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Posted: Fri Dec 8th, 2006 05:03 pm |
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Pediatric Physical Therapy: Volume 17(1) Spring 2005 pp 77-78
PARTIAL WEIGHT BEARING TREADMILL TRAINING IN THE HOME WITH YOUNG CHILDREN WITH CEREBRAL PALSY: A STUDY OF FEASIBILITY AND MOTOR OUTCOMES.
[Section Information: Abstracts of Platform and Poster Presentations for the 2005 Combined Sections Meeting: Poster Presentations]
Dannemiller, L; Heriza, C; Burtner, P; Gutierrez, T
Rocky Mountain University of Health Professions, Provo, UT, USA (Dannemiller)
Physical Therapy Program, University of Colorado Health Sciences Center, Denver, CO, USA (Heriza)
Occupational Therapy Program, University of New Mexico School of Medicine, Albuquerque, NM, USA (Burtner)
Physical Therapy Department, Mary Bridge Children's Health Center, Tacoma, WA, USA (Gutierrez)
PURPOSE/HYPOTHESIS: The purpose of this study was to document feasibility, and motor and participation outcomes for young children with cerebral palsy (CP) who received parent-administered partial weight bearing treadmill training (PWBTT).
NUMBER OF SUBJECTS: Three nonambulatory children under the age of 3, participated in this single-subject, multiple baseline study. All children had quadriplegic CP, one was Level III and 2 were Level IV on the Gross Motor Function Classification System (GMFCS).
MATERIALS/METHODS: Parents were trained to administer PWBTT 5 days/wk for 8min/day. Participants received 2, 3, or 4 months of PWBTT. Study duration was 6 months including baseline phase, intervention phase, and follow-up probe. Measured outcomes included: 1) % alternating and parallel steps, 2) Supported Walker Ambulation Performance Scale (SWAPS) scores, 3) the Gross Motor Function Measure (88 and 66) scores, and 4) a participation questionnaire.
RESULTS: Parents of the 3 participants averaged 92.3% of the expected minutes of treadmill training. One child had significant changes in alternating and parallel steps on the treadmill and a significant increase in SWAPS scores. All participants made greater changes on GMFM-88 scores for a 6-month period, compared to published data for children of similar ages and GMFCS levels. One participant made greater change on the GMFM-66, compared to published data for children of a similar age and GMFCS level. Two of the 3 families reported a moderate change in their child's participation in their family and community.
CONCLUSIONS: Although outcomes varied for the individual children, parent-administered PWBTT may be a feasible intervention to promote improvements in motor outcomes for children with quadriplegic cerebral palsy.
CLINICAL RELEVANCE: This study may contribute to the body of literature for clinical decision-making about the use of PWBTT with young children with CP. Parents were able to carry out a prescribed PWBTT program. A treadmill speed of 0.6 to 1.0mph, body weight support of 10-40%, frequency of 8 min/day, 5 days/wk and 2 mo duration were appropriate for the population of children in this study. The child who benefited the most from the PWBTT intervention in this study had mild spasticity, a preferred mobility pattern of supported walking, and parents who made detailed observations about the intervention they were performing.
Pediatric Physical Therapy: Volume 17(1) Spring 2005 p 73
EFFECT OF AN INTENSIVE PHYSICAL THERAPY PROGRAM WITH PARTIAL BODY WEIGHT TREADMILL TRAINING ON A 2 YEAR-OLD CHILD WITH SPASTIC QUADRIPLEGIC CEREBRAL PALSY
[Section Information: Abstracts of Platform and Poster Presentations for the 2005 Combined Sections Meeting: Poster Presentations]
Begnoche, D; Sanders, E; Pitetti, K H.
Heartspring, Wichita, KS, USA (Begnoche, Sanders)
Physical Therapy, Wichita State University, Wichita, KS, USA (Pitetti)
PURPOSE/HYPOTHESIS: To examine the effects of an intensive physical therapy program using traditional treatment methods with partial body weight treadmill training (PBWTT) on functional motor capacity and ambulatory skills of a 2 year-old child with spastic quadriplegic cerebral palsy (CP).
NUMBER OF SUBJECTS: Participant was a female child (2.3 yrs) with spastic quadriplegic CP, GMFCS Level IV, subsequent to premature birth at 29.5 weeks gestation with complication of periventricular leukomalacia.
MATERIALS/METHODS: Intensive physical therapy consisted of 4 sessions per week for 4 weeks, two hours per session, for a total of 16 sessions, including traditional PT (e.g. neurodevelopmental treatment, myofascial release, stretching, gait training) combined with PBWTT. Child's body weight was partially supported by a harness attached to an overhead structure to allow facilitation of gait pattern while stepping over a treadmill. PBWTT consisted of three, 5-minute bouts at 0.4 to 0.5 mph, followed by manually facilitated gait training in walker wearing Theratogs and DAFO's. The Gross Motor Function Measure (GMFM), Pediatric Evaluation of Disability Inventory (PEDI), Timed 10-Meter Walk Test, and Doc-U-Prints pedographs were completed within 3 days of treatment.
