Cerebral palsy (CP) is a congenital disorder resulting from a lesion in the immature brain. This nonprogressive condition affects five of every 2,000 newborns (births) in the United States and 5% of all premature infants. 1,2 CP may result in abnormalities in motor development; alterations in sensation, vision, and speech; and social and emotional problems. 3 Because children with CP reach developmental milestones later than children who develop normally, abnormal postural and movement patterns emerge as the child is forced to compensate to accomplish new activities. This further interferes with the child’s motor development. 4
A common functional goal for children with CP is the attainment of walking. Children who are able to walk are more successful in social roles and the accomplishment of activities of daily living (ADL) than children who use a wheelchair. 5 Despite this, children with moderate to severe tetraplegia are frequently required to use a wheelchair for locomotion. 5,6
Traditional models of treatment for the movement disorders associated with CP are focused on the attainment of sequential developmental milestones and facilitation of normal movement patterns for the training of functional activities. The specific goals of standing and walking are part of an overall program that emphasizes postural alignment and quality of movement. Therapists provide facilitation and support during standing, weight shifting, and stepping, which are incorporated into the practice of walking. 3
Researchers investigating the neural control for mammalian locomotion have contributed to the recent advances in the retraining of gait in human subjects. Following complete severance of the lumbosacral spinal cord, adult cats that received locomotor training while treadmill walking with harness support regained the ability to independently step with their hindlimbs. 7–10 Trainers provided specific sensory cues to enhance motor performance during treadmill walking. These included placement or guidance of the limb or paws during swing and stance phases, limb loading to maximize extensor muscle activation, and facilitation of appropriate joint kinematics timed appropriately for each phase of gait. 10
Initially shown to be efficacious for retraining gait in persons following spinal cord injury, 11–15 locomotor training on the treadmill with body weight support (BWS) has proved to be beneficial for subjects with other neurological conditions such as cerebrovascular accident 16–18 and supranuclear palsy. 19 Based on the cat model, specific training procedures were used to provide sensory cues related to gait 15–17 and to facilitate the neural circuits to generate phasic efferent patterns for stepping. 12
Contemporary models of motor control and motor learning advocate a task-specific approach that emphasizes repetition and practice of the specific task. Demonstrating the activity-dependent plasticity of the mammalian lumbar spinal cord, spinalized cats that were trained to stand were successful at this task but were unable to step. Cats trained to step on a treadmill were able to perform this task but required assistance for standing. 20 Similar findings in hemiparetic adults demonstrated that standing balance training was effective for improved standing balance but did not necessarily lead to improved locomotor ability. 21
Recently, clinicians and researchers demonstrated that locomotor training on a treadmill with BWS is beneficial for children with CP. Children of varying ages and abilities have demonstrated improvements in ambulation, decreased reliance on assistive devices, and improved performance of ADL. 6,22 Partially unweighted by the harness system, the children were able to practice walking at a faster, more normal pace without the exertion that would be expected at a similar speed with over-ground ambulation. 23 With the child supported in the harness, trainers were able to manually guide the lower extremities for improved alignment and joint kinematics during the stance and swing phases of gait. Treadmill speed was increased and BWS decreased to emphasize limb loading as the child was able to support more weight and ambulate at a faster pace. 6,22
In a study of 10 children with CP, ages six to 18 years, six demonstrated improvements in walking. Three of the six children who were nonambulatory prior to training were able to achieve over-ground ambulation. One of these children was able to walk independently with verbal supervision, while the other two needed continuous assistance to support their weight and maintain balance. 6
Locomotor training using these described principles 6,12,15–17,22 in an environment that allows trainers to provide gait-specific sensory cues may provide children with spastic tetraplegic CP who have never ambulated the opportunity to achieve improvements in their upright and ambulation skills. The purpose of this case report is to describe locomotor training on a treadmill with BWS designed to provide a nonambulatory child with CP the guidance and sensory input for the achievement of treadmill and over-ground ambulation.
Child and History.
