Enhancing Balance, Strength, Flexibility and Spatiotemporal Gait Parameters in Pediatric Cerebral Palsy: Treadmill Training at Variable Inclinations

Year 2025, Volume: 16 Issue: 1, 133 - 153, 30.04.2025

Mustafa Hapak , Berna Ramanlı , Ahmet Alptekin , Hande Şenol , Neşe Toktaş

https://doi.org/10.54141/psbd.1573314

Abstract

This study aimed to evaluate the effect of treadmill training at different inclinations on balance, strength, flexibility, and gait parameters in children with cerebral palsy in addition to traditional physiotherapy applications. Forty-two participants with cerebral palsy aged 7–18 years and at Gross Motor Function Classification System level II were randomized into three groups: downhill walking, uphill walking, and walking with no incline. Balance, isometric strength, flexibility, and gait parameters were assessed at baseline (2nd week) and at 11th week. The groups were provided with treadmill training and conventional treatment. All groups showed improvement in balance. Isometric strength values showed improvement in knee flexion on the affected side for both downhill walking and uphill walking groups, as well as in knee extension force for the uphill walking and walking with no incline groups. In flexibility, hip flexion, hip extension, and ankle dorsiflexion improved in all groups, while knee flexion and ankle plantar flexion improved only in downhill walking and walking with no incline. The duration of the modified timed up-and-go test showed significant improvements in both the downhill walking and uphill walking groups. Treadmill training performed at different inclinations improved balance, isometric strength, flexibility, and gait parameters on both the affected and less affected sides.

Keywords

Downhill walking , Gait analysis , Range of motion , Treadmill training , Uphill walking

