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Treadmill Training
Evidence reviewed as of before
01-01-2021 Author(s): Ogourtsova, T. (PhD OT); Steven, E. (MSc App OT); Iliopoulos, G. (MSc App OT); Deleva, V. (MSc App OT) & Majnemer, A. (PhD, OT, FCAHS)Share this
intervention:
Treadmill training
Introduction
The development of independent and efficient walking is an important therapeutic goal for most children with cerebral palsy. Treadmill training is an intervention used to promote the attainment of that goal as well as to improve gross motor skills, such as standing, balance, and stair climbing. It is based on the principle of motor learning which suggests that practice, repetition and task-specific training are essential for improvement in activities such as walking in people with neurological disorders.
Treadmill training has been extensively studied in rehabilitation of adults with stroke or spinal cord injury. It commonly involves the use of a suspension system to provide support which is known as partial body weight support treadmill training (PBWSTT).
Treadmill training is an intervention aimed at the development of independent and efficient walking and improvement of walking speed and endurance in children with neuromotor disorders, such as cerebral palsy and Down syndrome. During partial body weight supported treadmill training (PBWSTT), the body weight of the child is supported by a suspension system (such as a harness attached to the ceiling or a rail) or by adult assistance (a therapist or parent). This support allows for an upright posture and for a reduced load on the lower limbs, and therefore decreased demand for muscle strength during walking.
If the child is unable to take steps on their own, their legs can be advanced with manual assistance (from the therapist/parent) or with robotic assistance. The amount of support provided is based on the child’s abilities and the therapeutic goals and can gradually be reduced as the training progresses. Other parameters of the training, such as the speed, the amount of assistance provided, and the session length, can also be modified with time.
PBWSTT is an intervention used to work on gait training and improving gross motor skills in children with cerebral palsy and other neuromotor disorders. Due to the body-weight support provided during training, the child feels safe which gives them the confidence and motivation to practice stepping and walking. Then, as the body-weight support is gradually decreased, the training provides the child with opportunities to develop better postural control, muscle strength, coordination of movements, endurance, and balance, in a safe and efficient way.
There aren’t different types of treadmill training. However, some of the elements of the training can vary. For example, it can be used with or without partial body-weight support (depending on the population it’s used for). There are also different ways the support is provided (different suspension systems), different types of assistance for moving the limbs during training (manual vs. robotic), etc.
Most research on the use of treadmill training has been carried out in children with Down syndrome or school-aged children with CP. There is limited evidence regarding the effectiveness of PBWSTT in children with CP under the age of 5. Only two recent studies on the use of treadmill training in this population are currently available.
The first high quality study showed no difference in the motor development of preterm infants at risk of having cerebral palsy who followed a home exercise program of kicking and stepping vs. no treatment. The study had a small sample size and the compliance with the home program was low which may have affected the results.
The results of the second lower quality study suggested that treadmill training combined with typical physiotherapy is more effective than physiotherapy alone in improving mobility in children (9 to 36 months of age) with cerebral palsy. There was no difference in walking speed or gross motor function between the two groups at the end of the study, however.
To sum up, PBWSTT is a task-specific approach with an emphasis on repetition and practice which may be showing some promise as an intervention for children with cerebral palsy. However, more rigorous research is needed to determine its effectiveness and develop clinical guidelines for its use.
Prior to starting a treadmill training program for your child, you can expect to have a session with a physiotherapist who would perform an initial assessment of your child to determine their abilities and develop an individualized program with specific goals. Most commonly, the training sessions would take place in a clinic due to the need for specialized equipment (treadmill, suspension systems) and/or manual assistance from trained staff. In some instances, home programs can also be possible following an initial training session of the parent/caregiver by the physiotherapist and the use of a portable treadmill (or a suspension system to be used over an existing treadmill).
Treadmill training is typically provided by physiotherapists in outpatient clinics. However, in some instances, parents or caregivers can conduct the sessions at home with supervision by a physiotherapist after an initial training session.
In the reviewed studies, the intervention was carried out by parents/caregivers using portable treadmills in the home environment, under the supervision of physiotherapists.
There is no specific protocol for the use of PBWSTT and the treatment period can vary. Research suggests that effective interventions are intensive and require a time commitment. In the reviewed studies, the training was carried out for a minimum of 5 and up to 20 min/day, 5-6 days/week, for at least 6 weeks.
Treadmill training is generally safe if performed correctly. No adverse side effects have been reported in children participating in PBWSTT. However, supervision is required at all times to avoid injury. A thorough assessment by a physiotherapist prior to the start of training is also essential in order to evaluate the child’s abilities and set realistic goals and to ensure the training is safe and effective. Finally, it’s also important to make sure that any shoes or orthotics required for walking are placed correctly to prevent blisters or pressure wounds.
PBWSTT is a task specific intervention which focuses on repetition and active participation of the child. In the reviewed studies, it was used in infants and young children with cerebral palsy or at risk of having cerebral palsy where the goal was to take advantage of neuroplasticity at that age (the young brain’s ability to adapt and learn).
