My seminar While Pursuing Master of Physiotherapy (MPT) at Manipal University

1. TREADMILL
TRAINING
IN RECENT
CHILDREN ADVANCES

2. Contents
 Treadmill training
 Need
 TMT for preterm
 TMT for CP
 TMT for SCI
 TMT for Downs
 TMT for cerebellar disorders
 Role of robotics
 Recent trend
 conclusion

3. The history of TMT-Begins
Barbeau H & Rossingnol S
1983-1986
Recovery of locomotion after chronic
spinalization in the adult cat
Brain Res 1987;412:84–95

4. Treadmill training
 Task specific
 Repetition training of whole gait cycle
 Reduces the impact of poor balance on
the child’s ability to maintain weight
bearing during walking
 Dynamic system approach for attainment
of locomotor skills in CP

5. SACKETT LEVEL OF EVIDENCE

6. PEDro Scale (Physiotherapy
Evidence Database)

7. Preterm infants
 Enter this world with a disadvantage
 Increases risk of neurodevelopmental
sequelae
 Attains walking ability at older ages
 Poorer quality of walking movement
Gait Posture 2008;27:340–346

8. Alternating steps
 Full-term infants produces coordinated,
alternating steps by 7 months of age in
treadmill
 preterm infants exhibited alternating steps
on a treadmill by 9 months of age
Early Hum Dev. 1994;39:211–223

9. Pre-term walking attainment
 Tung et al (2009) longitudinally examines
the supported stepping in preterm and
full-term infants and to explore the step
parameters associated with walking
attainment
Phys Ther. 2009;89:1215–1225

10. Study description
Characteristic Intervention Outcome Result
SS-29/20 children were GMF-AIMS
Pre-term - <37 supported
weeks under the arms 6 to 8 steps
Full-term - 38 to by an examiner during the 20-
42 weeks and stepped for second video
2 minutes at segments.
0.2 m/s on a
treadmill
7 months –
walking/18 mo
Phys Ther. 2009;89:1215–1225

11. Walking parameters

12. From the study
 Tung et al (2009) conclude that preterm
infants had an increased risk of late
walking attainment compared to their
fullterm counterparts
Phys Ther. 2009;89:1215–1225

13. TMT for cerebellar ataxia
 Locomotor training using BWS on a
treadmill in conjunction with overground
gait training may be an effective way to
improve ambulatory function in
individuals with severe cerebellar ataxia
Phys Ther. 2008;88:88–97

14. Case Description
Case Intervention outcome Result
• 13 yr old girl BWST-15 min Gillette 2-2-6
• Post.fossa H Overground Functional
• Cerebellar & walking BWS-15 Walking Scale
brainstem Inf to 20 min
• Ataxia BWS-30% - 10% Pediatric
• Weakness TM speed- Functional
• Decreased 0.18 m/s – 0.3 Independence 3-4-6
coordination m/s Measure
5 times / week (WeeFIM)
for 4 weeks
4 months No.of
unassisted steps 0-128-200

15. From this case report
 Locomotor training using BWST is a
promising intervention for improving gait in
patients with severe cerebellar ataxia who
are non-ambulatory
Phys Ther. 2008;88:88–97 LOE-4, PEDro-2

16. PBWSTT
 Special overhead structure supporting a
harness
 Encircles the trunk of the child
 Allows the child’s body weight to be partially
or fully supported to
 Facilitates a normal gait pattern while
stepping on a treadmill

17. TRAINING PARAMETERS
 Mean treadmill speed 0.23 m/sec - 0.34
m/sec
 Net walking time 12.8 min - 18.6 min
 BWS ranged from 20% to 40%
J Neurol Rehabil 2010;9:47-65

18. Duration of training
 2-3 sessions of treadmill training per week
 3-4 months of training
J Neurol Rehabil 2010;9:47-65

19. Traditional PT Vs PBWSTT
 An intensive episode of physical therapy
that includes partial body weight treadmill
training may be effective in improving
gross motor skills of children with spastic CP
 Statistically significant but not clinically
Pediatr Phys Ther 2007;19:11–19 LOE-4

20. Effects of PBSWTT
 Walking velocity
 Distance covered
 Endurance – clinical significance but not
statistically
 Balance – no significant difference

21. Effects of PBSWTT
 Lower extremity strength improves
 Functional improvements (standing,
transfers & rising)
 Physiologically sound gait pattern

22. Intensive locomotor TMT
A systematic review by Katrin Mattern-
Baxter showed that TMT training was
effective but had longer duration of 4
weeks & above
Pediatr Phys Ther. 2009;21:12–22
 No study compare the short term
intervention

