Objectives. Importance of Walking 8/10/2014. From Evidence to Practice: Optimizing Walking Outcomes in Young Children with Neuromotor Impairment

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1 From Evidence to Practice: Optimizing Walking Outcomes in Young Children with Neuromotor Impairment AACPDM 68 th Annual Meeting September 10-13, 2014 Katrin Mattern Baxter, PT, DPT, PCS Assistant Professor, Department of Physical Therapy California State University, Sacramento Stefani McNeil, PT, MSPT, PCS Vice President of Pediatric Services Easter Seals, Sacramento Objectives Understand the current evidence on treadmill training in young children with neuromotor impairment. Identify indicators of readiness for the task specific practice of walking in young children with neuromotor impairment. Develop an understanding of the required dosage for intensive treadmill training to promote the acquisition of walking. Guide practitioners in implementing an intensive treadmill training and walking program into clinical practice by demonstrating a successful model. Importance of Walking Family goals/motivations Bone mineral density/joint development Cardiopulmonary endurance Obesity prevention Social interaction Hutton, 2002; Wilmshurst, 1996; Chien, 2006; LePage,

2 Why Treadmill Training? Kinematic similarity with over ground walking Increased cadence Automaticity of stepping Consistency of speed and duration Protected environment Damiano et al, 2011; Lee et al, 2008 Why Intensive Training? Errors allowed Multiple repetitions Active participation Motor Learning Kamm&Thelen, 1990; Scholz 1990 Why at a Young Age? potential for cortical reorganization in children < 6 years neuronal cells and synaptic connections Experience dependent competition for pruning Maturation of inhibition, extracellular matrix and myelination Cramer et al,

3 Cochrane Review Treadmill interventions with partial body weight support in children under six years of age at risk of neuromotor delay 5 studies included Earlier onset of walking in children with DS Early use of orthotics might hinder progress in children with DS Further investigation needed for children with high risk and CP Valentin Gudiol et al., 2011 Down Syndrome and Intensity RCT n=30 Age at study entry 9 10 months Low intensity group: 5x/week, 6 min sessions, 0.18m/s High intensity group: 5x/week, individualized with speeds and duration + ankle weights HI group showed accelerated motor milestones and alternating steps Ulrich et al, 2008 Down Syndrome and Intensity HI group also showed: cadence gait velocity step length step width obstacle clearance Angulo Barroso, 2008; Wu,

4 Spinal Cord Injury and Treadmill Training Case study 4.5 years 16 months post injury w/c dependent, non ambulatory ASIA C 16 weeks, 76 sessions Ambulation with Kaye walker in Kindergarten Behrman et al, 2008 Myelomeningocele and Treadmill Trial RCT n=24, 12 TD, 12 MMC lumbar or sacral level Tested at 1,3, 6, 9, 12 months, twelve 20 sec trials Treadmill practice in children with MMC elicited stepping behavior, but less than in TD Highly variable muscle ac va on, but compared to TD Teulier et al, 2009 Sansom et al, 2013 Myelomeningocele and Sensory Input n= months L1 or below Six 30 sec trials with different conditions Baseline Visual flow (checkerboard belt) Velcro Friction (Dycem) Dycem and visual flow produced more steps than normal belt Pantall et al,

5 Infants with Moderate Risk for Delay RCT, n= months corrected age Treadmill group: PT plus 8 min/day, 5 days/week TT until walking onset; Average of 5.2 months of TM training Control group: PT only Quality of stepping be er in TM group ( alterna ng steps, toe contact) High frequency of alternating steps correlated to earlier walking onset in both groups No difference in walking onset between groups Angulo Barroso et al., 2013 CP Systematic Reviews Some evidence for older children Little information available for young children Most effective with GMFCS levels I III walking speed gross motor func on Longer and more intense protocols be er results Damiano & DeJong,2009; Mattern Baxter, 2009 School Aged Children with CP RCT, n= years GMFCS I III Treadmill and overground walking group 2x/week for 7 weeks All children made significant improvements in walking distance, fx mobility and balance Only treadmill group maintained gains at post intervention assessments Grecco et al.,

6 Toddlers and CP Quasi RCT n=12 Mean age 21 months Inclusion criteria Cerebral palsy GMFCS levels I II Ages 9 to 36 months Signs of walking readiness Sits for 30 sec Takes 5 7 steps when supported by adult Exclusion criteria Genetic syndrome Medical contraindication for standing or walking Spasticity reducing medication in the past 6 months Previous or current use of treadmill in PT Mattern Baxter et al, 2013 Study Design 5.5 months Both groups receive regularly scheduled PT Control group: no treadmill training Treadmill group: treadmill training Preintervention 6 week postintervention 1 month postintervention 4 month postintervention Protocol for Treadmill 6 weeks, home based 6x/week, twice daily, for up to 20 min/each Minimal manual contact Progressively increased speed Mean minutes walked/day 28.2 ±

