Effects of Traditional Treatment and Partial Body Weight Treadmill Training on the Motor Skills of Children With Spastic Cerebral Palsy: A Pilot Study

Denise M. Begnoche, PT, and Ken H. Pitetti, PhD, FACSM

Summary by Sonya Seif, Mobility Research, 3 August 2007

This study was designed to examine the effects of partial body weight treadmill training (PBWTT) combined with intensive traditional physical therapy treatment on motor and ambulatory skills in children with cerebral palsy. Five children between the ages of 2 and 10 participated in a four week therapy program consisting of three to four two-hour sessions per week. Outcomes were measured and analyzed using standardized testing procedures such as pedographs and the Gross Motor Function Measure (GMFM). Results included positive measurable outcomes of the paired methods, indicated by improved motor and ambulatory skills in individual children. Thus, intensive episodes of physical therapy of reasonable frequency and duration performed in combination with PBWTT may be effective in improving motor skills of children with spastic CP. (Pediatric Physical Therapy 2007; 19:11-19)

Over the last three decades, the neurodevelopment (NDT) approach has been the most common method of physical therapy utilized when treating children with spastic cerebral palsy. This approach advocates facilitation techniques to inhibit spasticity and aid more normal movement patterns. The child, however, remains a relatively passive recipient of the NDT treatment. This leads to atypical motor patterns established over time through both practice and "competition of motor patterns," influenced by musculoskeletal components. This observation led to a new model, one in which the child actively participates in repetitive, task-specific practice.

In order to acheive motor learning and improve locomotor skills under this model, a novel type of task-specific approach to treatment has been identified: partial body weight treadmill training (PBWTT). PBWTT utilizes an overhead structure to support a harness that encircles the trunk of the patient, allowing for partial or full support of his or her body weight during therapy. In this manner, normal gait patterns can be facilitated via manual guidance of foot and leg movements in a repetitive, task-specific approach to walking on a moving treadmill.

A limited number of studies have been performed on the efficacy of various combinations of partial weight bearing and traditional therapy, nearly all dealing with relatively long-term therapy programs ranging from three to four months. In these studies, improvements recorded in the measured outcomes were possibly influenced by non-therapy related changes such as growth or maturation. The purpose of this study was to further examine the effects of an intensive, short-term physical therapy program using traditional treatment methods combined with treadmill training on functional motor capacity and ambulatory skills of five children with CP of different ages and levels of severity.

The five children (pre-test ages of 2.3, 5.3, 8, 8.8, and 9.6 years) varied in levels of severity. At baseline, one child was perambulatory, two walked independently, and two walked with assistive mobility devices. Two-hour physical therapy sessions were administered four days per week for four weeks, with the exception of one patient who attended three days per week. Sessions consisted of traditional therapy techniques: NDT in a dynamic systems approach. Therapeutic exercises to stimulate muscle lengthening and strengthening were performed using a variety of methods including myofascial release, kinesiotape, climbing stairs, ladders and cargo net, and tricycling. The partial weight bearing portion of the therapy generally consisted of three to five segments per session, 15 to 35 minutes total. PBWTT was performed using the Standard WalkAble™ on the GaitKeeper™ treadmill (Mobility Research, Tempe, AZ). During PBWTT, the child's body weight was supported in an erect posture allowing for full knee extension during midstance phase and full hip extension during terminal stance phase of gait. The therapist was positioned behind the child to facilitate a proper gait pattern by stimulating full range of hip extension and equal stance time on each limb, preventing premature initiation of swing phase, insuring heel strike at initial contact, and preventing knee hyperextension during midstance. Facilitation was provided from the pelvis, behind the knees, or at the ankles as determined necessary by the individual's gait pattern.

In order to analyze the data gathered, a Wilcoxon paired-sample test was used to examine the differences between week 1 and week 4 for the progression of treadmill speed and time for PBWTT, total score for GMFM, Doc-U-Prints pedograph measure, and Timed 10-Meter Walk Test. Though no significant changes were observed across all patients, positive percent changes in each of the five dimensions were noted in different individuals and four of the five participants improved in their total percent score. Pre- and post-test scaled score results for functional skills and caregiver assistance domains of the Pediatric Evaluation of Disability Inventory (PEDI) indicated a similar pattern with certain individuals showing statistically significant increases in a few areas, specifically improved mobility. Pedograph results showed improvements in all the following areas: right and left step length, right and left stride length, symmetry of step and stride, and base of support. The improved symmetry reflects possible improvement in dynamic postural control during gait. Group significance was not shown, but each child also improved in speed of walking.

Though various treatments have been shown to be effective, no systematic approach has been published that has established a high probability of producing measurable changes in gait. This pilot study was an attempt to validate a treatment approach, namely intensive physical therapy with PBWTT, and identify clinical tests that effective measure treatment outcomes. Motor learning in an intensive episode of physical therapy requires active, assisted, task-specific practice of skills in various therapeutic activities with components for strengthening and opportunities for unpredictable perturbations of balance. PBWTT and gait training over ground were conducted during each session in this study, providing an excellent opportunity for the repeated, task-specific practice of gait parameters.