Biomedical & Pharmacology Journal, June 2022. Vol. 15(2), p.

651-662

Comparison of Integrated Task Oriented Bodyweight Supported

Overground Training with Body-Weight Supported Treadmill
Training to Improve Functional Mobility in Children with
Spastic Diplegic Cerebral Palsy - A Single Blinded Randomized
Control Trial
Nishad Kassim*, Monalisa Pattnaik, Patitapaban Mohanty and Mary Kavi

Swami Vivekanand National Institute of Rehabilitation Training and

Research, Olatpur, Cuttack, Odisha, India.
*Corresponding Author E-mail: kassim.nishad@gmail.com

https://dx.doi.org/10.13005/bpj/2404

(Received: 22 September 2020; accepted: 28 May 2022)

Functional gait training in cerebral palsy can involve over ground gait training or
treadmill-based gait training which incorporates partial body weight support (PBWS) system.
Insufficient clinical evidence prevails to recommend the superiority over the other intervention.
ICF model has created a paradigm shift in understanding motor learning mechanisms, with
the use of repetitive, task-specific movements beneficial to restructuring motor pathways. The
primary aim of the study was to compare the effect of integrated task oriented Body Weight
Supported overground Training (BWSOGT) against the Body Weight Supported Treadmill
Training (BWSTT) and the conventional gait training protocols to improve the functional
mobility in Cerebral Palsy. Methods: A Single-blinded, randomised control design. Sixty-children
with GMFCS Level of III, IV were recruited in the study with an age ranges between 4 to 14
years (mean age = 9). Participants were randomly assigned into three groups using simple
randomisation method with 20 subjects in each group for 8 weeks. The training programme
consists of Group A with 40% of body weight supported walker with overhead pulley system
which allows multiple degrees of freedom. Body weight- supported treadmill training (Group
B) in a closed environment and conventional gait protocol using standard walkers (Group
C). Outcome measures: Gross Motor Function Measure dimension-88 (GMFM-88) score. Gait
kinematics (Stride length, Step length, Cadence) and 10 meter walk test. Tukey’s Post Hoc for
group and time interactions, Krushkal Wallis test for overall significance and Mann Whitney’s
U test to compare the significance between the groups. BWSOGT group showed significance
over the BWSTT and Control group in GMFM score with p = 0.000 p = 0.002, respectively. Step
length of gait parameter remained unchanged in all the three groups. Integrated task oriented
BWSOGT might be an effective intervention to improve functional ambulation in children
with spastic cerebral palsy due to the usage of a context specific environment and the training
protocol.

Keywords: BWS Over Ground Training; GMFM; Gait Parameters; NDT;

Task Oriented Training; Treadmill Training.

Cerebral palsy [CP] is defined as the approximately 2 to 2.5 cases per 1000 live births.
permanent and non-progressive disorders of the In India, it is estimated at around 3 cases per 1000
developing brain resulting in disorders of posture live births; however, being a developing country
and movement1.The worldwide incidence of CP is the actual figure may be much higher than probable

This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-BY).
Published by Oriental Scientific Publishing Company © 2022
652 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022)

