Case Report Hospital, Columbus,

Ohio.

K. Bush, BS, Division of

Physical
Therapy, School of
Health and
Rehabilitation Sciences, The
Ohio
State University.

M. Butler, PT, DPT,

Outpatient
Rehabilitation Services,
Wexner
Medical Center, The Ohio
State
University.

J.J. Buehner, PT, MS,

J.C. Outpatient
Heathco Rehabilitation Services,
ck, PT, Wexner
MPT, Medical Center, The Ohio
State
PhD,
University.
Division
of D.M. Basso, PT, EdD,
Physical School of Health and
Therapy Rehabilitation Sci-ences,
, School The Ohio State University.
of
Health [Heathcock JC,
and Christensen C, Bush K, et
Rehabili al. Treadmill training after
ta-tion surgical removal of a
Science spinal tumor in infancy.
s, The Phys Ther. 2014;94:1176
Ohio 1185.]
State 2014 American Physical
Uni- Therapy
versity, Association
453 W
10th Published Ahead of Print:
Ave, April 17, 2014
Colum- Accepted: April 8, 2014
bus, OH
Submitted: October 23,
2013
43210
(USA).
Address
all Post a Rapid
corresp Response to this
ondence article at:
to Dr ptjournal.apta.or
Heathco g
ck at:
jill.heath
cock@o
sumc.ed
u.

C.
Christen
sen, PT,
DPT,
Division
of
Clinical
Therapi
es,
Nation
wide
Childre
ns
 cal
Removal
of a
Spinal
T
Tumor in
r
Infancy
e Jill C. Heathcock,
a Catie Christensen,
Karah Bush, Marisa
d Butler, Jeffrey J.
Buehner, D.

m Michele Basso

il Background and
Purpose. Step
l training
treadmill
on
is
a
a
T common inter-
vention for adult
r and
patients
pediatric
with
spinal cord
a injuries (SCI).
Treadmill training
i has not been used
as an intervention
n for infants and
toddlers with SCI
i before walking
onset. This case
report describes
n the intervention
and stepping
g behaviors on a
treadmill and
A overground of a
toddler after the
ft surgical removal
of a rare spinal
tumor resulting in
e SCI.

r
Case
S Description. The
toddler presented
u with an inability
to step on the left,
r rare stepping on
the right, and an
g apparent lack of
sensation in the
i lower extremities.
After py.
spina
l
tumo Outcomes.
r Independent
excisi symmetrical
on at stepping emerged
5.5 both on and of
week the treadmill over
s of 20 months.
age, Improvements in
step the number and
traini pattern of steps
ng on occurred with
a training. Walking
tread speed increased,
mill and milestones
and important to
overg overground
roun walking
d developed.
occur
red
once Discussion.
per Independent steps
week developed during
from the intervention
15 to with little motor
35 development of
mont the lower
hs of extremities during
age the first year of
in life. Furthermore,
addit improvements in
ion stepping
to alternation,
tradit standing, and
ional walking occurred
physi despite no
cal evidence of
thera sensation in the
lower extremities.

