Step Forward: Treadmills Help Developmentally Delayed Infants
Monday August 16, 2010
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In a study headed by University of Michigan researchers, 15 infants (average age 9.9 months) with neuromotor delays showed improved development after therapy involving walking on treadmills. The infants were at risk of neuromotor delay from prenatal complications or from injury at birth, which often can result in self-correcting or fixable neuromotor delays, as well as more serious diagnoses such as cerebral palsy.
The study, “Treadmill Responses and Physical Activity Levels of Infants at Risk for Neuromotor Delay,” appeared in the Spring 2010 issue of Pediatric Physical Therapy.
Randomized clinical trials have shown that parent-implemented, home-based treadmill training meaningfully reduces the delayed onset of walking in this population and improves walking gait, according to Dale Ulrich, PhD, professor in the department of movement at the university’s School of Kinesiology and one of the study authors. These children further benefit from earlier onset of walking, he added, because locomotion enables many other important developments.
“Once locomotion occurs, in any child, other developmental factors occur because a child can explore the environment,” Ulrich says. “You see more cognitive development, more socialization. So if we speed up the onset of walking by four or five months, that’s four or five months of additional learning the child can experience.”
Treadmill work also improved walking gait. “It’s difficult to measure balance in infants, but we assume that when toddlers can take a longer step, and balance on one foot longer, it suggests that they have better balance,” he says.
Following up on the clear benefits of eight minutes a day on the treadmill five days a week, researchers then gave individualized, higher intensity treadmill training to another experimental group, which showed even greater benefit, Ulrich says. Speed and time were increased, and small weights were attached to the children’s ankles.
“The higher intensity generally continued to lower the age of onset of walking, continued to improve gait over the lower intensity and, the most important factor to my mind, produced a more physically active infant and toddler. We measured their activity throughout, and as intensity increased, the level of activity also increased, up to six months after treatment stopped.”
Higher-intensity training also made infants more successful in negotiating obstacles in their pathway, demonstrating what Ulrich considered a more mature strategy of negotiating obstacles.
Appropriate Equipment
The treadmills used with this population are small in size, about the dimensions of a box of copier paper packages, says Vickie Moerchen, PT, PhD, assistant professor of physical therapy at the University of Wisconsin-Milwaukee. “It needs to be tiny if you’re putting it in a home, and babies are small, so you don’t need a large surface area. Usually, parents sit on a stool, rest their elbows on their knees and hold the baby’s hands in an appropriate position.”
Therapists can use adult-sized treadmills, though, provided the equipment can be set at a slow enough speed, says Beth A. Smith, PT, DPT, PhD, postdoctoral fellow, Oregon Health and Science University Balance Disorders Laboratory. Smith worked with Ulrich while completing her PhD at Michigan. “You have to figure out a way to hold the child appropriately, perhaps with a bench across the treadmill to hold the child in front of you, between your knees. Therapists have to play with the setup and space they have.” It’s important, Smith adds, that children support as much of their own weight as possible on the treadmill, with only minimal support.
Treadmills work because the motion of the belt as it moves backward helps extend the hip, she added, which is one sensory cue to encourage stepping. “You’re trying to initiate that stepping response. Treadmill training is very task-specific for walking, very similar to walking over ground, but it allows for repetitions. Many repetitions is a principle of neuroplasticity, and the only practical way to incorporate it is with a treadmill.”
It isn’t realistic to expect parents to buy these treadmills, though, Ulrich says. “I would hope clinicians and hospital-based systems would buy them to rent out to parents for a period of months. It’s a short-term need, typically starting at 10 months of age with the child walking by 18 months.”
Designing Therapy
Most studies found that when infants are able to take about six steps a minute, they are ready for treadmill therapy, Smith says. “Six steps while being supported on the treadmill seems to be a good marker.” Therapy should start with one minute on the treadmill followed by a minute break, increasing the time between breaks and gradually working up to walking for eight consecutive minutes.
However, there are some patients for whom treadmill work might not be appropriate, Moerchen says, such as those with a cardiac diagnosis that makes them unable to tolerate the level of exercise, or children on certain medications. “Contraindications would be very few, though. Even kids with deformities who can’t bear weight on their own, we hold them so their feet just touch the belt and it seems to give them incentive to move their feet. The support gets around what would otherwise be an orthopedic contraindication.”
Another challenge for therapists, Smith says, is that many children in this population have multiple medical issues, which can shift the priority away from therapy interventions that are focused on long-term goals such as walking. “Other issues might take precedence at certain ages,” she says. “Also, caregivers and parents can perceive infants as very fragile, and from a neuroplasticity standpoint we know that many, many repetitions are required. These infants need lots of practice moving their legs before they start walking, and if they aren’t getting it, that can cause delay in walking. It is challenging to get that many repetitions and have that focus so early in life with so many things going on, but it really is key.”
