[Gait training with full body weight Treadmill Training and NDT facilitation to increase gait speed

and endurance in a highly functioning child with spastic paraplegic cerebral palsy: A case Report] Purpose: Identify any effects of whole body weight treadmill training (FBWTT) used simultaneously with NDT facilitating techniques to enhance gait speed and endurance in a high functioning child with spastic paraplegic cerebral palsy (CP). Case Description: The child was a 12 year old boy with a prior Gross Motor Function Measure (GMFM) of 3. He had the ability to walk independently for household distances using his posterior walker and bilateral lower extremity AFO’s; however, his gait pattern was slow and cumbersome. Methods: The 10 meter walk test (10MWT) and the 6 minute walk test (6MWT) were administered during the initial examination and at the final clinical session to determine changes in gait speed and endurance. The parameters of 30 minute sessions of FBWTT with NDT, 5 times per week for 4 weeks over an 8 week period were utilized. Outcomes: The child increased his gait speed and endurance after an 8 week long FBWTT/NDT program. He walked faster during the 10MWT, decreasing his time to finish 10 meters by 3.8 seconds and increased his 6MWT distance by 56 meters. His increased gait speed was not deemed statistically significant; however, his increased endurance was. Discussion: The utility of the 10MWT for speed and 6MWT for endurance testing are adequate outcome measures to use for this study; however, the use of different measures in the future may capture more in-depth information on gait changes. Further research using the task-oriented FBWTT/NDT approach to improve gait speed and endurance in children with CP is needed. I propose that multiple high-level studies be completed to determine the effectiveness of gait training using FBWTT/NDT for children with CP. Total Word Count=5,223

2017

DPT 895 Administration and ManagementJoshua Scribben

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Introduction

Cerebral palsy (CP) is a non progressive neurological disorder attributed to an insult in the developing fetal or infant brain.1 In the United States, approximately five of every 2,000 children will be diagnosed with CP and it is the number one contributor to physical disabilities in developed countries.1 CP originates during the prenatal, perinatal and postnatal periods; however, it is oftentimes undiagnosed until the age of six months, as it becomes evident that developmental milestones are not being reached.1,2 The incidence of CP increases with premature birth, having multiple births, genetics and atypical uterine growth1

CP causes a variety of different impairments in cognition, behavior, motor development, and communication.2The inability to achieve typical motor development is regarded by many parents and children as the primary cause for a decrease in a child’s quality of life.3 Abnormalities in body structures and function include: muscle tone/extensibility, muscle strength, skeletal structure, selective control of muscles, postural control, sensation, balance and coordination.1 As a result of these impairments, children develop compensatory movement strategies at a young age.3 Activities such as crawling, rolling, sitting, reaching, creeping, standing and walking become limited and awkward. Invariably, 90 percent of children with CP have difficulty with ambulation, making walking the primary goal for many CP children and their parents.3,4

With an emphasis on the ability to walk, physical therapists’ (PT’s) are among the leading healthcare professionals involved in rehabilitating children with CP. PT’s have used a variety of different theories and techniques to improve walking for CP children. The neurodevelopmental (NDT) approach has been the driving force behind much of the treatment performed in the last two decades.5 The NDT approach is based around the concept of modifying an impaired central nervous system by facilitating proper movement patterns while inhibiting abnormal movement patterns.5 Many researchers have found success with the NDT approach in improving gait in children with CP; however, many others have found the outcomes of NDT to be disappointing.6 Some PT’s conclude that the treatment techniques of true NDT are too passive and do not result into the acquisition of gait.6

Task-specific training is a second approach used to teach children with CP how to walk efficiently. As one researcher stated “If walking is the goal of the treatment, then the individual must practice walking”.5 In a study conducted by Barbeau et al7 cats that incurred a complete spinal cord resection learned to walk once again after intensive gait specific treadmill training. This important breakthrough encouraged many PT’s to pursue the use of treadmill training on neurologically impaired patients.5 Treadmill training is a trusted intervention for re-training gait