1176 f Physical Therapy Volume 94

Number 8
August 2014
Treadmill Training After Surgical Removal of Spinal Tumor in Infancy
cular fitness and some recovery
can facilitate when it is used to
Walking,
important an
mile-stone in
appro-priate social
interactions and
promote relearning
or refining walk-ing
infant
develop-
ment, play in toddlers.7 that has already
facilitates In addition, developed.
participa-
tion throughout dynamic inter- Whether treadmill
life. After spinal actions among training is efec-
cord injury (SCI), postural control, tive when SCI
treadmill training mus-cle strength, occurs before
can facilitate and balance walking has
relearning of facilitate walking developed is
stepping and are improved unknown.
alternation and through the trial
and error of early
walking in adults.1,2 Training and
However, for walking.8 stepping on a
children who Independent treadmill have been
sustain SCI before walking is a goal implemented and
learning to walk, shared by families tested before
of children with walking has
there is a paucity of
motor disabilities. developed in
information
regarding populations of
interventions for children other than
facilitating step- those with SCI,
ping. In this case In some methods with good results.16
report, we describe for facilitating 19
The most well-
step-ping, stepping
the response to studied pediatric
alternation, and
treadmill training populations are
loco-motion in very
of a toddler with an infants and
young children,
in utero spinal toddlers with Down
tread-mill training
tumor resulting in syndrome; in brief,
approaches with
SCI and little to no children who were
known eficacy in
sensation below the preambula-tory and
older children or
injury. participated in an
adults have been
at-home treadmill
adapted.9 11 In training program
Independent older chil-dren
mobility provides walked 3 months
with cerebral palsy, earlier than those
infants with the treadmill training
ability to interact who received
increased walking
with the standard care.20
speed, endurance,
environment, thus Augment-ing
and gross motor
improv-ing depth treadmill training
perception, func-tion.9,10 In
with higher doses
exploration, and adults and older
induced even
social and children with SCI,
earlier walking
psychological locomotor training
onset and further
also improved
skills.35 As infants improved stepping
walking speed,
learn to walk and behaviors and
lower extremity
move, they learn strength, balance, motor milestones,21
more about the whereas
and gross motor
world. Upright augmenting with
standing, indepen- function.2,1115
orthoses had a
dent steps, and There-fore,
detrimental efect
walking experience treadmill training
on motor
are important promotes
milestones.22
factors in bone and Treadmill
muscle health6 as experience also
well as cardiovas-
appeared to tics, including and toes. Patel-lar,
increase stepping paralysis, plantar grasp,
with an alternating weakness, varying Babinski, and anal
pattern in infants tone, abnormal wink reflexes were
who were reflexes, and absent bilater-ally.
preambulatory and decreased or He had no response
at risk for cerebral absent sensation. to painful
palsy2325 and in stimulation until his
infants with The primary high left groin and
myelomeningocele. purpose of this right upper thigh.
26,27 case report is to
Fur-thermore, One dose of
a home-based describe the chemotherapy was
treadmill program stepping behaviors administered
for 1 toddler who of a toddler with before he
was not ambulatory an in utero spinal underwent T9 to L5
and had cord tumor osteo-plastic
myelomeningo-cele resulting in SCI laminectomy with
resulted in during an intensive decom-pression of
ambulation with a treadmill training the spinal cord and
walker.28 program. The goal exci-sion of the
of the program was intraspinal
to allow as much extradural
In pediatric repet-itive, neoplasm on day 40
populations, alternating, and of life. Nerve roots
damage to the independent at T11 and T12
spinal cord occurs stepping practice were resected, and
in 2 major forms: as possible. We did the tumor was
(1) traumatic injury, this by manually removed. Some
typically well after facilitating spontaneous left
independent stepping with hip flexion was
walking has been normal kinematics observed after
established, and (2) and by trial and surgery. Traditional
develop-mental error during physical therapist
defects, such as independent step- services began at 3
myelomenin-gocele, ping attempts on months of age. His
in which typical and of the familys goal was
walking milestones treadmill.
are limited or
absent. Spi-nal cord Patient History
damage in children and Review of Availa
results in unique ble
Systems With
impairments The toddler in this This
important for the case report had an Article
development and in utero spinal at
rehabilitation of tumor (from T11 to ptjour
stepping behaviors. L4) that was nal.ap