The child was a nine-year-old boy with spastic tetraplegic cerebral palsy. He was born at 33 weeks gestation (date of birth was 01/13/92) with abruptio placenta and required intubation for one day. The boy stayed in the neonatal intensive care unit for 31 days during which he required oral gastric feeds, propylthiouracil for hypothyroidism, and propranolol for a heart rate above 200 beats per minute. During his stay, the child was also treated for suspected sepsis and hyperbilirubinemia of prematurity. Cranial ultrasounds were performed on postdelivery days one, eight, and 22 with no signs of intercranial hemorrhage, but he did have increased periventricular echogenicity on the right greater than left. His ventricles were normal. The child was discharged to home with oxygen and an apnea monitor. The boy required no hospitalizations until complications arose from a trial dorsal rhizotomy procedure in July 1998. During a caudal epidural block, the needle entered the vascular space resulting in two grand mal seizures and respiratory distress. He recovered without change in physical and/or cognitive status. On 11/16/98 at the age of six years 10 months, the child underwent a baclofen pump implantation to reduce muscle tone. His dosage was titrated to 2,000 μg/mL delivered at a rate of 240 μg per day over the first six months, and he has remained on that dosage. One year later on 11/22/99, he underwent bilateral adductor tenotomies, open reduction of dislocated hips, proximal varus derotational osteotomies, and pelvic Pemberton osteotomies. He was in a spica cast for six weeks following these procedures.
After the implantation of the baclofen pump, the child had two complications requiring hospitalizations. In May 2000 and January 2001, surgical revisions of the catheter portion of the pump were performed. He recovered without complications from both incidents.
The child’s rehabilitation history began at approximately five months of age with physical and occupational therapies. Speech therapy was started at three years of age. His physical therapy over the years consisted of developmental treatment, stretching, and functional skills training such as transfer techniques and family education. Prior to the implementation of the baclofen pump at age six years, the child’s progress had slowed considerably due to the increase in muscle tone throughout his extremities and trunk. At that time, he was able to ring sit with close supervision using his upper extremities for propping, take minimal weight through both extended lower extremities with the trunk fully supported, was dependent for all transfers, and required assistance to roll. After the baclofen pump implantation, the child’s skills began to improve again. Treatment was focused on proximal stability activities in a variety of positions and progressed to more distal control skills. The child demonstrated improvements in sitting, rolling, and weight shifting in prone and short-sit; protective extension in sitting began to emerge, and he demonstrated increased lower extremity active movement in gravity-eliminated positions.
After recovering from the hip surgery in November 1999, bilateral knee-ankle-foot orthoses (KAFOs) (knee joints locked when upright) were fabricated for the child, and he began practicing upright skills in the parallel bars and at a table. He then progressed to using his upper extremities for play for short times while requiring moderate to minimal assistance at the trunk. The child also worked on weight shifting while wearing the KAFOs in a postural control walker while the therapist moved his lower extremities. This was his functional level prior to the initiation of the treadmill training.
Rationale for Assessment Tools
The GMFM is a standardized evaluative measure that was designed to assess changes in gross motor skills over time in the child with CP. 24 This criterion-based tool is used to assess the ability of the child to perform 88 specific gross motor skills in five “dimensions” without the assistance of a parent or therapist. These dimensions are 1) lying and rolling, 2) sitting, 3) crawling and kneeling, 4) standing, and 5) walking, running, and jumping. Each of these sections is weighted equally in the scoring process. The score for each item is based on a four-point scale: zero, does not initiate; one, initiates (less than 10% of the task); two, partially completes (10% to less than 100% of the task); 3, completes the task. In the Guidelines for Item Scoring section, the starting position for each item is stated, the skill to be measured is described, and the scoring criteria are listed. The GMFM is a valid instrument for detecting varying levels of changes in gross motor function in children with CP. 24,25
The Pediatric Evaluation of Disability Inventory (PEDI) is a criterion-based tool used to assess the functional capabilities of children in three domains (self-care, mobility, and social function). 26 Each of these domains has a corresponding caregiver assistance portion that is used to assess the actual performance of the child by assessing the caregiver’s perception of how much help is given to the child on a regular basis. The last portion of the PEDI is the modification frequency, which is used to assess the type and amount of equipment that the child needs to perform functionally in his/her environment. Each of the capability domains, the caregiver assistance domains, and the modification frequency can be scored separately and independently.
