Centre of Excellence, Rehabilitation Center ‘de Hoogstraat’, Utrecht, The Netherlands (Verschuren)
Faculty of Medicine, Division of Pediatrics, Utrecht University, Child Development and Exercise Center, University Medical Center and Children’s Hospital, Utrecht, The Netherlands (Helders)
“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 expensive, 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.
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