figures. There are about Twenty-five hundred income countries. The current study is focusing
thousand CP children in India as per the available on evaluating the efficiency of an integrated
statistical information2. task-oriented BWSOGT over the BWSTT and the
The Gait pattern is altered in individuals conventional over ground training.
with spastic diplegia due to increase in muscle Aims and objectives
tone causing scissoring pattern of lower limbs3. Our study aims at comparing the effect
The delicate integration of vision, vestibular of integrated task oriented body weight supported
system, and proprioception has jeopardised the over ground training [BWSOGT] over the body
entire locomotion in children affected with CP4. weight supported treadmill training [BWSTT] and
The neuromuscular dysfunction in spastic diplegia the conventional gait training protocols to improve
includes, loss of selective motor control, altered the functional mobility in Cerebral Palsy.
muscle tone, leading to an imbalance between Methodology
agonist and antagonist muscles. In addition; they A Single-blinded (Assessor) Randomised
have significant coordination disorders and motor Control Trial with 60 children recruited from
planning difficulties5. In recent years, gait training the paediatric rehabilitation unit; Department of
on a treadmill has been used in the treatment Physiotherapy; SVNIRTAR. The children were
of children with CP aiming to enhance postural included after signing the informed consent forms
stability. Treadmill training is believed to improve by the parents, and the study was approved as per
postural control by allowing multiple repetitions Helsinki ethical declaration. Age group ranged
of the gait cycle in a rhythmic pattern, thereby from 4 years to 14 years (with mean age 9);
improving synchronization between agonist and divided into three groups with 20 subjects in each
antagonist muscles and thus resulting in improved group, namely BWSOGT group [mean age 8.75],
static and dynamic balance6. BWSTT [mean age 8.10] and conventional group
Improvement in the mobility function [mean age 8.45] 66.7% of subjects were males
has been an important concept in the recent & 33.3 % of subjects were females. The children
rehabilitation approaches7. Motor theory suggests were randomised using a simple random sampling
that the best way to improve a motor skill is to method and allocated sequentially in to group A,
conduct a context specific repetitive task training8. B and C respectively using chit paper method.
Modern concept of motor learning indicates that the Inclusion criteria
training is most effective; when a training activity is Children diagnosed as spastic diplegic
most specific to the intended outcome9. The optimal CP, whose age range between 4 to 14 years with
improvement in function will occur as a result of GMFCS level III to IV. Participant should be able
precise and structured training programme10. to follows instructions and independent in standing
Currently partial body-weight-supported with aids.
treadmill training [PBWSTT] has been more widely Exclusion criteria
used in rehabilitating people with neurological Children with the following were
conditions. The available literatures, either has excluded. Intellectual Disability, epileptic attack
insufficient sample size or lack of randomisation in past 6 months, hemiplegic, athetoid, ataxic,
in the study. and flaccid CP, cardio vascular illness, visual
There are limited evidences towards the and cognitive deficits, under another gait training
effect of robotic and treadmill training in the field protocol, congenital musculoskeletal defects,
of paediatric rehabilitation especially for children dislocations of hip, significant hip and knee
with central motor dysfunction11. There are several contractures, behavioural disorders, recent
studies which reported the superiority of over- botulinum toxin injections.
ground gait training above the treadmill training Dependent Variables
with effectiveness of task oriented training for Gross Motor Function Measure dimension
functional recovery in cerebral palsy children12. [GMFM-88] score, Gait kinematics [Stride length,
Body weight-supported training over Step length, Cadence], 10 meter walk test [self-
level ground is affordable. This is predominantly dependent and fast velocity].
important consideration for the low and middle-
 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022) 653