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in stroke survivors and patients with spinal cord injuries.8 In the past 18 years, pediatric PT’s have begun to incorporate task-specific training into their regiment of CP treatment.3

Partial body weight supported treadmill training (PBWSTT) has quickly become a major component of CP rehabilitation. PBWSTT is accomplished with the use of a specialized treadmill that allows the de-weighting of children with an overhead harness system. Results of PBWSTT have been encouraging; however, few high quality research articles that examine the outcomes of PBWSTT have been published.5 Mutlu et al8 completed a systematic review of research articles on the effects of PBWSTT on children with CP. They reported that from 1950-2007 only eight papers on this topic were written, and of those, only one was considered higher than a level 3 on the Sacket level of evidence. Furthermore, the cost of a treadmill system that can de-weight a child is oftentimes too expensive or not utilized enough for physical therapy clinics to purchase.

The benefits of both NDT and PBWSTT show huge promise for the future of physical therapy (PT) intervention for children with CP; however, the cost of a treadmill system with de-weighting capabilities and the critique of passivity for NDT have stumped some PT’s. One novel way to incorporate these techniques while eliminating their barriers is to use a standard treadmill with full body weight training (FBWTT) while simultaneously using manual NDT techniques to facilitate a normal gait pattern. Few evidenced based articles exist to determine the effectiveness of this technique. The purpose of this case report is to utilize the 10 meter walk test (10MWT) and the six minute walk test (6MWT) to determine the effects of whole body weight treadmill training (FBWTT) simultaneously with NDT facilitating techniques to enhance gait speed and endurance in a high functioning child with spastic paraplegic CP.

Case Description

Child and History. The child is a 12 year old boy, approximately 5’6” in height and weighing 120#’s, with spastic paraplegic CP. He is El Salvadorian, and was adopted by his English, American mother 2 years ago. His adopted mother is single and has no other children. Her socio-economic status for the area is considered high-middle class. The child attends private school and is currently in the sixth grade, with no reported learning or behavioral deficits. He is fluent in both Spanish and English, with no communication barriers. He is highly motivated to participate in PT, making him a good candidate for this intervention.

The medical history was reported by the mother and child during the examination. He was given “high doses” of Baclofen before his adoption to treat his lower extremity spasticity; however, since the child has been in her care he has not received Baclofen. He underwent

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bilateral lower extremity hamstring and gastrocnemius lengthening surgeries while in El, Salvadore. The mother was unable to provide an exact date of the lengthening surgeries. One month prior to the examination he was given bilateral hip adductor and right hamstring Botox injections to control his spasticity. It was reported that the doctor injected the Botox in the wrong hamstring, injecting the right extremity instead of the left extremity. They reported no other impairments in bodily systems including pulmonary, cardiovascular or musculoskeletal.

The child has been receiving PT services from a local PT agency for the past year; however, the mother discontinued those services due to a lack of results. Per mother and child the focus of interventions were on bilateral lower extremity strengthening, flexibility and balance training, using a treadmill only once. The mother was concerned that the interventions did not focus on gait, so she decided to switch PT providers. The child is also involved in aquatic therapy, provided by a recreational therapist, where he focuses on swimming techniques. During this case report, the child continued to work with the recreational therapist 1 time per week for 30 minute sessions.

The child used a posterior walker for ambulation and had bilateral lower extremity solid AFO’s which were set in neutral ankle position. A Gross Motor Function Classification System (GMFCS) level of 3 was given by the prior PT agency. He was capable of walking household and community distances with his posterior walker; however, the mother felt relegated to monitor him because of a slow and awkward gait. The chief complaint of the mother and son is that his walking ability was not being targeted in therapy, decreasing his independent capabilities at school and home. Their goal was to increase his gait speed and endurance while using his posterior walker in order to increase his independence.