Common identified at birth ta.org
characteristics (Fig. 1). His left leg
include upper and A video of the
had no sponta- patients progress
lower motor neuron neous movement through the
signs, marked and reduced mus- treadmill training
movement cle bulk and tone. intervention over
asymmetries, and His right leg had time
incom-plete motor some spontaneous
and sensory movements of the
characteris- hip, knee, ankle,
August 2014 Volume
94 Number 8 Physical Therapy f 1177
Treadmill Training After Surgical Removal of Spinal Tumor in Infancy
lower extremities toddler were very
and trunk. This motivated to
unique patient had achieve a form of
impairments ambulation. There-
similar to those in fore, the toddler
children with appeared to be a
myelomenin-gocele good candidate for
and adults and an intensive
children with treadmill program.
SCI. Treadmill
programs were
used successfully To better determine
with a child who whether the use of
was preambulatory a treadmill
and had program would
myelomenin-gocele benefit the toddler,
and with children we planned further
and adults who had examination,
SCI.2,14,28 The including
family and administra-tion of
the Bayley Scales
of Infant
Development III,
Pediatric Evalua-
tion of Disabilities
Index, Modified
Ashworth Scale,
Figure 1.
anthropometric
Sagittal T2-weighted
magnetic resonance image measurements,
of the tumor at spinal levels reflex tests, and a
T11 to L4 (arrow) in a 1-day- treadmill trial.
old infant.
Examination
An examination
for him to have an was completed
independent form when the patient
of ambulation; was 10 to 12
therefore, at 15 months old to
months of age, he determine
began the 20- appropri-ateness
month treadmill for treadmill
program described training. The
in this case report. Bayley Scales of
Infant Development
III, reflex tests, and
Clinical Impression a treadmill trial
It is likely that the were conducted
in utero tumor and when the child was
surgical resection 10 months old. The
caused injury to the Bayley Scales of
sensorimotor spinal Infant Development
system, resulting in III, valid and
the asymmetrical reliable norm-
weak-ness, sensory referenced scales
deficits, and used to evaluate
abnormal reflexes motor function in
in the toddlers chil-dren who are 1
to 42 months old, relate significantly was ruled out by
were administered with neurological radiography.
to evaluate the level, ability to
toddlers motor walk, and indepen- Clinical Impression
skills.7 His gross dence in activities Overall, the patient
motor skills but not of daily living in had profound
his fine motor skills children with spina sensorimotor loss
were found to be bifida.31 The tod- in both lower
delayed, as noted dlers standard extremities,
by scale scores of 1 scores of 49.2 for including
and 9, respectively. self-care, 38.4 for asymmetrical
The Achilles, mobility, and 49.9 strength, growth,
patellar, and for social function and antigravity
Babinski reflexes indicated mobility movements, noted
delays. as worse on the
were absent
bilaterally. When left. Tone was
suspended over the generally
treadmill, he The Modified hypotonic, with
stepped a few times Ashworth Scale flaccid paralysis.
independently with and We cautiously
his right lower anthropometric assumed that he
extremity and was measurements had no sensation in
unable to step on were administered either lower
the left. when the child was extremity on the
12 months old to basis of a lack of
evaluate spasticity attention or
and lower physical response
The Pediatric extremity
to stimulation;
Evaluation of symmetry.32 All however, he was
Disabili-ties Index, lower extremity too young to
a reliable and valid joints scored 0 on verbally answer or
clini-cal assessment the Modified understand
instrument that Ashworth Scale, questions about
sam-ples key with the exception sensation.
functional of the right hip
capabilities and exten-sors, which
performances in scored 1. His lower The lack of
children from 6 extremity tone was sensation in either
months to 7.5 years generally hypo- lower extremity
of age, was tonic. was a concern
administered when Anthropometric because
the child was 11 measure-ments of experimental
months old.29,30 the lower evidence for SCI
Standard scores on extremities has shown that
the instrument are revealed greater some sensation
based on a mean of size on the right appears to be
50 and a standard than on the left: important for the
deviation of 10, and 1.5 cm for length, recovery of
scores have been 1.5 cm for the stepping
found to cor- thigh behaviors.33 The
circumference, and risk that the
2 cm for the calf toddler might not
circumference. respond to
These diferences treadmill training
warranted evalua- was mitigated by
tion for hip his ability to take a
dislocation, which few independent
1178 f Physical Therapy Volume 94 Number 8
August 2014
Treadmill Training After Surgical Removal of Spinal Tumor in Infancy

steps on the Intervention

treadmill with his An intensive
right lower stepping-focused
extremity. inter-vention was
added to
The evaluation traditional physical
confirmed that the therapy. The step
childs impairments training program
were similar to occurred at The
those found in Ohio State
patients with University Medical
myelo-meningocele Center, and tradi-
and SCI. Given that tional physical
the child therapy was
demonstrated the delivered at
ability to step with Nationwide
his right leg on the Childrens
tread-mill despite a Hospital. The
loss of sensation intensive stepping-
and that treadmill focused inter-
training has been vention at The
suc-cessfully used Ohio State
to improve ambula- University Medical
tory skills in Center, consisted
patients with of tread-mill
similar training once per
impairments, week for 20
treadmill training months and was
con-tinued to be a combined with a
good option for this home treadmill
patient. It was still training program
unknown whether a performed by the
toddler who had family 8 minutes
not pre-viously per day, 5 days per
walked, had no week, for 16
sensation, and had months.
very limited left leg
mobility would be
able to perform Treadmill training
alternating steps. with a harness and
Therefore, the body weight
primary goal of the support included 2
treadmill training pri-mary
was to improve components:
stepping. The stepping manu-ally
planned outcome facilitated by
measures included trainers and unas-
independent sisted,
stepping frequency independent
and pattern on the stepping attempts
treadmill, by the toddler. In
overground static previous work with
standing, and treadmill training
stepping in a for infants, the
walker. moving belt of the
tread-
mill provided an combination of Finally, we added
environment that facil-itated, bouts of
aforded unassisted, and independent
stepping.16,17,24,27,34 overground stepping with both
Manual facilitation training in legs
generally is progressively
unnecessary longer bouts for 50
because infants at to 60 minutes per
various ages and ses-sion. During
with various facilitated
diagnoses produce stepping, 3
independent trainers provided
steps.16,17,23,24,26,27,3537 manual assistance
In our patient, only
to facilitate the
sporadic steps on 1
proper alignment
side occurred.
of all body
Therefore, we
segments and
selected facilitation
alternating and
to provide expe-
rience with symmetrical steps.
frequency of Facilitation was
stepping and provided at the
alternating steps. pelvis to achieve
The overarch-ing rotation and at
objective was to each leg to
encourage the maintain proper
toddler to step as limb kinematics
independently as during swing and
possible. Given that stance. Initially, we
learning to step alternated 1
depends on minute of step
volitional, training with
independent bilateral
movement on the facilitation and 1
treadmill,11,20 the minute without
toddler was facilitation to
encouraged to encourage
produce unassisted indepen-dent
steps on the attempts to step.
treadmill. Typically, we
Facilitated delivered 6 to 10
overground bouts per session.
locomotor training The training
was added to the progressed to
training program unilateral
once independent facilitation with
alternat-ing independent step-
stepping emerged ping of the
at 24 months of opposite limb. The
age. tran-sition to
unilateral training
occurred when
The treadmill attempts to swing
program was com- the left leg
pleted by 4 trainers emerged. We used
with 5 years of fewer bouts but
experience in adult increased bout
step training; they duration to 5
delivered a minutes or more.
to develop toddler per-formed without lower
alternating standing training extremity
stepping and bouts with little or no facilitation and use
of backward body weight of the WalkAble
walking to improve support. Standing Pediatric LiteGait
active hip bouts varied WK100 suspension
extension. We between double- system (LiteGait,
added 3 to 5 of limb stance and Tempe, Arizona)
these bouts per ses- single-limb stance. with lower
sion and continued The toddler also extremity facili-
each bout until performed dynamic tation by the family.
alternating standing training After 16 months of
stepping ceased. by moving from sit- home training, the
All inde-pendent ting to standing family moved and
training bouts and back to sitting no longer had
included manual with facilitation as access to the home
assistance at the needed. Age- treadmill
pelvis for rotation. appropriate games, equipment.
songs, bubbles,
and toys were used Outcome
Embedded within as motivators for Data Reduction and
the training pro- participation and Analysis
gression were a positive reinforce- Each weekly
reduction of body ment throughout treadmill
weight support and all parts of the intervention
higher treadmill treatment sessions. session was
speeds. These digitally recorded
parameters were and used for
adjusted to deliver The home treadmill behavioral analysis.
the lowest body training pro-gram Before each
weight support and consisted of training session,
the highest speed. approximately 8 data from two 1-
minutes of both minute bouts of
manual suspension independent step-
Between bouts, the over the treadmill ping were collected
as the toddler

August 2014 Volume

94 Number 8 Physical Therapy f 1179
Treadmill Training After Surgical Removal of Spinal Tumor in Infancy
each stepping
pattern served as
pri-mary outcomes
per session. To
mea-sure
overground
performance, we
calculated gait
speed from video
recordings
collected at a
sagittal angle, a
rate of 30 frames
Figure 2. per second, and a
(A) Test for independent stepping on the treadmill measured distance.
without facilitation. (B) Facilitated step training. Progres-sion of
walking and
standing was based
on a chart review of
traditional physical
therapy sessions.

Independent
Stepping
Frequency on
the Treadmill
At 15 months of
age, a low rate of
independent
stepping was
observed, with only
10 steps per
minute. The rate of
independent
stepping pro-
was held over the parallel, or double a result, was
treadmill by a on the basis of preceded or
trainer (Fig. 2). No previous followed by a step
facilitation literature.17 with the opposite
occurred. These Specifically, an leg. When a step
bouts served as our alternating step with 1 leg was not
measure of was initiated pre-ceded or
stepping frequency within 20% to 80% followed by a step
and pattern when of the step cycle on with the opposite
analyzed frame by the opposite leg leg, it was a single
frame (30 frames and, as step. In a parallel
per second). A step step, both feet
was defined as the initiated the swing
foot moving past phase at
the hip joint during approximately the
the swing phase same time. A
and moving at least double step
1.5 foot lengths in occurred during a
the sagittal sequence of
20,27
plane. Each alternating steps
step-ping pattern when a second step
was classified as was taken with 1
alter-nating, single,
leg without a gressively steps on the left
second step being increased with (Fig. 3B). Over the
taken with the intensive treadmill 20-month inter-
opposite leg; this training to 45 steps vention period,
pattern appears as per minute by 35 stepping with the
a stutter months of age (Fig. right and left legs
step.20,24,38 The 3A). Of note, only increased, with a
average number of the right leg greater rate of
steps per 1-minute accounted for most improvement being
bout of indepen- of the stepping observed for the
dent stepping and rate from 15 left leg, suggesting
the percentage of through 20 months improvements in
of age because symmetry and
there were few or bilateral function
no independent (Fig. 3).