References

• Acavedo, S. J. (1999). Physical Therapy for the Child with Cerebral Palsy. In: Tecklin, J. S. (Ed). Pediatric Physical Therapy. 3. ed. Philadelphia: Saunders WB. p.: 107-162.
• Ameer, M. A., Fayez, E.S., & Elkholy, H.H. (2019). Improving spatiotemporal gait parameters in spastic diplegic children using treadmill gait training. Journal of Bodywork and Movement Therapies. 23(4):937-942. https://doi.org/10.1016/j.jbmt.2019.02.003
• Aminian, K., Najafi, B., Büla, C., Leyvraz, P. F., & Robert, P. (2002). Spatio-temporal parameters of gait measured by an ambulatory system using miniature gyroscopes. Journal of Biomechanics. 35(5):689-699. https://doi.org/10.1016/S0021-9290(02)00008-8
• Armand, S., Decoulon, G., & Bonnefoy-Mazure, A. (2016). Gait analysis in children with cerebral palsy. EFORT open reviews. 1(12):448-460. https://doi.org/10.1302/2058-5241.1.000052
• Ballaz, L., Plamondon, S., & Lemay, M. (2010). Ankle range of motion is key to gait efficiency in adolescents with cerebral palsy. Clinical Biomechanics. 25(9):944-948. https://doi.org/10.1016/j.clinbiomech.2010.06.011
• Berker, N., & Yalçın, S. (2010). The Help Guide to Cerebral Palsy. Merrill Corporation Washington.
• Cherng, R.J., Liu, C.F., Lau, T.W., & Hong, R.B. (2007). Effect of treadmill training with body weight support on gait and gross motor function in children with spastic cerebral palsy. American Journal of Physical Medicine & Rehabilitation. 86(7):548-555. https://doi.org/10.1097/PHM.0b013e31806dc302
• Cortés-Pérez, I., González-González, N., Peinado-Rubia, A.B., Nieto-Escamez, F.A., Obrero-Gaitán, E., & García-López, H. (2022). Efficacy of robot-assisted gait therapy compared to conventional therapy or treadmill training in children with cerebral palsy: A systematic review with meta-analysis. Sensors. 22(24):9910. https://doi.org/10.3390/s22249910
• Dhote, S.N., Khatri, P.A., & Ganvir, S.S. (2012). Reliability of “modified timed up and go” test in children with cerebral palsy. Journal of Pediatric Neurosciences. 7(2):96. https://doi.org/10.4103%2F1817-1745.102564
• Dimakopoulos, R., Syrogiannopoulos, G., Grivea, I., Dailiana, Z., Youroukos, S., & Spinou, A. (2022). Kinematic and temporospatial changes in children with cerebral palsy during the initial stages of gait development. Developmental Neurorehabilitation. 25(1):10-18. https://doi.org/10.1080/17518423.2021.1914763
• Duncan, P. W., Weiner, D. K., Chandler, J., & Studenski, S. (1990). Functional reach: a new clinical measure of balance. Journal of Gerontology. 45(6):M192-M197. https://doi.org/10.1093/geronj/45.6.M192
• Grecco, L. A., Tomita, S. M., Christovão, T. C., Pasini, H., Sampaio, L. M., & Oliveira, C. S. (2013). Effect of treadmill gait training on static and functional balance in children with cerebral palsy: a randomized controlled trial. Brazilian Journal of Physical Therapy. 17:17-23. http://dx.doi.org/10.1590/S1413-35552012005000066
• Hikosaka, O., Nakamura, K., Sakai, K., & Nakahara, H. (2002). Central mechanisms of motor skill learning. Current opinion in neurobiology. 12(2),217–222. https://doi.org/10.1016/s0959-4388(02)00307-0
• Hoffman, R. M., Corr, B. B., Stuberg, W. A., Arpin, D. J., & Kurz, M. J. (2018). Changes in lower extremity strength may be related to the walking speed improvements in children with cerebral palsy after gait training. Research in Developmental Disabilities. 73:14-20. https://doi.org/10.1016/j.ridd.2017.12.005
• Hösl, M., Böhm, H., Eck, J., Döderlein, L., & Arampatzis, A. (2018). Effects of backward-downhill treadmill training versus manual static plantarflexor stretching on muscle-joint pathology and function in children with spastic Cerebral Palsy. Gait & Posture. 65:121-128. https://doi.org/10.1016/j.gaitpost.2018.07.171
• Kurz, M. J., Corr, B., Stuberg, W., Volkman, K. G., & Smith, N. (2011). Evaluation of lower body positive pressure supported treadmill training for children with cerebral palsy. Pediatric Physical Therapy. 23(3):232-239. https://doi.org/10.1097/PEP.0b013e318227b737
• LEGSysTM User’s Guide. Version 2.3: BioSensics LLC; 2015.
• Millichap, J. G. (2015). Gait training and ankle dorsiflexors in cerebral palsy. Pediatric Neurology Briefs. 22-22. https://doi.org/10.15844/pedneurbriefs-29-3-5
• Niznik, T. M., Turner, D., & Worrell, T. W. (1996). Functional reach as a measurement of balance for children with lower extremity spasticity. Physical & Occupational Therapy in Pediatrics. 15(3):1-16. https://doi.org/10.1080/J006v15n03_01
• Otman, A. S., & Köse, N. (2014). Tedavi Hareketlerinde Temel Değerlendirme Prensipleri. Hipokrat Kitabevi.
• Qian, G., Cai, X., Xu, K., Tian, H., Meng, Q., Ossowski, Z., & Liang, J. (2023). Which gait training intervention can most effectively improve gait ability in patients with cerebral palsy? A systematic review and network meta-analysis. Frontiers in Neurology. 13:1005485. https://doi.org/10.37766/inplasy2022.10.0108
• Scholtes, V. A., Dallmeijer, A.J., Rameckers, E.A., Verschuren, O., Tempelaars, E., Hensen, M., & Becher, J.G. (2008). Lower limb strength training in children with cerebral palsy–a randomized controlled trial protocol for functional strength training based on progressive resistance exercise principles. BMC Pediatrics. 8(1):1-11. https://doi.org/10.1186/1471-2431-8-41
• Serway, R. A., & Beichner, R. J. (2000). Physics for Scientists and Engineers with Modern Physics. 5th Edition: Saunders College Publishing.
• Tekin, F., & Kavlak, E. (2021). Short and long-term effects of whole-body vibration on spasticity and motor performance in children with Hemiparetic cerebral palsy. Perceptual and Motor Skills. 128(3):1107-1129. https://doi.org/10.1177/0031512521991095
• Verschuren, O., Smorenburg, A. R., Luiking, Y., Bell, K., Barber, L., & Peterson, M. D. (2018). Determinants of muscle preservation in individuals with cerebral palsy across the lifespan: a narrative review of the literature. Journal of Cachexia, Sarcopenia and Muscle. 9(3):453-464. https://doi.org/10.1002/jcsm.12287
• Valadão, P., Piitulainen, H., Haapala, E. A., Parviainen, T., Avela, J., & Finni, T. (2021). Exercise intervention protocol in children and young adults with cerebral palsy: the effects of strength, flexibility and gait training on physical performance, neuromuscular mechanisms and cardiometabolic risk factors (EXECP). BMC Sports Science, Medicine and Rehabilitation. 13(1):1-19. https://doi.org/10.1186/s13102-021-00242-y
• Willemse, L., Brehm, M. A., Scholtes, V. A., Jansen, L., Woudenberg-Vos, H., & Dallmeijer, A. J. (2013). Reliability of isometric lower-extremity muscle strength measurements in children with cerebral palsy: implications for measurement design. Physical Therapy. 93(7):935-941. https://doi.org/10.2522/ptj.20120079
• Willerslev-Olsen, M., Petersen, T. H., Farmer, S. F., & Nielsen, J. B. (2015). Gait training facilitates central drive to ankle dorsiflexors in children with cerebral palsy. Brain : a journal of neurology. 138(Pt 3), 589–603. https://doi.org/10.1093/brain/awu399