Clinical Impression #1

The child was a 12 year old boy with spastic paraplegic CP who was coming to PT in hopes of enhancing his gait speed and endurance while utilizing his posterior walker. There are no differential diagnoses to consider based on the fact that he was given a medical diagnosis of CP several years ago; however, a formal examination was needed to determine the severity of his impairments and functional limitations. This child was an ideal candidate for this case report because of his willingness to participate, his ability to ambulate independently, his minimal exposure to treadmill training and the absence of co-morbidities.

The reported history of surgeries and medical treatments for spasticity were vague, making a thorough examination of his lower extremities a priority. Lower extremity strength, spasticity and range of motion measurements were needed to determine current impairments and possible causes of gait limitations. The child’s gait speed and endurance were examined using the 10MWT and the 6MWT outcome measures.

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Examination

MUSCLE STRENGTH. It is widely accepted in the PT community that adequate muscle strength in the lower extremities is needed to maintain gait. Manual muscle testing (MMT) techniques described by Berryman Reese9 were followed to examine bilateral lower extremity muscle strength. Berryman Reese9 emphasize a “break test” in which the muscle is positioned against gravity and in the midpoint range of motion (ROM) while the PT exerts a force on the muscle in order to “break” the static holding power of that muscle. See figure 1 for a definition of scoring interpretation of MMT.

Figure1. Reproduced from Reese NB. Muscle and sensory testing. ST. Louis: Elsevier Saunders; 2012

The inter-rater and intra-rater reliabilities of the manual muscle testing procedure show conflicting data.9 Consistently using the standardized protocol reported by Berrymann Reese increases reliability to appropriate levels .9 MMT is a valid measure of assessing muscle strength; however, scores above 4 lose some of their discriminative abilities secondary to a PT’s subjectivity in regards to the amount of resistance given.9 Table 1 lists the MMT scores for the child’s lower extremity strength.

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Table1. Lower Extremity Manual Muscle TestingBody Part/Action Right LeftAnkleDorsiflexion 3- 3Plantarflexion 3+ 3+KneeFlexion 4 4+Extension* 2+ 2HipFlexion 5 5Extension 4 4+Abduction 3 3Adduction 4+ 5* Indicates discomfort secondary to decreased range of motion.

After reviewing the examination results it was determined that he had sufficient lower extremity muscle strength to initiate and maintain ambulation with the use of his bilateral lower extremity AFO’s and posterior walker. It was apparent that his previous bilateral gastrocnemieus lengthening procedures had affected his ability to produce normal strength; however, the use of his solid AFO’s provided adequate stability for function. He also scored low on bilateral hip extensor and abduction strength; however, his hip adduction and flexor strengths were high. This finding is indicative of tight hip flexors and adductors, which is common in children with CP.

JOINT ROM/SPASTICITY: Joint ROM is oftentimes abnormal in children with CP as a direct result of abnormalities in muscle tone, extensibility and abnormal reflexes.1 Spasticity is the most common impairment in children with CP and it is described as neural resistance to passive muscle stretch which increases with speed and varies with the direction of the joint movement.1 In order for children with CP to function at their highest ability, it is paramount that joint ROM and muscle spasticity are recognized and treated.

Both passive and active ROM were examined using the techniques outlined by Berrymann-Reese and Bandy.10 The reliability and validity of ROM examinations have been found to be poor for the CP population. Goniometric errors of 10-14 degrees have been found to occur during same day measurements by the most experienced PT’s.1 It has been recommended that ROM changes of 20 degrees or more be found before 95% confidence can be made that a “true” change has occurred. In order to maintain a high degree of reliability and validity, video recording technology (Coach’s Eye) was utilized to examine ROM. Table 2 lists the results of the lower extremity ROM examination. The Modified Ashworth Score (MAS) was utilized to determine the child’s spasticity levels. The MAS is conducted by placing the child in

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supine and positioning flexor muscles into full flexion and then extending that muscle to maximum extension in one second. The opposite is done for muscles in the extensor groups. The scoring of the MAS is depicted on Figure 2.

