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Effects of Intensive Locomotor Treadmill Training on Young Children

with Cerebral Palsy

Article in Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association · December 2009
DOI: 10.1097/PEP.0b013e3181bf53d9 · Source: PubMed

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 R E S E A R C H R E P O R T

Effects of Intensive Locomotor

Treadmill Training on Young
Children with Cerebral Palsy
Katrin Mattern-Baxter, PT, PCS, DPT, Sandra Bellamy, PT, DPT, PCS, and Jim K. Mansoor, PhD
Department of Physical Therapy, University of the Pacific, Stockton, California

Purpose: To examine whether an intensive, short-term locomotor treadmill training program helps children
with cerebral palsy (CP) younger than 4 years of age improve their gross motor skills related to ambulation,
walking speed, and endurance. Methods: Six children with cerebral palsy, ages 2.5 to 3.9 years, participated in
treadmill training 3 times per week for 1-hour sessions consisting of 2 individualized treadmill walks, for 4
weeks, and were tested before and after the intervention and at a 1-month follow-up. The outcome measures
included the Gross Motor Function Measure-66, the Pediatric Evaluation of Disability Inventory, a timed 10-m walk
test, and a 6-minute walk test. Results: Significant differences were found in the Gross Motor Function Measure-66
Dimensions D and E, the Pediatric Evaluation of Disability Inventory Mobility Scales, over-ground walking speed,
and walking distance. Conclusions: The results of this study provide preliminary evidence that children with CP
younger than 4 years of age can improve their gross motor function, walking speed, and walking endurance after
intensive locomotor treadmill training. (Pediatr Phys Ther 2009;21:308 –319) Key words: activities of daily living,
age factors, cerebral palsy/therapy, child/preschool, exercise therapy, gait, human movement system, physical
therapy modalities/instrumentation, treatment outcome, walking

INTRODUCTION dren with CP state ambulation as an explicit goal for their

Children with cerebral palsy (CP) show different motor
patterns than children with typical development. Their move-
ments are defined by excessive muscle cocontraction, altered
joint kinematics, and decreased postural reactions, resulting
in difficulty with ambulation for 90% of these children.1 Am-
bulation with or without assistance is important for various
reasons. It has been shown that children who are ambulatory
are more accomplished in their daily activities and peer inter-
actions compared with children who use a wheelchair.2 The
additional benefits of walking include increased bone mineral
density, cardiopulmonary endurance, and obesity preven-
tion.3,4 Furthermore, the majority of parents of young chil-
0898-5669/109/2104-0308
Pediatric Physical Therapy
Copyright © 2009 Section on Pediatrics of the American Physical
Therapy Association.
Address Correspondence to: Katrin Mattern-Baxter, PT, PCS, DPT, De-
partment of Physical Therapy, University of the Pacific, 3601 Pacific
Avenue, Stockton, CA 95211. E-mail: kbaxter@pacific.edu
Grant Support: Part of the equipment used in this study was obtained with
a Scholarly/Artistic Activity Grant from the University of the Pacific,
Stockton, Calif.
DOI: 10.1097/PEP.0b013e3181bf53d9
child.5 Young children with CP achieve their motor mile-
stones at an accelerated rate compared with older children
with CP.6 In light of this, it is crucial to provide intensive
physical-therapy intervention for children with CP during the
earlier years of childhood. In the past 10 years, locomotor
training on a treadmill (LTT) has been used in the treatment
of children with CP in an attempt to maximize walking inde-
pendence, gait speed, and walking endurance. Locomotor
training is designed to provide task-specific training with
multiple repetitions of the walking task. Active participation
of the child and explicit feedback in the form of verbal and
tactile reinforcement have been shown to aid in the achieve-
ment of new motor skills.7–9
Locomotor training has been studied in both ambulatory
and nonambulatory children with CP, with most studies hav-
ing been conducted with children ages 5 to 18 years.10 –15 Im-
provements in walking speed and endurance were shown in a
clinically controlled study of 14 school-age children ages 5.5
to 14.7 years with moderate to severe impairments (GMFCS
levels III and IV).14 In a study of 6 children ages 6 to 14 years
with mild impairments (GMFCS level I), significant improve-
ments were seen in the Energy Expenditure Index and gait
speed.12 When examining the effects of a 3-month LTT inter-
vention on gross motor function in 10 school-age children

