DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Effects of a supported speed treadmill training exercise program on

impairment and function for children with cerebral palsy
THERESE E JOHNSTON 1 | KYLE E WATSON 2 | SANDY A ROSS 3 | PHILIP E GATES 4 | JOHN P GAUGHAN 5 |
RICHARD T LAUER 6 | CAROLE A TUCKER 6 | JACK R ENGSBERG 7

1 Department of Physical Therapy, University of the Sciences, Philadelphia, PA. 2 Department of Physical Therapy, Shriners Hospitals for Children, Philadelphia, PA. 3 School of
Health Professions, Maryville University, St Louis, MO. 4 Medical Staff, Shriners Hospitals for Children, Shreveport, LA. 5 Department of Physiology, Temple University,
Philadelphia, PA. 6 Department of Physical Therapy, Temple University, Philadelphia, PA. 7 School of Medicine, Washington University, St Louis, MO, USA.
Correspondence to Dr Therese E Johnston at Department of Physical Therapy, Sansom College of Health Sciences, University of the Sciences in Philadelphia, 600 South 43rd Street, Box 39, Philadelphia,
PA 19104, USA. E-mail: t.johnston@usp.edu

This article is commented on by Low on page 680 of this issue.

PUBLICATION DATA AIM To compare the effects of a supported speed treadmill training exercise program (SSTTEP)
Accepted for publication 16th March 2011. with exercise on spasticity, strength, motor control, gait spatiotemporal parameters, gross motor
Published online 17th June 2011. skills, and physical function.
METHOD Twenty-six children (14 males, 12 females; mean age 9y 6mo, SD 2y 2mo) with spastic
ABBREVIATIONS cerebral palsy (CP; diplegia, n=12; triplegia, n=2; quadriplegia n=12; Gross Motor Function Classifi-
MCID Minimum clinically important cation System levels II–IV) were randomly assigned to the SSTTEP or exercise (strengthening)
difference group. After a twice daily, 2-week induction, children continued the intervention at home 5 days a
PBWSTT Partial body-weight-supported week for 10 weeks. Data collected at baseline, after 12-weeks’ intervention, and 4 weeks after the
treadmill training intervention stopped included spasticity, motor control, and strength; gait spatiotemporal parame-
PODCI Pediatric Outcomes Data Collection
ters; Gross Motor Function Measure (GMFM); and Pediatric Outcomes Data Collection Instrument
Instrument
SSTTEP Supported speed treadmill training (PODCI).
exercise program RESULTS Gait speed, cadence, and PODCI global scores improved, with no difference between
groups. No significant changes were seen in spasticity, strength, motor control, GMFM scores, or
PODCI transfers and mobility. Post-hoc testing showed that gains in gait speed and PODCI global
scores were maintained in the SSTTEP group after withdrawal of the intervention.
INTERPRETATION Although our hypothesis that the SSTTEP group would have better outcomes
was not supported, results are encouraging as children in both groups showed changes in
function and gait. Only the SSTTEP group maintained gains after withdrawal of intervention.

Developing the ability to walk is an important functional goal
for children with cerebral palsy (CP). A relationship has been
shown between locomotor ability and the performance of
activities of daily living and social roles.1 Children with CP in
lower levels on the Gross Motor Function Classification
System (GMFCS) and, thus, greater mobility impairments
display a decrease in overall daily walking activity2 and an
increased energy cost of walking3 than those in higher
GMFCS levels. Therefore, interventions targeted at improv-
ing walking ability in children in lower GMFCS levels are
important for developing methods to improve overall function
and activity.
Partial body-weight-supported treadmill training (PBWSTT)
is more widely used in the rehabilitation of populations with
neurological conditions than previously, including children
with CP. Literature on PBWSTT in CP consists mainly of case
reports and small non-randomized trials with or without com-
parison groups. Recently, three separate reviews of PBWSTT
in children with CP have been published4–6 as well as one
review on PBWSTT in pediatric rehabilitation.7 Two
reviews4,6 concluded that PBWSTT may be safe and effective
for improving gait speed, and one concluded that it may be
beneficial for improving gross motor skills.4 However, a third
review concluded that there is insufficient evidence to deter-
mine if PBWSTT leads to improvements for children with
CP.5 In the review of PBWSTT in pediatric rehabilitation,7 it
was concluded that the evidence is weak for outcomes for chil-
dren with CP, and that randomized trials are needed to exam-
ine issues such as effectiveness and dosing. These reviews
suggest that research that is more stringent is needed to
determine the effectiveness of PBWSTT for children with CP.
Changes in gait spatiotemporal parameters after PBWSTT
have been reported. Two studies reported significant increases
in gait speed for children aged 6 to 14 years classified in
GMFCS level I8 (walks without restrictions but has limitations
in more advanced gross motor skills)9 or ages 6 to 14 years
classified in GMFCS levels III and IV10 (III, walks with
assistive mobility devices but has limitations walking outdoors