Table 2. Lower Extremity Range of MotionBody Part/Action Right (MAS Score) Left (MAS Score)Ankle Passive Active Passive ActiveDorsiflexion 0-58 (0) 0-33 0-41 (0) 0-30Plantarflexion 0-55 0-50 0-54 0-48KneeFlexion 0-135 0-120 0-130 0-122Extension* 0-3 (3) -2 0-1 (3) -4HipFlexion 0-125 0-121 0-126 0-122Extension* -13 -16 -11 -11Abduction* 0-22 0-14 0-29 0-19Adduction 0-35 0-30 0-32 0-31* Indicates discomfort secondary to decreased range of motion.

GAIT SPEED AND ENDURANCE: In order to assess whether task-specific FBWTT with NDT facilitation improved gait speed and endurance it was imperative to analyze his ability to walk both household and community distances during the examination. The two outcome measures chosen to record gait speed and endurance were the 10MWT and the 6MWT, respectively. The 10MWT has been found to have excellent test-retest reliability (ICC 0.91) in children with neurological impairments.11 The 6MWT has shown to be reliable and valid when compared to the valid cycle-ergometer assessment for cardiopulmonary fitness in children with CP, making the 6MWT an adequate measure to assess this child’s endurace.12

Figure2. Modified Ashworth Scale.

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The 10MWT was conducted in a basketball gym. The child was instructed to start in a standing position and use his posterior walker to reach the taped line (10 meters) that was taped to the ground. He was directed to reach the tape as quickly as he could without running. The child began when the tester said “go” and the child stopped after he crossed the line. The time between the word “go” and the point in which one of his feet crossed the line was measured with a stop watch. See table 3 for results.

The 6MWT was conducted in a basketball gym with a rectangular area (20 m x 45 m) marked off by orange cones. The child was instructed to walk in a clockwise fashion around the cones as fast as he could without running. The examiner walked behind the child with a measuring wheel and recorded the distanced traveled at the end of the 6 minute mark. The child was informed he could take rests if needed and verbal encouragement was given approximately every 30 seconds. The scores on the 10MWT and 6MWT were used as baseline measurements to indicate any improvements in gait speed and endurance after an 8 week long FBWTT program. See table 3 for results.

Table 3. Initial Examination 10MWT/6MWTTest Time Distances

10MWT 15.8 seconds 10 meters6MWT 6 minutes 255 meters*

* Indicates 3 rest breaks taken during exam

Clinical Impression #2

After garnishing a history and evaluating the examination findings it was evident that the child had significant abnormalities in his gait speed and endurance. The amount of instability in his bilateral ankle structures due to his previous gastrocnemius lengthening surgery was a cause for concern. It was apparent that he relied heavily on the stability provided by his fixed lower extremity AFO’s. The inability to actively extend his hip to neutral during both MMT and ROM testing reinforced the idea of tightened hip flexor/adductor musculature.

The child continued to be an appropriate participant in this case report because of his ability to complete both the 10MWT and the 6MWT without assistance. His mother and he continued to state that they were excited to continue with the FBWTT therapy regiment outlined to both at the beginning of the examination. The Plan of Care was to see the child 5 days per week, every other week for 8 weeks. During the treatment sessions flexibility and strengthening interventions would be performed before the treadmill training program to pinpoint the aforementioned lower extremity impairments in ROM and strength. The FBWTT

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program would consist of 30 minute sessions at the child’s preferred walking speed. During the training, the PT would facilitate bilateral lower extremity hip extension and upright spinal posture by giving manual and verbal cues. The FBWTT program will continue for 8 weeks (4 total weeks, 20 total sessions) and the 10MWT/6MWT will be conducted. The results of two outcome measures will be compared between the initial examination and the end of the 8 week period.