This evaluation tool was designed for use with children with a variety of physical and/or cognitive disabilities. Normative scores are based on children aged six months to 7.5 years; however, the PEDI is also designed for use with older children whose functional level falls within the stated range. The scaled scores give an estimate of the level of capability of a child in each domain regardless of age and are determined by using a scale from zero to 100 to distribute the scores from each domain (zero, no measurable functional ability and 100, capability in all test items in that domain). The scaled score is the most appropriate score for an older child functioning at a lower level. The PEDI may be administered by therapists and/or educators who know the child well or by parent interview. The PEDI has demonstrated high levels of reliability 26,27 and validity 26–28 for determination of a child’s functional capability.
Prior to beginning the locomotor training on 6/25/01, the GMFM 24 and the caregiver portion of the PEDI 26 were administered. The child was nine years five months old at the time the tests were administered. A review of physical therapy documentation indicated that his function had remained essentially unchanged for the previous nine months.
He was cooperative throughout the administration of the GMFM with the scoring system motivating him to put forth maximal effort throughout the test. The GMFM was performed without ankle-foot orthoses (AFOs) until the standing portion when bilateral solid-ankle AFOs were donned for his comfort and compliance.
As anticipated, the child scored the highest in the areas that required the least amount of postural control against gravity. As he was asked to assume postures against gravity, scores dramatically declined. Results are reported in Table 1. His goal total score, which included standing and walking/running dimensions (sum of the percentage of scores for each dimension identified as a goal area/number of goal areas), was only 2% prior to the locomotor training.
The PEDI was administered through interview of the boy’s mother for the functional skills, caregiver assistance, and modification frequency portions. Results of the mobility functional skills and caregiver assistance are reported in Table 2. The modification frequency portion identifies the number of functional activities requiring modifications such as a child-sized spoon (child modification), a walker (rehabilitation equipment modification), or use of a lift device (extensive modification). Modifications were counted only when the child needed the equipment to perform an activity. This child required one child modification (sits in a store-bought chair), one rehabilitation equipment modification (toilet chair), and three extensive modifications (van lift, hospital bed, and wheelchair).
Treadmill and Unweighting System.
A Biodex RTM 400 rehabilitation treadmill (Biodex Medical Systems, Inc., Shirley, NY) was used for the locomotor training, and it allowed for speeds from zero to eight miles per hour in 0.1-mile increments. The base of the treadmill was 20 × 64 in. with a 6-in. step-up to the walking platform. A digital control panel was located at the front of the treadmill with easy accessibility to stop, start, and adjust the speed of the treadmill. A pneumatic lift (Neuro II; Vigor Equipment Inc., Stevensville, MI) suspended over the treadmill was used to support the boy’s body weight. A large dial, with a digital read out, could be adjusted to vary the amount of vertical unweighting provided by the lift. A steel bar on the overhead cable was used for attaching the harness. A separate safety cable was attached to prevent the possibility of the boy collapsing to the floor in the event of a slip or a trip.
A harness (Medical Harness; Robertson Harness, Henderson, NV) was used to support the child. It was applied with the child in the supine position and then readjusted in the standing position, if necessary, so that it fit snugly around the pelvis and chest. The pelvic band of the harness fit around the iliac crests just below the anterior superior iliac spines, and the trunk or thoracic component of the harness was just below the nipple level and had padded shoulder straps.
Padded straps from the pelvic band wrapped between the legs and around the upper inner thigh to hold the harness securely in place (much like a climbing harness). Webbing straps with metal rings extended from the trunk harness upward and were attached via carabiners to the steel bar of the BWS system. When applying the harness with the child supine, it was always tightened from the bottom up so that it would fit snugly around the pelvis and not ride up on the child when he was standing.
The child wore very light-weight, thin, rubber-soled beach shoes and no socks to provide as much sensory input to the foot as possible during the stance phase of gait. He never wore his AFOs during the gait training on the treadmill.
Each locomotor training session began with the following:
* Lower extremity stretching of the hamstrings, gastrocnemius/soleus, and adductors in the supine position
* Applying the harness
* Placement of the child in a sitting position on a bench on the treadmill
* Attachment of the BWS system
* Assisted standing and attachment of the safety cable with the BWS at 60%
* Decrease of the BWS system gradually from 60% to 20% while encouraging the child to stand with an upright posture and to load the lower extremities as much as possible with assist at hips and knees
* Weight shifting and stepping forward with one foot in a stride position with instruction for the child to “push into the ground” to facilitate active weight-bearing (extension of hips, knees, and trunk) (this activity was assisted by one or two therapists who provided support at the knees to encourage knee and hip extension)
* Attachment of rubber “bungee” cords diagonally from the front and back of the treadmill to the harness to further stabilize the trunk (these cords were removed as the child progressed in the training)
* Starting of the treadmill and actual stepping on the treadmill
A mirror was used at the front of the treadmill so that the child could see himself and assist with his postural alignment as well as to provide motivation. After several minutes of standing, followed by several minutes of assisted stepping forward with one foot and then the other, the actual step training began.