Smith recently presented a course on the evidence behind treadmill training in pediatrics, and she and other researchers see more therapists interested in incorporating it in their work with this population. “I think it is fairly minimal, but increasing,” Smith says. “There is definitely interest among the PT community.” •
Melissa Gaskill is a freelance writer.
The study, “Treadmill Responses and Physical Activity Levels of Infants at Risk for Neuromotor Delay,” appeared in the Spring 2010 issue of Pediatric Physical Therapy.
Randomized clinical trials have shown that parent-implemented, home-based treadmill training meaningfully reduces the delayed onset of walking in this population and improves walking gait, according to Dale Ulrich, PhD, professor in the department of movement at the university’s School of Kinesiology and one of the study authors. These children further benefit from earlier onset of walking, he added, because locomotion enables many other important developments.
“Once locomotion occurs, in any child, other developmental factors occur because a child can explore the environment,” Ulrich says. “You see more cognitive development, more socialization. So if we speed up the onset of walking by four or five months, that’s four or five months of additional learning the child can experience.”
Treadmill work also improved walking gait. “It’s difficult to measure balance in infants, but we assume that when toddlers can take a longer step, and balance on one foot longer, it suggests that they have better balance,” he says.
Following up on the clear benefits of eight minutes a day on the treadmill five days a week, researchers then gave individualized, higher intensity treadmill training to another experimental group, which showed even greater benefit, Ulrich says. Speed and time were increased, and small weights were attached to the children’s ankles.
“The higher intensity generally continued to lower the age of onset of walking, continued to improve gait over the lower intensity and, the most important factor to my mind, produced a more physically active infant and toddler. We measured their activity throughout, and as intensity increased, the level of activity also increased, up to six months after treatment stopped.”
Higher-intensity training also made infants more successful in negotiating obstacles in their pathway, demonstrating what Ulrich considered a more mature strategy of negotiating obstacles.
Appropriate Equipment
The treadmills used with this population are small in size, about the dimensions of a box of copier paper packages, says Vickie Moerchen, PT, PhD, assistant professor of physical therapy at the University of Wisconsin-Milwaukee. “It needs to be tiny if you’re putting it in a home, and babies are small, so you don’t need a large surface area. Usually, parents sit on a stool, rest their elbows on their knees and hold the baby’s hands in an appropriate position.”
Therapists can use adult-sized treadmills, though, provided the equipment can be set at a slow enough speed, says Beth A. Smith, PT, DPT, PhD, postdoctoral fellow, Oregon Health and Science University Balance Disorders Laboratory. Smith worked with Ulrich while completing her PhD at Michigan. “You have to figure out a way to hold the child appropriately, perhaps with a bench across the treadmill to hold the child in front of you, between your knees. Therapists have to play with the setup and space they have.” It’s important, Smith adds, that children support as much of their own weight as possible on the treadmill, with only minimal support.
Treadmills work because the motion of the belt as it moves backward helps extend the hip, she added, which is one sensory cue to encourage stepping. “You’re trying to initiate that stepping response. Treadmill training is very task-specific for walking, very similar to walking over ground, but it allows for repetitions. Many repetitions is a principle of neuroplasticity, and the only practical way to incorporate it is with a treadmill.”
It isn’t realistic to expect parents to buy these treadmills, though, Ulrich says. “I would hope clinicians and hospital-based systems would buy them to rent out to parents for a period of months. It’s a short-term need, typically starting at 10 months of age with the child walking by 18 months.”
Designing Therapy
Most studies found that when infants are able to take about six steps a minute, they are ready for treadmill therapy, Smith says. “Six steps while being supported on the treadmill seems to be a good marker.” Therapy should start with one minute on the treadmill followed by a minute break, increasing the time between breaks and gradually working up to walking for eight consecutive minutes.
However, there are some patients for whom treadmill work might not be appropriate, Moerchen says, such as those with a cardiac diagnosis that makes them unable to tolerate the level of exercise, or children on certain medications. “Contraindications would be very few, though. Even kids with deformities who can’t bear weight on their own, we hold them so their feet just touch the belt and it seems to give them incentive to move their feet. The support gets around what would otherwise be an orthopedic contraindication.”
Another challenge for therapists, Smith says, is that many children in this population have multiple medical issues, which can shift the priority away from therapy interventions that are focused on long-term goals such as walking. “Other issues might take precedence at certain ages,” she says. “Also, caregivers and parents can perceive infants as very fragile, and from a neuroplasticity standpoint we know that many, many repetitions are required. These infants need lots of practice moving their legs before they start walking, and if they aren’t getting it, that can cause delay in walking. It is challenging to get that many repetitions and have that focus so early in life with so many things going on, but it really is key.”
Smith recently presented a course on the evidence behind treadmill training in pediatrics, and she and other researchers see more therapists interested in incorporating it in their work with this population. “I think it is fairly minimal, but increasing,” Smith says. “There is definitely interest among the PT community.” •
Melissa Gaskill is a freelance writer.
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Monday August 16, 2010