Instrumentation of legs during the training. The assistance of one

BWSOGT person was required to progress the suspension
It’s a custom made walker system; frame for those who had limited ability to propel
attached four wheels with brake facility. Dimension the suspension frame. The subjects were directed to
of the walker is 160 x 53 [LXB]. The walker frame perform certain activities like picking up ball from
has a suspension system with adjustable overhead- the ground and pass the ball to care taker, kicking
pulley through which a string is introduced. One the ball, obstacle clearance, stepping over a small
end of the string is attached with the suspension foot stool.
harness; whereas the other end attached to a Group B: Body weight-supported treadmill
removable weighted system which allows addition training
and removal of the weights. Participants in Group B were trained on
BWSTT a body weight supported treadmill. Gait efficiency
The Tech-Med; Physio200model treadmill was checked by allowing them to walk for one
was used in this study. minute in order to adjust the weight support.
Running surface: 53 x150 cm, Speed Manual guidance of the legs was provided until
range: 0.1 to 10 km/h, Inclination: level 6. Partial independence in stepping was achieved. Inclination
body weight support system: Tech med body weight of the treadmill was altered as a progression in
support system which works with a hydraulic lift order to equalize the difficulty level in all the
system with a total lift capacity of 200 kg. groups.
Procedure Group C: Conventional gait training
Subjects who met the inclusion criteria The participants of this group after the
were screened using GMFCS and were randomly regular therapy session were provided with gait
allocated in to three groups A, B, and C respectively. training using standard walking frames and parallel
All participants underwent an initial baseline bars. Walking experiences were naturalized, except
assessment of Gross Motor Function Measure, Gait that the body was suspended and addition of a task
kinematics including cadence, step length, stride to enrich the learning experience. The subjects
length, and the 10 Meter Walk test. Participants in were allowed to use the orthosis during the training
all three groups were subjected to the regular NDT session.
protocol; which included functional stretching, After completion of 8 weeks all participants
task oriented activities for trunk control and received follow up assessments of Gross Motor
balance. The gait training for the participants were Function Measure, gait kinematics[stride length,
performed using the specific interventions like step length, cadence], 10MWT.
BWSOGT, BWSTT, Conventional gait training Data Analysis
using parallel bars and walkers in group A, B, Statistical analysis was performed using
C respectively. The intervention period was of 8 SPSS version 23.0.
weeks duration, 3 days/week, 30 minutes/session. The Gait kinematics [Stride length, Step
Group A: Body Weight Support Overground length, Cadence] and 10MWT were analysed using
Training a [GLM] General Linear Model ANOVA, 2x3 with
The participants of this group were 2 as a time factor and 3 as a group factor. There
initially trained with the modified walker. Initially, was one between factor [group] with three levels
40% of the participant’s bodyweight was added [Groups: A, B and C] and one within factor [time]
through weights to the pulley system. Knee flexion with two levels [time: Pre and Post]. All pair wise,
during the stance phase of walking was used as an post - hoc comparisons were analysed using a 0.05
indication for increasing the weight support, and level of significance.
heel off during the stance phase as an indication for The change in function post to pre
reducing the weight support. Gait efficiency was between the groups, as the data followed a
checked by allowing a trial walk of 10 meters to positively skewed curve and falls under non
adjust the weight support if required. Participants normative distribution. Krushkal Wallis test was
were allowed to walk at their self-selected speed; used to determine the overall difference between
which eliminated the need of manual assistance the groups. The effect between the groups were
 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022) 654

analysed with Mann-Whitney U test by calculating [mean age 8.75] & BWSTT [mean age 8.10] and
the median of GMFM-88 [post minus pre scores]. conventional group [mean age 8.45]. 66.7% of
Separate comparisons between the groups were subjects were males & 33.3% of subjects were
obtained and tabulated. females.
1OMWT
RESULTS There was a significant improvement in
scores for all the three groups from pre to post-test
Demographics measurements. However, the BWSOGT group
A total number of 60 subjects with mean showed greater improvement than BWSTT and
age 6.3 were taken & divided into three groups Control group. There was no significance between
with 20 subjects in each group, namely BWSOGT

Fig. 1. Ramp Training Fig. 2. Balancing

BWSTT and control group at the end of 8 weeks

intervention.
Gait Kinematics
Stride Length Left
There was a significant improvement in
stride length scores for all the three groups from pre
to post-test measurements. However, the BWSOGT

Fig. 3. Overhead Throw Fig. 4. Treadmill was used

655 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022)

group showed significantly greater improvement from pre to post-test measurements. BWSOGT
than BWSTT and Control group. There was no group showed significantly greater improvement
significance between BWSTT and control group than BWSTT and Control group. There was no
at the end of 8 weeks of intervention. significance between BWSTT and control group
Stride Length Right at the end of 8 weeks of intervention
There was a significant improvement Step Length
in stride length score for all the three groups There was a clinical significance; on the

Fig. 5. Consort Flow Chart

 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022) 656

contrary it failed to register statistical significance Gross Motor Function Measures Goal Area -
between the groups and within the group. [GMFM -88]
Cadence BWSOGT had statistical significance
There was a significant improvement in over the BWSTT and the control, BWSTT had
cadence score for all the three groups from pre to significance over the control group.
post-test measurements. However, the BWSOGT
group showed significantly greater improvement Discussion
than BWSTT and Control group. BWSTT had
significance over control group at the end of 8 The overall result of this study showed
weeks of intervention. that all the three groups [Body weight supported
Gross Motor Function Measures Goal Area- Over ground training, Body weight supported
[GMFM -88] treadmill training and Conventional gait training]
A Kruskal-Wallis test was conducted to had statistical significance in terms of Gross Motor
determine whether the GMFM score remain same Function Measure, cadence, stride, and 10 MWT
in all three groups or they had variability among from pre to post-test measurements. However,
the performance after the intervention across the Step length parameter has showed no significance
groups. Results of that analysis indicated that there in all the three groups. From the present synthesis
was significance difference in GMFM Goal area of data in our study comparing all three groups
function between the 3 groups with H= [2] =15.412 BWSOGT group with BWSTT showed a large
and p=0.000.

Table 1. Descriptive Table

BWSOGT BWSTT Conventional

Pre-test Post-test Pre-test Post-test Pre-test Post-test

10MWT(meters) 0.2[.015] 0.26[.02] 0.19[.009] 0.21[.010] 0.16[.009] 0.19[.012]

Stride Length Left 25.4[1.30] 30.45[1.30] 24.85[1.20] 28.[1.17] 22.95[1.33] 25.65[1.29]
Stride Length Right 25.7[1.21] 30.95[1.30] 24.8[1.11] 27.85[1.18] 22.9[1.38] 25.50[1.38]
Step Length 11.9[.65] 14.10[.60] 11.1[.57] 13.[.52] 10.15[.54] 12.25[.56]
Cadence 37.3[1.81] 48.15[2.58] 35.8[1.85] 42.35[1.88] 33.80[1.58] 38.85[1.82]

In the table -Mean [Standard Error of Mean]

Table 2. Post hoc test table

Post hoc test table

Time Group Group x time
1,57,0.05 2,57,0.05 2,57,0.05

10MWT F=46.346, p= 0.000. F=3.855, p= 0.027. F=5.321, p=0.027

Step length F=154.084, p=0.000 F= 2.595, p= 0.083. F= 0.281, p=0.756,
Stride length left F=177.957, p=0.000 F=2.131, p= 0.128 F=6.991, p=0.002
Stride length right F=155.951, p=0.000 F=2.757, p= 0.072 F= 12.472, p= 0.000.
Cadence F =231.18, p=0.000 F = 2.853, p= 0.066. F= 12.472, p= 0.000.

Table 3. Mann Whitney’s table

Mann Whitney’s table

BWSOGT(V/S) BWSTT (Z)=-3.219 (p) = 0.001

BWSTT(V/S) CONTROL (Z)=-1.447 (p) = 0.148
BWSOGT(V/S) CONTROL (Z)=-3.327 (p) = 0.001
 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022) 657

effect on GMFM, while BWSIT showed better Similarly on inter-group comparison

improvement than Conventional group. BWSOGT had a difference of 9.99%, 14.65%
Walking velocity and gait kinematics in cadence, 7.67% to 8.6% in stride length and
On comparing inter-group on walking 1.31% - 0.2% in step length. Whereas, BWSTT
velocity using 10MWT showed significance in had a difference of 4.12 % cadence, 1.25% stride
all three groups. BWSOGT had a difference of length, 1.31% step length when compared to the
13.47%, 13.51% self-selected velocity when control group.
compared to the other two groups. While, BWSTT The improvement in the control group
compared to the control group had a difference of may be attributed to practice in the natural
0.04% velocity. environment. On the other hand, they had minimal