During the step training with BWS, manual assistance was provided to assist the lower extremities to perform the gait pattern. The following protocol was adapted from the work of Behrman and Harkema. 15 To begin step training, the legs were manually placed in a stride position and the treadmill was started and brought up to the child’s comfortable walking speed. Assistants were positioned on both sides of the treadmill to assist with each leg. One hand of the assistant was placed on the anterior surface of the tibia to assist with knee extension during the stance phase and was smoothly moved to the posterior knee to facilitate the medial hamstrings for knee flexion during swing. The other hand was placed at the ankle to assist with toe clearance during swing and appropriate foot placement at initial contact. The boy wore knee pads on occasion to avoid any discomfort from the assistants’ hand contact at the upper tibia. A third person sat behind the child on a bench that straddled the treadmill to assist in trunk stabilization and upright postural alignment. A fourth person started, stopped, and adjusted the treadmill speed and recorded times and percentage of BWS. The child’s primary therapist, who also served as an assistant, provided motivation to the child by telling him stories about walking through various environments. One example: “we are walking on a planet, and there is a lot of gravity here, so you really have to pick your feet up! OK, now we need to walk over this way and see what those aliens are doing.”
Training sessions were scheduled as follows: three training sessions per week for 10 weeks followed by two training sessions per week for 11 weeks.
The training schedule was spread out over a period of 25 weeks with a three-week break after the first eight weeks and a one-week break after the next seven weeks. The first break was due to the beginning of the school session and the added burden of scheduling after a long day at school. The second break was due to a perceived need as a reward for hard work. The child missed several sessions because of illnesses. The locomotor training was stopped for the final time due to scheduled orthopedic surgery (removal of hardware) for the child and for the Christmas and New Year holidays.
The child received a total of 44 training sessions. Each session lasted between one to one and one-half hours and included repeated bouts of stepping practice with the standing practice at the beginning of each session and during each rest period between stepping bouts. The duration of each step training bout depended on the child’s fatigue or the assistants’ ability to provide proper assistance and gait kinematics. BWS varied from 40% to 60% with the most common BWS of 55% provided during most of the step training. The speed of the treadmill was increased as the training sessions progressed. In the first training sessions, treadmill speed varied between 0.2 and 0.8 mph and by the last training sessions had increased to 1.3 mph. More assistance for the legs and trunk was required in the earlier sessions. Total standing times ranged from 19 to 31 minutes, and total stepping times ranged from 11 to 25 minutes during the training sessions. Table 3 provides summaries of times, speeds, and BWS used during the sessions.
During the training, the child continued with his regularly scheduled physical, occupational, and speech therapy sessions. He received his regular physical therapy twice per week and occupational and speech therapy each once per week.
When the locomotor training began, the child was unable to independently initiate a step even with 60% BWS and a treadmill speed of 0.6 mph. Those assisting with both swing and foot placement during initial contact were working hard to overcome increased flexor tone, and both assistants and child were easily fatigued. Many standing rest stops were taken during those early sessions, and the child was able to step for less than one to four minutes at a time. At the conclusion of the locomotor training, the child was able to maintain independent stepping for as many as 60 steps at a speed of 1.3 mph while in the harness. When assistance was necessary, it was primarily for sensory cues for foot placement during initial contact, to maintain knee extension throughout stance, and minimal assistance with swing. The child was walking for an average of three to six minutes at a time (sometimes 10 to 11 minutes) before a standing rest break.
The boy was nine years 10 months of age at the time of posttesting. He was very cooperative during the GMFM administration and motivated throughout. The scores of the GMFM improved in all dimensions and are reported in Table 1. These changes included an improvement in overall trunk control and lower extremity movement. The child was still the most limited in coming to stand, standing, and stepping; however, during the posttest he was able to attempt more items than in the pretest (19 more items) due to his improved abilities in upright positions. He had great difficulty with coming to stand from short sit from a bench where hips and knees were at 90 degrees. He did show improvement in coming to stand from his wheelchair. He was able to stand, at the time of the posttest, with upper extremity support on the therapist’s shoulders or on parallel bars with his AFOs donned with assistance ranging from minimal to contact guarding. He was also able to maintain this position and, with the opposite leg blocked at the knee, “step” to assist with a stand pivot transfer. This was a marked improvement from the pretest levels. When the child’s trunk and weight were supported, he was able to take steps, which he was not able to do at the time of the pretest.