308 Mattern-Baxter et al Pediatric Physical Therapy

from 6 to 18 years (GMFCS levels not specified), statistically
significant results in Gross Motor Function Measure
(GMFM) Dimensions D (standing) and E (walking, running,
and jumping) were found.11 In another group of 6 children
ages 2.3 to 9.7 years with a mean age of 6.8 years and with the
GMFCS levels ranging from I to V, improvement in gross
motor function and endurance were found after an LTT pro-
gram that was offered 3 to 4 times per week for 4 weeks.16 In
a study of 8 children ages 3.5 to 6.3 years with a mean age of
4.5 years and GMFM levels II and III, who received LTT 2 to
3 times per week for 36 weeks, significant improvements in
gross motor function and stride length were found.17
Despite these encouraging results, there is still a relative
paucity of literature on LTT related to younger children with
CP. In a case study, a 5-month-old infant with grade III intra-
ventricular hemorrhage and at high risk for developmental
disabilities was offered LTT for 23 weeks. This infant, who did
not have a diagnosis of CP, made great improvement in gross
motor function, including increased symmetry of gait, and
eventually achieved independent ambulation.18 In an ex-
tended study of 4 infants with CP who were nonambulatory
ages 1.7 to 2.3 years (mean age 2.0 years), LTT was provided
3 to 4 times per week for 4 months as an adjunct to traditional
physical therapy. All children showed improved gross motor
function, and 2 children attained independent walking.19
Both studies, however, were carried out for several months
and maturation effects could have played an important role.
The author of a recent systematic review concluded that there
was a lack of evidence regarding the effects of intensive, short-
term LTT on young children with CP younger than the age of
4 years.20
Accordingly, we examined the effects of intensive LTT in
children younger than 4 years with different types and sever-
ity of CP with respect to gross motor function, in particular,
standing and walking function. We used a short-term, inten-
sive intervention period of 4 weeks to limit gross motor
changes because of maturation. In particular, we were inter-
ested in determining whether this short-term, intensive pro-
gram would (1) increase the walking speed and the endur-
ance in children who were ambulatory with or without
supporting devices; (2) decrease the amount of assistance
needed for ambulation; (3) improve gross motor skills related
to standing and walking; and (4) decrease the amount of care-
giver assistance for the children.
METHODS
Study Participants
Approval for the study was obtained from the Institu-
tional Review Board of University of the Pacific, California.
Written informed consent was obtained from the parents,
and additional verbal assent was obtained from those chil-
dren who were old enough to understand the purpose of
the study. A convenience sample of 6 children with CP was
recruited from parent support groups, from referrals from
pediatric physical therapists in the community, and from
Early Intervention Programs in the Northern California
region. The inclusion criteria included (1) a diagnosis of
cerebral palsy, (2) age of 1 to 5 years, (3) weight less than
40 kg, (4) the ability to bear weight on legs with or without
support, and (5) parental ability to provide transportation.
The exclusion criteria included (1) a medical contraindi-
cation for standing or walking, (2) history of untreated
cardiac problems, (3) history of uncontrolled seizures, (4)
history of orthopedic surgery, and (5) use of medication to
control spasticity, including a baclofen pump or Botox in-
jections in the past 6 months. Ten children were screened
in their homes for participation in the study, with 6 chil-
dren meeting the inclusion criteria. All children who were
selected participated in the study, and 5 children attended
all scheduled sessions. Only 1 child missed 2 sessions be-
cause of respiratory illness.
The age of the children ranged from 2.5 to 3.9 years with
a mean age of 3.1 years, with 3 boys and 3 girls. Among them,
1 was GMFCS level I, 2 were GMFCS level II, 1 was GMFCS
level III, and 2 were GMFCS level IV; 3 children had spastic
diplegia, 1 had spastic quadriplegia, 1 had dystonic quadriple-
gia, and 1 had hypotonic CP. Of them, 3 children were able to
ambulate with supervision and supporting devices at the start
of the study, with 1 child beginning to take independent steps.
The other 3 children used gait trainers with maximal assist
(see Table 1 for subject characteristics).

TABLE 1
Characteristics of Participants at Entry into Study

GMFCS Height Weight

Subject Diagnosis Age (yr) Gender Race/Ethnicity Level Ambulatory Status Orthotics (cm) (kg)
1 Quadriplegic dystonic 2.8 F Multiracial IV Maximum assistance Bilateral solid 76 13.6
CP with gait trainer ankle AFOs
2 Spastic quadriplegic 3.3 M Multiracial IV Maximum assistance Bilateral solid 94 12.2
CP with gait trainer ankle AFOs
3 Hypotonic CP, cerebellar 2.9 M White III Maximum assistance with None 97 17.1
hypoplasia gait trainer
4 Spastic diplegic CP 3.9 F White II Supervision with reverse Bilateral solid 99 14.5
platform walker ankle AFOs
5 Spastic diplegic CP, 3.1 M Multiracial II Supervision with reverse None 86 10.9
chronic lung disease walker
6 Spastic diplegic CP 2.5 F White I Supervision with reverse Bilateral solid 74 11.8
walker ankle AFOs
CP indicates cerebral palsy; AFOs indicate ankle–foot orthoses.