Graph 1. Changes in 10 MWT in all the three groups

Graph 2. Changes in stride length in all the three groups

658 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022)

opportunity for exploring environment due to enabled the development of the Central Pattern
holding the walker. It was also noted; children were Generators. Over ground gait velocity increased
unable to complete the session, often take a break post adaptation due to increased stride length and
or discontinue the session which decreased the decreased stride duration after motor adaptation
repetitive training protocol. Decreased degree of during treadmill walking14.
freedom due to the necessity of holding the walker The treadmill provides an objective
also contributed to the poor sustainability13. measurement of speed and a precise measurement
The improvement in the BWSTT of distance, which can be quantified and progressed.
group could be because of the repetitive training Although over ground walking allows the
pattern. Moreover, the constant speed and the participant to practice the target skill, it is difficult
moving platform provided a trigger to initiate the for the individual to maintain a consistent speed
ambulation. This allowed the children to improve over longer distances15.
the gait parameters which could be another reason Our results suggested that the faster
for the fast velocity. The training would have walking speeds may have been accomplished after

Graph 3. Changes in stride length [right] in all three groups

Graph 4. Changes in step length in all three groups

659 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022)

the BWSOGT training by increasing the cadence. training, which would have lowered the motivation
Motor theory suggests the best way to improve a than the BWSOGT group.
motor skill is repetitive practice. BWSOGT also It’s well established, that task- oriented
has advantages over treadmill training by preparing programmes are necessary for motor learning to
patients for walking in the real-life environments16. occur and functional reorganisation. Therefore,
During treadmill locomotion with body weight- optimal training effect occurs; when the training
support, the ground moves relative to the person is similar to that of the real-life task18,19.
but the visual surround remains the same. In the There was a common phenomenon that
real-world, a person moves relatively to the ground occurred in all the three groups. In our study, it
and the visual surroundings17. was observed there is clinical significance in step
The control group and the BWSTT group length. However, the interventions failed to register
were not provided with the task-oriented skill as statistically significance. This could be because

Graph 5. Changes in cadence in all three groups

Graph 6. Changes in GMFM between the groups

 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022) 660

in diplegic CP both the lower limbs were equally control group.

involved and spasticity would have restricted The significance could be because of the
the smooth movement of the limbs. Spasticity task-specific motor activities, in comparison with
causes wide range of ambulatory disorders which the traditional activities, resulted in long-lasting
explains the individual difficulties in maintaining cortical reorganisation specific to corresponding
and restores both the static and dynamic balance20. area being used during practice 28,29 , recent
There is a strong relationship between balance and evidences has shown the task oriented interventions
single leg support time, which indicated as a test to are effective strategies to promote meaningful
measure the upright postural stability after upper motor response30.
motor neuron lesion21. BWSTT group had a repetitive gait pattern
The use of the treadmill imposes a using partial body weight gait training, which
different context altering propulsion and balance assists them in mobility increased the children
patterns22. Individual must apply sufûcient force motivation and participation. The games and the
toward the ûoor to propel limbs forward. On a activities incorporated were a real-life task. The
treadmill, the propulsion generated by the limbs is participants were devoid of the manual support,
not necessarily proportional to velocity23,24, as the which provided a better learning opportunity
belt allows for the limbs to passively move with and the trigger initiated by the moving platform
the minimized levels of muscle activation25,26. CP initiated the gait pattern which would have resulted
children may adopt a different strategy in balance in the cortical reorganisation31.
control, as they would adopt while walking over- Generally, children with cerebral palsy
the ground. The functional anticipatory postural deprived with limited environment stimulation
actions may be substantially preserved in CP27. that is necessary for learning experiences. Mobility
The anticipatory postural actions are factor plays a major hindrance in these children to
considered to be an essential factor in the postural become less exploratory and delayed in skills like
adaptations. In case of the treadmill, training over language development.
the moving platform applies a constant demand BWSOGT system is flexible depends on
on the subject for propulsion, where the subject the subject needs. Based on the progression, the
is not prepared for the specific action and cause amount of body weight suspended was reduced,
a poor learning experience with regards to the which increased the challenges to the participant
initiation factor. This demand might increase the and leads to a better learning experience. BWSOGT
abnormal muscle activation in the subjects. A system enabled the subjects to practice the various
sustained stretching pattern is believed to reduce components of the GMFM -88; maybe this could be
the spasticity in the central motor dysfunctions, or the reason for better GMFM scoring in this group.
any voluntary motor initiation is necessary for the Our results were similar to a study,
proper sequenced activation of the muscles. that BWSOGT system improves gait speed and
BWSOGT training might subtly have cadence. In addition, the article suggests that the
modulated the recruitment patterns and the influence on gait speed may be because of massed
anticipatory adjustment patterns. On comparing practice. There did not appear to be a significant
the suspension over ground system with treadmill observable change in gait pattern32.
training, BWSOGT provides more functional
performance, by providing both the trigger for Conclusion
walking and lateral shift. The moving platform of
the treadmill helps in the initiation of the gait and Children with spastic diplegia showed
provides a shift of equilibrium. However, it lacks significant improvement in terms of gait parameters
lateral weight shift. and functional performance. BWSOGT followed
Gross Motor Function Measure a training protocol in an open environment like
Our results showed that BWSOGT had walking in plane, irregular surfaces, ramp and play
5.7%, 6.49% of GMFM functional score when integrated activities like picking up and passing
compared to the other two groups. BWSTT had the ball along with a self-adjusting BWS system.
0.79% better performance when compared to This proves BWSOGT is better than BWSTT in
661 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022)