742 DOI: 10.1111/j.1469-8749.2011.03990.x ª The Authors. Developmental Medicine & Child Neurology ª 2011 Mac Keith Press

and in the community; IV, self-mobility with limitations but
is transported or uses power mobility outdoors and in the
community).9 Another study reported no change in gait speed
but significant increases in stride length for 3- to 6-year-old
children in GMFCS levels II (walks without assistive mobility
devices but has limitations walking outdoor and in the com-
munity)9 and III. Therefore, PBWSTT interventions have the
potential to impact upon these parameters. Several studies
have reported gains in Gross Motor Function Measure
(GMFM) scores after PBWSTT across various ages and
GMFCS levels, with most change reported in dimension E
(walking, running, and jumping activities).4,6
Spasticity, muscle weakness, and impaired motor control
are key impairments associated with CP. Knowledge of these
impairments is a part of any clinical examination or investiga-
tion of a child with CP because they provide key information
about the physical state of the child. Furthermore, quantifica-
tion of impairments is particularly valuable if measures may be
altered by an intervention. One small non-randomized study11
reported no change in spasticity as assessed by the Ashworth
scale or in motor control using a clinical ordinal scale after a
12-week PBWSTT program. However, no study has used
more rigorous objective measures to assess the effects of
PBWSTT on strength, spasticity, or motor control.
As children in GMFCS levels III and IV present with more
limitations in functional walking than those in higher GMFCS
levels, these children may experience greater benefits after an
intervention as small improvements in gait speed may signifi-
cantly improve their functional abilities.4 Therefore, a
PBWSTT program may be ideal to enable these children to
achieve consistent walking patterns and speed.
The purpose of this randomized controlled trial was to
compare the effects of a home-based PBWSTT protocol, the
supported speed treadmill training exercise program (SST-
TEP), with a home-based exercise program for spasticity,
strength, motor control, gait speed, gross motor skills, and
physical function. The goal of the SSTTEP intervention was
to encourage faster walking speeds (‘speed’ component in pro-
tocol title) while walking on the treadmill with partial body-
weight support (‘support’ component of protocol title). The
hypothesis was that children in the SSTTEP group would
show greater improvements than those in the home-based
exercise group.
METHOD
Participants
Children with spastic diplegic, triplegic, or quadriplegic CP
were recruited through and the study conducted at outpatient
clinics at three intervention sites in different regions of the
USA: the Shriners Hospitals for Children in Philadelphia, PA,
Shreveport, LA, and St Louis University and Washington Uni-
versity in St Louis, MO. The following inclusion criteria were
used: spastic CP; marginal ambulatory function (defined as
decreased gait velocity <80% of age-expected value regardless
of GMFCS level, or GMFCS level III or IV); ability to
take eight steps independently with or without assistive
devices; body weight less than 150 pounds (approximately
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What this paper adds
• This study is, to our knowledge, the only multi-site randomized controlled trial
to compare a partial body-weight-supported treadmill training intervention
with an exercise intervention.
• Children with CP can make gains in gait and function after an intensive
12-week intervention.
• No differences were found in strength, spasticity, or motor control as a result
of the treadmill training.
• Only the SSTTEP group maintained gains after withdrawal of the intervention.
68kg; equipment limits); age 6 to 13 years; and ability to follow
multiple-step commands during training and data collection.
Children were excluded for the following reasons: a medical
condition that would be negatively affected by exercise; lower
extremity orthopedic surgery in past year, botulinum toxin A in
the past 6 months, or dorsal rhizotomy in past 2 years; flexion
contractures greater than 30 at the hip or greater than 20 at
the knee or plantarflexion contractures greater than 15 with
the knee extended; intrathecal baclofen; or athetoid or mixed
types of CP.
Institutional review board approval was obtained at each
site. Parents (one parent per child) and children, ages 7 and
older, signed the approved consent and assent forms respec-
tively. Authorization required by the Health Insurance Porta-
bility and Accountability Act was obtained from parents.
Intervention
Children were randomly assigned to the SSTTEP or exercise
group using a block randomization schedule at each site using
blocks of eight group assignments (four of each intervention
per block). Children in each group underwent 2 weeks of
intensive training, in which two 30-minute sessions were con-
ducted 5 days a week under the supervision of a physical ther-
apist at one of the study sites or the child’s home. The goals of
the induction period were to establish each child’s program
and to train the parents on its implementation. After the
induction period, parents took home all equipment and con-
ducted the intervention for 30 minutes, five times per week
for 10 weeks. This protocol was based on previous unpub-
lished pilot work within our laboratory that suggested an
intensive induction followed by 5 days per week of treatment
led to better outcomes than a similar program without the
induction period. The duration of 12 weeks was based on neu-
rophysiological training effects; this duration was also reported
in a study that found improvements in functional ambulation
category and gross motor function in non-ambulatory
children with CP.12
The SSTTEP group used a home folding treadmill and a
pediatric suspension walker (Kaye Products, Hillsborough,
NC, USA) that fitted over the treadmill. Each child was
wore a harness for use with the walker. For the intervention,
the physical therapist or parent sat on a therapy bench
(Kaye Products) in front of the child to guide the child’s
leg, if needed. (Fig. 1). Children were allowed to use their
ankle–foot orthoses if they were unable to walk overground
without them or the therapist determined that the gait pat-
tern on the treadmill was poor without them. The initial
training speed was based on the child’s baseline gait speed
Function and Gait Following Treadmill Training Therese E Johnston et al. 743