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 309
Study Design and Outcome Measures
The intervention consisted of 12 treadmill training
sessions that were offered 3 times per week for a total of 4
weeks, with 1 or 2 days of rest between sessions. The train-
ing sessions consisted of 2 sets of treadmill walking with a
small break between sets. The children were encouraged to
walk for as long as possible and as fast as possible during
each set. All children were assessed at baseline within 10
days of the start of the intervention period. The post-
assessment was conducted within 7 days after completion
of the intervention period, and a 1-month follow-up was con-
ducted 1 month after the post-assessment. All dimensions
of the Gross Motor Function Measure (GMFM) and 3 do-
mains of the Pediatric Evaluation of Disability Inventory
(PEDI) (Mobility-Functional Skills, Mobility-Caregiver
Assistance, and Self-Help-Caregiver Assistance) were used
as tests of gross motor function. Additionally, performance
on the timed 10-m walk test, the 6-minute walk test, a
treadmill walk test, and standing balance on 2 feet was mea-
sured. The walking tests were conducted at a local facility in
Davis, California, by the same Pediatric Certified Specialist
(PCS) to ensure the same conditions for each child. All chil-
dren used their customary lower extremity orthotics during
the walking sessions. Four children wore bilateral lower ex-
tremity orthotics and shoes, and 2 children walked only in
shoes (Table 1).
Tests of Gross Motor Function. GMFM: This a stan-
dardized clinical instrument, which is designed to evaluate
6
changes in gross motor function in children with CP. The
GMFM has been shown to have high validity and reliabil-
ity.21 The GMFM-66 item version was used in this study.
All the GMFM dimensions (Dimension A: lying and roll-
ing; Dimension B: sitting; Dimension C: crawling and
kneeling; Dimension D: standing; Dimension E: walking,
running, and jumping) were measured in this study. The
children were videotaped in their homes during all 3 as-
sessments by a PCS with 22 years of pediatric experience.
The videotapes were analyzed, and the children were as-
sessed for GMFM levels by a different blinded PCS with 9
years of pediatric experience.
PEDI: This is an instrument that provides a clinical
assessment of a child’s current functional performance or
status.22 The PEDI is designed to evaluate 3 domains: self-
care, mobility, and social function. These domains are eval-
uated through parent interviews, direct observations, and
testing of the functional abilities of the children. The PEDI
includes caregiver assistance scales for each domain. The
Mobility-Functional Skills domain and the Caregiver As-
sistance domains for Mobility and Self-Help were used in
this study. PEDI administration was done in the children’s
homes by the same PCS who videotaped the children for
the GMFM.23
Walking Tests. Timed 10-Meter Walk Test: This is a
valid and reliable measure to assess walking speed in children
with CP.24 It can be used to assess self-selected walking speed
or maximum walking speed. The children walked as fast
as possible without running and were timed for 10 m.
310 Mattern-Baxter et al
The test was performed 2 consecutive times with a short
break between, and the faster time achieved was re-
ported. The children subsequently rested until resting
heart rate (HR) returned to pretest values, and then they
proceeded to the 6-minute walk test.
Six-Minute Walk Test: This test is a reliable and valid
measure to assess walking endurance in children with
CP.25 The children were encouraged to walk at a self-
selected walking speed but were discouraged from run-
ning and were allowed to vary their pace or rest as
needed. The total walking distance in meters was mea-
sured with a tape measure.
Treadmill Walk: The third method of measuring walk-
ing ability was done by measuring the total distance and the
speed walked on the treadmill during the 3 testing periods.
A pediatric weight-support harness system with a hydrau-
lic lifting mechanism (LiteGait Walkable 100) was placed
over a treadmill with adjustable speed (GaitKeeper
18WST). The subjects were fitted into the harness and
lowered onto the treadmill and were encouraged to take as
much weight as possible on their legs without buckling.
The percentage of weight support was calculated by weigh-
ing the children while in the harness and calculating the per-
centage in relation to their full body weight. All the children
held on to an adjustable handle bar during the treadmill train-
ing. The children received assistance with hand placement if
they could not maintain their grasp during walking. The chil-
dren were given 1 initial training session on the treadmill to
determine optimal walking speed and harness support. The
optimal walking speed was determined to be the speed at
which the children were able to take continuous steps with-
out dragging their feet for more than 5 seconds. The treadmill
distance and the walking speed were measured at the first
intervention training session and the last intervention train-
ing session and at the 1-month follow-up.
Balance. Children who were able to stand indepen-
dently were asked to stand on both feet as long as pos-
sible, without stepping or external support. Two consec-
utive trials were given, and the longer of the 2 trials was
recorded in seconds.
Intervention Protocol. The training sessions were
scheduled 3 days per week for 4 weeks, with 1 or 2 rest days
after each training day. The intervention lasted for 1 hour per
day. Five children completed all training sessions, and 1 child
missed 2 training sessions because of respiratory illness. All
children participated in their regularly scheduled physical
therapy sessions during the duration of the study. None of the
children received additional treadmill training during the
study period. All children were allowed to engage in their
normal everyday activities, including walking.
The starting treadmill speed was determined during
the initial training session and was increased as quickly as
possible throughout the sessions. The speed was increased
when the children could move their feet independently,
with verbal cues or minimal manual cues at the pelvis with-
out dragging their feet for more than 5 seconds. The chil-