a closed environment and the conventional gait 3. American Physical Therapy Association, 2001],
training without BWS system. Conversely, both the [“Facts about Cerebral Palsy,” 2015]. https://www.
training programme was found superior in terms of cdc.gov/ncbddd/HYPERLINK,”https://www.
cadence and gross motor function measure against cdc.gov/ncbddd/cp/facts.html”CPHYPERLINK
“https://www.cdc.gov/ncbddd/cp/facts.html”/
the open ground unsupported gait training. Few
facts.html.
limitations were the subjects were chosen from a 4. Nashner LM, Shumway-Cook A, Marin O.
similar geographical location. Carry over effect Stance posture control in selective groups
and measure of impairment has not been studied. of children with cerebral palsy: Deficits in
Energy expenditure index was not calculated for sensory organization and muscular coordination.
endurance parameter. Experimental Brain Research. 1983; 49:393–
Recommendations for future studies 409.
Further studies on clinically possible 5. Shumway-Cook A, Hutchinson S, Kartin D, Price
outcome measures to check endurance in non- R, Woollacott M. The effect of balance training
on recovery of stability in children with cerebral
ambulant CP. Usage of EMG analysis can be
palsy. Dev Med Child Neurol, 2003; 45: 591–602.
used to detect precise changes in muscle function 6. Smania N, Bonetti P, Gandolfi M, Cosentino
and advanced investigatory procedures are A, Waldner A, Hesse S, Werner C, Bisoffi
recommended to prove the neuronal reorganization G, Geroin C, Munari D: Improved gait after
similar study may be conducted on other CP repetitive locomotor training in children with
children. cerebral palsy. Am J Phys Med Rehabil, 2011;
90:137Y149.
Acknowledgement 7. H Barbeau and J Flung. The role of rehabilitation
in the recovery of walking in the neurological
population, Current opinion in neurology,
The author would like to acknowledge all
2001;14: 735-740.
faculties of Swami Vivekanand National Institute 8. Willoughby KL, Dodd KJ, Shields N, Foley
of Rehabilitation Training and Research and the S. Efficacy of partial body weight–supported
parents and children who volunteered to participate treadmill training compared with overground
in this study. Gratitude’s to my family and Friend walking practice for children with cerebral palsy:
Mr. Sankar for their constant moral support. a randomized controlled trial. Arch Phys Med
Conflict of Interest Rehabil 2010; 91:333-9.
The author declares no conflict of interest 9. H I Ma, G A Trombly and C Robinson – Podolski
Clinical utility The effect of context of skill acquisition and
transfer, American Journal Of Occupational
Despite the limitations, the results were
therapy, 1999; 53:138-144].
promising for the clinicians working with CP 10. N A Bayona J Bitensky, K Salter R Teasell, The
children. The study emphasizes on the usage of role of task specific\training in rehabilitation
a task-oriented activity based gait training with therapy, Top Stroke Rehabilitation, 2005; 12:
customised BWSOGT for CP children. BWSOGT 58-65.
system is cost effective; when compared with the 11. Damiano, D. L., & Abel, M. F. Functional
expensive treadmill with the partial body weight outcomes of strength training in spastic cerebral
support system. palsy. Archives of Physical Medicine and
Rehabilitation, 79(2):119-125. doi: S0003-
9993[98]90287-8].
rEFERENCES
12. Effect of Gait Training With Overground Gait
Trainer Support Versus Partial Body Weight
1. Rosenbaum P, Paneth N, Leviton A, et al. A Supported Treadmill Training in Children with
Report: The Definition and Classification of Spastic Diplegic Cerebral Palsy Nia M. Torres,
Cerebral Palsy. Dev Med Child Neurol. 2007; 2015.
109:8-14 13. Moreau, N. G., Bodkin, A. W., Bjornson,
2. Incidence of Cerebral Palsy Remains Constant K., Hobbs, A., Soileau, M., & Lahasky, K.
in India on Indian Health News. Available from Effectiveness of rehabilitation interventions to
:http://www.medindia.net/news/Incidence- improve gait speed in children with cerebral
of-Cerebral-Palsy-Remains-Constant-in- palsy: Systematic Review and Meta-analysis.
India-74912-1.htm .cdc.gov Physical therapy, 2016; 96(12): 1938–1954.
 Kassim et al., Biomed. & Pharmacol. J, Vol. 15(2), 651-662 (2022) 662

