Treadmill TrainingTreadmill Training

Jill Zwicker, PhD, OT(C)

Tanja Mayson, MSc, BScPT

Val Ward, BScPT

Pediatric SymposiumMarch 1, 2011

OutlineOutline

• Review methods and findings of our recently published overview of systematic reviews of treadmill training with children with motor impairment

• Share results of treadmill training pilot study conducted at Sunny Hill

• Share practical application of treadmill training with children through case study

• Discuss implications for practice

BackgroundBackground

• Several studies have examined the effectiveness of treadmill training (TT) with and without partial body-weight support (PBWS) in children with motor impairments

• Research results been variable - difficult to interpret which type of TT provides superior results and for which motor impairments it is effective

PBWSTTPBWSTT

• involves the use of a body-weight support (BWS) harness during the treatment

• is congruent with contemporary models of motor control and motor learning

• is a task-specific approach with emphasis on repetition and practice

Purpose of OverviewPurpose of Overview

• to synthesize the current evidence from systematic reviews on the effectiveness of TT with/without PBWS in children with motor impairments

• Inclusion criteria:

– systematic review

– either PBWS and/or TT as an intervention

– children 0-21 years of age

– a diagnosis consistent with having a motor impairment

MethodsMethods

• Systematically searched 10 databases

• Independently reviewed titles, abstracts, full-text articles

• Independently reviewed quality of each systematic review using the AMSTAR criteria, e.g.,

– duplicate study selection and data extraction

– comprehensive literature search

– scientific quality assessed and documented

– publication bias assessed

Methods continuedMethods continued

• Independently extracted descriptive and outcome data

• Classified individual studies according to Sackett’s Levels of Evidence

• Organized outcomes according to the components in the International Classification of Functioning, Disability and Health (ICF):

– Body Structures and Functions

– Activity and Participation

Article Inclusion/Exclusion FlowchartArticle Inclusion/Exclusion Flowchart

Summary of All Systematic ReviewsSummary of All Systematic Reviews

Children with CP in Each Review Children with CP in Each Review

Children with other Motor ImpairmentsChildren with other Motor Impairments

• Children with SCI only included in one systematic review (Damino et al., 2010)

– 7 children

• Level of injury: 5 cervical, 2 thoracic• ASIA Class: 1-A; 5-C; 1-D

– PBWSTT and mixed treadmill training

• Children with Down Syndrome

– Only children 4-13 months

– Treadmill training only

Children with other Motor ImpairmentsChildren with other Motor Impairments

• Other diagnoses:

Rett syndrome

cerebellar ataxia following brainstem infarct

traumatic brain injury

• PBWSTT, TT, and Mixed TT

Children with other Motor ImpairmentsChildren with other Motor Impairments

• Mixed diagnoses include:

congenital myotonia

Angelman syndrome

Guillain-Barré

incomplete paraplegia

stroke

encephalitis

• PBWSTT, Robotic PBWSTT, and Mixed TT

Levels of EvidenceLevels of Evidence

• As some studies were rated differently across the systematic reviews, we independently determined the level of evidence for each of the 38 studies

Number Level of Evidence

Type of Study

0 I Large RCT

6 II Small RCT

2 III Cohort studies with control group

17 IV Cohort studies with no control; case-control studies

13 V Case studies

ResultsResults

• No reported negative outcomes

• Many inconsistencies across reviews in how outcome data reported

• In this overview, outcomes classified as:

– Positive = trend toward better outcomes or if more than half of the sample achieved positive gains

– Positive = statistically significant positive findings

– No change or inconclusive

ResultsResults

Cerebral Palsy

• Largest number of studies

• Most pertain to PBWSTT

• Evidence levels II to V

Results: CPResults: CP

Results: CPResults: CP

Results: CPResults: CP

Results: CPResults: CP

Results Results

Down Syndrome

• 6 studies but only 2 samples

• TT

• Levels of evidence II and IV

Results: Down SyndromeResults: Down Syndrome

ResultsResults

Spinal Cord Injury

• 6 studies

• PBWSTT or Mixed TT

• Levels of evidence IV or V

Results: SCIResults: SCI

ResultsResults

Other diagnoses:

• 3 studies

• PBWSTT, robotic PBWSTT or Mixed TT

• Levels of evidence IV or V

Results: OtherResults: Other

DiscussionDiscussion

Comparison of Reviews:

• Very few studies included in all reviews

• Quality relatively high for 4 of 5 reviews (AMSTAR)

• Discrepancies in assignment of levels of evidence and how outcomes interpreted

DiscussionDiscussion

All systematic reviews concluded:

• TT is safe

• Results are encouraging, primarily in body structure and function

• Insufficient evidence to confidently conclude that TT has positive effects on walking in children with CP, other CNS impairments, and SCI

• 1 high quality review supports use of TT in children with DS

Clinical RelevanceClinical Relevance

Cerebral Palsy:

• Different types of TT are encouraging in BS and F and activity dimensions of ICF; not much information on participation

• Intervention parameters: highly variable

Clinical RelevanceClinical Relevance

Clinical RelevanceClinical Relevance

Clinical RelevanceClinical Relevance

Down Syndrome:

• Results significant in BS and F; no outcomes in A and P

• Intervention parameters:

• 20cm/s for 6-9 minutes per day until achievement of independent walking

Clinical RelevanceClinical Relevance

SCI

• PBWSTT research in early stages is encouraging

• Intervention parameters:

• Start with 40-80% BWS and decrease over time• At least 3 times per week for 8 weeks or more

Other CNS disorders

• All types of TT might be of benefit

• Intervention parameters: highly variable

Implications for ResearchImplications for Research

• Need more (rigorous) research regarding impact of TT on:

– Activity and Participation

– Individualized goals

• Need more research regarding which parameters are best for children with:

– CP

– SCI

– Other CNS impairments

Conclusion of OverviewConclusion of Overview

• For children with CP:

– most consistent and statistically significant improvements using PBWSTT or TT

– outcome measures: GMFM D and E dimensions

• For children with DS:

– TT can have a positive impact on BS and F dimensions, including onset of walking

• For children with SCI and other CNS impairments:

– insufficient evidence

Pilot StudyPilot Study

• Aim: To evaluate attainment of parents’ goals after their children with CP participated PBWSTT

• Inclusion criteria:

– Diagnosis of CP

– Ages 8-15 years

– GMFCS II or III

ProtocolProtocol

• 4-8 weeks of treadmill training

• 3x/week; up to 3 x 10 minute bouts with up to 5 min. break between bouts

• Orthoses worn during intervention

• BWS started between 0 and 80% and decreased to 0% by end of intervention

• Speed started at 0.4 to 0.5mph and reached 1.8 to 4.0 mph over course of intervention

Outcome MeasuresOutcome Measures

Goal Attainment Scaling

-2: Current level of attainment

-1: Less than expected improvement

0: Expected level of improvement

+1: Exceeds expectations

+2: Highly exceeds expectations

Outcome MeasuresOutcome Measures

Likert Scale Used to Rate Satisfaction

with Current Level of Goal Attainment

1= Very satisfied

2= Somewhat satisfied

3= Neither satisfied nor unsatisfied

4= Somewhat unsatisfied

5= Very unsatisfied

Results: ParticipantsResults: Participants

Participants Age (years)

Gender Cerebral Palsy Subtype

GMFCS Level

Orthoses

1 11.1 M Spastic diplegia II Bilateral fixed AFOs

2 15.0 F Spastic diplegia II Left articulated AFO

3 8.3 M Spastic diplegia II Bilateral articulated AFOs

4 9.4 F Spastic diplegia II Bilateral SMOs

Results: GAS and SatisfactionResults: GAS and Satisfaction

Participant Goal Goal Set By

Rater InitialAssessment

  FinalAssessment

   

        GAS Satisfaction Week 

GAS Satisfaction

1 -2: able to stop walking after 3-4 steps w/ assist of wall -1: will stop after 1-2 steps w/o falling 0: will stop w/o falling or holding on +1: will stop and turn w/o holding on +2: will stop and turn and continue walking w/o falling 

Parent Parent -2 2 5 +1 1

2 -2: walk inside mall for 30 min w/o asking to sit and rest -1: walk inside mall for 35 min w/o asking to sit 0: walk inside mall for 40 min w/o asking to sit +1: walk inside mall for 45 min w/o asking to sit +2: walk inside mall for 50 min w/o asking to sit 

Parent &

Participant

Parent -2 2 7 0 1

3 -2: walk 1 block w/o stopping -1: walk 2 blocks w/o stopping 0: walk 4 blocks w/o stopping +1: walk 5 blocks w/o stopping +2: walk 6 blocks w/o stopping 

Parent Parent -2 3 8 +1 1

4 -2: walk 1 block independently w/ 2 rest stops -1: walk 1 block w/ 1 rest stop 0: walk 1 block w/o stopping +1: walk 2 blocks w/o stopping +2: walk 4 blocks w/o stopping 

Parent Parent -2 3 8 +2 1

InterpretationInterpretation

• Treadmill training can help achieve individualized goals

• Subsequent treadmill training research would be well served by continued inclusion of family-centered goals as outcome measures

Clinical Example

• Types of patients

– Developmental delay

– Cerebral palsy

– Brain injury

• Pre-ambulatory, ambulatory, non-ambulatory

Video

H

• 12 yr old

• Cerebal palsy- spastic diplegia

• GMFCS II

• Started walking at age 6 after hamstring release

• Problems:

– planovalgus feet

– weakness

– stiff legged and crouch gait pattern

– hamstring and iliopsoas tightness

Goal

Pretraining level

• H is able to stop after 3-4 steps with assist

Goal

• H will be able to stop, turn and continue walking without falling

After Training

• H is able to stop and turn without holding on

Training sessions

• 3 times a week

• Started with 80%BWS gradually decreasing to no support and no harness

• Initially required 1 break

• Final session completed with no break

• Speed started at 0.4

• Speed for final session 1.4

• Worked on balance, backwards walking

Combined results from the pilot study

• Participates more in PE and at recess

• Able to walk in community without assistance

• Another client participated in the 1.5 km Sun Run after training

• Another client reported being able to shop with friends at the mall for 0.5 hr

Comments or Questions?Comments or Questions?