dren walked on the treadmill for as many minutes as pos-
sible to the point of fatigue. During all treadmill walking,
Pediatric Physical Therapy
the children were monitored with a HR monitor (Polar
Monitor Model 515), and the HR was recorded at 1-minute
intervals. The maximum allowable HR was 80% of the age-
predicted maximum HR. None of the children reached the
80% maximum HR. The HR was also continuously moni-
tored after the treadmill walk until it returned to resting
levels, at which point a second treadmill walk was initiated.
The children were not allowed to walk for more than a total
of 40 minutes per training session. The amount of weight
support was decreased as quickly as possible over the du-
ration of the study determined by their ability to take con-
tinuous steps without dragging their feet for more than 5
seconds. By week 2 of the intervention period, 5 of 6 chil-
dren did not require weight support anymore. The parents
were present during all the sessions.
The same physical therapist provided facilitation at
the pelvis when the child stumbled or stopped stepping.
The facilitation was not intended to correct the gait pattern
of the child. The children were allowed to make mistakes in
step length and height but were encouraged with verbal
and tactile cues to take symmetrical steps. The children
were encouraged to look up during walking and were mo-
tivated with singing, favorite toys, or stuffed animals.
Data Analysis
Nonparametric statistics were used in all analyses be-
cause of the lack of a normal population distribution. For
the primary analysis of all data, a Friedman analysis of
variance (pre-intervention versus post-intervention versus
1-month follow-up) was performed. Post hoc analysis for
pairwise comparisons was performed using the minimum
significant difference.26 An alpha level of ⱕ0.05 was used in
all analyses. For tests that the subjects were unable to com-
plete (eg, the 10-m and 6-minute walk tests), they were
assigned the worst ranks for data analysis purposes. The
data are presented as means plus or minus standard devia-
tions, unless otherwise indicated. Statistical analyses were
performed using SPSS version 16.0 for the MAC.
RESULTS
Tests of Gross Motor Function
GMFM. GMFM Dimensions A and B showed no sta-
tistically significant changes between pre-intervention and
post-intervention. Statistically significant changes were
found in the GMFM Dimensions C (p ⫽ 0.05), D (p ⫽
0.007), and E (p ⫽ 0.01) in the primary analysis. The post
hoc analysis revealed a significant difference between
pre-intervention and post-intervention and between
pre-intervention and 1-month follow-up, for both Di-
mensions D and E, indicating that the children improved
their functional standing and walking abilities (Fig. 1).
PEDI. The analysis of the Functional Skills Mobility
Scale, the Caregiver Assistance Mobility Scale, and the
Caregiver Assistance Self-Help Scale of the PEDI revealed
statistically significant changes in the Functional Skills
Mobility Scale (p ⫽ 0.022) and the Caregiver Assistance
Mobility Scale (p ⫽ 0.018) but not the Caregiver Assistance
Pediatric Physical Therapy
Self-Help Scale. The post hoc analysis of the Functional
Skills Mobility Scale showed a significant difference between
pre-intervention and 1-month follow-up but not between pre-
intervention and post-intervention. The post hoc analysis of
the Caregiver Assistance Mobility Scale revealed significant
differences between pre-intervention and post-intervention
and between pre-intervention and 1-month follow-up. This
indicates that the children increased their independence in
the functional mobility tasks and relied less on their caregiv-
ers for assistance (Fig. 2).
Walking Tests
Timed 10-Meter Walk Test. Three children were able
to complete the 10-m walk test at the pre-intervention as-
sessment; 4 children were able to complete the test at post-
intervention assessment, whereas all 6 children were able
to complete this test at the 1-month follow-up. Of the chil-
dren who learned to propel their gait trainers during the
study period, the steering wheels had to be locked during
the test because of their inconsistent ability to walk in a
straight line. Statistically significant changes were found
in the primary analysis (p ⫽ 0.011). Although all the
children improved their walking speed between pre-in-
tervention and post-intervention, the post hoc test
showed a significant difference only between pre-inter-
vention and 1-month follow-up (Fig. 3A).
Six-Minute Walk Test. Three children were able to
ambulate for 6 minutes during the pre-intervention testing.
By the 1-month follow-up, all the children were able to take
steps in their gait trainers independently and were thus
able to participate in the 6-minute walk test. The primary
analysis showed statistically significant differences (p ⫽
0.029), with nonsignificant improvements occurring be-
tween pre-intervention and post-intervention but signifi-
cant improvements occurring between pre-intervention
and 1-month follow-up (Fig. 3B).
Treadmill Walk. Statistically significant differences
were found in the primary analysis for the total distance
walked (p ⫽ 0.009) and walking speed (p ⫽ 0.002). The
post hoc analysis was significant for both variables between
pre-intervention and post-intervention and between pre-
intervention and 1-month follow-up. Some children re-
quired partial weight support during this activity. The
mean walking speed was 0.08 m/sec during the first train-
ing session with a range of 0.04 to 0.13 m/sec. The mean
walking speed during the last training session was 0.25
m/sec with a range of 0.13 to 0.45 m/sec. The mean dis-
tance walked during the first training session was 46.3 m
with a range of 4.0 to 79.0 m, and the mean distance walked
at the last training session was 151.8 m with a range of 36.0
to 434.0 m (Table 2).
In addition to these results, 1 child who was ambula-
tory with a walker at the beginning of the study achieved
independent walking during the intervention period.
Three children who used gait trainers with maximal assist
at the beginning of the study improved to intermittent as-
sistance by the end of the study. This intermittent support
was for steering of the gait trainer and for occasional help
Intensive Treadmill Training for Young Children with CP 311
 A
100
pre-intervention
post-intervention
1-month follow-up
80