RESULTS: GMFM scores improved in the following dimensions: lying & rolling (76% to 84%); sitting (35% to 42%); crawling & kneeling (10% to 14%); walking, running, & jumping (2% to 4%); standing scores were unchanged. Total score improved from 25% to 29%. PEDI standard scores improved in two functional skills domains: self-care (27.7 to 31.2), social function (48.4 to 63.3). Mobility standard scores remained below 10, however, scaled score improved (25 to 32). PEDI score improved in caregiver assistance domain: self-care (21.8 to 34.5); standard scores in mobility and social function showed minimal improvement, however, scaled scores increased in mobility (11.7 to 20.3) and social (55.3 to 59.3) domains. Mean spatial gait parameters measured on Doc-U-Prints with walker and trunk assist improved: stride length, +4.5 in; step length, +1.9 in; base of support, +4.1 in (negative to positive). Average time on Timed 10-M Walk Test decreased by 25 seconds.
CONCLUSIONS: Results indicate that the 4-week intensive physical therapy program produced positive outcomes in functional motor performance and development of walking skills. Documented increases in base of support and stride length indicate improvement in scissoring pattern. Speed of assisted ambulation improved, however, post-test pedograph showed increased toe walking.
CLINICAL RELEVANCE: An intensive physical therapy program using traditional therapy and PBWTT may be effective in developing assisted walking in pre-ambulatory children with CP,GMFCS Level IV.
Pediatric Physical Therapy: Volume 17(1) Spring 2005 p 72
THE EFFECT OF BODY WEIGHT SUPPORT TREADMILL TRAINING ON GAIT FUNCTION IN CEREBRAL PALSY: TWO CASE STUDIES
[Section Information: Abstracts of Platform and Poster Presentations for the 2005 Combined Sections Meeting: Poster Presentations]
Beard, L M.; Harro, C; Bothner, K E.
OTC Pediatrics, Mary Free Bed Hospital & Rehabilitation Center, Grand Rapids, MI, USA (Beard)
Physical Therapy Department, Grand Valley State University, Allendale, MI, USA (Harro)
Motion Analysis Center, Mary Free Bed Hospital & Rehabilitation Center, Grand Rapids, MI, USA (Bothner)
BACKGROUND AND PURPOSE: Previous research provides evidence that Body Weight Support Treadmill Training (BWSTT) improves gait function in individuals with stroke or spinal cord injuries, however applicability and efficacy of BWSTT in children with cerebral palsy (CP) is lacking. The purpose of these case reports were to examine the effect of BWSTT, using systematic progression of treadmill speed and level of body weight support, on gait function in children with CP.
CASE DESCRIPTION: Two subjects, both 13 year old males with tetraplegic cerebral palsy, participated in 30 minutes of BWSTT, three times a week for nine weeks. Subject one ambulated using a reverse wheeled walker, but used his wheelchair as his primary means of mobility prior to this study. Subject two ambulated using a Rifton gait trainer for therapy and used his power wheelchair as his primary means of mobility. Within each training session, subjects completed three ten-minute BWSTT trails. Treadmill speed was started at child's overground walking speed with 30% BWS. A systematic progression of treadmill speed was based on the subject's ability to maintain a rhythmic gait pattern for 60 seconds following facilitation given by the primary researcher for weight shift and hip extension for several minutes. Pre- and post-intervention measures included a computerized gait analysis to determine spatiotemporal parameters and the Normalcy Index, using the Vicon 512 motion capture system. Additionally, the following tests of walking function were administered: the Energy Expenditure Index (EEI), the six-minute walk test, and the Gillette Functional Assessment Questionnaire (FAQ). During this study neither subject received any physical therapy services other than school-based therapy weekly.
OUTCOMES: Subject one demonstrated increased cadence, a 55.6% increase in overground walking speed (53.1 cm/s to 82.6 cm/sec), and increased walking endurance, as evidenced by a 48.2 ft. increase in the 6-minute walk test. Subject two also demonstrated gains in walking endurance with a 60.9 ft. increase in 6-minute walk test. No measurable changes were noted in NI. Changes in functional walking level (FAQ) were also reported for both subjects.
DISCUSSION: These two case reports provide support that BWSTT has the potential to improve gait function in children with CP. Improvements in these two subjects included improved walking speed, cadence and endurance. These are the first case studies in which advancement of treadmill speed was controlled by specific, measurable criteria and type of facilitation was operationally defined. Potential applicability and treatment parameters of BWSTT need to be carefully considered for use by clinicians who treat children with CP. These case studies demonstrated beneficial effects of BWSTT in two children with CP. Further research is needed examine treatment parameters and the long-term effects of BWSTT on gait function in children with CP.
© 2005 Lippincott Williams & Wilkins, Inc.
Pediatric Physical Therapy: Volume 18(1) Spring 2006 pp 104-105
BODY-WEIGHT SUPPORT TREADMILL STEPPING IN INFANTS WITH SPINA BIFIDA
[Abstracts: Abstracts of Platform and Poster Presentations for the 2006 Combined Sections Meeting: Poster Presentations]
Smith, Beth A.1; Moerchen, Victoria A.2; Ulrich, Beverly D.1
1Division of Kinesiology, University of Michigan, Ann Arbor, MI, USA (Smith, Ulrich)
2Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA (Moerchen)
Purpose/Hypothesis:
The goal of this study was to map the developmental trajectory of the stepping responses of babies born with spina bifida (SB) over the first postnatal year when in a body-weight supported treadmill (BWST) context. Depending on the lesion level, 20% (high lumbar lesion) to 90% (sacral lesion) of infants with SB learn to walk but at a mean age of 3 years (Backer, 2002; Swank & Dias, 1992). Adults with spinal cord injuries receive early and aggressive physical therapy; infants with SB typically start therapy 6-9 months after birth (14-17 months post lesion). This delay is likely due to the difficulty in identifying developmental delays earlier than 6 months of age and the lack of evidence for early intervention approaches with this population. Previous studies involving infants with Down syndrome show that BWST training leads to earlier walking (Ulrich et al., 2001). Before therapeutic interventions can be designed and tested we need to know if, how, and when infants with SB will step on the treadmill.