23. Study description
Characteristic Intervention Outcomes Result
Inclusion 3 session/wk GMFM-66 item C (p=0.05)
criteria (1) a version D(p=0.007)
diagnosis of 4 wk E (p= 0.01)
cerebral palsy, PEDI P=0.018
(2) age of 1 to 12 TM session 6 min walk test P=0.029
5 years, (3) 10-Meter Walk
weight less Test P=0.011
than Treadmill Walk P=0.009
40 kg, (5)
parental
ability to
provide
transportation Pediatr Phys Ther 2009;21:308–319 LOE-4, PEDro-4

24. The result of the study says
 short-term intensive treadmill training
improves measures of gross motor
function, maximum and self-selected
walking speed, and walking distance in a
small sample of young children with CP
2.5 to 3.9 years of age
Pediatr Phys Ther 2009;21:308–319 LOE-4, PEDro-4

25. Quality of Life
 HRQOL directly relates b/w physical
impairment & physical well being
 Pediatric Quality of Life Inventory (PedsQL)
is used to evaluate HRQOL after PBWSTMT
 Assessed HRQOL after intense BWSTMT

26. PedsQL
 Three different age versions
- young children (5–7 years), children (8–12
years), and teen (13–18 years)
3 dimensions
- General fatigue - 0.90 0.60
- Sleep/rest fatigue - 0.83 0.82
- Cognitive fatigue - 0.92 0.65
Pediatr Phys Ther 2009;21:45–52 LOE-4, PEDro-4

27. HRQOL improves
 Clinically & statistical sig. decrease in post
mean scores of PedsQL except sleep/rest
fatigue
 Therapists must always consider the
impact of an intervention on the health,
well-being, and QOL of the client
Pediatr Phys Ther 2009;21:45–52 LOE-4, PEDro-4

28. PBWSTT vs overground walking
 PBWSTT was found to be no more effective
for improving walking speed, endurance,
and walking function at school than
practicing overground walking
Arch Phys Med Rehabil 2010;91:333-9 LOE-1B

29. Controversies
 This finding would appear to contrast with
findings from recently published systematic
reviews
Disabil Rehabil 2009;31:1971-9
Pediatric Neurorehabilitation 2009;33:27-44
 Which suggest that many PBWSTT programs
designed to improve walking in children with
CP

30. Reasons
 Poor quality
 Small sample sizes
 Lack of randomization, concealed
allocation, and blinded assessment
 Overestimation of their effect

31. TMT for Downs
 Down syndrome (DS) occurs approximately
1.36 times in every 1,000 live births
 Infants with Down syndrome (DS) are
consistently late walkers
Dev Med Child Neurol. 2009;51:453–462

32. Delayed motor skills
 Greater joint range of motion (ligamentous
Laxity)
 Delayed development of postural reactions
and myelination
 Low muscle tone all contribute to delayed
motor skills
Pediatr Clin North Am.1984;31:1331–1343

33. Reciprocal pattern
 Infants with DS can produce coordinated
alternating steps when supported under
their arms on a small motorized treadmill by
11 months of age
Dev Med Child Neurol. 1992;34:233–239

34. Milestones
GROSS MOTOR FUNCTION MONTHS
Sit without support 11
Pull up to standing position 17
Supported standing 20
Standing without support 24
walking 26
Arch Phys Med Rehabil. 2001;82:494–500

35. Treadmill speed
 0.15 m/s to 0.26 m/s for infants
 0.23 m/s to 0.34 m/s for children

36. On development
 Dale et al (2008) studied the effects of
individualized, progressively more intense
treadmill training on developmental
outcomes in infants with DS
Phys Ther. 2008;88:114–122

37. Study desciption
Characteristic Intervention Results
SS- 30 (16-HI & 14- Steps/min - 10-
LI ) ≤40
Age (mo) - Belt Speed
9.65±1.61 (m/s) – 0.15-0.3
Height (m) - Duration – 8-12
0.69±0.02 min
Weight (kg) - Ankle weight
8.49±1.05 (50%, 75%,
No significant 100%, and 125%)-
group HI
differences
Phys Ther. 2008;88:114–122 LOE-2B

38. Attain earlier milestones
 HI Treadmill training of infants with DS is an
excellent supplement to regularly
scheduled physical therapy intervention
for the purpose of reducing the delay in
the onset of walking
Phys Ther. 2008;88:114–122 LOE-2B, PEDro-3

39. Obstacle negotiation
 Dale et al (2008) along with Chad (2008)
Strategy used in obstacle negotiation by
studying the the percentage of the fall,
crawl, and walk strategies used by each
group
Exp Brain Res (2008) 186:261–272

41. Higher walk strategy
 HI group produced a significantly higher
percentage of walk strategy and a lower
percentage of crawl strategy than the LG
group
Exp Brain Res (2008) 186:261–272 LOE-2B, PEDro-4

42. Follow up – the gait cycle
 Dale et al (2008) extended his study along
with Rosa and Jianhua to find whether 2
treadmill interventions would have
different influences on the development
of joint kinematic patterns in infants with
DS – 1yr follow up study
Phys Ther. 2010;90:1265–1276

43. Phys Ther. 2010;90:1265–1276 LOE-2B

45. Inference from the study
 The timing of peak ankle plantar flexion
(before toe-off) in the HI group implies
further benefits from the HI intervention
 HI group may use mechanical energy
transfer better at the end of stance and
may show decreased hip muscle forces
and moments during walking

46. Joint kinematic pattern improves
 HI intervention can accelerate the
development of joint kinematic patterns
in infants with DS within 1 year after
walking onset
Phys Ther. 2010;90:1265–1276 LOE-2B, PEDro-3

47. TMT in SCI
 Treadmill helps in practice stepping
 Believed to trigger and enhance intrinsic
plasticity of the spinal cord central pattern
generators for locomotion
 Helps in neurotrophin expression serve as
inherent potential for neural circuit
reorganization
J Appl Physiol. 2004;96:1954–1960

48. Why not in children?
 Intense locomotor training after
incomplete spinal cord injury (SCI) have
been described in adults with acute and
chronic injuries and with various levels of
ambulatory function
 Laura et al & Robert et al explains about
motor improvement & neuroplasticity in
Children with SCI

49. Case description
Case Examination Intervention Outcome Result
measures
Age- ASIA-B (5D) 60-90 min ASIA UE-8/50 to
5yr10mo LEMS score- 3–5 d/wk WeeFIM II 31/50
GCS-13/15 4/50 20–30 min WISCI II LE-4/50 to
C4 level UEMS score- 6 month Mobility in 29/50
ASIA-A 8/50 BWS-80%- home, WeeFIM II
ASIA-C 10% school, and 5/35 to 21/35
(1mo) community in mobility
and from
8/54 to 34/54
in
self-care
WISCI-II – 0
to 12
Phys Ther. 2007;87:1224–1232 LOE-4

51. Activity-dependent plasticity
 Activity-dependent plasticity within spinal
circuitry may play a role in behavioral
response to training
 Supraspinal changes in response to
locomotor training
Phys Ther. 2007;87:1224–1232 LOE-4

52. Neuroplasticity in child ?
 Clinical literature does not indicate how
neuroplasticity in the young central
nervous system might be exploited by
newer rehabilitation strategies
 Treadmill and over-ground settings – a
case report by Robert et al

53. Case description
case Examination Locomotor result
training
• Age-3.5 yrs MAS Step train-20 to Reciprocal,
• Bullet entered Clonus 30 min in BWSTMT Rhy.stepping P
at T3 and Reflexes 0.8-1.2 m/s
lodged near ROM of LE
C6–7 7.01-
• ASIA – A calculated gait
• 3 mo-IP ASIA- speed 10-20 min over
A to ASIA-C WISCI-II ground Train
• Non-Amb., Accelerometer
not ind. Std -step F 5 session/wk
• ASIA-LE – 4/50
76 sessions
Phys Ther. 2008;88:580–590 LOE-4

54. Conclusion
 Independet standing
with a rolling walker,
but he could not stand
without external
support or
independently move
from a sit-to-stand
position

55. Evidence - Neuroplasticity
 Cortico-brain-stem-spinalsystem
(mesencephalic locomotor), such as the
reticulospinal tract, could support voluntary
activation of the SPGL without recovery of
isolated voluntary leg movements
Phys Ther. 2008;88:580–590

56. Gait training orthosis
 The Lokomat –
Robotic gait-training
orthosis
 Developed by A G
Hocoma in 19__ at
Volketswil,
Switzerland

57. The Lokomat
 Lokomat was developed in late 90s to
help automate manual-assisted BWSTMT
 The device is an exoskeleton that
attaches to the outside of the subjects leg
 Assists the subjects as he/she ambulates in
TM

58. Lokomat (Pediatric Version)
 Provide assistance ranges from full passive
mode to complaint mode
 Recently a pediatric Lokomat version was
released to public that allows children
approx. 4-12 yrs of age to participate in
gait training

59. Role of Robotics
 Automated locomotor training can be
given by commercially-available DGO
Lokomat

60. DGO – A promising tool
 DGO Lokomat provides higher intensity
gait therapy to regain or improve walking
capacity
 Reduces more effort & more therapist
LOE-4

61. conclusion
Condition Level of Result
Evidence
Pre-term infant
Cerebral Palsy 1A
Downs syndrome 2B,2B,2B Facilitates early
walking
Cerebellar 4
disorder
SCI 4
Role of Robotics

62. Take home message-I
 Efficacy of treadmill training in
accelerating walking development in
Down syndrome has been well-
demonstrated
J Neurol Phys Ther. 2009 March ; 33(1): 27–44

63. Take home message-II
 Evidence supporting the efficacy or
effectiveness of BWSTT in pediatric
practice for improving gait impairments
and level of activity and participation in
those with cerebral palsy, spinal cord
injuries, and other central nervous system
disorders remains insufficient
J Neurol Phys Ther. 2009 March ; 33(1): 27–44