Treadmill training for people with cerebral palsy

Last update: 9 May 2017

► Treadmill training may help a child or adult with cerebral palsy to improve their walking gait and distance travelled
► It can also be used to achieve mobility, physical activity or health and fitness goals
► It can be done with the support of a harness, also known as partial body weight supported treadmill training, if they can’t stand independently
► Research evidence suggests treadmill training as an alternative to physiotherapy for helping adults with cerebral palsy walk further.

Who is it for?

Treadmill training may be suitable for a child or adult with cerebral palsy who has these characteristics:

Age: Infants and Toddlers, Preschoolers, School-aged, Adolescents, Adults, Older adults

Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Quadriplegia, Triplegia, Unilateral cerebral palsy

Mobility : GMFCS I, GMFCS II, GMFCS III, GMFCS IV

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

Who can assist?

Treadmill training is provided by physiotherapists, exercise physiologists and other exercise and allied health professionals qualified in this intervention.

Cerebral Palsy Alliance offers a service where our physiotherapists and exercise physiologists can help someone decide if this intervention is a good choice for them, or a family member. They can also provide advice on the best type of program.

Find a Cerebral Palsy Alliance service

Fees

Therapy – Fees will apply for an exercise or health professional to conduct an assessment and carry out the exercise sessions. Fees will depend on the service provider and the number of sessions the person needs. You should check with your provider to see if there will also be fees for them to develop a home program, travel to the sessions and prepare reports.

Equipment – The treadmill will need to be accessed at a gym, or rented or purchased for home use. There may also be additional costs for a harness and hoist system if someone needs partial body weight support.

You can ask your health care provider if you are eligible for funding to assist with the treadmill training fees and equipment. People with a disability living in Australia may also be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Time

The time it takes for someone to benefit from treadmill training will vary. Each program is different, but general recommendations are that training is done:

For 30 minutes each time
2-3 times per week
For a minimum of 6 weeks^2-4.

Over time, the health professional will heighten the intensity of the training by increasing the walking speed, duration of the exercise and the slope of the treadmill.

To maintain the benefits they achieve, the client will need to continue their program over the long term.

More about treadmill training

Treadmill training offers a way for a person with cerebral palsy to get walking practice and potentially improve their walking pattern¹, and other aspects of their health.

The goals a person sets for their treadmill training will depend on the type and severity of their cerebral palsy but may include:

An improved or more symmetrical walking pattern
The ability to walk longer distances (walking endurance)
An increased walking speed
Improved balance
Cardiovascular fitness
Greater weight bearing abilities to strengthen their bones
For infants, the development of walking skills

Treadmill training can be carried out in the home, clinic or a community gym.

Things to note

When someone who can’t support their body weight on a standard treadmill needs the support of a harness system, this is known as partial body weight supported treadmill training
Injury can occur if treadmills are not used correctly. A treadmill is a mechanical device with moving parts and even minimum treadmill speeds can be fast. Therefore, supervision is recommended and is always required for people undertaking partial body weight supported treadmill training
For people who walk with an aid, additional overground practice of skills that are specific to their walking aid is required. These include pushing, pulling, slowing, stopping, turning and reversing, and negotiating spaces, objects, and uneven and inclined surfaces.

Assessments

There are two types of assessments necessary for people undertaking treadmill training.

To guide intervention

Before starting treadmill training, a person should receive a thorough assessment by an exercise or health professional who can determine their abilities and develop goals that make their treadmill training program effective and safe.

To measure the outcome of the intervention

The second type of assessment determines whether the training has met the individual’s needs and goals. The exercise or health professional, together with the person with cerebral palsy and their family, will decide on the most suitable measures. Some typical outcome measures for this intervention are:

Goal Attainment Scaling (GAS goals) – measures the extent to which a person’s goals are achieved
Timed Up and Go - tests a person’s mobility and balance by measuring the time it takes them to stand up, walk three metres, turn around, walk back and sit down again
Six Minute Walk Test - measures the distance an individual can walk in six minutes on a hard, flat surface
Ten Metre Walk Test – measures a person’s walking speed over a short duration. It can be performed at preferred walking speed or fastest walking speed possible
Gross Motor Function Measure (GMFM) – measures gross motor ability
Berg Balance Scale – measures a wide range of balance activities.

Best available research evidence

Where did we search?

We searched the medical and allied health literature to find research evaluating the effectiveness of treadmill training for children, adolescents and adults with cerebral palsy.

What were we looking for?