Intervention

Prior to the FBWTT/NDT intervention the child received passive stretching to his bilateral hamstrings, hip flexors and hip adductors. The targeted muscle groups were determined by the ROM recordings. Each procedure was performed with the child in supine with sustained stretches held for approximately 60 seconds at end range for three sets. The evidence for the use of static end range stretching to increase muscle length and decrease spasticity in children with CP varies; however, no detrimental effects of stretching have been noted in the literature.13 The time increment of 60 seconds was utilized based on evidence that supports positive outcomes in muscle length and spasticity reduction after prolonged periods of stretch for 60 seconds up to 30 minute invervals.13

Bilateral lower extremity muscle strengthening exercises were also performed prior to the FBWTT/NDT interventions. The targeted muscle groups were determined by the results of the manual muscle testing examination. Bilateral ankle dorsiflexion/plantarflexion, knee extension and hip extension/abduction were focused on for strength training using the universal exercise unit. Each exercise was completed in the supine position with resistance varying from 3 kilograms to 7 kilograms. The child performed 2 sets of 15 repetitions. Strengthening exercises were chosen based on the recent evidence that supports the use of lower extremity strengthening on overall functional mobility in children with CP.14

After the strengthening and stretching exercises were completed the child was assisted to the treadmill. A U-shaped bar attached to the front of the machine was fitted to mimic his posterior walker with ambulation. The child was instructed to walk as normally as possible using the u-bar for upper extremity support, just as he does with his walker. One PT was positioned on a bench that spanned over th the treadmill track to initiate NDT techniques. A second PT stood to the side of the child to facilitate spinal extension, maintain safety and control the panel of the treadmill.

The initial speed of the treadmill was set at 1.0 mph based on the child’s verbalization of fear and the PT’s clinical judgment of safety. The speed was then increased to 1.4 mph after 5 minutes based on the child’s verbalization of ambulation comfort and the PT’s observation of gait efficiency. The child then walked for 10 minutes at 1.4 mph with upper extremity assistance

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and PT facilitation techniques. After the 10 minutes of 1.4 mph walking the speed was then reduced once again to 1.0 mph for a 5 minute cool-down. This same procedure was followed for every treatment session. Quicker speeds were occasionally introduced; however, the child did not feel comfortable walking faster than 1.4 mph; therefore, the max speed of 1.4 mph was used throughout the plan of care.

NDT facilitation techniques were used throughout the aforementioned treadmill training. Facilitation included deep pressure to the bilateral gluteus maximus muscles immediately before heel strike and lasting until toe-off of the same lower extremity during every step. The thumbs and Thenar eminences were utilized to provide the deep pressure. Deep manual pressure is a muscle facilitation technique used by NDT practitioners to aid in motor learning.7 A second PT, standing to the side of the child provided deep pressure to the erector muscles of the lumbar spine approximately 2 inches above the noticeable dimples of the posterior superior iliac spines of the pelvis. Spinal extension facilitation was not set at a time interval; instead, it was performed whenever the PT noticed the child flexing his trunk in an exaggerated fashion. The gluteus maximus and lumbar erector spinae muscles were pinpointed for muscle facilitation secondary to their observable lack of firing during the child’s normal gait.

The literature identifies varying parameters of treadmill training to promote functional outcomes in children with CP. The parameters of 30 minute sessions 5 times per week for 8 weeks (one week training and one week off) were determined based on the child’s functional mobility, endurance and medical insurance. With the conflicting literature on what are the “best” parameters to increase functional results, an individualized plan of care was established to best fit the functional capacity of the child in this study.

Outcomes

10 Meter Walk Test: The 10MWT has been shown to be both reliable and valid when determining walking speed in children with neuromuscular disability. It was used to determine any changes in gait speed following the 8 week training. Measurements were taken and recorded during the examination and during the last day of the plan of care. See Table 4 for the results. The 10MWT was conducted identically on both occasions as outlined in the examination portion of this paper. The intra-rater reliability has an intra-class correlation coefficient of 0.81 with a 95%confidence interval ranging from 0.59-0.91, and a mean detectable change of 17.7 seconds with a 95% confidence interval and a standard of error measurement of 6.4 in CP children with a GMFCS score of 3.15

6 Minute Walk Test: The 6MWT has been consistently used in PT to assess the cardio vascular endurance for individuals of a variety of different ages and a variety of different