The PEDI posttest was performed through a combination of therapist testing and parental interview. The child demonstrated improvements in both domains of the PEDI, and these results are reported in Table 2. The amount of improvement, however, did not exceed the standard error for the scaled scores (there is overlap of the pre- and post-test scores when the standard error is used). Although the test scores showed only small improvements, the parental subjective comments demonstrated a significant improvement in contribution to assist with transfers and ADL. The mother reported that the child could now stand from his wheelchair using his upper extremities to hold onto her and allow his pants to be pulled down for toilet and bath transfers. This was a significant contribution since the parents had to lift him onto the bed to take off his pants prior to transferring him to the toilet. The parents also reported that the child was able to assist more in standing for wheelchair to bed transfers.
Prior to the locomotor training, the child was receiving physical therapy twice per week, occupational therapy once per week, and speech therapy once per week. As mentioned before, during and following the period of locomotor training, those frequencies were maintained. Prior to the locomotor training, the boy’s motivation to participate in therapies was low and he required continuous encouragement. He had an overall low affect and demonstrated frequent emotional breakdowns due to frustration and boredom. His primary physical and occupational therapist reported his progress was slow for all functional skills.
During his locomotor training, the occupational therapist noted that the boy’s affect was much more positive and he was more motivated to participate in therapy. She felt that his attention and his ability to work on difficult skills without breakdowns were much improved. The occupational therapist was able to address more mature skills with the boy rather than play skills. She also noted that he asked for more difficult tasks during his therapies.
The physical therapist also noticed improvements in his affect. The child now wanted to work on transfers, standing, and sitting balance rather than just play. He was much more motivated to be independent in his mobility and skills than prior to the locomotor training. This motivation assisted the therapist by allowing work on functional mobility, with the child giving his full effort. The child’s frustration level was much improved.
As reported, this child demonstrated marked improvement in antigravity activities and in his ability to initiate stepping on the treadmill. Only one study has been published reporting locomotor training for children with spastic tetraparesis of the age range of this boy. 6 In that study, the six subjects with spastic tetraplegia were able to stand holding on with both arms for at least three seconds but could not walk at all or required very firm support for ambulation prior to training. They, like this boy, used a wheelchair for daily activity. These authors speculated that improved function of their subjects was due to activation of existing spinal and supraspinal pattern generators. Such generators are an intrinsic neural circuitry providing for rhythmic, alternating patterns of activation. Specific to walking, pattern generators are hypothesized to activate the reciprocal pattern of flexion and extension. 29,30 After locomotor training with BWS and the treadmill, persons with gait impairment secondary to acquired upper motor neuron neurological pathologies (eg, stroke and incomplete spinal cord injury) have exhibited improved walking speed, decreased need of BWS, and carryover to overground walking. 11,13–15,31 Researchers similarly propose that locomotor training in persons with incomplete spinal cord injuries or after a stroke contributes to increased plasticity of preserved pathways and promotes activation of spinal central pattern generators. 30
This boy differed from persons with incomplete spinal cord injury or stroke in that he had never experienced walking. His development in a predominantly nonambulatory state may have altered the neural pathways that subserve locomotion at both spinal and supraspinal levels. Input from spinal circuits and supraspinal centers, although likely abnormal, may possess sufficient plasticity to benefit from the locomotor training experience. Investigating the types of changes that this boy may have experienced at the spinal or supraspinal level, in muscle performance, in cardiovascular endurance, or other mechanisms for change as a product of training are promising and areas of needed research.
