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Treadmill protocols across ages and stages: A fresh look at dosage Julia Looper, PT, PhD Associate Professor, Physical Therapy University of Puget Sound, Tacoma, WA Katrin Mattern Baxter, PT, DPT,

1 Treadmill protocols across ages and stages: A fresh look at dosage Julia Looper, PT, PhD Associate Professor, Physical Therapy University of Puget Sound, Tacoma, WA Katrin Mattern Baxter, PT, DPT, PCS Associate Professor, Physical Therapy California State University, Sacramento Noelle Moreau, PT, PhD Associate Professor, Physical Therapy Louisiana State University Health Sciences Center, New Orleans Kristie F. Bjornson, PhD, PT, PCS Associate Professor, Pediatrics Seattle Children s Research Institute, WA Disclosure Information The speakers have no financial relationships to disclose. The speakers declare no conflict of interest. Objectives 1. Describe the theoretical and neuroplastic mechanisms behind infant treadmill protocols 2. Describe the available evidence on treadmill training in preambulatory children with CP and neuromotor impairment 3. Describe muscle performance impairments in children with CP and the implications for treadmill training 4. Describe implementation and outcomes of short burst interval treadmill training in ambulatory children with CP no reprints without permission 1

2 Objective 1. Describe the theoretical and neuroplastic mechanisms behind infant treadmill protocols Infant Stepping Infants are born with a stepping response Legs are alternating One leg has knee and hip extension Other leg has knee and hip flexion Usually disappears in the first 2 months of life Manipulating the Stepping Response Thelen showed that the stepping response can be manipulated (1982) In infants who still exhibit the stepping response, adding weight to their legs will make it disappear In infants who no longer exhibit the stepping response, submerging their legs in water will make it reappear Zelazo showed that if the stepping response is practiced is does not disappear AND children who practice stepping walk earlier (1972,1983) no reprints without permission 2

3 Infant Stepping in Supine? Video of 5 month old baby with typical development The stepping movement does not really disappear but takes the form of supine kicking. (Thelen and Fisher, 1982) Has less strength demands that upright stepping Typically Developing infants are practicing the stepping pattern well before they start to pull to stand Practice leads to synaptic change A synapse changes in strength depending on its past activity Increased frequency of firing or strength of activation leads to Long Term Potentiation (more likely to fire again) Decreased frequency of firing or strength of activation leads to Long Term Depression (less likely to fire again) Long term potentiation is enhanced in the young brain (Crair and Malenka, 1995) Children have more synapses than adults (Huttenlocher& de Court, 1987) This provides more neurological options and greater plasticity Variable Repetition Gait is an individual solution to the problem of how to get from point A to point B So development of the pattern is individualized too Variable repetition allows for an adaptive pattern no reprints without permission 3

4 How does this relate to the Treadmill? Children who are not typically developing do not develop supine kicking in the same way So, they do not get the same amount of stepping practice Children with DS show less antigravity movement (Ulrich and Ulrich, 1995) Infants born preterm display decreased dissociation of their lower limbs when kicking (Jeng, Chen, & Yau, 2002) One way to help children with DD practice a stepping pattern is the treadmill How does the treadmill help? It provides an environment that helps to facilitate stepping It provides the opportunity for multiple repetitions It provides the opportunity for variable practice It allows for a varied level of trunk control Down Syndrome: An example of treadmill training in action 8 min./day, 5 days/week Support infant s body weight through the trunk Allow the infant to actively explore the stepping pattern Infants seem to respond to the treadmill when they begin to sit independently no reprints without permission 4

5 Down Syndrome: An example of treadmill training in action Leads to earlier walking onset (101 days on average) (Ulrich et al, 2001) Better gait parameters (Wu et al., 2007) Increased intensity led to improved gait parameters and ability to clear an object (Wu et al., 2007) Waiting until the children can pull to stand may be too late (Looper & Ulrich, 2010) Objective 2. Describe the available evidence on treadmill training in pre ambulatory children with CP and neuromotor impairment no reprints without permission 5

Updated Review 6 studies included (151 children) Accelerated onset of walking in children with Down syndrome Early use of orthotics might hinder progress in children with Down

larger sample size and to determine optimal dosage Valentin Gudiol et al., 2011, 2015 update Study Design 5.

6 Updated Review 6 studies included (151 children) Accelerated onset of walking in children with Down syndrome Early use of orthotics might hinder progress in children with Down syndrome Emerging evidence for accelerated walking skills in children with CP Benefits on step quality in infants with moderate risk for delay Further investigation needed with larger sample size and to determine optimal dosage Valentin Gudiol et al., 2011, 2015 update 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 no reprints without permission 6

7 Subjects 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 Trial Diagram of Participants Screening by telephone (n=29) Screening at home (n=23) Does not meet inclusion criterion of age/refused (n=6) Does not meet inclusion criteria/refused (n=8) Meet inclusion criteria (n=15) Quasi-randomized by age and GMFCS level Treadmill group at pretest (n=9) (Treadmill training) Attrition (n=3) Illness (n=1) Family reasons (n=1) Change of diagnosis to genetic syndrome (n=1) Control group (n=6) Mean age (6.07) GMFCS level I (n=2) GMFCS level II (n=4) Treadmill group (n=6) Mean age (6.50) GMFCS level I (n=2) GMFCS level II (n=4) Protocol for Treadmill Group 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 ± 11.2 from personal archives, with permission from parents no reprints without permission 7

Disability Inventory (PEDI) Mobility Scale Fast Timed 10 meter walk test Functional Mobility Scale

8 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 Fast Timed 10 meter walk test Functional Mobility Scale GMFM Dimension D and E p=0.004 * PDMS 2 Locomotion Subtest p=0.01 * p=0.009 * no reprints without permission 8

9 PEDI Mobility p=0.01 * p=0.09 * p=0.04 * 250 Unable to walk with or without assistive device 200 Walking Speed Control Group Child 1 Child 2 Child 3 Child 4 Child 5 Child Unable to walk with or without assistive device 200 Treadmill Group Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Significant Between Group Results GMFM D at post test 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 no reprints without permission 9

Translation of Clinical Research into Practice + Collaboration of clinical and academic setting Supported Treadmill Exercise Program

10 Functional Ambulation Control Treadmill Control Treadmill Control Treadmill Control Treadmill Group Group Group Group Group Group Group Group Preintervention Postintervention 1 month post intervention 4 month post intervention Perceived Problem Reality Research Translation of Clinical Research into Practice + Collaboration of clinical and academic setting Supported Treadmill Exercise Program at Sacramento State Easter Seals STEPS = from personal archives, with permission from parents/students no reprints without permission 10

11 STEPS Overview Free group based treadmill program at University Twice weekly sessions during spring and fall semesters for 14 weeks Sessions individualized for each child 3 5 DPT students/day, supervised by PT/faculty Additional over ground walking activities Consultation/collaboration on orthotics/equipment >50 children served since Spring 2013 from personal archives, with permission from parents/students Personalized Training pictures from personal archives, with permission from parents/students Effects of a Group Based Treadmill Program on Pre Ambulatory Children with Neurodevelopmental Impairment Katrin Mattern Baxter no reprints without permission 11

12 Subjects n=12 n=4 Cerebral Palsy n=5 genetic syndrome n=3 other Mean age 30.4 (19 47) months M:F ratio 7:5 from personal archives, with permission from parents/students Program Admission Child receives physical therapy Child shows signs of walking-readiness sit for 30 seconds take 5-7 steps when supported Does not have any exclusion criteria Uncontrolled seizures Prior orthopedic surgery/contraindications for standing/walking PT refers child to STEPS Child attends treadmill sessions in addition to ongoing PT until independent walking onset or age 5 years Outcome Measures At program entry and at end of program Timed 10 meter walk test Gross Motor Function Measure, Dimensions D and E Pediatric Evaluation of Disability Inventory Mobility Caregiver Scale Functional Mobility Scale no reprints without permission 12

Results Mean Minutes Walked/Week Mean Treadmill Speed minutes 40 35 30 25 20 15 10 17.4 37.30 29.

05 0 week 1 week 7 week 13 0 week 1 week 7 week 13 Program Utilization 23% missed sessions 77% attended

13 Results Mean Minutes Walked/Week Mean Treadmill Speed minutes meters/second week 1 week 7 week 13 0 week 1 week 7 week 13 Program Utilization 23% missed sessions 77% attended sessions Results p= * p=0.001 ** p=0.001 Functional Mobility Scale p=0.039 Results Timed 10 meter Walk Test p=0.06 Pre Test Post Test no reprints without permission 13

Parent Survey Conclusions Group based treadmill programs can Developmental skill related to standing/walking Support needed for walking Caregiver dependence for

optimal dosage Intensive home based treadmill training and walking attainment in young children with cerebral palsy (Mattern Baxter, Bjornson, Looper) Enrolling

14 Parent Survey Conclusions Group based treadmill programs can Developmental skill related to standing/walking Support needed for walking Caregiver dependence for mobility Provide good utilization/ high satisfaction by families Provide cost effective alternative as an adjunct to PT Future Research Funded study to examine optimal dosage Intensive home based treadmill training and walking attainment in young children with cerebral palsy (Mattern Baxter, Bjornson, Looper) Enrolling 24 children with spastic CP High intensity versus low intensity treadmill training Effects on walking attainment and physical activity no reprints without permission 14

15 Thank you Thanks to all of the children and their families who participated and all the DPT students who assisted during the studies Objective 3. Describe muscle performance impairments in children with CP and the implications for treadmill training Muscle Structure, Function, and Plasticity in CP: Implications for Treadmill Training Combined Sections Meeting 2016 Noelle G. Moreau, PT, PhD no reprints without permission 15

Theoretical Framework for Improving Walking Task Specific (Treadmill, BWSTT, robotic devices) Impairmentbased (strength, power, ROM) Do we need more practice?

16 Theoretical Framework for Improving Walking Task Specific (Treadmill, BWSTT, robotic devices) Impairmentbased (strength, power, ROM) Do we need more practice? Are we lacking the underlying muscular resources? Theoretical Framework International Classification of Function (ICF) Cerebral Palsy Body Structure Muscle Architecture Body Functions Muscle Function Activities Gait Participation Society Treatment & Dosing Muscle Architecture Muscle architecture determines the forcevelocity properties of muscles!! no reprints without permission 16

Muscle Architecture Muscle size is directly proportional to maximal force

shortening velocity of a muscle and excursion Fascicle or pennation angle >

respond in a fairly stereotypical manner to the amount and type of activity

Spaceflight Paralysis Neurological Disorders Cerebral Palsy (CP) Stroke

17 Muscle Architecture Muscle size is directly proportional to maximal force generation in healthy muscle Fiber length is proportional to the maximal shortening velocity of a muscle and excursion Fascicle or pennation angle > allows more contractile material to be packed in a given volume Muscles respond in a fairly stereotypical manner to the amount and type of activity imposed upon them Lieber et al, 2004 Negative Bedrest Immobilization Spaceflight Paralysis Neurological Disorders Cerebral Palsy (CP) Stroke Traumatic Brain Injury Positive Resistance training Exercise & Activity no reprints without permission 17

Muscle Structure Function Relationships in CP Muscle Performance - Strength - Power Architectural Basis for Strength Deficits in CP Strength deficits ranging between 40% and 85% of normal have been

Brain Dev, 2006; Oberhofer et al, Clin Biom, 2010; Moreau et al, DMCN, 2009; Elder et al.

18 Muscle Structure Function Relationships in CP Muscle Performance - Strength - Power Architectural Basis for Strength Deficits in CP Strength deficits ranging between 40% and 85% of normal have been reported for LE muscle groups (Eek & Beckung, DMCN, 2008; Ross & Engsberg, DMCN, 2002; Wiley & Damiano, DMCN, 1998) Decreased muscle volume and crosssectional area of LE (14% to 50%) (Lampe et al, Brain Dev, 2006; Oberhofer et al, Clin Biom, 2010; Moreau et al, DMCN, 2009; Elder et al., DMCN, 2003; Malaiya et al Electromyogr Kinesiol, 2007) Less sarcomeres working in parallel results in a decrease in force generating capacity Overlengthened sarcomeres (Lieber & Friden, Muscle Nerve, 2002; Smith et al, J Phys, 2011) Strength Training?? Cerebral Palsy Body Structure Muscle Architecture Body Functions Muscle Function Activities Gait Participation Society Treatment & Dosing no reprints without permission 18

strength training (Moreau et al, NNR, 2013) No change in Walking or functional mobility!

19 Muscle Plasticity Strength Evidence for muscle hypertrophy in response to strength training in CP but no change in walking! Increase in plantarflexor muscle volume after 8 weeks of strength training (McNee et al, DMCN, 2009) Increase in quadriceps cross sectional area and muscle thickness after 8 weeks of knee extensor strength training (Moreau et al, NNR, 2013) No change in Walking or functional mobility!! Evidence: Strength Training in CP Despite moderate increases in strength, there is no higher level evidence that resistance training improves walking speed or other measures of functional walking capacity (Scianni et al, AJPT, 2009; Verschuren et al, PTJ, 2011) Small but clinically insignificant effects on GMFM (Scianni et al, AJPT, 2009) Muscle Power the ability to exert a maximal force in as short a time as possible generating as much force as fast as possible no reprints without permission 19

Architectural Basis for Muscle Power Deficits 2 Important Components: 1. Muscle size 2. Fiber (fascicle) length (Reproduced with permission: Lieber RL.

Muscle Architectural Basis for Diminished Muscle Power Studies have shown decreases in rectus femoris and gastrocnemius cross sectional area and fascicle length in children with CP compared to TD

20 Architectural Basis for Muscle Power Deficits 2 Important Components: 1. Muscle size 2. Fiber (fascicle) length (Reproduced with permission: Lieber RL. Skeletal muscle structure, function, and plasticity: the physiological basis for rehabilitation. 3rd ed. Baltimore: Lippincott Williams & Wilkins; 2010). Muscle Architectural Basis for Diminished Muscle Power Studies have shown decreases in rectus femoris and gastrocnemius cross sectional area and fascicle length in children with CP compared to TD children. (Moreau et al., 2009; Malaiya et al, 2007; Mohagheghi et al, 2007; 2008) CSA Decreased Force Production Fascicle Length Decreased Shortening Velocity Muscle Power CP % of TD children % by 82% 18% 0 Knee Extensors Peak Torque Power (Moreau et al, NNR, 2013) no reprints without permission 20

Muscle Power Take Home: youth with CP have difficulty producing torque at higher speeds of movement, which is often required

? Cerebral Palsy Body Structure Muscle Architecture Body Functions Muscle Function Activities Gait Participation Society

21 Muscle Power Take Home: youth with CP have difficulty producing torque at higher speeds of movement, which is often required during daily activities; therefore, muscle power should be considered for therapeutic interventions! Power Training?? Cerebral Palsy Body Structure Muscle Architecture Body Functions Muscle Function Activities Gait Participation Society Treatment & Dosing Muscle Plasticity Power Muscle architectural changes specific to power/velocity training in CP and improved walking! Increase in rectus femoris cross sectional area and fascicle length after 8 weeks of velocity training for knee extensor muscle power! (Moreau et al, NNR, 2013) Accompanied by increases in walking speed and functional mobility!! no reprints without permission 21

22 Evidence Summary Muscle power is a key ingredient for walking performance and other functional activities, such as transfers and sit to stand! Improvements in strength alone do not translate into improvements in walking What Type of Training and Dosage Does It Take to Induce Muscle Plasticity? Specificity of Training Dosing!!! Key Ingredients Dosing Guidelines Summary Muscle Strength (High resistance) Power (High resistance & High speed) Intensity Volume Speed >85% of 1RM 40 85% of 1RM Build to 3 sets of 6 10 Build to 6 sets of 5 6 Faigenbaum et al, Youth resistance training. Updated position statement paper from the NSCA Slow to moderate; controlled Concentric part as fast as possible Frequenc y 2 3 x/wk (nonconsecutive) 2 3 x/wk (nonconsecutive) Rest 1 2 min between sets; 24 hrs btw sessions 1 2 min between sets; 24 hrs btw sessions Duration 8 20 weeks 8 20 weeks no reprints without permission 22

Functions Muscle Function Activities Gait Participation

Adequate Stimulus to Effect Changes in Muscle Architecture

? Task Specific (Treadmill training, BWSTT, robotic devices)

BWSTT, robotic devices) Adult Protocols lower intensity

23 Treadmill Training?? Cerebral Palsy Body Structure Muscle Architecture Body Functions Muscle Function Activities Gait Participation Society Treatment & Dosing Can Treadmill Training Provide an Adequate Stimulus to Effect Changes in Muscle Architecture and Power? Specificity of training?? Task Specific (Treadmill training, BWSTT, robotic devices) Impairmentbased (strength, power, ROM) Task Specific (TT, BWSTT, robotic devices) Adult Protocols lower intensity endurance based (i.e., walk for 30min) Appropriate for Children with CP? BWS & Robotic Decrease Muscle Activation!! no reprints without permission 23

24 Activity Patterns Differ Between Children and Adults! Higher Intensity Children Moderate Intensity Lower Intensity BWS Adults.. CP Hours in day (Bjornson et al, 2007;2012) Can Treadmill Training Provide an Adequate Stimulus to Effect Changes in Muscle Architecture and Power? BWSTT, Overground, or Robotic > NO! Children with CP have difficulty ramping up their walking intensity to moderate and high levels. Ho: Requires muscle power as an underlying resource, and muscle power generation is significantly impaired in CP!! Can Treadmill Training Provide an Adequate Stimulus to Effect Changes in Muscle Architecture and Power? Current Work: Does treadmill training delivered in intervals of high intensity walking alternating with low/moderate intensity provide the necessary stimulus? Up Next!! no reprints without permission 24

25 Objective 4. Describe implementation and outcomes of short burst interval treadmill training in ambulatory children with CP Short Burst Interval Training: Walking Capacity &Performance- Pilot study Bjornson, Moreau, Bodkin, Rashid Funding: SCRI CHBD Stimulus Fund 2013 K23 HD060764, UL1RR025014, NCT Background/Significance: Muscle power production and rapid force development are deficient in children with CP as compared to TD youth (Moreau, 2013 & 2012). Youth with CP have limitations in the ability to ramp up their walking activity into medium and/or high stride rates. (Bjornson, 2013, 2007) TD children engage in very short bursts of intense walking and physical activity interspersed with varying intervals of low and moderate intensity (Armstrong, 1990, Bailey, 1995). LTT protocols for children with CP have been based on adult walking activity patterns and do not approximate the high intensity short burst patterns of TD children (Dobkin, 2006 Duncan, 2011) no reprints without permission 25

Short-burst Interval Locomotor Training will enhance muscle power production and subsequently walking performance and capacity through training patterns that are motivating and mirror the walking and

9) 3 = female Independent walking primary mode of mobility No ortho/neurosurgery in last 12 months No injection therapy in last 3 months No serial casting in 30 days Uncontrolled seizure disorder

26 Short-burst Interval Locomotor Training will enhance muscle power production and subsequently walking performance and capacity through training patterns that are motivating and mirror the walking and physical activity patterns of TD youth Pilot Study/Sample: Pre/Post Design N = 6, Spastic Diplegia GMFCS Levels II = 4 III = 2 Average Age: 7.7 (5.1 to 10.9) 3 = female Independent walking primary mode of mobility No ortho/neurosurgery in last 12 months No injection therapy in last 3 months No serial casting in 30 days Uncontrolled seizure disorder Short Burst Interval Training Protocol: 20 total sessions 5 days/week over 4 weeks 30 minutes total treadmill walking 30 seconds self selected speed slow 30 seconds - fast walking speed- fast Wearing current clinically prescribed orthotics Screen fail 2 subjects in adequate orthotic support Training speeds based on 75-85% of baseline 10 meter walk tests Training speeds: Average self-selected speed: 1.5 mph Average Fast speed: 2.6 no reprints without permission 26

activity StepWatch accelerometer Average Strides/day Peak Activity Index average step rate/minute of the highest 30 minutes/day

27 Short-Burst Interval Treadmill training Outcomes: Walking Capacity clinic based measures 10 meter walk test (10MWT)- m/sec Self-selected walking speed Fast walking speed 1 Minute Walk Test (1MWT) meters Outcomes: Walking Performance- community walking activity StepWatch accelerometer Average Strides/day Peak Activity Index average step rate/minute of the highest 30 minutes/day % of walking time : low, moderate and high activity* *Bjornson, 2010 Ped Ex Sci, Bjornson 2010, 2014 no reprints without permission 27

Walking stride activity was defined as Low 1-30

60 strides/min *Bjornson, 2010 Ped Ex Sci,

clinic measures 10 Meter Self Selected walking

28 Methods: Average of 5 days of StepWatch accelerometry data. Walking stride activity was defined as Low 1-30 strides/min Moderate strides/min High > 60 strides/min *Bjornson, 2010 Ped Ex Sci, Bjornson 2010, 2014 Results: Walking Capacity clinic measures 10 Meter Self Selected walking speed Average increase of.20 m/sec (MCID.1 m/sec) MPH no reprints without permission 28

29 10 Meter Fast walking speed Average increase of.17 m/sec (MCID.1 m/sec) MPH One Minute Walk Test (meters) Average increase 11.4 meters Meters Results: Community Walking Performance no reprints without permission 29

30 Walking Performance: Average Strides/day TDY and youth with CP Bjornson, 2014 Dis & Rehab SW: Average Strides/day Mean difference GMFCS level I to II = 1284 Bjornson, 2014 Dis & Rehab Average Strides/day Average increase 1441 strides/day (GMFCS level I to II = 1284 strides) Bjornson, 2014 Dis & Rehab no reprints without permission 30

31 Average strides/day StepWatch: Peak Stride Activity Index StepWatch: Peak Stride Activity Index Average increase 3.4 stride/min no reprints without permission 31

32 StepWatch: Peak Stride Activity Index Average % of Total Strides/day: Low, Medium & High Stride rates TDY & Youth with CP Bjornson, 2014 Dis & Rehab Average % of Total Strides/day- Low, Medium & High: PRE Training no reprints without permission 32

Average % of Total Strides/day- Low, Medium & High: POST

feasible May translate to clinical setting Short burst

Walking capacity Community walking activity Requires adequate

mechanisms architecture power rapid force production Questions?

33 Average % of Total Strides/day- Low, Medium & High: POST Training TAKE HOME PEARLS Pilot data suggests: SBLTT is feasible May translate to clinical setting Short burst interval treadmill training has potential positive influence Walking capacity Community walking activity Requires adequate orthotic support midstance Current work exploring muscle level mechanisms architecture power rapid force production Questions??? kristie.bjornson@seattlechildrens.org no reprints without permission 33

34 References Crair MC, Malenka RC. A critical period for long term potentiation at thalamocortical synapses. Nature. 1995; 375(6529): Huttenlocher PR, de Court. The development of synapses in striate cortex of man. Hum Neurobiol. 1987; 6:1 9. Jeng SF, Chen LC, & Yau KIT. Kinematic analysis of kicking movements in preterm infants with very low birth weight and full term infants. Physical Therapy, 2002; 82(2): Looper J, UlrichDA. Effects of various treadmill interventions on the development of joint kinematics in infants with Down syndrome. Phys Ther. 2010;90(9): Thelen E., Fischer DM. Newborn stepping: An explanation for a "disappearing" reflex. Developmental Psychology. 1982; 18(5): Ulrich BA, Ulrich DA. Spontaneous Leg Movements of Infants with Down Syndrome and Nondisabled Infants. Child Development. 1995; 66(6): Ulrich DA, Ulrich BD, Angulo Kinzler RM, Yun J. Treadmill training of infants with Down syndrome: evidence based developmental outcomes. Pediatrics. 2001;108(5):E84. References Wu et al., Exploring effects of different treadmill interventions on walking onset and gait patterns in infants with Down syndrome. Dev Med Child Neurol. 2007; 49: Zelazo PR, Zelazo NA, Kolb S. "Walking" in the newborn. Science. 1972; 176(4032): Zelazo PR. The development of walking: new findings and old assumptions. J Mot Behav. 1983;15(2): Valentin Gudiol M, Mattern Baxter K, Girabent Farrés M, Bagur Calafat C, Hadders Algra M, Angulo Barroso R. Treadmill interventions with partial body weight support in children under six years of age at risk of neuromotor delay. Cochrane Database Syst Rev; 2011; Art. No.: CD Mattern Baxter K, McNeil S, Mansoor JK. 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; 2013; 94: Mattern Baxter K. Effects of a Group Based Treadmill Program on Pre Ambulatory Children with Developmental Disability.2015; Ped Phys Ther (in press) REFERENCES: Bjornson, K.F., et al., Ambulatory Physical Activity Performance in Youth With Cerebral Palsy and Youth Who Are Developing Typically. Physical Therapy, (3): p Bjornson, K., Zhou, C., Stevenson, R.D., Christakis, D., Song, K., Walking activity patterns in youth with cerebral palsy and youth developing typically. Disability & Rehabilitation, (15): p Armstrong, N., et al., Patterns of physical activity among 11 to 16 year old British children. BMJ, : p Bailey, R.C., et al., The level and tempo of children's physical activities: an observational study. Medical Science Sport Exercise, (7): p Dobkin B, A.D., Barbeau H, Basso M, Behrman A, Deforge D, Ditunno J, Dudley G, Elashoff R, Fugate L, Harkema S, Saulino M, Scott M; Spinal Cord Injury Locomotor Trial Group., Weight supported treadmill vs over ground training for walking after acute incomplete SCI. Neurology, (4): p Duncan, P.W., et al., Body Weight Supported Treadmill Rehabilitation after Stroke. New England Journal of Medicine, (21): p Bjornson, K., et al., Measurement of walking activity throughout childhood: influence of leg length. Pediatric Exercise Science, (4): p no reprints without permission 34