Figure 1: Photograph of set-up for the supported speed treadmill training
exercise program (SSTTEP) group.
determined by gait analysis and adjusted as needed based on
the child’s response while walking on the treadmill. The
goals for this group during the induction period were to
decrease body-weight support to less than 30% and then
increase speed toward normal values. Decisions to alter
body-weight support and speed were based on the child’s
ability to achieve and maintain a foot–flat or heel–toe pat-
tern, initiate swing and achieve knee extension in stance,
and obtain consistent foot placement.
The exercise group participated in an exercise program
based on impairments and functional tasks, with an emphasis
on strengthening exercises and on standing-weight-bearing
activities. Specific components were forward step-ups, squats,
upper and lower extremity progressive resistive exercise, and
core strengthening. Assistance was provided by the physical
therapist (induction period) or the parents (at home) as
needed, and assistive devices were allowed to be used for the
weight-bearing exercises. The program was determined indi-
vidually for the children, taking into account their individual
standing abilities and overall strength and endurance for each
exercise. However, as with the SSTTEP group, the duration
of each child’s session was 30 minutes.
All home training for each group was monitored by each
site’s primary physical therapist through weekly telephone
calls to the parents. At that time, decisions were made about
increasing the speed for the SSTTEP group or advancing the
exercise program. Advances in the exercise program first
included increasing the number of repetitions performed and
then adding resistance by cuff weights. Parents of children in
each group kept weekly logs to record that each session had
been completed.
744 Developmental Medicine & Child Neurology 2011, 53: 742–750
14698749, 2011, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03990.x by Cochrane Saudi Arabia, Wiley Online Library on [17/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Data collection
Before and after the 12-week intervention period (2wks’
induction, 10wks’ home training), data were collected at each
child’s primary site by the same evaluator as at baseline to
measure spasticity, strength, motor control, gait spatiotempo-
ral parameters, gross motor skills, and physical function. An
additional data collection session was performed 4 weeks after
the intervention ended to quantify any carryover effects. Two
sites were able to blind the evaluators to group assignment
(representing 16 children) but the third site was unable to
because of personnel issues. All evaluators were blinded to
results and trained on each measure for which written study-
specific protocols were available at each site. Inter- and
intrarater reliability testing was not performed. All evaluators
routinely used these measures within their practice settings
before the study.
Spasticity of the plantarflexors and knee flexors was assessed
with the child in a semi-supine position on a KinCom com-
puterized dynamometer (Chattanooga Group, Chattanooga,
TN, USA).13–15 This test was chosen rather than a more clini-
cal measure such as the Ashworth scale, which has question-
able validity.16,17 Using a computerized dynamometer allows
the limb to be moved at a constant speed across tests and
across participants and meets the criteria for a spasticity test to
measure velocity-dependent resistance to movement.14,17 For
the test, the child’s hip was flexed approximately 25 and the
knee was in full extension. The pelvis, thigh and lower leg
were secured with straps. For the ankle, the child was
instructed not to move and to remain as relaxed as possible as
the ankle joint rotated passively from a plantarflexed to a
dorsiflexed position (maximum of 40 of plantarflexion and
maximal dorsiflexion for each child). The ankle was rotated
three times at 5 ⁄ s for gravity correction. For the spasticity
tests, 10 repetitions were randomly performed at angular
velocities of 15, 60, 90, and 180 ⁄ s. Values representing the
amount of work required to move the ankle passively through
the range of motion were determined for each angular velocity
for each child. The process was similar for the knee, with a
range of motion from 20 to 90 of flexion. Spasticity values of
the ankle plantarflexor and knee flexor were calculated from
the slope of a linear regression of the angular velocity–work
values. Test–retest reliability for this test is moderate for chil-
dren with CP.13 One site was unable to collect spasticity data
because the dynamometer was unable to accelerate quickly
enough to obtain the desired angular velocities. The sample
size for the spasticity assessment was 18 (10 in SSTTEP, eight
in exercise).
Strength was measured using the same set-up as the spastic-
ity assessment.15,18 The child exerted the maximum amount of
dorsi- and plantarflexion or knee flexion ⁄ extension concentric
force over the range of motion during a 10 ⁄ s isokinetic test.
Testing through the range of motion at a slow speed allows
the child time to generate force and provides strength data
for more than just one angle, including end-range knee
extension.18 The maximum gravity-corrected values normal-
ized by dividing by body mass were used as the measure of
strength. For all strength tests, three trials were performed