GMFM Dimension D percent score

60

40

20

B
100
GMFM Dimension E percent score

80

60

40

20

0
1 2 3 4 5 6
Subject

Fig. 1. Individual GMFM Scores for Dimensions D and E. Subject 2 had scores of 0 for pre-intervention Dimension D and for pre-intervention,
post-intervention, and 1-month follow-up for Dimension E. Means were statistically different between pre-intervention and post-intervention
for Dimensions D and E.

when getting stuck, but all 3 children were able to self-
propel their gait trainers, which they had previously been
unable to do.
Balance
Because of their young age and the functional level of
the children, standing balance on 1 foot could not be at-
tained by any of the children. Therefore, standing balance
on 2 feet was used as a measure of balance, which could
only be attained by 2 of the children. Both the children
approximately doubled their standing balance time from
pre-intervention to post-intervention and continued to
show gains at the 1-month follow-up.
DISCUSSION
The findings of this study add to the body of knowl-
edge that functional standing and walking skills can be
improved by intensive treadmill training in children
with CP. In this study, young children of ages 2.5 to 3.9
years with various types of CP and different functional
levels were able to make significant improvements in
their walking ability, as measured by walking distance
and gait speed. They also showed improvement in func-
tional gross motor skills related to standing and walking.
These changes, in general, were greater in children with
higher GMFCS levels compared to children with lower
GMFCS levels at study onset. Additionally, no adverse
effects such as excessive fatigue or harness discomfort
from the intensive LTT training program used in this
study were observed.
Five of the 6 children were able to improve in their
functional standing skills as measured by Dimension D
and were able to maintain those skills at the 1-month
follow-up. The child who did not show any changes in

312 Mattern-Baxter et al Pediatric Physical Therapy

 A
35
pre-intervention
30 post-intervention
functional skills mobility standard score

1-month follow-up
25

20

15

10

B
40

35
care giver assist mobility standard score

30

25

20

15

10

C
45
care giver assist self-help standard score

40

35

30

25

20

15

10

0
1 2 3 4 5 6
subject

Fig. 2. Individual PEDI Standard Scores for Functional Skills Mobility Scale, Caregiver Assistance Mobility Scale, and Caregiver Assistance
Self-Help Scale. Means were statistically different for the Functional Skills Mobility Scale between pre-intervention and 1-month follow-up
and for the Caregiver Assistance Mobility Scale between pre-intervention and post-intervention, and between pre-intervention and
1-month follow-up.

Dimension D was ambulatory with a walker at the onset
of the study but had a diagnosis of chronic lung disease
causing him to miss 2 training sessions because of respira-
tory illness. This child did, however, make improvements
in his functional walking skills as measured by Dimension
E of the GMFM. An additional 4 children showed improve-
ment in Dimension E. One child with spastic CP did not
improve in this dimension. This child, who was nonambu-
latory GMFCS level IV, and dependent in all gravity-de-
pendent positions, had to use partial weight support on the
treadmill throughout the entire study, and had strong
lower extremity spasticity. Schindl et al11 found that after a
3-month intensive treadmill-training program a decrease
in assistance was required for ambulation in 3 of 6 children

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 313
 A
200
pre-intervention
post-intervention
1-month follow-up

10 M walk time (sec) 150

100

50

B
250

200
distance walked in 6 min (m)

150

100

50

0
1 2 3 4 5 6
subject

Fig. 3. Individual scores for the 10-m walk test (A) and 6-minute walk test (B). Subjects 1, 2, and 3 were not able to complete the 10-m walk
test and the 6-minute walk test for some of the conditions. Means were statistically different for the 10-m walk test between pre-
intervention and 1-month follow-up and for the 6-minute walk test between pre-intervention and 1-month follow-up.

ages 6 to 18 years with spastic tetraparesis who were pre-
viously nonambulatory. This suggests that improvements
in gross motor skills related to ambulation might necessi-
tate a prolonged intensive treadmill training program for
children with lower GMFCS levels and higher levels of
spasticity.
In an effort to assess the children’s functioning in so-
cietal roles according to the International Classification of
Functioning, Disability, and Health Model of the World
Health Organization,27 we used the PEDI Caregiver Assis-
tance Scale.22 Caregiver assistance is an important factor
that contributes to a child’s ability to participate in society
at this young age. Parents and guardians play a central role
in the child’s ability to fulfill social roles at this age and are
often the sole providers of support during outings in the
community.28 This was particularly true for the 3 children
in this study who were nonambulatory and who com-
pletely relied on their caregivers’ ability to provide mobility
because none of the children had access to independent
power mobility devices. Although these 3 children used
gait trainers, they required maximum assistance for ambu-
lation and were usually in adaptive strollers or carried by
their parents during community outings. It might be de-
batable whether the significant results in the caregiver por-
tion of the Mobility Scale represented increased participa-
tion in societal roles in these children, but it clearly
reflected a decreased burden on caregivers. Indeed, the
PEDI is a reliable and valid assessment tool that reflects
caregivers’ perceptions of the performance of their child
and is sensitive to change over time.29
The primary emphasis of this study was to enable
young children with CP to take independent steps on the

314 Mattern-Baxter et al Pediatric Physical Therapy

 treadmill with as little support or facilitation as possible.