35 References Damiano, D. L., Martellotta, T. L., Sullivan, D. J., Granata, K. P., & Abel, M. F. (2000). Muscle force production and functional performance in spastic cerebral palsy: Relationship of cocontraction. Eek MN, Beckung E. Walking ability is related to muscle strength in children with cerebral palsy. Gait Posture 2008;28(3): Elder GC, Kirk J, Stewart G et al. Contributing factors to muscle weakness in children with cerebral palsy. Dev Med Child Neurol 2003;45(8): Faigenbaum, A. D., Kraemer, W. J., Blimkie, C. J., Jeffreys, I., Micheli, L. J., Nitka, M., et al. (2009). Youth resistance training: Updated position statement paper from the national strength and conditioning association. Journal of Strength and Conditioning Research / National Strength & Conditioning Association, 23(5 Suppl), S Lampe R, Grassl S, Mitternacht J, Gerdesmeyer L, Gradinger R. MRT measurements of muscle volumes of the lower extremities of youths with spastic hemiplegia caused by cerebral palsy. Brain Dev 2006;28(8): Lieber RL, Friden J. Spasticity causes a fundamental rearrangement of muscle joint interaction. Muscle Nerve. 2002;25( ; 2): References Lieber RL, Steinman S, Barash IA, Chambers H. Structural and functional changes in spastic skeletal muscle. Muscle Nerve 2004;29(5): Malaiya R, McNee AE, Fry NR, Eve LC, Gough M, Shortland AP. The morphology of the medial gastrocnemius in typically developing children and children with spastic hemiplegic cerebral palsy. J Electromyogr Kinesiol 2007;17(6): Moreau NG, Teefey SA, Damiano DL. In vivo muscle architecture and size of the rectus femoris and vastus lateralis in children and adolescents with cerebral palsy. Dev Med Child Neurol 2009;51(10): Moreau NG, Simpson KN, Teefey SA, Damiano DL. Muscle architecture predicts maximum strength and is related to activity levels in cerebral palsy. Phys Ther 2010;90(11): Moreau NG, Falvo MJ, Damiano DL. Rapid force generation is impaired in cerebral palsy and is related to decreased muscle size and functional mobility. Gait Posture 2012;35(1): Moreau, N. G., & Holthaus, K. (2011). Motor severity negatively affects muscle architecture in CP: a comparison between GMFCS levels, hemiplegia, and typically developing children. Dev.Med.Child Neurol., 53(s5), 78 References Moreau NG, Holthaus K, Marlow N. Differential Adaptations of Muscle Architecture to High Velocity Versus Traditional Strength Training in Cerebral Palsy. Neurorehabil Neural Repair 2013,27(4): Oberhofer K, Stott NS, Mithraratne K, Anderson IA. Subject specific modelling of lower limb muscles in children with cerebral palsy. Clin Biomech (Bristol, Avon ) 2010;25(1): Perry, J., & Burnfield, J. M. (2010). Gait analysis: Normal and pathological function. Thorofare, NJ: SLACK, Inc. Rose J, McGill KC. Neuromuscular activation and motor unit firing characteristics in cerebral palsy. Dev Med Child Neurol 2005;47(5): Ross SA, Engsberg JR. Relation between spasticity and strength in individuals with spastic diplegic cerebral palsy. Dev Med Child Neurol 2002;44(3): Smith LR, Lee KS, Ward SR, Chambers HG, Lieber RL. Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length. J Physiol (Lond ). 2011;589( ; ): Wiley ME, Damiano DL. Lower extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol 1998;40(2): no reprints without permission 35

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

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