and the highest value from the three trials was defined as the
maximal strength.
Motor control of the quadriceps was tested in the same
position as spasticity and strength testing.19 Testing for
motor control in this manner allows an objective measure to
be obtained,19 and testing one joint in isolation decreases the
complexity of the task, allowing the child to focus on one
motion. The dynamometer was set to the isokinetic mode,
with an angular velocity of 10 ⁄ s. A ‘target’ force (20% of the
maximum value determined during strength testing) was dis-
played on the computer monitor as a horizontal line on a
force–angle diagram. The child was then asked to match that
force as the knee was moved toward extension from
maximum knee flexion. The standard deviation (SD) of the
force–angle data was used as the outcome value because it
quantified the variability of the force application over the
range of motion.
Gait speed, cadence, and stride length were measured by
three-dimensional motion analysis. Children walked at their
self-selected speed using their commonly used assistive device
and ankle–foot orthoses if unable to walk without them. Gross
motor skills were assessed using dimensions A to E of the
GMFM, a standard criterion-referenced test designed to assess
change in gross motor function in children with CP.20 Physi-
cal function was measured using the parent report (paper and
pencil version) of the Pediatric Outcomes Data Collection
Instrument (PODCI).21 The PODCI has been shown to have
good validity, reliability, and sensitivity for children aged 2 to
18 years. It includes scales of global function, physical sports
and activities, transfers and mobility, upper extremity function,
and comfort. The parent report for the PODCI global func-
tion score, and the transfers and mobility scores, were used as
the primary measures of physical function. Children were
required to complete at least 40 out of 50 full sessions (80%
adherence) to participate in data collection.
Statistical analysis
From a priori data analysis, the projected sample size
with a=0.05 (two-tailed test) and a power of 80% was 54
participants. Gait speed was used as the primary outcome
measure, with a clinically meaningful increase of 0.10m ⁄ s
Table I: Assistive device use and body-weight support (BWS) for the children enrolled in the study
Initial percentage
Group Assistive device BWS
SSTTEP None (n=1) 35.4 (SD 14.2)
Cane (n=1)
Anterior walker (n=1)
Posterior walker (n=11)
Exercise None (n=1)
Canes (n=1)
Forearm crutches (n=2)
Posterior walker (n=6)
Gait trainer (n=2)
For the supported speed treadmill training exercise program (SSTTEP) group, percentage BWS and treadmill speed were included for the initial
induction training session and the last home session.
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identified. Based on pilot work and the work of
Engsberg et al.,22 an SD of 0.19m ⁄ s was used to determine
sample size.
The dependent variables were treated as continuous vari-
ables for all analyses. Means, sums, and SDs are presented for
all variables. The experimental design was a three-factor
(treatment group, time, trial) mixed design with repeated mea-
sures on one factor (time). The null hypothesis was that there
was no difference in the measured parameters among the
treatment groups or between time periods (0, 12, 16). Before
analysis, all data were tested for normality using the Shapiro–
Wilk test. The data for the dependent variables were signifi-
cantly non-normal. To apply analysis of variance (ANOVA)
methods, a ‘normalized-rank’ transformation23 was applied to
the data before analysis. The rank-transformed data were ana-
lyzed using a mixed-model ANOVA for repeated measures
followed by multiple comparisons to detect significant individ-
ual mean differences at each time. Multiple pair-wise compari-
sons used an experiment-wise type I error of 0.05. Differences
between group means, times, etc. (rejection of the null
hypothesis) were considered significant if the probability of
chance occurrence was less than or equal to 0.05 using two-
tailed tests.
The minimum clinically important difference (MCID) has
been calculated for several commonly used measures for chil-
dren with CP in order to establish the clinical meaningfulness
of change.24 Therefore, the MCID for each child was used as a
secondary measure to begin to understand changes that
occurred in the GMFM, PODCI, and the gait spatiotemporal
parameters. MCIDs reported by Oeffinger et al.24 (PODCI
and gait spatiotemporal parameters) and Wang and Yang25
(GMFM) were used to examine the data in this study. Oeffinger
et al.24 only reported data for children classified in GMFCS
levels I to III, so level III MCID data were used for the children
classified in level IV in our study.
RESULTS
Thirty-eight children were screened and 26 completed the
study, with 14 assigned to the SSTTEP group and 12 to the
exercise group (Table I and Table SI [supporting material
online], and Fig. 2). The SSTTEP group consisted of seven
End percentage Initial treadmill End treadmill
BWS speed (m ⁄ s) speed (m ⁄ s)
15.7 (SD 17.0) 0.36 (SD 0.18) 0.64 (SD 0.33)
Function and Gait Following Treadmill Training Therese E Johnston et al. 745