Number of Subjects:
11 Infants Born With Sb And 7 Infants With Typical Development (TD) Participated.
Materials/Methods:
Newborn stepping response (NSR) and treadmill responses (treadmill) were elicited at 1, 3, 6, 9, and 12 months. NSR trials consisted of infants being held under the arms in a semi-weightbearing position and moved forward slowly along a firm surface. During treadmill trials we also held infants under the arms in a semi-weightbearing posture for 2 20s trials in the following conditions: baseline (treadmill belt stationary), 0.08, 0.12, 0.16, 0.20, and 0.24 m/s. We collected the following data: video, joint position, EMG, & anthropometrics. For purposes of this presentation we will focus on stepping responses only.
Results:
Trained behavior coders watched videos (60Hz) and identified steps taken (alternating, single, parallel, double) during NSR and treadmill trials. Mean total number of NSR steps taken by infants with TD remained relatively constant at 4.5 across months (though SD reduced). For infants with SB, mean decreased from 4.5 to 2.5 across months (SD also reduced). Mean number of treadmill steps taken by infants with TD increased non-linearly from 90 steps at month 1 to 160 steps at month 12. Infants with SB showed a mean decrease from month 1 to 3 (60 to 40 steps), followed by a plateau before increasing between 9 and 12 months to 90 steps.
Conclusions:
Infants with SB showed a similar response to infants with TD during newborn stepping trials at month 1. Over time, infants with SB decreased stepping while infants with TD retained a low but more stable response. Infants with SB stepped less on the treadmill overall, compared to peers with TD. They also showed a period of minimal progress over the first 9 months. Nevertheless, infants with SB did respond to the BWST context over the first postnatal year, demonstrating the potential value for this as part of an intervention strategy.
Clinical Relevance:
Infants with SB demonstrate a delay as early as 3 months of age and BWST intervention has the potential to promote earlier onset of gait in this population.
Keywords:
spina bifida; infant stepping; treadmill
© 2006 Lippincott Williams & Wilkins, Inc.
Pediatric Physical Therapy: Volume 18(1) Spring 2006 pp 82-83
THE EFFECT OF BODY WEIGHT SUPPORTED TREADMILL TRAINING ON GAIT FUNCTION IN CHILDREN WITH CEREBRAL PALSY
[Abstracts: Abstracts of Platform and Poster Presentations for the 2006 Combined Sections Meeting: Poster Presentations]
Accivatti, Cara1; Harro, Cathy C.2; Bothner, Krisanne E.3
1Mary Free Bed Guild Pediatric Physical Therapy Fellow, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, USA (Accivatti)
2Department of Physical Therapy, Grand Valley State University, Grand Rapids, MI, USA (Harro)
3Motion Analysis Center, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, USA (Bothner)
Purpose/Hypothesis:
Research has demonstrated that Body Weight Supported Treadmill Training (BWSTT) is a feasible treatment environment for children with cerebral palsy (CP) and may be beneficial for improving ambulation skills. The purpose of this study was to examine the effects of BWSTT using a systematic progression of treadmill speed and level of body weight support (BWS) on gait function in children with cerebral palsy. The researchers hypothesized that subjects would improve in gait function following intensive BWSTT.
Number of Subjects:
Six subjects with CP, four with spastic diplegia and two with spastic tetraplegia, ages 7 to 11 years, participated in this study. All subjects were classified as limited community ambulators, four used assistive devices and four used orthotics for walking.
Materials/Methods:
Subjects were assessed before and after an eight-week control period during which they received only school physical therapy services. Following the control period subjects participated in eight weeks of BWSTT, three times per week. During training, facilitation was provided for weight shift and hip extension. Subjects completed three 10-minute bouts of BWSTT each session. A systematic progression of treadmill speed was used during the intervention, with advancement of speed based on ability to maintain a rhythmic gait pattern for 60 seconds following facilitation for several minutes. Level of BWS began at 30% and was decreased in 5% increments when subjects reached a speed of 0.8 m/s (1.7 mph). Pre- and post-training dependent measures included a computerized gait analysis to determine spatiotemporal parameters, the Normalcy Index, the Energy Expenditure Index, the six-minute walk test, and the Gillette Functional Assessment Questionnaire.
Results:
All subjects completed 8 weeks of training and progressed in treadmill speed. Four subjects decreased BWS during intervention (5-30%). No significant changes were found in dependent measures during control period, supporting a stable baseline. Paired t test (P < 0.01) revealed no significant group differences between pre-and post-training gait measures. However, some individual subjects did show isolated gains in gait measures following BWSTT. There was high variability between subjects in response to BWSTT.