Figure 3.
Stepping frequency. (A) Monthly means and standard deviations of independent steps taken
on the treadmill during testing sessions.
(B) Comparison of right and left steps that contributed to the average number of steps
per minute. An increase in the number of steps was observed over time, with the
greatest improvement being noted for the left lower extremity.

1180 f Physical Therapy Volume 94 Number 8

August 2014
Treadmill Training After Surgical Removal of Spinal Tumor in Infancy
facilitated and unassisted training.
Stepping Pattern
During
Treadmill Testing
Sessions
Of the 4 possible
treadmill stepping
patterns described
in the literature for
infants and
toddlers,17,27,38 only
single or
alternating steps
on the treadmill
were taken by the
toddler in this case
report. An increase
in the percentage
of alternating steps
and a matching
decrease in the
percentage of
single steps over
the 20-month
intervention period
were observed (Fig.
4). Importantly, at
30 months of age, a
pattern of
alternating
stepping on the
treadmill occurred
more than 80% of
the time. In sharp
contrast, during the
initial 6 months of
train-ing,
alternating steps
comprised fewer
than 10% of the
total steps. The
improvement in
alternating
stepping coincided
with gains in
independent
stepping on the
tread-mill and
overground (Fig. 4,
solid lines).
Meaningful
attempts at inde-
pendent stepping
with the left leg on
the treadmill
occurred after 6
months of
 Figure 4.
Pattern of stepping. The percentage of alternating steps
on the treadmill increased dramatically as the
percentage of single steps decreased. Initially, a
response to training occurred during facilitated stepping
(solid purple line). Variability in stepping pattern
coincided with less facilitation and more unassisted
stepping during training (solid orange line). A stable
alternating pattern emerged after several months of
unassisted stepping and overground (solid green)
training. From 21 months on, responsiveness to both
unassisted stepping (solid orange line) and facilitated
stepping (broken purple line) occurred on the treadmill
and overground in the clinic.
emerged.

those that did

Overground occur required
In summary, before
Stepping and facili-tation. The
the intervention,
Independent toddler displayed
the patient
Standing greater deficits in
produced few or no
Table 1 shows the steps in the the left lower
development and treadmill extremity, as
progression of environment, and observed by
overground occasional but
walking during the unsuc-cessful
period of intensive attempts to step
tread-mill training. with the left leg.
Performance began Improvements
with static standing noted during the
with arm sup-port treadmill training
on the walker and program included
reached inde- an increase in the
pendent walking total number of
with a reverse steps taken, more
walker. The pattern symmetrical step-
of walking var-ied, ping, a shift from a
as did gait speed, single-step pat-tern
which was to an alternating
measured at 0.048 stepping pat-tern,
and 0.040 m/s at 31 and the ability to
and 35 months of take independent
age, respec-tively. steps with a
Coinciding with reverse walker. A
changes in walking video of the
were gains in patients prog- ress
standing dur-ing through the
functional tasks treadmill training
and indepen-dently intervention over
(Tab. 2). During time is available
both walking and online at
standing, reliance ptjournal.apta.org.
on assistance
decreased over
time, and indepen- Discussion
dence in walking Intensive locomotor
and standing treadmill train-ing
in combination with walk take hun-
traditional physical dreds of practice
therapy and a home sive treadmill steps per day.39
tread-mill training training program Treadmill training
program may be was designed to provides a task-
efec-tive for a promote the specific
toddler with SCI develop-ment of intervention option
after the removal of walking despite a for step training for
a spinal tumor. The lack of sensation in infants with motor
inten- and severe motor dis-abilities. The
impairments of the belt speed, body
legs. The toddler weight support,
showed great and type of physical
improvements in therapist
step-ping facilitation can be
frequency, modified to
stepping pattern, accommodate a
standing, and variety of physical
walking. He needs and
developed the maximize voluntary
ability to ambulate step-ping. We used
approxi-mately 6 m these techniques to
(20 ft) in his promote
walker with consecutive
standby assistance. stepping prac-tice
in a toddler who
had SCI and had
Infants learning to