devote 3 hours a weeks to one student. I also do not think his parents would devote this type of time to an intervention outside of the school setting. Yes these finding exceed minimally importance differences. This was not directly said in the article but was hinted at. Can you apply this valid, important evidence about an intervention in caring for your patient/client? What is the external validity? 105. Does this intervention sound appropriate for use (available, affordable) in your clinical setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? I do think the time commitment might not be appropriate for the school setting. I was able to see my student for 2 hours a week, but that was pushing my limits. The therapist s caseloads are just too large to commit 3 hours a week for 4 weeks to one child, in the school setting.

80 Are the study subjects similar to your patient/ client? a. If not, how different? Can you use this intervention in spite of the differences? 107. Do the potential benefits outweigh the potential risks using this intervention with your patient/client? 108. Does the intervention fit within your patient/client s stated values or expectations? a. If not, what will you do now? Yes he is. He meets all the studies eligibility requirements. Yes, this treatment seems to be low risk and potentially high reward. Yes my patient really enjoys walking on the treadmill Are there any threats to external validity in this study? Yes, the sample size is extremely low! In addition, the 6 individuals they used had different diagnoses of CP and were at extremely different levels. Although all the children were compared against themselves, I do think this still affects the external validity. What is the bottom line? PEDRO score (see scoring at end of form) 4 Summarize your findings and relate this back to clinical significance This study indicates that a high intensity treadmill training program for children with CP, below the age of 4, could increase their walking speed, walking distance, standing balance, and decrease their need of assistance in their functional mobility. In addition, these results seem to last even a month after treatment.

81 81 Intervention Evidence Appraisal Worksheet Citation (APA format): 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 scale): 1b Is the purpose and background information sufficient? Study Purpose Stated clearly? Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. Yes, the therapist wanted to describe the effect of treadmill training, without body weight support, on a child with diplegic CP s walking speed. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Literature Relevant background presented? A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic. Describe the justification of the need for this study Yes, the therapist presented a relatively thorough review of the current research and the current gap which need to be further examined, including the need to examine the effect of treadmill training without partial weight bearing for ambulatory children with CP.

82 82 Does the research design have strong internal validity? Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression This is a case study and therefore potential threats to internal validity are not addressed or applicable. Are the results of this therapeutic trial valid? 110. Did the investigators randomly assign subjects to treatment groups? a. If no, describe what was done b. What are the potential consequences of this assignment process for the study s results? 111. Did the investigators know who was being assigned to which group prior to the allocation? a. If they were not blind, what are the potential consequences of this knowledge for the study s results? 112. Were the groups similar at the start of the trial? Did they This is a case study. N/A N/A

83 83 report the demographics of the study groups? a. If they were not similar what differences existed? b. Do you consider these differences a threat to the research validity? How might the differences between groups affect the results of the study? 113. Did the subjects know to which treatment group they were assign? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 114. Did the investigators know to which treatment group subjects were assigned? a. If yes, what are the potential consequences of the subjects knowledge for this study s results 115. Were the groups managed equally, apart from the actual experimental treatment? a. If not, what are the potential consequences of this knowledge for the study s results? 116. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research? a. If not, what are the potential consequences of this knowledge for the study s results? 117. Did all the subjects originally enrolled complete the study? a. If not how many subjects were lost? b. What, if anything, did the authors do about this attrition? N/A N/A N/A Yes the child was assessed 3 weeks after her post test intervention as well. N/A

84 84 c. What are the implications of the attrition and the way it was handled with respect to the study s findings? 118. Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)? a. If not, what did the authors do with the data from these subjects? b. If the data were excluded, what are the potential consequences for this study s results? Are the valid results of this RCT important? N/A 119. What were the statistical findings of this study? a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences With p-values and CI c. Include effect size with p- values and CI d. Include ARR/ABI and RRR/RBI with p-values and CI e. Include NNT and CI f. Other stats should be included here 50 feet walking speed: o After 6 week treadmill training period, the student was able to decrease her 50 ft walking time, using her posterior walker from seconds to seconds. After 3 weeks no treadmill training she walked it in seconds. This was faster than the average walking speed of typical developing kindergarteners 13.5 seconds. 458 feet walking Speed: o After 6 week treadmill training period, the student was able to decrease her 458 ft walking time, using her posterior walker from 4 minutes 27 seconds to 2 minutes 55 seconds. Her average speed after the 3 week follow-up was 3 minutes 1 second. GMFM-88 (pre and post-test) o Sitting increased 2% o Crawling and kneeling increased 9% o Standing increased 3%

85 What is the meaning of these statistical findings for your patient/client s case? What does this mean to your practice? 121. Do these findings exceed a minimally important difference? Was this brought up or discussed? a. If the MCID was not met, will you still use this evidence? o Lying/rolling & standing/walking did not increase The use of an adult treadmill to increase a child with CP s speed is a viable option and may double their current walking speed. My patient has nonspecified CP and he does not have spastisticy. However, he also walks with a posterior walker. I think my patient would really benefit from this intervention, and I think this protocol is almost doable in the school setting. I think a school therapist could manage 2, 30 minute sessions instead of 3 a week. Yes these finding exceed minimally importance differences. This little girl was able to start keeping up with her peers when walking in the classroom line. This greatly increased her ability to participate with the class. Can you apply this valid, important evidence about an intervention in caring for your patient/client? What is the external validity? 122. Does this intervention sound appropriate for use (available, affordable) in your clinical setting? Do you have the facilities, skill set, time, 3 rd party coverage to provide this treatment? 123. Are the study subjects similar to your patient/ client? a. If not, how different? Can you use this intervention in spite of the differences? 124. Do the potential benefits outweigh the potential risks using this intervention with your patient/client? 125. Does the intervention fit within your patient/client s stated values or expectations? Yes, the treadmill is very accessible. The school PT in this setting performed treadmill training for 30 minute sessions, 3 times a week. I think 2 times per week is more appropriate for the setting I am in. My student is very similar to the girl in the case study. However, he is a couple of years younger and he does not have spasticity. I do think he would benefit from the same intervention. Yes, this treatment seems to be low risk and potentially high reward. Yes my patient really enjoys walking on the treadmill.

86 86 a. If not, what will you do now? 126. Are there any threats to external validity in this study? Yes, this is a case study. It is therefore not necessarily generalizable without reservation. What is the bottom line? PEDRO score (see scoring at end of form) N/A Summarize your findings and relate this back to clinical significance 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 GMFM score. These results continued to be the case 3 weeks after the intervention.