Motor learning investigators have demonstrated the importance of task-specific training for optimal skill acquisition. 21,32 If a person is to learn to stand, then practice in standing is necessary; if walking is the goal, then the person must practice walking. Because of this child’s severe limitations, he had been unable to practice the task of ambulation or any of the essential components such as upright balance, weight shifting, and stepping prior to the initiation of locomotor training. The unique environment of the treadmill and BWS system provided a permissive condition that allowed him to experience the characteristics of rhythmic ambulation as well as the specific sensory input, such as correct timing, hip/knee extension, limb loading, and proper trunk posture 31 to promote a stepping response. The therapists were able to provide facilitation and feedback specific to the task as well as provide a motivating environment. The fact that this child progressed to walking on the treadmill at 1.3 mph for six to 11 minutes before resting and that he could initiate and maintain independent stepping for as many as 60 steps indicated a marked improvement in upright motor skills.
Schindl et al 6 reported in their study that paresis played a minor role because their subjects required very little BWS (average of 23.3%) and used the harness system primarily for balance. Finch et al 33 had reported that BWS under 70% could be beneficial for training. Although this child demonstrated marked paresis, requiring 55% to 60% BWS throughout the entire training period, it was this safe, partially unweighted environment that allowed him to practice upright alignment and balance. He was unable to stand without locked KAFOs prior to the locomotor training and could not actively move his lower extremities except occasionally in a flexion synergy while lying supine. These facts indicated that, contrary to the subjects in the study by Schindl et al, 6 lower extremity weakness may have had a major impact on this child’s abilities. In support of our findings, several authors have reported abnormal muscle tone with underlying weakness in children with CP. 32,34–39 Without the use of the harness system, this child’s best effort to support himself against gravity was ineffectual and led to fear of falling and an increase in muscle tone. The BWS system allowed the therapists and assistants to manually assist him with alignment in the weight-bearing activity without the fear of falling. These factors may have helped reduce the influence of abnormal tone.
After the locomotor training on treadmill with BWS was stopped, a strengthening program with emphasis on quadriceps, hip flexors, and hip extensors was initiated. He began walking over ground with an anterior support rolling walker and ground or floor reaction AFOs. These AFOs were designed with a solid anterior surface and an anterior trim-line just below the patella. They restricted dorsiflexion and allowed the child a more erect gait by keeping him from sinking into his usual crouched position. He was able to walk a total of 5 ft with maximal assistance of two persons. One person provided assistance at his pelvis/stance leg, and the second person provided minimal assistance at his trunk. Four months after training ended, the child had increased his walking distance to a total of 24 ft in five- to eight-foot intervals with the same walker and AFOs, minimal to moderate assistance at his pelvis, and minimal assistance at his low trunk to maintain midline. Eight months after training ended, the child was ambulating a total of 100 ft in 25-ft intervals with only minimal assistance of two persons at his left pelvis and low trunk. One year after training was completed, the child was ambulating with minimal assistance of one person at his pelvis. His distance decreased to a total of 60 ft in 15-ft intervals, but he now could walk with only one person assisting rather than two.
This child’s gait pattern and endurance improved in terms of distance, quality, and assistance required over the past year. He began with a significant crouch gait, severe left pelvic lateral thrust, left foot only with step to stride, right lateral trunk lean, and poor lower extremity dissociation causing buckling of the stance leg when attempting to flex the opposite leg for swing. The boy continues to demonstrate a crouch gait, but this is significantly less; the left pelvis has only a mild lateral thrust at times that he is able to correct, the left lower extremity advances past the right, and his trunk is midline. When fatigued, he does demonstrate mild scissoring that he is able to correct with verbal cues.
It is important to note that this child did not experience any adverse effects during the locomotor training. He had no skin breakdown from the harness, no reported increase in his spasticity, and no abnormal physiological responses. Although not measured, he appeared to demonstrate a decrease in body fat and a concomitant increase in aerobic capacity and endurance. An increase in motivation and self-confidence was also observed. These results were similar to those reported by Schindl et al. 6 Future studies are indicated to explore these and other possible secondary benefits such as increased bone density, improved self-esteem, and quality of life.
At present, the time, equipment, and personnel needed to provide this treatment are substantial, especially if the child is nonambulatory or requires significant assistance. In addition to these resources, it is also important that the child and family demonstrate the motivation and commitment to participate in this training. These facts may preclude utilizing this approach with many children. However, in situations in which a child has reached a plateau with traditional therapy and is self-motivated and where the required resources are available, treadmill training with BWS may assist the child in progressing further with functional abilities. Although this boy benefited from locomotor training that began at age nine, the potential impact of initiating training at an earlier age is also an important consideration for clinicians working with children with CP.
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