1. Treadmill Training Jill Zwicker, PhD, OT(C) Tanja Mayson, MSc, BScPT Val Ward, BScPT Pediatric Symposium March 1, 2011

2. Outline 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

4. Background 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

5. PBWSTT 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

6. Purpose 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

7. Methods 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

8. Methods 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

9. Article Inclusion/Exclusion Flowchart

10. Summary of All Systematic Reviews

11. Children with CP in Each Review

12. Children 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

13. Children with other Motor Impairments Other diagnoses: Rett syndrome cerebellar ataxia following brainstem infarct traumatic brain injury PBWSTT, TT, and Mixed TT

14. Children with other Motor Impairments Mixed diagnoses include: congenital myotonia Angelman syndrome Guillain-Barré incomplete paraplegia stroke encephalitis PBWSTT, Robotic PBWSTT, and Mixed TT

15. Levels 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 NumberLevel of Evidence Type of Study 0ILarge RCT 6IISmall RCT 2IIICohort studies with control group 17IVCohort studies with no control; case-control studies 13VCase studies

16. Results 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

17. Results Cerebral Palsy Largest number of studies Most pertain to PBWSTT Evidence levels II to V

18. Results: CP

22. Results Down Syndrome 6 studies but only 2 samples TT Levels of evidence II and IV

23. Results: Down Syndrome

24. Results Spinal Cord Injury 6 studies PBWSTT or Mixed TT Levels of evidence IV or V

25. Results: SCI

26. Results Other diagnoses: 3 studies PBWSTT, robotic PBWSTT or Mixed TT Levels of evidence IV or V

27. Results: Other

28. Discussion 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

29. Discussion 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

30. Clinical 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

31. Clinical Relevance

33. 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

34. Clinical 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

35. Implications 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

36. Conclusion 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

37. Pilot 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

38. Protocol 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

39. Outcome 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

40. Outcome 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

41. Results: Participants ParticipantsAge (years) GenderCerebral Palsy Subtype GMFCS Level Orthoses 111.1MSpastic diplegiaIIBilateral fixed AFOs 215.0FSpastic diplegiaIILeft articulated AFO 38.3MSpastic diplegiaIIBilateral articulated AFOs 49.4FSpastic diplegiaIIBilateral SMOs

42. Results: GAS and Satisfaction ParticipantGoalGoal Set By RaterInitial Assessment Final Assessment GASSatisfactionWeek GASSatisfaction 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 -225+11 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-22701 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 -238+11 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 -238+21

43. Interpretation 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

44. Clinical Example Types of patients –Developmental delay –Cerebral palsy –Brain injury Pre-ambulatory, ambulatory, non-ambulatory

45. Video

46. 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

47. 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

48. 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

49. 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

50. Comments or Questions?