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diagnosis’.15 The 6MWT was used to determine changes in community distance gait ability after the 8 week program. The child was instructed to complete the test in an identical manner during the initial examination and after the 8 week period. The testing protocol that was followed as outlined in the examination section of this paper. The intra-class correlation coefficient was found to be 0.97 for test-retest reliability with a 95% confidence interval between 0.93-0.99.15 The minimal detectable change of the 6MWT for children with a GMFCS level of 3 is 47.4 meters with a standard error of measurement of 17.1 meters.15

Table 4. 10MWT/6MWT10 Meter Walk Test 6 Minute Walk Test

Initial 15.8 seconds 255 meters (3 rest breaks)Final 12.0 seconds 311 meters (0 rest breaks)

Change -3.8 seconds *56 meters* Indicates a significant change

The child increased his gait speed and endurance after an 8 week long FBWTT/NDT program. He walked faster during the 10MWT, decreasing his time to finish 10 meters by 3.8 seconds. This increase in walking speed was not found to be statistically significant; however, the child stated “I feel much faster and more comfortable when I walk now, now I can walk closer to my friends.” According to his mother “He can walk around the house better than before.” The child also increased his endurance as indicated by the statistically significant increase of 56 meters on the 6 MWT. He completed the final 6MWT without a rest break as compared to needing 3 rest breaks during the initial examination. The child verbalized his excitement with his increase in community walking ability when he stated “I can walk around the neighborhood with my mom now when she walks the dog.” These findings and the subjective reports given by the child and his mother show increased gait abilities with both household and community distances after the 8 week FBWTT/NDT training.

Discussion

The child increased his ability to ambulate using his posterior walker and bilateral lower extremity AFO’s for both household and community distances after an 8 week long FBWTT/NDT training program. A variety of studies,2,3,4,5,11 have identified positive outcomes in ambulatory capabilities with partial body weight support treadmill training; however, few studies have provided insight into the effectiveness of FBWTT. NDT has also been one of the major interventions used to increased gait for CP children; however, many PT’s have concluded that NDT approaches are too passive and do not carry over into gait improvements.7,16 This author

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combined FBWTT and NDT facilitation techniques to assess changes in gait speed and endurance after an 8 week training regimen.

The results of this study are promising for future studies. With ever-increasing costs in the technology used to treat neurological disorders, the use of a less expensive treadmill system that does not decrease body weight during training may be beneficial to many PT clinics. This study demonstrated that using a regular treadmill combined with NDT facilitation techniques may help improve gait speed and endurance for CP children.

A true cause-effect relationship between the FBWTT/NDT training and increased gait ability cannot be made at this time. There are many limiting factors to this study that must be realized. First, the child received both stretching and strengthening exercises before his treadmill training. Stretching and strengthening have been found to increase functional mobility in children with CP; however, the data is currently conflicting.1,13,14 A second limitation to this report was the fact that the child continued to receive aquatic therapy during the study. Prior studies have determined aquatic therapy a positive intervention for children with CP, having statistically significant findings in muscle strength, energy expenditure, gross motor function, and ambulation ability in both home and community distances.17 Thirdly, gait mechanics were not thoroughly assessed during this study. Many studies have pinpointed certain gait parameters including step length, step width, foot clearance, stance time, knee extension and hip extension as their primary focus of the interventions.1,4 The increase or decrease in these parameters may have been the driving force behind the child’s increased gait abilities, making targeted interventions to these areas more time efficient; however, the focus of this report was on gross functional gait improvements and not on the individual gait mechanic improvements that may be beneficial for CP children. A fourth limiting factor in this study was the temporal parameters used to assess the outcome measurements. The child completed the 6MWT and 10MWT only twice during the course of the 8 week period. Common sense dictates that individual changes in gait performance can be elicited on nothing more than differing times the test is given. For example, the child may have had an extremely “bad” day during the first testing procedure and a “good” day when completing the final test, causing the differences in his scoring.

The outcome measures used in this study have not been extensively studied or utilized in the CP population. Finding high quality evidence to determine the reliability, validity and statistically important changes was difficult. The study used to determine these important statistics had a sample size of only 30 children, with only 14 of those in the GMFCS level of 3.15 It is imperative that future studies determine the effectiveness of these outcome measures so that definitive differences in gait ability can be assessed.