Pre-intervention Post-intervention Follow-up

0.3 ⫾ 0.2
1-Month

0.18
0.13
0.13
0.45
0.18
0.45
This invariably led to more mistakes during LTT, and a
chance for the children to self-correct before outside
correction was provided. Although the children received

Treadmill Speed (m/sec)

ongoing explicit verbal feedback, tactile feedback was

0.3 ⫾ 0.2
kept to a minimum, and the children were not corrected

0.18
0.13
0.13
0.45
0.18
0.45
regarding step height or step length. This is in contrast
to other studies in which facilitation was provided at the
hips, knees, and feet by 1, 2, and, in some instances, 3
therapists.11,14,15,17,19 Furthermore, the amount of weight

0.1 ⫾ 0.0
support was decreased, and the treadmill speed was in-
0.09
0.04
0.04
0.13
0.09
0.09
creased as quickly as possible throughout the interven-
tion period. Three of 4 children who required weight
support at study onset no longer required weight sup-
152.0 ⫾ 143.9* 122.2 ⫾ 87.1†
Follow-up

port at the end of the intervention period. All children

1-Month

97
89
37
106
113
291

increased their treadmill speed by at least 100%, and 1

child increased her speed by 500% by the end of the
Total Distance Walked (m)

4-week intervention period. Increases in treadmill speed

Pre-intervention Post-intervention

have been previously reported in school-age children

with CP12,16 and in studies with adults after stroke30 but
86
89
36
106
160
434

were not as large as in this sample of young children

with CP. Begnoche and Pittetti16 reported increases in
treadmill speed of 50% to 80% over 4 weeks in a study of
5 children with a mean age of 6.7 years. Provost et al12 pro-
46.2 ⫾ 31.2
Progression of Treadmill Ambulation

gressed the treadmill speed by 61% to 65% in 6 children with

43
15
4
79
68
69

a mean age of 10.5 years. However, the starting speeds in our

study were lower than those in other studies because of the
young age and the inexperience of our subjects in walking on
TABLE 2

564.5 ⫾ 241.6* 492.2 ⫾ 142.2†

a treadmill. It was observed initially that the children with

Follow-up
1-Month

lower GMFCS levels tended to sit in the harness during tread-

451
540
224
600
539
599

mill training and seemed unsure how to move their legs—a

Total Time Walked (seconds)

trend that was reversed with the training at progressively

higher treadmill speeds and decreased weight support. This
Subject Pre-intervention Post-intervention Follow-up Pre-intervention Post-intervention

finding is consistent with studies of school-age children when

weight support was decreased as quickly as possible to allow
393
548
215
600
736
895

maximal active involvement of the children.12,16 This im-

provement in stepping ability with decreased weight support
might have been triggered by an increase in proprioceptive
372.0 ⫾ 223.9

†Indicates p ⱕ 0.05 from pre-intervention to 1-month follow-up.

input from the increased joint pressure throughout the ki-

*Indicates p ⱕ 0.05 from pre-intervention to post-intervention.

netic chain.31 Similar increases in stepping ability with de-

352
185
49
441
605
600

creased weight support over time have been observed in pe-

diatric patients with Down syndrome when the children
received additional proprioceptive input by use of ankle
1-Month

weights during treadmill walking.32–34 Additionally, improved

0
0
0
0
0
0

stepping ability at faster treadmill speeds may have been due

to a greater stretch of the hip flexors, leading to an increased
activation of central pattern generators mediated at the spinal
% Weight Support

level.35
0
17
0
0
0
0

We saw significant decreases in the 10-m walk test

Mean ⫾ SD

times and significant increases in the 6-minute walk test

distance in our young subjects. In contrast to other studies
in which the timed 10-m walk test was used to assess com-
fortable walking speed,12,14,16 we used it to examine maxi-
42
40
45
20
0
0

mum walking speed over 10 m. Although other investiga-

tors have observed improvements in self-selected walking
speed over 10 m in children of ages 5 to 18 years,12,14,16 our
study is the first to show improvements in maximal walk-
1
2
3
4
5
6