Screened for study (n=38)
Randomized (n=34)
Allocated to SSTTEP
(n=18)
Received allocated
intervention (n=16)
Did not receive allocated
intervention (n=2)
Lost to follow-up (n=2)
Discontinued participation
part way though intervention
period
Analyzed (n=14)
Excluded from analysis
(n=0)
Figure 2: Consort flow diagram. SSTTEP, supported speed treadmill training exercise program.
males and seven females (mean age 9y 7mo, SD 2y 2mo). Eight
children had diplegic and six quadriplegic CP, and were in
GMFCS levels II (n=1), III (n=9), and IV (n=4). In the exercise
group, the seven males and five females had a mean age of
9 years 6 months (SD 2y 4mo), with four with diplegic, two
with triplegic, and six with quadriplegic CP. GMFCS levels
were II (n=1), III (n=6), and IV (n=5).
Six participants were lost to follow-up at the 12-week point
because of personal and family reasons not related to the inter-
vention. Two children (in the SSTTEP group) did not partici-
pate in data collection after the washout period. All children
obtained an adherence rate of at least the required 80%. Study
power was calculated to be 12.7% for the 26 children who
completed the study.
After the intervention there were no differences within or
between groups for spasticity, strength, or motor control
(Table II). The variability, as indicated by the SD, was large
for all measures. Changes were found in all spatiotemporal
parameters (p<0.001), with no difference between groups
(Table II). Gait speed and cadence improved, with inconsis-
tent changes seen with stride length. Post-hoc testing showed
an increase in gait speed for both groups (SSTTEP, p=0.008;
746 Developmental Medicine & Child Neurology 2011, 53: 742–750
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Did not meet inclusion
criteria (n=4)
Allocated to exercise
(strengthening) group (n=16)
Received allocated
intervention (n=16)
Did not receive allocated
intervention (n=0)
Lost to follow-up (n=4)
Discontinued participation
part way though intervention
period
Analyzed (n=12)
Excluded from analysis
(n=0)
exercise, p=0.007) after the intervention, but the gains were
only maintained in the SSTTEP group (p=0.545 between the
12- and 16-week periods). Cadence improved for children in
the exercise group after 12 weeks (p<0.001), with no signifi-
cant decline in values after the washout period (p=0.170
between the 12- and 16-week periods). Post-hoc testing for
stride length showed a gain for the SSTTEP group ( p=0.001)
after the intervention was withdrawn. However, there was a
decline in stride length for both groups after the intervention
(SSTTEP, p=0.001; exercise, p=0.005).
There were no significant changes ( p=0.31) in GMFM
scores in either group or differences between groups ( p=0.66;
Table II). The PODCI global score improved for all partici-
pants ( p=0.003) but there was no difference between groups
( p=0.73). Post-hoc testing showed gains in the PODCI global
score in the SSTTEP group ( p=0.001) after the intervention,
which was maintained after the intervention was withdrawn
( p=0.866 between the 12- and 16-week periods). There
were no significant changes ( p=0.31) in the PODCI
transfers and mobility scores across all children, and no
difference between groups over time ( p=0.47). To compare
the effects of the interventions measured on different scales
 14698749, 2011, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03990.x by Cochrane Saudi Arabia, Wiley Online Library on [17/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Table II: Means (SD) for outcome measures for the 26 children (14 in supported speed treadmill training exercise program [SSTTEP], 12 in exercise)