Conclusions:
This study demonstrated methodology for progression of BWSTT parameters in children with CP where advancement of treadmill speed and decrease of BWS were controlled by specific, measurable criteria. Due to the small sample and high inter-subject variability, no significant changes in gait measures were evident for this sample.
Clinical Relevance:
Children in this study tolerated intensive BWSTT and were able to progress in treadmill speed and level of BWS. Effectiveness of BWSTT on the subjects' gait function was variable. Further research is needed to examine this systematic application of BWSTT to determine which children with CP are ideal candidates, in terms of level of severity a
CONDITIONING EFFECTS OF PARTIAL BODY WEIGHT SUPPORT TREADMILL TRAINING IN CHILDREN WITH CEREBRAL PALSY
[Section Information: Abstracts of Platform and Poster Presentations for the 2005 Combined Sections Meeting: Poster Presentations]
DeJong, S L.; Stuberg, W A.; Spady, K L.
Motion Analysis Lab and Dept. of Physical Therapy, Munroe-Meyer Institute, University of Nebraska Medical Center, Omaha, NE, USA
PURPOSE/HYPOTHESIS: This study evaluated the effects of a treadmill training program with partial body weight support (PBWS) to improve walking endurance in children with cerebral palsy (CP).
NUMBER OF SUBJECTS: This study included six children (4 males, 2 females) with a mean age of 10.2 (sd 4.3) years. Diagnoses included spastic diplegia (4), spastic hemiplegia (1) and athetoid quadriplegia (1). All subjects could walk at the start of the study, two with walkers, two with forearm crutches and two with no device. Four wore orthoses. Four were classified as Level 3 on the Gross Motor Function Classification System, one as Level 2, and one as Level 1.
MATERIALS/METHODS: Subjects walked on a treadmill using a Biodex Unweighing System for 20 minutes, three times per week for 12 weeks. PBWS of 40% of body weight was provided initially and weaned to 15% by the end of the study. Each session included a three minute warm-up and a 17 minute training phase. Speed was increased each minute, as tolerated. No physical assistance was provided. Heart rate (HR) was monitored continuously. Average HR during the training phase was calculated for each session. During the second week of training and during the last week, a graded treadmill exercise testing protocol was used to assess endurance. Computerized 3D gait analysis was also completed during over-ground walking, before and after the training. Outcome variables included over-ground walking speed, mean walking speed on the treadmill, and energy expenditure index [EEI = (HR walking-HR rest)/walking speed in m/min].
RESULTS: The subjects completed an average of 33.5 (sd 1.2) sessions over a period of 83 (sd 12.5) days. Average HR during the training phase ranged from 65% to 82% of estimated maximum HR (220 minus age in years). Pre vs post training comparisons revealed significant increases in over-ground walking velocity (41.8 (sd 20.6) m/min pre vs 45.9 (sd 19.1) m/min post, t = -2.14, P < 0.05). Mean treadmill walking speed increased significantly from a mean of 31.9 (sd 10.4) m/min during the second week of training to 43.8 (sd 12.9) m/min during the final week of training (t = 12.93, P < 0.02). The change in mean EEI scores was not significant with pre EEI of 1.91 (sd 0.92) beats/m vs post EEI score of 1.86 (sd 0.89) beats/m (t = 0.34, P = 0.38). Improvement in EEI scores was seen in four of the six children.
CONCLUSIONS: This study demonstrated an effective protocol using PBWS treadmill training to increase walking speed and endurance in children with CP. Although no significant change in EEI scores was noted, the sample size was small with a low level of power (P = 0.95).
CLINICAL RELEVANCE: Treadmill training with PWBS was found to be an effective intervention to improve cardiovascular endurance and walking speed in a cohort of children with CP. This gait training method provides a safe and controlled environment for children to perform continuous walking at a cardiovascular training intensity to improve their gait and fitness.
© 2005 Lippincott Williams & Wilkins, Inc.
nd age at treatment, and to examine immediate and long-term effects on gait function.
Pediatric Physical Therapy: Volume 16(2) Summer 2004 pp 106-113
Locomotor Training with Partial Body Weight Support on a Treadmill in a Nonambulatory Child with Spastic Tetraplegic Cerebral Palsy: A Case Report
[CASE REPORT]
Day, Jane A. PhD, PT; Fox, Emily J. MHS, PT; Lowe, Jodi DHSc, PT; Swales, Holly B. BS, PT; Behrman, Andrea L. PhD, PT
Department of Physical Therapy, College of Public Health and Health Professions, University of Florida (J.A.D., A.L.B.), Gainesville; Institute of Physical Therapy, University of St. Augustine for Health Sciences (E.J.F., J.L.), St. Augustine, Florida; and Shands Children's Hospital at the University of Florida (H.B.S.), Gainesville.
Address correspondence to: Jane A. Day, PhD, PT, Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, PO Box 100154, Gainesville, FL 32610-0154. Email: jday@phhp.ufl.edu
[size=Abstract TOP]
Purpose: Recent findings by neuroscientists serve as the basis for a new approach to training stepping after neurologic injury. The purpose of this case report was to describe the outcomes for one child with cerebral palsy after locomotor training.