ing speed over 10 m in children younger than 4 years of age

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 315
with CP as a consequence of locomotor training. Three
children with GMFCS levels I and II were able to complete
the timed 10-m walk test and the 6-minute walk test as part
of the pretest. By the posttest, 1 additional child at
GMFCS level III was able to complete the 10-m walk test by
independently moving his gait trainer. At the 1-month
follow-up, 2 additional children at GMFCS level IV were
able to walk 10 m with their gait trainers. However, the 3
children who used gait trainers for locomotion continued
to need assistance for steering and were able to move their
gait trainers only on level, smooth ground. Although these
gains were only functional in an optimal environment
without barriers, they were reported as major improve-
ments by these young children’s parents. Similar results
have been found after a 4-month LTT intervention proto-
col in 4 toddlers ages 1.7 to 2.3 years.19 However, these
toddlers were younger than the subjects in our study, and
the intervention period spanned a 4-month period, indicat-
ing that maturation may have been responsible for some of
the positive changes. Although some degree of maturation
cannot be ruled out in the 2-month period between pre-
intervention assessment and 1-month follow-up, the great-
est gains in our study were made immediately after the
4-week intervention period, probably indicating that the
children improved because of intervention rather than
maturation. Moreover, we cannot discount the role of con-
tinued practice after the intervention period, which may
have played an important role in the improvements seen at
the 1-month follow-up.
Our self-selected walking speed was calculated from
the 6-minute walk test, and all our subjects showed im-
provements attributable to the LTT. These improvements
in self-selected walking speed were similar to those found
by Provost et al,12 who reported significant improvements
in self-selected walking speed in children who were ambu-
latory ages 5 to 18 years after 6 weeks of LTT. However, in
2 other studies on school-age children,14,16 improvements
in self-selected walking speed did not reach statistical sig-
nificance. The 3 children in our study who were ambula-
tory with supporting devices at study onset made relatively
larger gains than did those who were nonambulatory.
Their ages were 2.5, 3.1, and 3.9 years. Children who de-
velop typically in this age range achieve self-selected mean
TABLE 3
Comparison of Walking Speed Across Tests (m/sec)
Treadmill Walk 6-Minute Walk Test at Self-Selected Walk
Speed (m/sec)
1-Month
Subject Pre-intervention Post-intervention Follow-up Pre-intervention Post-intervention Follow-up Pre-intervention Post-intervention Follow-up
1 0.09 0.18 0.18 Unable
2 0.04 0.13 0.13 Unable
3 0.04 0.13 0.13 Unable
4 0.13 0.45 0.45 0.22
5 0.09 0.18 0.18 0.09
6 0.09 0.45 0.45 0.33
Mean treadmill walking speeds were significantly different between pre-intervention and post-intervention and between pre-intervention and
1-month follow-up.
316 Mattern-Baxter et al
walking speeds of 0.86 to 0.99 m/sec, whereas mean self-
selected walking speed increases to 1.12 and 1.16 m/sec by
kindergarten age and school age, respectively.36,37 The chil-
dren in our study who were ambulatory showed self-se-
lected walking speeds of 0.14, 0.55, and 0.59 m/sec by the
1-month follow-up, which is still considerably slower than
those of peers with typical development. However, their
maximum walking speeds by the 1-month follow-up were
0.24, 0.86, and 1.34 m/sec, indicating that, with effort,
these children could temporarily keep up with their
peers.38
There were significant improvements in the distance
walked during the 6-minute walk test between preassess-
ment and 1-month follow-up in our study. The lack of
significance between preassessment and postassessment
(immediately after the intervention period) might indicate
that a period longer than 4 weeks is necessary to make
significant physiological changes in endurance in young
children with CP. These results are similar to those of 2
other studies that did not find significant improvements in
the 6- or 10-minute walk test after a 6-week LTT interven-
tion that was offered 2 times per week to children with CP
aged 5 to 14 years.12,14 These findings indicate that pro-
longed, more intensive LTT programs might be necessary
to make physiological changes in endurance.
An additional interesting finding was the significant cor-
relation (r ⫽ 0.98; p ⫽ 0.004) between self- selected walking
speed in the 6-minute walk test and walking speed on the
treadmill. We determined treadmill walking speed based on
the children’s ability to step without dragging their feet for
more than 5 seconds. This indicates that the criterion for
selecting treadmill speed in this study was a good reflection of
the child’s self-selected over-ground walking speed. This find-
ing suggests that a reliable, clinical estimate of a child’s gait
speed could be made by observing the ability to advance the
legs on the treadmill without dragging the feet for more than
5 seconds. This might prove a useful approach for practitio-
ners when selecting treadmill walking speed for children with
CP (Table 3).
LIMITATIONS
A limitation of this study is the lack of a control group
for this convenience sample of children with CP. Because
10-m Walk Test at Maximum Walk
Speed (m/sec) Speed (m/sec)
1-Month 1-Month
Unable Unable Unable Unable 0.15
Unable 0.05 Unable Unable 0.05
0.03 0.18 Unable 0.1 0.75
0.46 0.59 0.6 0.8 1.34
0.15 0.14 0.1 0.3 0.24
0.54 0.55 0.4 0.7 0.86
Pediatric Physical Therapy
our study occurred over a 2-month period, history and
maturation effects cannot be ruled out; however, none of
the children engaged in other intensive interventions dur-
ing the study, except for their regularly scheduled physical
therapy sessions. Additional limitations are the small sam-
ple size and the lack of homogeneity in our group, with
children having different types of CP and GMFCS levels I
through IV. The results of this study are preliminary for
this small sample of young children, limiting external va-
lidity. Although a blinded assessor scored the GMFM from
videotapes of the children at preassessment, postassess-
ment, and 1-month follow-up, the walking and balance
tests were conducted by the same nonblinded assessor.
Although these tests were measured objectively by timing
the children and measuring the walking distance, the chil-
dren might have performed better because they were more
comfortable with the assessor, the facility, or both. The
parents of the children in this sample were motivated to
drive to a facility 3 times per week and were able to take
time out of their week to participate in the intervention.
This type of intensive training might be limited to children
whose parents are able to provide time and transportation.
Outside the research setting, it may be difficult to obtain
funding for this type of intensive treadmill training, creat-
ing a socioeconomic advantage to those families who can
afford it.
CONCLUSIONS
The results of this study provide preliminary evi-
dence that short-term intensive treadmill training im-
proves measures of gross motor function, maximum and
self-selected walking speed, and walking distance in a
small sample of young children with CP 2.5 to 3.9 years
of age. These changes were maintained after a 1-month
follow-up period, potentially indicating long-term changes.
Although the results of this study are encouraging, this
type of intensive intervention at a facility requires a large
time commitment for parents and children and may be
difficult to fund outside the research setting. Other re-
searchers have found home-based intervention on small
portable treadmills feasible and beneficial in children with
Down syndrome.33 Although one study exists to date that
showed the feasibility of LTT in an infant at high risk for
developmental disabilities,18 future research should exam-
ine whether home-based treadmill training is feasible for
young children with CP and whether it can lead to a more
convenient and cost-effective delivery model for intensive
intervention.
ACKNOWLEDGMENTS
The authors thank Physical Edge, a private physical
therapy practice in Davis, Calif, for providing their space
and support during the intervention period. They thank
the parent groups, physical therapists, and other early in-
tervention providers in the community who referred chil-
dren to this study. They also thank the student volun-
teers Jennifer Reynolds, Erin Turner, Marina Nguyen,
and Jessica Johnson from the University of California,
Pediatric Physical Therapy
Davis, Calif, and Seth Mailloux and Kyleigh Short from
Sacramento State University, Sacramento, Calif. Part of
the equipment used in this study was obtained with a
Scholarly/Artistic Activity Grant from the University of
the Pacific, Stockton, Calif. The treadmill was provided
on loan from Mobility Research, Tempe, Ariz. Most im-
portantly, the authors thank the children and their par-
ents who participated in this study.
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body weight support in nonambulatory patients with cerebral palsy.
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12. Provost B, Dieruf K, Burtner P, Phillips J, et al. Endurance and gait in
children with cerebral palsy after intensive body weightsupported
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13. McNevin NH, Coraci L, Schafer J. Gait in adolescent cerebral palsy:
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14. Dodd KJ, Foley S. Partial body-weight-supported treadmill training
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16. Begnoche D, Pitetti K. Effects of traditional treatment and partial
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17. Cherng R, Liu C, Lau T, Hong R. Effect of treadmill training with
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Pediatric Physical Therapy
 CLINICAL BOTTOM LINE
Effects of Intensive Locomotor Treadmill Training on Young Children with Cerebral Palsy