Baseline 12wks Washout

SSTTEP Exercise SSTTEP Exercise SSTTEP Exercise

Plantarflexor spasticity (J ⁄  ⁄ s) 0.0013 (0.0012) 0.0030 (0.0024) 0.0016 (0.0024) 0.0030 (0.0021) 0.0012 (0.0018) 0.0026 (0.0013)
Knee flexor spasticity (J ⁄  ⁄ s) 0.0088 (0.0114) 0.0032 (0.0044) 0.0074 (0.0133) 0.0072 (0.0137) 0.0083 (0.0139) 0.0053 (0.0044)
Knee extension strength (N ⁄ kg) 3.90 (3.09) 3.09 (3.15) 3.58 (2.82) 3.80 (4.22) 3.66 (3.25) 3.69 (3.66)
Knee flexion strength (N ⁄ kg) 2.47 (1.45) 2.35 (2.04) 2.43 (1.54) 2.98 (3.26) 2.57 (1.65) 2.54 (2.09)
Dorsiflexion strength (N ⁄ kg) 0.86 (1.21) 0.62 (0.75) 0.69 (0.78) 0.77 (0.66) 1.02 (1.54) 0.62 (0.53)
Plantarflexion strength (N ⁄ kg) 3.44 (1.91) 3.06 (3.62) 3.23 (1.45) 3.14 (3.32) 3.65 (2.13) 3.35 (3.17)
Motor control SD (N) 28.3 (14.9) 27.5 (16.4) 22.1 (9.0) 27.8 (5.6) 26.8 (11.6) 24.4 (8.7)
GMFM 62.7 (17.5) 58.4 (26.9) 63.3 (16.2) 60.1 (25.1) 65.3 (16.5) 60.6 (26.7)
PODCI global 50.4 (11.2) 50.9 (14.9) 59.1 (11.4) 52.0 (22.6) 60.0 (10.0) 55.4 (21.7)
PODCI transfers and mobility 46.4 (23.0) 60.6 (26.7) 55.0 (22.9) 55.4 (21.7) 56.9 (20.7) 49.9 (36.2)
Gait speed (m ⁄ s) 0.50 (0.26) 0.44 (0.35) 0.62 (0.31) 0.50 (0.39) 0.63 (0.28) 0.44 (0.34)
Cadence (steps ⁄ min) 76.9 (33.9) 53.3 (24.0) 82.2 (38.2) 60.7 (26.8) 81.2 (38.6) 55.5 (24.8)
Stride length (m) 0.71 (0.27) 0.61 (0.29) 0.68 (0.29) 0.55 (0.29) 0.78 (0.28) 0.64 (0.31)

The sample size for the spasticity assessment was decreased compared with other measures to 18 (10 in SSTTEP, eight in exercise) as one site’s
data could not be used. GMFM, Gross Motor Function Measure; PODCI, Pediatric Outcomes Data Collection Instrument.

over time, the within-group standardized effects over time
were calculated for each parameter with the 95% confidence
intervals (Fig. 3).
As shown in Table II, there was large variability in the
data, which contributed to the lack of statistical significance
between and ⁄ or within groups for the tested measures.
Therefore, MCID findings are important for understanding
the potential clinical significance of the results. Table III and
Table SII (supporting material online) show the MCID
results for each child for the GMFM,25 the PODCI, and gait
spatiotemporal parameters.24 These results show mixed
responses, with some children experiencing positive changes
and others negative changes across groups. Overall, it
appeared that the SSTTEP group had greater changes in the
PODCI and gait speed, and the exercise group had greater
change in the GMFM.
Minor anticipated adverse events were noted for three chil-
dren: two complained of leg ⁄ knee discomfort off the treadmill,
which resolved without intervention; and one child developed
a blister beneath his ankle–foot orthosis during the induction
period.
DISCUSSION
This study found gains in gait spatiotemporal parameters and
functional activity (PODCI), regardless of intervention group.
Therefore, both groups benefited from participation in the
study. However, there were no significant changes in the
impairment level measures of spasticity, strength, or motor
control for either group. Our hypothesis that the SSTTEP
group would show greater gains overall was not supported.
Despite this finding, the results of this study are encouraging.
Children were able to participate successfully in an intensive

Plantarflexor spasticity
Knee flexor spasticity
Knee extension strength
Knee flexion strength
Plantarflexion strength
Dorsiflexion strength
Quadriceps motor control
Gait speed
Cadence
Stride length
GMFM
PODCI global
PODCI transfers and mobility

1.8 –1.6 –1.4 –1.2 –1 –0.8 –0.6 –0.4 –0.2 0 0.2 0.4 0.6 0.8 1 1.2 1.4
Standardized effect size

Figure 3: Within-group standardized effects over time and their 95% confidence intervals for outcome measures. The solid line represents the supported
speed treadmill training exercise program (SSTTEP) group, the dashed line represents the exercise group. Results are considered significant if the 95%
confidence interval line does not include zero. GMFM, Gross Motor Function Measure; PODCI, Pediatric Outcomes Data Collection Instrument.

Function and Gait Following Treadmill Training Therese E Johnston et al. 747
 14698749, 2011, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03990.x by Cochrane Saudi Arabia, Wiley Online Library on [17/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Table III: Children in each group who showed minimal clinically important differences (MCIDs) after intervention

Group GMFM PODCI global PODCI transfers Gait speed Cadence Stride length

SSTTEP (n) )1 (3) )2 (0) )2 (2) )2 (0) )2 (0) )2 (4)