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Further research using the task-oriented FBWTT/NDT approach to improve gait speed and endurance in children with CP is needed.I propose that multiple high-level studies be completed to determine the effectiveness of FBWTT/NDT for children with CP. Decreasing the aforementioned limiting factors including: multiple interventions (strength/stretching), interventions provided by multiple professionals, an in-depth study of gait mechanic improvements and multiple outcome assessments can increase the clinical acceptability of FBWTT/NDT techniques with CP children. The clinical implications of providing adequate evidence for the use of FBWTT/NDT techniques can greatly reduce the cost of CP treatment and increase the number of PT’s capable of utilizing task-oriented treadmill training into their therapeutic repertoire for this deserving population.

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References1. Palisano RJ, Campbell SK, Orlin M. Physical Therapy for Children. Elsevier Health

Sciences; 2015.2. Day JA, Fox EJ, Lowe J, Swales HB, Behrman AL. Locomotor Training with Partial Body

Weight Support on a Treadmill in a Nonambulatory Child with Spastic Tetraplegic Cerebral Palsy: A Case Report. Pediatric Physical Therapy. 2004;16(2):106-113. doi:10.1097/01.pep.0000127569.83372.c8.

3. Mattern-Baxter K, Bellamy S, Mansoor JK. Effects of Intensive Locomotor Treadmill Training on Young Children with Cerebral Palsy. Pediatric Physical Therapy. 2009;21(4):308-318. doi:10.1097/pep.0b013e3181bf53d9.Mutlu A,

4. Mutlu A, Krosschell K, Spira DG. Treadmill training with partial body-weight support in children with cerebral palsy: a systematic review. Developmental Medicine & Child Neurology. 2009;51(4):268-275. doi:10.1111/j.1469-8749.2008.03221.x.

5. Dodd KJ, Foley S. Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial. Developmental Medicine & Child Neurology. 2007;49(2):101-105. doi:10.1111/j.1469-8749.2007.00101.x.

6. Shumway-Cook A, Woollacott MH. Motor control theory and practical applications. Enskede: TPB; 2004.

7. Butler C, Phd JD, Adams R, et al. Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence report. Developmental Medicine & Child Neurology. 2007;43(11):778-790. doi:10.1111/j.1469-8749.2001.tb00160.x.

8. Barbeau H, Rossignol S. Recovery of locomotion after chronic spinalization in the adult cat. Brain Research. 1987;412(1):84-95. doi:10.1016/0006-8993(87)91442-9.

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neuromuscular disease: comparison between two assessment methods." Journal of Pediatric Orthopaedics 2003 23(3): 302

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13. Pin T, Dyke P, Chan M. The effectiveness of passive stretching in children with cerebral palsy. Developmental Medicine & Child Neurology. 2006;48(10):855. doi:10.1017/s0012162206001836.

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14. Scholtes VA, Dallmeijer AJ, Rameckers EA, et al. 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. 2008;8(1). doi:10.1186/1471-2431-8-41.

15. Thompson P, Beath T, Bell J, et al. Test-retest reliability of the 10-metre fast walk test and 6-minute walk test in ambulatory school-aged children with cerebral palsy. Developmental Medicine & Child Neurology. 2008;50(5):370-376. doi:10.1111/j.1469-8749.2008.02048.x.

16. Begnoche DM, Pitetti KH. Effects of Traditional Treatment and Partial Body Weight Treadmill Training on the Motor Skills of Children With Spastic Cerebral Palsy. Pediatric Physical Therapy. 2007;19(1):11-19. doi:10.1097/01.pep.0000250023.06672.b6.

17. Gorter JW, Currie SJ. Aquatic Exercise Programs for Children and Adolescents with Cerebral Palsy: What Do We Know and Where Do We Go? International Journal of Pediatrics. 2011;2011:1-7. doi:10.1155/2011/712165.