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
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
ResultsResults
Other diagnoses:
• 3 studies
• PBWSTT, robotic PBWSTT or Mixed TT
• Levels of evidence IV or V
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
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
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