0 (7) )1 (2) )1 (0) )1 (1) )1 (1) )1 (1)
1 (4) 0 (3) 0 (3) 0 (8) 0 (5) 0 (4)
1 (0) 1 (1) 1 (1) 1 (4) 1 (0)
2 (6) 2 (6) 2 (4) 2 (3) 2 (4)
ND (3) ND (2) ND (1) ND (1)
Exercise (n) )1 (2) )2 (2) )2 (1) )2 (1) )2 (0) )2 (3)
0 (2) )1 (0) )1 (0) )1 (0) )1 (1) )1 (0)
1 (8) 0 (3) 0 (4) 0 (6) 0 (5) 0 (4)
1 (2) 1 (2) 1 (0) 1 (0) 1 (1)
2 (1) 2 (1) 2 (3) 2 (4) 2 (2)
ND (4) ND (4) ND (2) ND (2) ND (2)

Means (SDs) are calculated from the MCID codes to indicate overall positive or negative change. MCID codes: )2, large negative change (effect
size 0.8); )1, medium negative change (effect size 0.5 for Pediatric Outcomes Data Collection Instrument [PODCI] and gait. For the Gross Motor
Function Measure [GMFM] )1 indicates a negative change as no distinction was made between large and medium changes). 0, no significant
change; 1, medium positive change (effect size 0.5 for PODCI and gait. For the GMFM, 1 indicates a negative change as no distinction was made
between large and medium changes); 2, large positive change (effect size 0.8). SSTTEP, supported speed treadmill training exercise program;
ND, no data.

12-week, primarily home-based, intervention program with
positive outcomes.
Dodd and Foley10 examined gait speed after a 6-week
treadmill training intervention for children aged 5 to 14 years
with CP classified in GMFCS levels III and IV. They found
no difference in gait speed between a non-intervention com-
parison group and those using a treadmill. However, gains
were reported within the treadmill group with an effect size
of 1.02 and mean increase in gait speed of 0.7m ⁄ s, with no
change within the comparison group. Willoughby et al.26
found no changes in gait speed for children classified in
GMFCS levels III and IV, who were randomly assigned to a
9-week treadmill or overground walking program conducted
twice a week. In our study, both groups received an interven-
tion and improved in gait speed. However, children in our
study participated in a more intensive program than that of
Dodd and Foley10 or Willoughby et al.26 Finally, in a small
pilot study by Begnoche and Pitetti,27 a younger sample (ages
2–9y) of children with CP significantly improved step length
after a 4-week treadmill training intervention, although gait
speed and cadence did not change. These findings are oppo-
site to ours.
The focus of the exercise program was on muscles impor-
tant for walking and on standing-weight-bearing activities,
which were challenging for many children, especially those
classified in GMFCS level IV. The inclusion of weight-
bearing activities might help to explain the lack of significant
differences between groups for gait parameters, the PODCI,
and the GMFM in this study. Dobkin et al.28 found compara-
ble gains in walking speed and distance between a locomotor
program using body-weight-supported treadmill training and
an overground ambulation training program for people with
acute incomplete spinal cord injury. In their study, the over-
ground ambulation program involved more weight-bearing
activities than are typically performed in an acute rehabilita-
tion setting. As indicated by Dobkin et al.,28 the differences
between the two interventions may not have been significant
enough to find a statistical difference in the outcomes
measured, which may also be the case in our study.
Although there was no difference between groups, the post-
hoc findings for gait speed and the PODCI are important.
Children in both groups increased gait speed after the inter-
vention. However, only the SSTTEP group maintained this
improvement after the intervention was withdrawn. These
findings suggest that motor learning may have been a factor
based on task specificity and repetition with walking on the
treadmill. In addition, only children in the SSTTEP group
showed gains in PODCI global scores, which were maintained
without continued intervention, suggesting carryover effects.
Further research is needed to determine how long carryover
effects might last or if additional periodic training might be
needed to maintain gains.
The results for spasticity and motor control support previ-
ous work indicating no significant change as a consequence of
PBWSTT.11 As with the present investigation, Cherng et al.11
reported no changes in spasticity or motor control after non-
randomized intervention (n=8). Their measures for spasticity
(modified Ashworth scale) and motor control (graded scale)
differed from those used in our study, yet the results were the
same. Cherng et al.11 suggested that as assessments of spastic-
ity and motor control were performed under a ‘static’ condi-
tion, they might not be related to the ‘dynamic’ condition
associated with the PBWSTT intervention, and muscle tone
and motor control might not be associated with walking
performance or gross motion function. The unlinking of
spasticity and motor control to gait and gross motion function
has some merit, and little relationship has been reported
between spasticity, gait speed, and GMFM scores.29 In an
unpublished investigation, no correlation was found between a
measure of ankle motor control30 and gait speed and gross
motor function.
No difference was found in strength as a result of the
PBWSTT. The result is an interesting contrast to what is
characteristic of many previous studies in which a strength

748 Developmental Medicine & Child Neurology 2011, 53: 742–750


training regime was used, and strength and function changes
were assessed.31,32 Scholtes et al.32 used a progressive resis-
tance strength training program for children with CP (three
times a week for 12wks). They found that although strength
increased, there was no change in mobility. However, another
study31 had children with CP perform an ankle-strengthening
program (three times a week for 12wks). It found that strength
and gross motor function improved, and that gait speed was
improved for participants strengthening the plantarflexors. In
both of these studies, the strategy was to improve the impair-
ment and determine if function improved. In the current
study, the strategy was to improve the function directly (i.e.
gait for SSTTEP group) and to determine if function and
impairments improved. In terms of the International Classifi-
cation of Functioning, Disability and Health, these measures
reflect Body Function (strength) and Activity (gait and gross
motor function) and their interactions.33 Understanding the
mechanisms leading to improvement in function would be
helpful in developing training protocols for children with CP.
A recent report34 has suggested that activity-based interven-
tions are more important for improving activity than impair-
ment-based interventions.
The use of MCID is becoming important in rehabilitation,
as a statistical change may not be clinically meaningful, and a
meaningful clinical change may not achieve statistical signifi-
cance. Therefore we decided to examine additionally the out-
comes of this study in relation to MCID values available in the
literature. As seen in Table III, the MCID results are mixed:
some children showed gains in most or all areas, others
showed a mix of improvements and declines, and some
showed no change and ⁄ or decline. These data are challenging
as many variables could account for differences such as
GMFCS level, baseline values for the measures studied, the
amount of body weight support and speed for the SSTTEP
group, and the intensity of the exercises completed by the
exercise group. A larger study with sufficient power is needed
to examine these relationships.
MCID suggested greater clinical change in GMFM for the
exercise group and in the PODCI and gait speed for the SST-
TEP group. This result should be interpreted with caution
owing to our small sample size. MCID data for spatiotemporal
gait parameters showed an interesting trend in that a greater
number of children aged 10 years and younger improved than
did those older than 10 years. Of note, our sample size of
younger compared with older children was small; however,
perhaps an intensive intervention, such as those used in this
study, may have a greater impact on younger than older chil-
dren. Future studies should examine differences in outcomes
across age groups to guide the appropriate timing of the inter-
vention.
There are several limitations of this study. First, there was
considerable variability in the data, thus weakening the overall
power of the study. We chose to work with marginally ambu-
latory children, which is a large undertaking and has an impact
on potential issues with variability. The issue of variability was
also reported by Dodd and Foley10 and is problematical for
14698749, 2011, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03990.x by Cochrane Saudi Arabia, Wiley Online Library on [17/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
research with this population. The initial goal of the study was
to have 54 children complete it, to give adequate statistical
power; however, the final number of children was much smal-
ler (50% of this goal) within the funding period for the grant.
The biggest challenge to recruitment was the 2-week clinic-
based induction period, which was sometimes difficult for par-
ents to accommodate around their home and work demands.
The large variability due to a small sample size possibly led to
a type II error. Based on the results of this study, a sample size
of 58 children per group would be needed to detect a differ-
ence of 0.1m ⁄ s in gait speed between groups with 80% power
(p=0.05 two-tailed test).
The inability to blind the evaluators at one site was another
potential limitation whose effects are unknown; however, the
data from that site showed increases and decreases in different
variables for children in each group, similar to what occurred
at the other two sites. The lack of data on spasticity at one site
also was a limitation, thus decreasing the sample size for this
measure. Another potential limitation was that most of the
intervention was conducted at home. Although this method
may have increased adherence, some control over routine
decision-making was potentially lost despite the regular
telephone calls to parents. Another limitation was the use of
MCID as data were unavailable for the PODCI and gait
spatiotemporal parameters for children classified in GMFCS
level IV. Therefore data from level III were used; however, the
accuracy of their use for level IV is unknown. Finally, measure-
ment error is not known for two of the impairment tests per-
formed in this study, so it is not known if the error affected the
findings.
CONCLUSION
Although our hypothesis that the SSTTEP group would have
better outcomes was not supported, the results are encourag-
ing as children in both groups showed important changes in
the functional measures. However, only children in the
SSTTEP group were able to maintain gains in some variables
once the intervention was withdrawn. Future research should
include a randomized controlled trial with a non-intervention
comparison group and a larger sample size; this would provide
greater protection against a type II error and determine
the factors that contribute to which children make the most
gains.
ACKNOWLEDGEMENTS
This study was funded by Shriners Hospitals for Children, grant
number 9147. We acknowledge Rosemary Norris and Debra Banks
for their efforts with training and monitoring progress of the children,
and Anna Means and Trent Wierick for assistance with data
collection. The funding agency was not involved in study design, data
collection, data analysis, manuscript preparation, or publication
decisions.
ONLINE MATERIAL ⁄ SUPPORTING INFORMATION
Additional material and supporting information for this paper may be
found online.
Function and Gait Following Treadmill Training Therese E Johnston et al. 749

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