The search aimed to find the best available research evidence to identify whether treadmill training can improve someone’s participation in activities for everyday life. It covered areas like quality of life, balance, and the ability to stand, transfer and walk in the community (functional mobility). We did not consider outcomes measured in a gait laboratory such as joint kinematics, muscle power, cadence and oxygen consumption. Nor did we examine treadmill training of infants and very young children under the age of six-years-old.

What did we find?

The best available research evidence for children and adolescents was an overview of systematic reviews⁵ and five randomised controlled trials (RCTs) published since this overview^2-4,6-7. The outcomes measured in these studies were: functional mobility, gross motor ability, static and dynamic balance. We found only one RCT evaluating treadmill training in adults with cerebral palsy⁸.

Children and adolescents

The overview of systematic reviews⁵ included five systematic reviews, each of which included study designs from RCTs through to case studies. Most studies, however, were at lower levels of study design (Levels 4 and 5) and the majority included studies of partial body weight supported treadmill training. Overall, results were positive, suggesting treadmill training, with or without partial body weight support, assists with walking. More specifically, it was found to improve gross motor ability across the GMFCS levels, and functional mobility in children and adolescents at GMFCS Levels I to III. However, the overview cautioned that these results were based mainly on lower level evidence. More higher level, good quality research was required to fully inform the implementation of treadmill training.

The other five studies considered to be the best available evidence included participants who had either some walking ability (that is, GMFCS Levels I to III)^2-4,7 or more significant mobility limitations (GMFCS Levels IV and V)⁶. The aims of treadmill training are different for these people. We present the results of these two categories of studies separately below.

Children and adolescents at GMFCS Levels I to III

- Functional mobility and gross motor ability

Functional mobility was measured using tests such as the Timed Up and Go, 6 Minute Walk Test, 10 Metre Walk Test and Pediatric Evaluation of Disability Inventory. Gross motor ability was measured using the Gross Motor Function Measure.

Two good quality RCTs compared the outcomes of treadmill training with an equal intensity intervention (e.g., overground walking training² or conventional physiotherapy⁴) with children at GMFCS Levels I to III. Both studies concluded that treadmill training was more effective than the comparison intervention in improving functional mobility and gross motor ability.

An additional study⁷ used partial body weight supported treadmill training with children and adolescents at GMFCS Levels II and III. This study concluded the intervention was equally effective as overground walking training.

Taken together with the findings of the overview of systematic reviews⁵, the results of these three studies^2,4,7 provide moderate quality evidence to suggest treadmill training without partial body weight support is more effective for improving functional mobility and gross motor ability for children and adolescents at GMFCS Levels I to III than partial body weight support treadmill training, overground walking training or conventional physiotherapy.

- Balance

Two good quality RCTs^2-3 evaluated the effects of treadmill training, compared with equal intensity overground walking training, on static and dynamic balance for children at GMFCS Levels I to III. Both studies concluded that treadmill training was more effective for improving dynamic balance. The results for the effects on static balance were inconsistent within and between studies, and therefore provide no guidance.

Overall, for children and adolescents at GMFCS Levels I to III, moderate quality evidence suggests it is worthwhile to pursue treadmill training to increase their functional mobility, gross motor ability and dynamic balance. The studies reporting positive outcomes gradually increased walking speed on a treadmill in 30 minute sessions, two or three times per week, for seven or 12 weeks.

Children and adolescents at GMFCS Levels IV and V

One moderate quality RCT⁶ evaluated partial body weight supported treadmill training in children and adolescents at GMFCS Levels IV and V. The outcomes were compared with a group of children who participated in their usual, and less intensive, physiotherapy program. Treadmill training was associated with small improvements in their scores on the standing domain of the Gross Motor Function Measure but there was no change on the walking, running and jumping domain of this measure. Considered alongside the promising, but not decisive, conclusions of the overview of systematic reviews⁵, there appears low quality evidence of a possible effect of partial body weight supported treadmill training on standing ability. Before trialling this intervention, carefully consider the evidence, the amount of commitment required, and other potential benefits apart from gross motor ability (for example, benefits of an upright posture and fitness).

Adults

We located a moderate quality RCT⁸ evaluating treadmill training, compared with equal intensity conventional physiotherapy, in adults with cerebral palsy who could walk. The participants could walk significantly further overground during a 6 Minute Walk Test than the comparison group. This is a promising finding which should encourage adults with cerebral palsy who can walk to consider trialling this intervention. They should carefully consider whether it will meet their needs and help them achieve their goals.

Date of literature searches: July 2016