7 Outcome Measures Blinded Gross Motor Function Measure 66 (GMFM 66) Dimension D and E Peabody Developmental Motor Scales 2 (PDMS 2) Locomotion Subscale Parent Reported Pediatric Evaluation of Disability Inventory (PEDI) Mobility Scale Timed 10 meter walk test Functional Mobility Scale Significant Between Results PDMS 2 at post test and 1 month follow up PEDI at post test, 1 month and 4 month follow up FMS at the post test Moderate effect size (Cohen s d=0.47) for walking speed Functional Ambulation Control Treadmill Control Treadmill Control Treadmill Control Treadmill Preintervention Postintervention 1 month post intervention 4 month post intervention 7

8 Future Research number of subjects GMFCS level III Optimal dosage of intervention Treadmill training versus over ground walking Effects of treadmill training in conjunction with Botox injections Effects on overall activity level and participation Feasibility of publicly available treadmills Implementation into Practice Treadmill Loan Program and STEPS program Collaboration of clinical and academic setting Observations, Family/Child Preferences Translation of Clinical Research into Practice Current Clinic based treadmill Problem Treadmill Loan Program: Initial Concept Many client services home based Opportunity: Collaboration with UC Davis Biomedical Engineering Department Fundraising by ES Guild ($10,000 for 6 treadmills) 8

9 Collaborate Innovate Treadmill Loan Program Started: September 2012 Additional equipment loan library for walking devices Home Treadmill Protocol Referral Protocol Inclusion/exclusion criteria Weekly monitoring by PT Equipment release form TM management 9

10 Treadmill Loan Program Results STEPS Free university based program Twice weekly sessions during spring and fall semesters Ongoing referrals from community PTs 10 DPT students, supervised by PT/faculty Consultation on orthotics Loan program for adaptive walking devices STEPS-Results 10

11 SummerSTEPS First summer session offered in 2014 Due to family feedback Paid by fundraising, run by ES PTs with 10 DPT students Overall decreased utilization in summer by families Collaboration/Innovation Department of Engineering Senior project Funded by internal grant Scheduled prototype completion fall 2014 Specifications per STEPS faculty Additional sensored treadmill from fundraising efforts for additional data collection on gait parameters Selected References Damiano D, Norman T, Stanley C, et al. Comparison of elliptical training, stationary cycling, treadmill walking and overground walking. (2011). Gait Posture June ; 34(2): Lee SJ, Hidler J. Biomechanics of overground vs. treadmill walking in healthy individuals. Appl Physiol. 2008; 104(3): Cramer S, Sur M, Dobkin B, et al. Harnessing neuroplasticity for clinical applications. (2011) Brain. 134; Valentin Gudiol M, Mattern Baxter K, Girabent Farrés M, Bagur Calafat C, Hadders Algra M, Angulo Barroso R (2011). Treadmill interventions with partial body weight support in children under six years of age at risk of neuromotor delay. Cochrane Database of Systematic Reviews. Issue 12. Art. No.: CD DOI: / CD pub2 Ulrich DA, Lloyd MC, Tiernan C, et al. Effects of intensity of treadmill training on developmental outcomes and stepping in infants with Down syndrome. (2008) Phys Ther.88: Wu J, Looper J, Ulrich DA, Angulo Barroso RM. Effect of various treadmill interventions on the development of joint kinematics in infants with Down syndrome (2010). Phys Ther.90 (9): PMID:

12 Selected References Behrman A, Nair P, Bowden M, et al. Locomotor Training Restores Walking in a Nonambulatory Child With Chronic, Severe, Incomplete Cervical Spinal Cord Injury. (2008) Phys Ther. 88(5) Teulier C, Smith B, Kubo M, et al. (2009). Stepping Responses of Infants with Myelomeningocele When Supported on a MotorizedTreadmill. Phys Ther; 89: Pantall A, Teulier C, Smith BA, et al. (2011). Optimization of the Treadmill Context to Elicit Stepping in Infants Born with Myelomeningocele. Pediatric Physical Therapy, 23(1), Grecco LAC, Zanon N, Sampaio LMM., Oliveira CS. (2013) Effect of treadmill gait training on static and functional balance in children with cerebral palsy: a randomized controlled trial. Brazilian Journal of Physical Therapy / Revista Brasileira de Fisioterapia ;17(1):17 23 Angulo Barroso R, Tiernan C, Chen L, et al. (2013) Treadmill training in moderate risk preterm infants promotes stepping quality Results of a small randomised controlled trial. Res Dev Disabil; 34(11): Selected References Mattern Baxter K. (2009). Effects of partial body weight supported treadmill training on children with cerebral palsy Pediatr Phys Ther.21(1): Damiano D & DeJong S. (2009). A systematic review of the effectiveness of treadmill training and body weight support in pediatric rehabilitation. J Neurol Phys Ther. 33(1): Mattern Baxter K, McNeil S, Mansoor JK. (2013) Effects of Home Based Locomotor Treadmill Training on Gross Motor Function in Young Children With Cerebral Palsy: A Quasi Randomized Controlled Trial. Arch Phys Med Rehabil; 94: