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?
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