“How should I apply this information?”

Canchild’s motor growth study has shown that young children with cerebral palsy (CP) achieve their motor milestones
at an accelerated rate compared with that of older children with CP.1 From these data, it seems crucial to provide intensive
physical therapy intervention at a young age to children with CP. One of these interventions is the use of locomotor
treadmill training (LTT) in an attempt to maximize walking independence, walking endurance, and gait speed. LTT
differs from body weight–supported treadmill training in that LTT uses as little weight support as possible. LTT fits in
current rehabilitation opinions for providing task-specific training with multiple repetitions to children with CP. LTT has
been studied in children with CP, both ambulatory and nonambulatory. Despite encouraging results, relatively few studies
have been performed in the younger age group. To fill this gap in the literature, the effects of an intensive LTT intervention were
examined in children younger than 4 years with different types and severity of CP on functional standing and walking skills.
Young children with CP were enabled to take independent steps on the treadmill with as little support or facilitation as possible.
The possible adverse effects of LTT such as excessive fatigue or other forms of discomfort were also studied. The study provided
preliminary evidence that intensive LTT in this small sample of preschoolers with CP improved gross motor function, maximum
and self-selected walking speed, and walking endurance, with no harmful side effects.
“What should I be mindful about in applying this information?”
The findings of this study add to the body of knowledge that functional standing and walking skills can be improved by
intensive treadmill training in preschool children with CP. This study is important in that it describes an intensive
physical therapy program for young children, which can be easily adapted to the child’s level of skill.
The next 3 factors were beyond the scope of this study, but these should be considered when applying the results. First,
it is crucial that preschoolers develop competence in movement skills, which are the basis for more complex movement
tasks later in life. Because locomotor training for preschoolers with CP is designed to provide task-specific training, it can
be questioned whether intensive walking is the best intervention for all children with CP. For children classified under
Gross Motor Function Classification System (GMFCS) levels IV and V, intensive therapy on a bicycle or wheelchair seems
to be more task specific. At an older age, these children may continue to walk for only short distances with physical
assistance at home, relying more on wheeled mobility.
Second, the authors note that for preschoolers a program longer than 4 weeks might be necessary to make significant
physiological changes in endurance. A minimum of 6 weeks with 3 training sessions per week seems to be more
appropriate and might lead to better results.
Third, the authors also note that intensive LTT requires a large time commitment for parents and children and is
difficult to continue outside a research setting. They suggest that home-based treadmill training might be beneficial and
cost-effective for this population. However, a weight-support harness system with hydraulic lifting mechanism is expen-
sive, not easy to use, and needs supervision. Moreover, home treadmills, which have been growing steadily in popularity,
pose a specific hazard to preschoolers, and safety is always a concern while supervision is necessary. Additional home
treadmill safety guidelines must be established.
Although long-term effects of intensive physical training at a young age are not known, one can only assume that an
early introduction to a lifestyle that includes intensive exercise would be beneficial for the future health and physical
activity of children with CP. The pediatric physical therapist is a key player in educating parents about their role in giving
their children a healthy start. An intensive intervention, such as LTT, early in life may help boost levels of physical activity,
which may have a more influential impact on obesity and other health risks later in life.
REFERENCE
1. Rosenbaum P, Walter S, Hanna S, et al. Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA.
2002;288:1357–1363.

Olaf Verschuren, PT, PhD, PCS

Centre of Excellence, Rehabilitation Center ‘de Hoogstraat’, Utrecht, The Netherlands
Paul J.M. Helders, PT, PhD, MSc, PCS
Faculty of Medicine, Division of Pediatrics, Utrecht University, Child Development and Exercise Center,
University Medical Center and Children’s Hospital, Utrecht, The Netherlands

Pediatric Physical Therapy Intensive Treadmill Training for Young Children with CP 319

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