The study showing an improvement in mobility after a treadmill training home program involved children with milder cerebral palsy (GMFCS levels I and II).
More studies are necessary to better understand who can most benefit from this intervention.
One high quality RCT (Campbell et al., 2012) investigated the effects of a home exercise program consisting of kicking + treadmill stepping on motor development among preterm infants with periventricular brain injury (38% later diagnosed with CP, GMFCS level II, IV, V). In this high quality RCT, infants were randomized to receive a home exercise program consisting of kicking + treadmill stepping or no treatment. Motor development was assessed using the Alberta Infant Motor Scale during treatment (age 4 months, 6 month, 10 months) and at post-treatment (12 months). No significant between-group differences were found at any time point.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a home exercise program of kicking and treadmill stepping is as effective as the comparison intervention (no treatment) in improving motor development in preterm infants with periventricular brain injury.
One poor quality quasi-RCT (Mattern-Baxter et al., 2013) investigated the effects of a home-based locomotor treadmill-training program on gross motor development among children with cerebral palsy (hypotonic/spastic; GMFCS level I-II). In this poor quality RCT, children were quasi-randomized to receive home-based locomotor treadmill training or typical physical therapy only. Gross motor development was assessed using the Gross Motor Function Measure-66 (GMFM-66 – dimension D & E) at post-treatment (6 weeks), and follow-up (1 month post-intervention and 4 months post-intervention). A significant between-group difference was found on the GMFM-66 (dimension D) at 1month follow-up, favoring home-based locomotor treadmill training program vs. typical physiotherapy.
Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that home-based locomotor treadmill training is as effective as the comparison intervention (typical physiotherapy only) in improving gross motor development in children with CP (hypotonic/spastc, GMFCS level I-II).
One poor quality quasi-RCT (Mattern-Baxter et al., 2013) investigated the effects of a home-based locomotor treadmill-training program on mobility among children with cerebral palsy (hypotonic/spastic; GMFCS level I-II). In this poor quality RCT, children were quasi-randomized to receive home-based locomotor treadmill training or typical physical therapy only. Mobility was assessed using the Functional Mobility Scale (FMS), the Peabody Developmental Motor Scale-2 (PDMS-2: Locomotion subscale), and the Pediatric Evaluation of Disability Inventory (PEDI: Mobility subscale) at post-treatment (6 weeks), and follow-up (1-month post-intervention and 4 months post-intervention). A significant between-group difference was found at post-treatment for FMS; at post-treatment and 1 month follow-up for PDMS-2: Locomotion subscale; and at all timepoints for PEDI: Mobility subscale, favoring home-based locomotor treadmill training program vs. typical physiotherapy.
Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that home-based locomotor treadmill training is more effective than a comparison intervention (typical physiotherapy only) in improving mobility in children with CP (hypotonic/spastic, GMFCS level I-II).
One poor quality quasi-RCT (Mattern-Baxter et al., 2013) investigated the effects of a home-based locomotor treadmill-training program on walking speed among children with cerebral palsy (hypotonic/spastic; GMFCS level I-II). In this poor quality RCT, children were quasi-randomized to receive home-based locomotor treadmill training or typical physical therapy only. Walking speed was assessed using the 10-minute walk test at post-treatment (6 weeks), and follow-up (1 month post-intervention and 4 months post-intervention). No significant between-group differences were found at any time point.
Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that home-based locomotor treadmill training is as effective as the comparison intervention (typical physiotherapy only) in improving walking speed in children with CP (hypotonic/spastic, GMFCS level I-II).
References
Campbell, S. K., Gaebler-Spira, D., Zawacki, L., Clark, A., Boynewicz, K., deRegnier, R. A., Kuroda, M. M., Bhat, R., Yu, J., Campise-Luther, R., Kale, D., Bulanda, M., & Zhou, X. J. (2012). Effects on motor development of kicking and stepping exercise in preterm infants with periventricular brain injury: a pilot study. Journal of pediatric rehabilitation medicine, 5(1), 15–27. https://doi.org/10.3233/PRM-2011-0185
Mattern-Baxter, K., McNeil, S., & Mansoor, J. K. (2013). Effects of home-based locomotor treadmill training on gross motor function in young children with cerebral palsy: a quasi-randomized controlled trial. Archives of physical medicine and rehabilitation, 94(11), 2061–2067. https://doi.org/10.1016/j.apmr.2013.05.012
A group of lifelong disorders affecting a person’s movement, coordination, and muscle tone and which are the result of damage to the brain before, during, or shortly after birth.
Gross Motor Functional Classification System. It is a tool used to categorize the gross motor skills of children with cerebral palsy into 5 different levels across 5 age bands. It evaluates the child’s abilities in sitting, walking and wheeled mobility as well as the type of assistive devices needed for mobility. The levels are assigned based on the severity of the limitations, ranging from mild (level I) to severe (level V).
