Original research| Volume 101, ISSUE 2, P204-212, February 2020

Low-Intensity vs High-Intensity Home-Based Treadmill Training and Walking Attainment in Young Children With Spastic Diplegic Cerebral Palsy

Published:October 31, 2019DOI:



      To compare the effect of low-intensity (LI) vs high-intensity (HI) treadmill training (TT) on walking attainment and overall walking activity in children with cerebral palsy (CP).


      Prospective, multisite, randomized controlled trial.


      Homes of the participants.


      Children with spastic diplegic CP, Gross Motor Function Classification System Level I and II, ages 14-32 months (N=19; male, n=8).


      The children were randomized to LI TT (2×/wk for 6wk) (n=10) and HI TT (10×/wk for 6wk) (n=9). The TT was carried out by the families with weekly instruction by the researchers.

      Main Outcome Measures

      Children were assessed at study onset, post intervention, and 1 and 4 months post intervention with the Gross Motor Function Measure Dimension D/E (GMFM D/E), average strides per day and percentage of time spent walking with accelerometers, the Peabody Developmental Motor Scales-2 (PDMS-2), Pediatric Evaluation of Disability Index Mobility Scale, timed 10-m and 1-minute walk test, and Functional Mobility Scale. Blinding was conducted for GMFM D/E and PDMS-2. Linear mixed effects regression models were applied to all outcomes.


      No significant between-group differences were found in any outcome measure at any of the time points. Children in the HI group did not show significant improvement immediately following the intervention in GMFM E (P=.061), while children in the LI group did (P=.003), but no statistically significant differences were detected over time (P=.71). Children in the HI group showed better walking independence on the Functional Mobility Scale at all postintervention assessments.


      A twice-weekly dosage was equally effective in improving skills related to walking compared with a 10×/wk program and can be more readily implemented into clinical practice.


      List of abbreviations:

      CP (cerebral palsy), DS (down syndrome), FMS (Functional Mobility Scale), GMFCS (Gross Motor Function Classification System), GMFM D/E (Gross Motor Function Measure-66 Dimensions D and E), HI (high-intensity), LI (low-intensity), MCID (minimally clinically important difference), PDMS-2 (Peabody Developmental Motor Scales-2), PEDI (Pediatric Evaluation of Disability Inventory), TT (treadmill training), 1MWT (1-minute walk test), 10MWT (10-m walk test)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hutton J.L.
        • Pharoah P.O.
        Effects of cognitive, motor, and sensory disabilities on survival in cerebral palsy.
        Arch Dis Child. 2002; 86: 84-89
        • Palisano R.J.
        • Hanna S.E.
        • Rosenbaum P.L.
        • et al.
        Validation of a model of gross motor function for children with cerebral palsy.
        Phys Ther. 2000; 80: 974-985
        • Kamp F.A.
        • Lennon N.
        • Holmes L.
        • Dallmeijer A.J.
        • Henley J.
        • Miller F.
        Energy cost of walking in children with spastic cerebral palsy: relationship with age, body composition and mobility capacity.
        Gait Posture. 2014; 40: 209-214
        • Lepage C.
        • Noreau L.
        • Bernard P.M.
        Association between characteristics of locomotion and accomplishment of life habits in children with cerebral palsy.
        Phys Ther. 1998; 78: 458-469
        • Wilmshurst S.
        • Ward K.
        • Adams J.E.
        • Langton C.M.
        • Mughal M.Z.
        Mobility status and bone density in cerebral palsy.
        Arch Dis Child. 1996; 75: 164-165
        • Ryan J.M.
        • Hensey O.
        • McLoughlin B.
        • Lyons A.
        • Gormley J.
        Reduced moderate-to-vigorous physical activity and increased sedentary behavior are associated with elevated blood pressure values in children with cerebral palsy.
        Phys Ther. 2014; 94: 1144-1153
        • Cramer S.C.
        • Sur M.
        • Dobkin B.H.
        • et al.
        Harnessing neuroplasticity for clinical applications.
        Brain. 2011; 134: 1591-1609
        • Hadders-Algra M.
        Early brain damage and the development of motor behavior in children: clues for therapeutic intervention?.
        Neural Plast. 2001; 8: 31-49
        • Schmidt R.A.
        • Young D.E.
        • Swinnen S.
        • Shapiro D.C.
        Summary knowledge of results for skill acquisition: support for the guidance hypothesis.
        J Exp Psychol Learn Mem Cogn. 1989; 15: 352-359
        • Kleim J.A.
        • Jones T.A.
        Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage.
        J Speech Lang Hear Res. 2008; 51: S225-S239
        • Damiano D.L.
        • DeJong S.L.
        A systematic review of the effectiveness of treadmill training and body weight support in pediatric rehabilitation.
        J Neurol Phys Ther. 2009; 33: 27-44
        • Mattern-Baxter K.
        Effects of partial body weight supported treadmill training on children with cerebral palsy.
        Pediatr Phys Ther. 2009; 21: 12-22
        • Valentin-Gudiol M.
        • Mattern-Baxter K.
        • Girabent-Farres M.
        • Bagur-Calafat C.
        • Hadders-Algra M.
        • Angulo-Barroso R.M.
        Treadmill interventions with partial body weight support in children under six years of age at risk of neuromotor delay.
        Cochrane Database Syst Rev. 2011; 12: CD009242
        • Cherng R.J.
        • Liu C.F.
        • Lau T.W.
        • Hong R.B.
        Effect of treadmill training with body weight support on gait and gross motor function in children with spastic cerebral palsy.
        Am J Phys Med Rehabil. 2007; 86: 548-555
        • Angulo-Barroso R.M.
        • Tiernan C.
        • Chen L.C.
        • Valentin-Gudiol M.
        • Ulrich D.
        Treadmill training in moderate risk preterm infants promotes stepping quality--results of a small randomised controlled trial.
        Res Dev Disabil. 2013; 34: 3629-3638
        • Mattern-Baxter K.
        • McNeil S.
        • Mansoor J.K.
        Effects of home-based locomotor treadmill training on gross motor function in young children with cerebral palsy: a quasi-randomized controlled trial.
        Arch Phys Med Rehabil. 2013; 94: 2061-2067
        • Gannotti M.E.
        • Christy J.B.
        • Heathcock J.C.
        • Kolobe T.H.
        A path model for evaluating dosing parameters for children with cerebral palsy.
        Phys Ther. 2014; 94: 411-421
        • Bjornson K.F.
        • Zhou C.
        • Stevenson R.
        • Christakis D.
        • Song K.
        Walking activity patterns in youth with cerebral palsy and youth developing typically.
        Disabil Rehabil. 2014; 36: 1279-1284
        • McDowell B.C.
        • Kerr C.
        • Parkes J.
        • Cosgrove A.
        Validity of a 1 minute walk test for children with cerebral palsy.
        Dev Med Child Neurol. 2005; 47: 744-748
        • Provost B.
        • Heimerl S.
        • McClain C.
        • Kim N.H.
        • Lopez B.R.
        • Kodituwakku P.
        Concurrent validity of the Bayley Scales of Infant Development II Motor Scale and the Peabody Developmental Motor Scales-2 in children with developmental delays.
        Pediatr Phys Ther. 2004; 16: 149-156
        • Boyd R.
        • Fatone S.
        • Rodda J.
        • et al.
        High- or low- technology measurements of energy expenditure in clinical gait analysis?.
        Dev Med Child Neurol. 1999; 41: 676-682
        • Feldman A.B.
        • Haley S.M.
        • Coryell J.
        Concurrent and construct validity of the Pediatric Evaluation of Disability Inventory.
        Phys Ther. 1990; 70: 602-610
        • Harvey A.R.
        • Morris M.E.
        • Graham H.K.
        • Wolfe R.
        • Baker R.
        Reliability of the functional mobility scale for children with cerebral palsy.
        Phys Occup Ther Pediatr. 2010; 30: 139-149
        • Ulrich D.A.
        • Lloyd M.C.
        • Tiernan C.W.
        • Looper J.E.
        • Angulo-Barroso R.M.
        Effects of intensity of treadmill training on developmental outcomes and stepping in infants with Down syndrome: a randomized trial.
        Phys Ther. 2008; 88: 114-122
        • Fowler E.G.
        • Knutson L.M.
        • Demuth S.K.
        • et al.
        Pediatric endurance and limb strengthening (PEDALS) for children with cerebral palsy using stationary cycling: a randomized controlled trial.
        Phys Ther. 2010; 90: 367-381
        • Patikas D.
        • Wolf S.I.
        • Mund K.
        • Armbrust P.
        • Schuster W.
        • Doderlein L.
        Effects of a postoperative strength-training program on the walking ability of children with cerebral palsy: a randomized controlled trial.
        Arch Phys Med Rehabil. 2006; 87: 619-626
        • Kruse A.
        • Schranz C.
        • Tilp M.
        • Svehlik M.
        Muscle and tendon morphology alterations in children and adolescents with mild forms of spastic cerebral palsy.
        BMC Pediatr. 2018; 18: 156
        • Gillett J.G.
        • Boyd R.N.
        • Carty C.P.
        • Barber L.A.
        The impact of strength training on skeletal muscle morphology and architecture in children and adolescents with spastic cerebral palsy: a systematic review.
        Res Dev Disabil. 2016; 56: 183-196
        • Moreau N.G.
        • Holthaus K.
        • Marlow N.
        Differential adaptations of muscle architecture to high-velocity versus traditional strength training in cerebral palsy.
        Neurorehabil Neural Rep. 2013; 27: 325-334
        • Bjornson K.F.
        • Moreau N.
        • Bodkin A.W.
        Short-burst interval treadmill training walking capacity and performance in cerebral palsy: a pilot study.
        Dev Neurorehabil. 2019; 22: 126-133
        • Balemans A.C.
        • Bolster E.A.
        • Brehm M.A.
        • Dallmeijer A.J.
        Physical strain: a new perspective on walking in cerebral palsy.
        Arch Phys Med Rehabil. 2017; 98: 2507-2513
        • Oeffinger D.
        • Bagley A.
        • Rogers S.
        • et al.
        Outcome tools used for ambulatory children with cerebral palsy: responsiveness and minimum clinically important differences.
        Dev Med Child Neurol. 2008; 50: 918-925