Case Description: The child was a nine-year-old boy diagnosed with spastic tetraplegic cerebral palsy. He could not support his weight upright against gravity and had never experienced walking.
Methods: Forty-four sessions of locomotor training with partial body weight support (BWS) included static step practice, weight shifting, and walk training on a treadmill. The Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI) were administered prior to and immediately after training.
Outcomes: The child demonstrated improvements in all domains of the GMFM and both domains of the PEDI. He was able to complete up to 60 independent steps on the treadmill while supported in the BWS harness. Four months after training, he was able to walk over ground short distances with a rolling walker and minimal assistance.
Discussion: This case report is the first to report improvement in stepping on a treadmill with carryover to over-ground walking in a nonambulatory child of this age with spastic tetraplegic cerebral palsy.
INTRODUCTION [size=TOP]
Cerebral palsy (CP) is a congenital disorder resulting from a lesion in the immature brain. This nonprogressive condition affects five of every 2,000 newborns (births) in the United States and 5% of all premature infants. 1,2 CP may result in abnormalities in motor development; alterations in sensation, vision, and speech; and social and emotional problems. 3 Because children with CP reach developmental milestones later than children who develop normally, abnormal postural and movement patterns emerge as the child is forced to compensate to accomplish new activities. This further interferes with the child's motor development. 4
A common functional goal for children with CP is the attainment of walking. Children who are able to walk are more successful in social roles and the accomplishment of activities of daily living (ADL) than children who use a wheelchair. 5 Despite this, children with moderate to severe tetraplegia are frequently required to use a wheelchair for locomotion. 5,6
Traditional models of treatment for the movement disorders associated with CP are focused on the attainment of sequential developmental milestones and facilitation of normal movement patterns for the training of functional activities. The specific goals of standing and walking are part of an overall program that emphasizes postural alignment and quality of movement. Therapists provide facilitation and support during standing, weight shifting, and stepping, which are incorporated into the practice of walking. 3
Researchers investigating the neural control for mammalian locomotion have contributed to the recent advances in the retraining of gait in human subjects. Following complete severance of the lumbosacral spinal cord, adult cats that received locomotor training while treadmill walking with harness support regained the ability to independently step with their hindlimbs. 7-10 Trainers provided specific sensory cues to enhance motor performance during treadmill walking. These included placement or guidance of the limb or paws during swing and stance phases, limb loading to maximize extensor muscle activation, and facilitation of appropriate joint kinematics timed appropriately for each phase of gait. 10
Initially shown to be efficacious for retraining gait in persons following spinal cord injury, 11-15 locomotor training on the treadmill with body weight support (BWS) has proved to be beneficial for subjects with other neurological conditions such as cerebrovascular accident 16-18 and supranuclear palsy. 19 Based on the cat model, specific training procedures were used to provide sensory cues related to gait 15-17 and to facilitate the neural circuits to generate phasic efferent patterns for stepping. 12
Contemporary models of motor control and motor learning advocate a task-specific approach that emphasizes repetition and practice of the specific task. Demonstrating the activity-dependent plasticity of the mammalian lumbar spinal cord, spinalized cats that were trained to stand were successful at this task but were unable to step. Cats trained to step on a treadmill were able to perform this task but required assistance for standing. 20 Similar findings in hemiparetic adults demonstrated that standing balance training was effective for improved standing balance but did not necessarily lead to improved locomotor ability. 21
Recently, clinicians and researchers demonstrated that locomotor training on a treadmill with BWS is beneficial for children with CP. Children of varying ages and abilities have demonstrated improvements in ambulation, decreased reliance on assistive devices, and improved performance of ADL. 6,22 Partially unweighted by the harness system, the children were able to practice walking at a faster, more normal pace without the exertion that would be expected at a similar speed with over-ground ambulation. 23 With the child supported in the harness, trainers were able to manually guide the lower extremities for improved alignment and joint kinematics during the stance and swing phases of gait. Treadmill speed was increased and BWS decreased to emphasize limb loading as the child was able to support more weight and ambulate at a faster pace. 6,22
In a study of 10 children with CP, ages six to 18 years, six demonstrated improvements in walking. Three of the six children who were nonambulatory prior to training were able to achieve over-ground ambulation. One of these children was able to walk independently with verbal supervision, while the other two needed continuous assistance to support their weight and maintain balance. 6
Locomotor training using these described principles 6,12,15-17,22 in an environment that allows trainers to provide gait-specific sensory cues may provide children with spastic tetraplegic CP who have never ambulated the opportunity to achieve improvements in their upright and ambulation skills. The purpose of this case report is to describe locomotor training on a treadmill with BWS designed to provide a nonambulatory child with CP the guidance and sensory input for the achievement of treadmill and over-ground ambulation.
