Clinical Bottom Line
“How should I apply this information?”
This article demonstrates that lower body positive pressure supported (LBPPS) treadmill training can be used with positive outcomes in children with spastic diplegia, with ages ranging from 8 to 18 years, to improve strength, balance, and walking performance. The children improved their fitness as a side effect of this training. If children can walk for a longer period of time in addition to at a faster pace, they may become more functional in their home and community environments.
If children with spastic diplegia are able to remain upright, push off during terminal stance, and clear their toe during swing, they would be candidates to use this modified body weight support system. This unique system is extremely appealing with respect to the increased comfort level for the child in comparison to using a harness system. There was 100% compliance with the training sessions with the children enjoying the experience. In addition to comfort, the LBPPS treadmill training offers the potential for a child to experiment with his/her stepping pattern to find the most effective means to walk. This increased freedom to play with the possible degrees of freedom approximates authentic active learning. The LBPPS treadmill training also allows the arms of the child to be free, which is ideal for a child who cannot hold on to bars or handles. Children in this setup can practice balancing more readily than when the upper torso is constrained with a chest corset and straps. The opportunity for self-exploration and the possibility for variation in some movement sequences such as “single leg stands, bouncing, kicking, jumping, and tall-kneeling to stand transfers” represent the potential of LBPPS treadmill training as a challenging and active learning experience for children.
“What should I be mindful about in applying this information?”
In applying this information to patients, the reader must be aware of some constraints in the design, implementation, and results, though not major ones as to cause harm to patients. This study was carried out on a small number of children, only one of each of several ages except for the 16-year-olds (3 of this age). The children were varied in their diagnoses and abilities. The children with the diagnosis of spastic diplegia made significant gains, while the child with spastic hemiplegic cerebral palsy (CP) did not. Therefore, LBPPS treadmill training must be further investigated with children with different types and classifications of abilities of CP. An important aspect of body weight–supported treadmill training is the manual support offered by the physical therapist, which is not possible with LBPPS treadmill training. This may be a deterrent to use for those children who are unable to elicit a step, have appropriate weight bearing, or who cannot clear the surface in swing phase. The dosing must be further investigated in terms of the most appropriate age to benefit from this intervention, the frequency of treatments per week, and the duration of treatment time over months. Also, many children with spastic diplegic CP use orthoses to assist them with stability and efficiency in walking. The training with LBPPS does not take advantage of these aids nor were the children in the study tested wearing their ankle-foot orthoses. This aspect may have altered the results in either direction. The authors mentioned there was no control group, which prevents comparison and provides no control for extraneous variables. The benefits of LBPPS treadmill training may be important as an alternate means for supporting the body weight of children with CP, increasing their comfort and thus enjoyment, and promoting vigorous and active self-exploration of movements. This study should be repeated and expanded with a control group, larger number of subjects with specific diagnoses, and other appropriate iterations.
Marcia Levinson, PT, PhD, MFT
Thomas Jefferson University
Jessica Bush, DPT
Cadence Physical Therapy
Chester Springs, Pennsylvania