Pediatric Body-Weight Supported Treadmill Training. John Buchwald, Olivia Graciana, Kathryn Hayes & Caroline Thomsen

Transcription

1 Pediatric Body-Weight Supported Treadmill Training John Buchwald, Olivia Graciana, Kathryn Hayes & Caroline Thomsen

2 What is body-weight supported treadmill training? BWSTT provides a system for working on strength, endurance, and task-specific gait training where the body weight of the child is unloaded [and] the legs are advanced Methods of unloading: 1. Adult assistance 2. Counter-weight harness system Methods of advancing the legs: 1. Actively by the child 2. Manually assisted by PT or caregiver 3. Robotically (Section on Pediatrics, 2010)

3 Theory of BWSTT (Høyer et al., 2012)

4 Methods of Advancing the Legs - Actively by Child

5 Methods of Advancing the Legs - Manually by Adult Suspension System Adult BW Support

6 Methods of Advancing the Legs - Robotically

7 History of BWSTT Barbeau & Rossignol Cat study - treadmill training & BW support to regain normal locomotion patterns in cats with a given SCI Suggests removal of BW may be therapeutic tool in gait training Finch, Barbeau & Arsenault Study on 10 non-disabled men Results found BW supported training could provide an easier progression from stance to the swing phase of gait May help with training neurological population by making the task easier

8 History of Treadmill Training with Children Cochrane Review of Treadmill Training in Children up to 6 Years Old at Risk of Neuromotor Delay Reviewed 5 RCTs to determine the efficacy of treadmill intervention in this population Chen (2008), Cherng (2007), Looper (2010), Ulrich (2001), Ulrich (2008) Results suggest treadmill training may accelerate the development of independent walking in children with Down syndrome Further research is needed to address if treadmill training can accelerate walking onset of children with CP

9 Based on evidence for adult BW supported training & pediatric full weight treadmill training... Could body weight supported treadmill training be an effective intervention in the pediatric population?

10 A Systematic Review of the Effectiveness of Treadmill Training and Body Weight Support in Pediatric Rehabilitation Diane L. Damiano, PT, PhD and Stacey L. DeJong, PT, MS (2009) Goal: To explore the evidence supporting or negating the use of treadmill training and body weight support in pediatric patients with motor disabilities. To determine if guidelines for use of this therapy exist. Literature search led to the evaluation of 29 studies including children (0-21yo) with motor disability diagnoses: - Cerebral palsy, other central motor impairments - Spinal cord injuries - Down syndrome

11 Interpretation of Results For each subject group, what evidence supports or does not support the use of TT and BWS? Best Evidence: Sackett s Level 2 Significant: Levels 3-5 Improved but not Significant Damiano and DeJong (2009)

12 Treatment Efficacy - Body Structure and Function CP/Central Disorder: Significant: Increased isometric strength at hip, knee, and ankle, improved lateral step test (strength), decreased energy expenditure with gait, decreased resting heart rate during training interval (Rett Syndrome), decreased difference between R and L step lengths Improved but not significant: Improved Functional Reach in sitting and standing, decreased Modified Ashworth Scale for LE muscles - decrease in bilateral hamstring score Down Syndrome: Significant: Increased stride/step length, mature gait construct SCI : No body structure and function results related to SCI. Damiano and DeJong (2009)

13 Treatment Efficacy - Activity Limitations CP/Central Disorder: Best Evidence: Increased self-selected gait speed, Improved GMFM scores in Standing and Walking, Running, Jumping Significant: number of unassisted steps increased, improved sit to stand, improved ability to go up and down stairs Down Syndrome: Best Evidence: Improved cadence, velocity, step length; Walk earlier with help and walk earlier alone, walk earlier independently for 3 steps SCI : Improved but not significant: WeeFIM transfers and mobility subscale Damiano and DeJong (2009)

14 Treatment Efficacy - Participation Restrictions Down Syndrome: Significant: Increased walking strategy of obstacle negotiation, decreased crawl strategy. Maintained for 6 months. Improved but not significant: Improved parent report of walking participation in school, church, and community No participation restriction related results for central motor impairment or SCI studies Damiano and DeJong (2009)

15 Treatment Efficacy - Personal/Environmental Factors Cerebral Palsy: Subjective reports by OT/PT reported positive change in affect, motivation, and attention, decreased required caregiver assistance No results related to personal/environmental factors in Down Syndrome or SCI categories of studies. Damiano and DeJong (2009)

16 Conclusion of Systematic Review Efficacy of BW supported treadmill training in pediatric populations. Best evidence for improved GMFM scores - D&E (CP), walking velocity and earlier onset of walking (DS) Conclusions drawn from studies with variable application of additional therapies, length of treatment, and onset of treatment Lack of long term follow-up Limited high quality evidence and multiple contradictory results in lower quality evidence articles limit interpretation

17 Over Ground Walking and Body Weight Supported Walking Improved Mobility Equally in Cerebral Palsy: a randomised controlled trial Swe et al. (2015) Study Design: Randomised controlled trial Participants 30 children (15 per group), GMFCS II, III (Age= 6-18yo) Blocked Randomization used to assign groups Methods Each Groups practiced for 30 min, 2x per week, 8 weeks Control group: practiced over ground with assistive device Intervention Group used partial body weight supported treadmill training Outcome Measures included: Six Minute Endurance Walk Ten-Meter Walking Velocity GMFM (Dimension D & E)

18 Results Swe et al. (2015) Body Structure & Function Both Groups significantly improved endurance and velocity Intervention group improved more in the short term (4 weeks), but was not significantly different than the control group in any outcome measure after 8 weeks Endurance or velocity Activity Limitations Significant improvement in GMFM dimension D&E Standing, Walking, Running, Jumping Ambulation Outcome measures were all a component of gait

19 Inferences of Results Swe et al. (2015) Participation Restrictions Increased endurance and velocity could lead to increased community ambulation and participation within the child s environment Easier to walk between classes Easier to keep up with peers Personal/Environmental Factors No results related to this level

20 Endurance and Gait in Children With Cerebral Palsy After Intensive Body Weight-Supported Treadmill Training Provost et al. (2007) Study Design: Descriptive Case Series Participants 6 children with spastic CP, GMFCS I (Age= 6-14yo) Methods 30% Body weight offset, gradually decreased to 0% Speed of treadmill started at 1.5 m/hr and gradually increased to 3.1 m/hr 30min x2 per day, 6 days per week, 2 weeks Outcome measures included: Six Minute Endurance Walk Ten-Meter Walking Velocity Energy Expenditure Measurement GMFM (Dimension E) Single Leg Balance Test

21 Results Provost et al. (2007) Body Structure & Function Group change in walking velocity was +2.8 m/sec (p=0.038)* Group change in EEI was (p=0.029)* There was no statistically significant difference between the Six Minute Endurance Walk, Single Leg Balance Test Activity Limitations Outcome measures related to Gait No significant improvement in GMFM Dimension E (walking/running/jumping)

22 Inferences of Results Provost et al. (2007) Participation Restrictions Increased endurance and velocity could lead to increased community ambulation and participation within the child s environment Personal/Environmental Factors No results related to this level

23 Efficacy of Individual Studies Swe et al. (2015): strong study due to control group and number of participants Study limited in: Range of GMFCS level Wide age range Determination to increase body offload or increase velocity was subjective Provost et al. (2007): weak study due to limitations in: Number of participants Wide age range Lack of control group Determination to increase body offload or increase velocity was subjective Overall, studies tend to lack unified treatment parameters, small group size, lack of control group, and wide ranges of GMFCS levels

24 Who is this intervention appropriate for? Children with Down Syndrome Upcoming, but weaker evidence: Children with CP, SCI, Myelomeningocele Children with motor delays that require more task specific practice

25 Contraindications BW > 297 Lbs Severe contractures Bone fx risk (osteoporosis, current fx, etc.) Open skin lesions in LE/ torso Circulation/ cardiac problems/ severe vascular problems of LE Psychotic/ unstable psychological state or cognitive deficits Long-term infusions Mechanical ventilation Severe dysplasia or malformation of LE bones and/or spine Bed rest orders Hip/ knee/ ankle arthrodesis Orthosis not adapted for body (

26 Continuing Education LiteGait Offers both online and on-site CEU training Range from $100 (refresher) - $1,450 (extended on-site)

27 Take Home Messages Goal is repetitive, task specific training which encourages motor learning to improve function Few research articles are high levels of evidence Improved cadence/velocity Earlier ability to ambulate May vary by diagnosis More RCT should be done with clearly defined controls and intervention parameters with long term follow-up. Safe & Efficacious

28 References Barbeau, H., & Rossignol, S. (1987). Recovery of locomotion after chronic spinalization in the adult cat. Brain Research, 412(1), Beth Provost, Kathy Dieruf, Patricia A. Burtner, John P. Phillips, Ann Bernitky-Beddingfield, Katherine J. Sullivan, Chantel A. Bowen, Lesley Toser. Endurance and Gait in Children with Cerebral Palsy After Intensive Body Weight-Supported Treadmill Training. Pediatric Physical Therapy (2007). PubMed. Web. 20 March Campbell, Suzann K., Robert J. Palisano, and Vander Linden Darl W. Physical Therapy for Children. 4th ed. St. Louis, MO: Elsevier Saunders, Print. Damiano DL, DeJong SL. A systematic review of the effectiveness of treadmill training and body weight support in pediatric rehabilitation. J Neurol Phys Ther. 2009;33: Høyer, E., Jahnsen, R., Stanghelle, J. K., & Strand, L. I. (2012). Body weight supported treadmill training versus traditional training in patients dependent on walking assistance after stroke: a randomized controlled trial. Disability & Rehabilitation, 34(3), (Picture Citation) Ni Ni Swe, Sunitha Sendhilnnathan, Maayken van Den Berg, Christopher Barr. Over Ground Walking and Body Weight Supported Walking Improve Mobility Equally in Cerebral Palsy: a Randomised Controlled Trial. Clinical Rehabilitation (2015): PubMed. Web. 19 March Section on Pediatrics. (2010). Body-Weight Supported Treadmill Training: Using Evidence to Guide Physical Therapy Intervention Alexandria, VA: APTA. Valentin-Gudiol, M., Mattern-Baxter, K., Girabent-Farrés, M., Bagur-Calafat, C., Hadders-Algra, M., & Angulo-Barroso, R. M. (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 Reviews.