Case Description [size=TOP]
Child and History. TOP
The child was a nine-year-old boy with spastic tetraplegic cerebral palsy. He was born at 33 weeks gestation (date of birth was 01/13/92) with abruptio placenta and required intubation for one day. The boy stayed in the neonatal intensive care unit for 31 days during which he required oral gastric feeds, propylthiouracil for hypothyroidism, and propranolol for a heart rate above 200 beats per minute. During his stay, the child was also treated for suspected sepsis and hyperbilirubinemia of prematurity. Cranial ultrasounds were performed on postdelivery days one, eight, and 22 with no signs of intercranial hemorrhage, but he did have increased periventricular echogenicity on the right greater than left. His ventricles were normal. The child was discharged to home with oxygen and an apnea monitor. The boy required no hospitalizations until complications arose from a trial dorsal rhizotomy procedure in July 1998. During a caudal epidural block, the needle entered the vascular space resulting in two grand mal seizures and respiratory distress. He recovered without change in physical and/or cognitive status. On 11/16/98 at the age of six years 10 months, the child underwent a baclofen pump implantation to reduce muscle tone. His dosage was titrated to 2,000 μg/mL delivered at a rate of 240 μg per day over the first six months, and he has remained on that dosage. One year later on 11/22/99, he underwent bilateral adductor tenotomies, open reduction of dislocated hips, proximal varus derotational osteotomies, and pelvic Pemberton osteotomies. He was in a spica cast for six weeks following these procedures.
After the implantation of the baclofen pump, the child had two complications requiring hospitalizations. In May 2000 and January 2001, surgical revisions of the catheter portion of the pump were performed. He recovered without complications from both incidents.
The child's rehabilitation history began at approximately five months of age with physical and occupational therapies. Speech therapy was started at three years of age. His physical therapy over the years consisted of developmental treatment, stretching, and functional skills training such as transfer techniques and family education. Prior to the implementation of the baclofen pump at age six years, the child's progress had slowed considerably due to the increase in muscle tone throughout his extremities and trunk. At that time, he was able to ring sit with close supervision using his upper extremities for propping, take minimal weight through both extended lower extremities with the trunk fully supported, was dependent for all transfers, and required assistance to roll. After the baclofen pump implantation, the child's skills began to improve again. Treatment was focused on proximal stability activities in a variety of positions and progressed to more distal control skills. The child demonstrated improvements in sitting, rolling, and weight shifting in prone and short-sit; protective extension in sitting began to emerge, and he demonstrated increased lower extremity active movement in gravity-eliminated positions.
After recovering from the hip surgery in November 1999, bilateral knee-ankle-foot orthoses (KAFOs) (knee joints locked when upright) were fabricated for the child, and he began practicing upright skills in the parallel bars and at a table. He then progressed to using his upper extremities for play for short times while requiring moderate to minimal assistance at the trunk. The child also worked on weight shifting while wearing the KAFOs in a postural control walker while the therapist moved his lower extremities. This was his functional level prior to the initiation of the treadmill training.
Rationale for Assessment Tools [size=TOP]
The GMFM is a standardized evaluative measure that was designed to assess changes in gross motor skills over time in the child with CP. 24 This criterion-based tool is used to assess the ability of the child to perform 88 specific gross motor skills in five dimensions without the assistance of a parent or therapist. These dimensions are 1) lying and rolling, 2) sitting, 3) crawling and kneeling, 4) standing, and 5) walking, running, and jumping. Each of these sections is weighted equally in the scoring process. The score for each item is based on a four-point scale: zero, does not initiate; one, initiates (less than 10% of the task); two, partially completes (10% to less than 100% of the task); 3, completes the task. In the Guidelines for Item Scoring section, the starting position for each item is stated, the skill to be measured is described, and the scoring criteria are listed. The GMFM is a valid instrument for detecting varying levels of changes in gross motor function in children with CP. 24,25
The Pediatric Evaluation of Disability Inventory (PEDI) is a criterion-based tool used to assess the functional capabilities of children in three domains (self-care, mobility, and social function). 26 Each of these domains has a corresponding caregiver assistance portion that is used to assess the actual performance of the child by assessing the caregiver's perception of how much help is given to the child on a regular basis. The last portion of the PEDI is the modification frequency, which is used to assess the type and amount of equipment that the child needs to perform functionally in his/her environment. Each of the capability domains, the caregiver assistance domains, and the modification frequency can be scored separately and independently.
This evaluation tool was designed for use with children with a variety of physical and/or cognitive disabilities. Normative scores are based on children aged six months to 7.5 years; however, the PEDI is also designed for use with older children whose functional level falls within the stated range. The scaled scores give an estimate of the level of capability of a child in each domain regardless of age and are determined by using a scale from zero to 100 to distribute the scores from each domain (zero, no measurable functional ability and 100, capability in all test items in that domain). The scaled score is the most appropriate score for an older child functioning at a lower level. The PEDI may be administered by therapists and/or educators who know the child well or by parent interview. The PEDI has demonstrated high levels of reliability 26,27 and validity 26-28 for determination of a child's functional capability.
Examination [size=TOP]
Prior to beginning the locomotor training on 6/25/01, the GMFM 24 and the caregiver portion of the PEDI 26 were administered. The child was nine years five months old at the time the tests were administered. A review of physical therapy documentation indicated that his function had remained essentially unchanged for the previous nine months.
He was cooperative throughout the administration of the GMFM with the scoring system motivating him to put forth maximal effort throughout the test. The GMFM was performed without ankle-foot orthoses (AFOs) until the standing portion when bilateral solid-ankle AFOs were donned for his comfort and compliance.
As anticipated, the child scored the highest in the areas that required the least amount of postural control against gravity. As he was asked to assume postures against gravity, scores dramatically declined. Results are reported in Table 1. His goal total score, which included standing and walking/running dimensions (sum of the percentage of scores for each dimension identified as a goal area/number of goal areas), was only 2% prior to the locomotor training.
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TABLE 1 GMFM Results Pre- and Postlocomotor Training on the Treadmill with BWS
The PEDI was administered through interview of the boy's mother for the functional skills, caregiver assistance, and modification frequency portions. Results of the mobility functional skills and caregiver assistance are reported in Table 2. The modification frequency portion identifies the number of functional activities requiring modifications such as a child-sized spoon (child modification), a walker (rehabilitation equipment modification), or use of a lift device (extensive modification). Modifications were counted only when the child needed the equipment to perform an activity. This child required one child modification (sits in a store-bought chair), one rehabilitation equipment modification (toilet chair), and three extensive modifications (van lift, hospital bed, and wheelchair).
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TABLE 2 PEDI Results Pre- and Postlocomotor Training on the Treadmill with BWS
Equipment [size=TOP]
Treadmill and Unweighting System. TOP
A Biodex RTM 400 rehabilitation treadmill (Biodex Medical Systems, Inc., Shirley, NY) was used for the locomotor training, and it allowed for speeds from zero to eight miles per hour in 0.1-mile increments. The base of the treadmill was 20 × 64 in. with a 6-in. step-up to the walking platform. A digital control panel was located at the front of the treadmill with easy accessibility to stop, start, and adjust the speed of the treadmill. A pneumatic lift (Neuro II; Vigor Equipment Inc., Stevensville, MI) suspended over the treadmill was used to support the boy's body weight. A large dial, with a digital read out, could be adjusted to vary the amount of vertical unweighting provided by the lift. A steel bar on the overhead cable was used for attaching the harness. A separate safety cable was attached to prevent the possibility of the boy collapsing to the floor in the event of a slip or a trip.
Harness [size=TOP]
A harness (Medical Harness; Robertson Harness, Henderson, NV) was used to support the child. It was applied with the child in the supine position and then readjusted in the standing position, if necessary, so that it fit snugly around the pelvis and chest. The pelvic band of the harness fit around the iliac crests just below the anterior superior iliac spines, and the trunk or thoracic component of the harness was just below the nipple level and had padded shoulder straps.
Padded straps from the pelvic band wrapped between the legs and around the upper inner thigh to hold the harness securely in place (much like a climbing harness). Webbing straps with metal rings extended from the trunk harness upward and were attached via carabiners to the steel bar of the BWS system. When applying the harness with the child supine, it was always tightened from the bottom up so that it would fit snugly around the pelvis and not ride up on the child when he was standing.
Shoes [size=TOP]
The child wore very light-weight, thin, rubber-soled beach shoes and no socks to provide as much sensory input to the foot as possible during the stance phase of gait. He never wore his AFOs during the gait training on the treadmill.
Intervention [size=TOP]
Each locomotor training session began with the following:
* Lower extremity stretching of the hamstrings, gastrocnemius/soleus, and adductors in the supine position
* Applying the harness
* Placement of the child in a sitting position on a bench on the treadmill
* Attachment of the BWS system
* Assisted standing and attachment of the safety cable with the BWS at 60%
* Decrease of the BWS system gradually from 60% to 20% while encouraging the child to stand with an upright posture and to load the lower extremities as much as possible with assist at hips and knees
* Weight shifting and stepping forward with one foot in a stride position with instruction for the child to push into the ground to facilitate active weight-bearing (extension of hips, knees, and trunk) (this activity was assisted by one or two therapists who provided support at the knees to encourage knee and hip extension)
* Attachment of rubber bungee cords diagonally from the front and back of the treadmill to the harness to further stabilize the trunk (these cords were removed as the child progressed in the training)
* Starting of the treadmill and actual stepping on the treadmill
A mirror was used at the front of the treadmill so that the child could see himself and assist with his postural alignment as well as to provide motivation. After several minutes of standing, followed by several minutes of assisted stepping forward with one foot and then the other, the actual step training began.
During the step training with BWS, manual assistance was provided to assist the lower extremities to perform the gait pattern. The following protocol was adapted from the work of Behrman and Harkema. 15 To begin step training, the legs were manually placed in a stride position and the treadmill was started and brought up to the child's comfortable walking speed. Assistants were positioned on both sides of the treadmill to assist with each leg. One hand of the assistant was placed on the anterior surface of the tibia to assist with knee extension during the stance phase and was smoothly moved to the posterior knee to facilitate the medial hamstrings for knee flexion during swing. The other hand was placed at the ankle to assist with toe clearance during swing and appropriate foot placement at initial contact. The boy wore knee pads on occasion to avoid any discomfort from the assistants' hand contact at the upper tibia. A third person sat behind the child on a bench that straddled the treadmill to assist in trunk stabilization and upright postural alignment. A fourth person started, stopped, and adjusted the treadmill speed and recorded times and percentage of BWS. The child's primary therapist, who also served as an assistant, provided motivation to the child by telling him stories about walking through various environments. One example: we are walking on a planet, and there is a lot of gravity here, so you really have to pick your feet up! OK, now we need to walk over this way and see what those aliens are doing.
Training sessions were scheduled as follows: three training sessions per week for 10 weeks followed by two training sessions per week for 11 weeks.
The training schedule was spread out over a period of 25 weeks with a three-week break after the first eight weeks and a one-week break after the next seven weeks. The first break was due to the beginning of the school session and the added burden of scheduling after a long day at school. The second break was due to a perceived need as a reward for hard work. The child missed several sessions because of illnesses. The locomotor training was stopped for the final time due to scheduled orthopedic surgery (removal of hardware) for the child and for the Christmas and New Year holidays.
The child received a total of 44 training sessions. Each session lasted between one to one and one-half hours and included repeated bouts of stepping practice with the standing practice at the beginning of each session and during each rest period between stepping bouts. The duration of each step training bout depended on the child's fatigue or the assistants' ability to provide proper assistance and gait kinematics. BWS varied from 40% to 60% with the most common BWS of 55% provided during most of the step training. The speed of the treadmill was increased as the training sessions progressed. In the first training sessions, treadmill speed varied between 0.2 and 0.8 mph and by the last training sessions had increased to 1.3 mph. More assistance for the legs and trunk was required in the earlier sessions. Total standing times ranged from 19 to 31 minutes, and total stepping times ranged from 11 to 25 minutes during the training sessions. Table 3 provides summaries of times, speeds, and BWS used during the sessions.
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TABLE 3 Training Session Summaries
During the training, the child continued with his regularly scheduled physical, occupational, and speech therapy sessions. He received his regular physical therapy twice per week and occupational and speech therapy each once per week.
Outcomes [size=TOP]
When the locomotor training began, the child was unable to independently initiate a step even with 60% BWS and a treadmill speed of 0.6 mph. Those assisting with both swing and foot placement during initial contact were working hard to overcome increased flexor tone, and both assistants and child were easily fatigued. Many standing rest stops were taken during those early sessions, and the child was able to step for less than one to four minutes at a time. At the conclusion of the locomotor training, the child was able to maintain independent stepping for as many as 60 steps at a speed of 1.3 mph while in the harness. When assistance was necessary, it was primarily for sensory cues for foot placement during initial contact, to maintain knee extension throughout stance, and minimal assistance with swing. The child was walking for an average of three to six minutes at a time (sometimes 10 to 11 minutes) before a standing rest break.
The boy was nine years 10 months of age at the time of posttesting. He was very cooperative during the GMFM administration and motivated throughout. The scores of the GMFM improved in all dimensions and are reported in Table 1. These changes included an improvement in overall trunk control and lower extremity movement. The child was still the most limited in coming to stand, standing, and stepping; however, during the posttest he was able to attempt more items than in the pretest (19 more items) due to his improved abilities in upright positions. He had great difficulty with coming to stand from short sit from a bench where hips and knees were at 90 degrees. He did show improvement in coming to stand from his wheelchair. He was able to stand, at the time of the posttest, with upper extremity support on the therapist's shoulders or on parallel bars with his AFOs donned with assistance ranging from minimal to contact guarding. He was also able to maintain this position and, with the opposite leg blocked at the knee, step to assist with a stand pivot transfer. This was a marked improvement from the pretest levels. When the child's trunk and weight were supported, he was able to take steps, which he was not able to do at the time of the pretest.
The PEDI posttest was performed through a combination of therapist testing and parental interview. The child demonstrated improvements in both domains of the PEDI, and these results are reported in Table 2. The amount of improvement, however, did not exceed the standard error for the scaled scores (there is overlap of the pre- and post-test scores when the standard error is used). Although the test scores showed only small improvements, the parental subjective comments demonstrated a significant improvement in contribution to assist with transfers and ADL. The mother reported that the child could now stand from his wheelchair using his upper extremities to hold onto her and allow his pants to be pulled down for toilet and bath transfers. This was a significant contribution since the parents had to lift him onto the bed to take off his pants prior to transferring him to the toilet. The parents also reported that the child was able to assist more in standing for wheelchair to bed transfers.
Subjective Outcomes [size=TOP]
Prior to the locomotor training, the child was receiving physical therapy twice per week, occupational therapy once per week, and speech therapy once per week. As mentioned before, during and following the period of locomotor training, those frequencies were maintained. Prior to the locomotor training, the boy's motivation to participate in therapies was low and he required continuous encouragement. He had an overall low affect and demonstrated frequent emotional breakdowns due to frustration and boredom. His primary physical and occupational therapist reported his progress was slow for all functional skills.
During his locomotor training, the occupational therapist noted that the boy's affect was much more positive and he was more motivated to participate in therapy. She felt that his attention and his ability to work on difficult skills without breakdowns were much improved. The occupational therapist was able to address more mature skills with the boy rather than play skills. She also noted that he asked for more difficult tasks during his therapies.
The physical therapist also noticed improvements in his affect. The child now wanted to work on transfers, standing, and sitting balance rather than just play. He was much more motivated to be independent in his mobility and skills than prior to the locomotor training. This motivation assisted the therapist by allowing work on functional mobility, with the child giving his full effort. The child's frustration level was much improved.
DISCUSSION [url=http://www.pedpt.com/pt/re/pedpt/fulltext.00001577-200401620-00005.htm;jsessionid=FLHJLdd15c8RFn5Qps22b6yj9jb5JlTRqb9h3cdSZsfzcRq4nhr0!1209472165!-949856144!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search#toptop][size=[colo
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