https://doi.org/10.2522/ptj.20150401. activation in treadmill versus overground

14. Fosdahl, M. A., Jahnsen, R., Kvalheim, K., & walking. Neurorehabilitation and Neural Repair,
Holm, I. Effect of a combined stretching and 2004; 18: 154–160.
strength training program on gait function in 24. Han, Y. G., & Yun, C. K. Effectiveness of
children with cerebral palsy, GMFCS Level I treadmill training on gait function in children
& II: A Randomized Controlled Trial. Medicina with cerebral palsy: meta-analysis. Journal of
(Kaunas, Lithuania), 2019; 55(6): 250. exercise rehabilitation, 2020; 16(1): 10–19.
15. DeJong & Damiano, D. L, S. L. A systematic https://doi.org/10.12965/jer.1938748.374
review of the effectiveness of treadmill 25. Stackhouse C, Shewokis PA, Pierce SR, Smith B,
training and body weight support in pediatric McCarthy J, Tucker C. Gait initiation in children
rehabilitation. Journal of Neurological Physical with cerebral palsy. Gait Posture, 2007; 26:
Therapy, 2009; 33(1):27–44 301–8.
16. Hyun-Kyung Hana, and Yijung Chungb Effects 26. Ming Wu,Janis Kim, Pooja Arora, Deborah J.
of task-oriented training for Gross Motor Gaebler-Spira, and Yunhui Zhang Kinematic
Function Measure, balance and gait function in and EMG Responses to pelvis and leg assistance
persons with cerebral palsy. Phys Ther Rehabil force during treadmill walking in children
Sci 2016;5:9-14 with cerebral palsy Neuroplasticity Hindawi
17. Nishi Gupta Rajeev Mehta Comparison of gait Volume 2016 |Article ID 5020348 | https://doi.
performance of spinal cord injury subjects: body org/10.1155/2016/5020348
weight supported treadmill training versus over 27. Pavão, S. L., dos Santos, A. N., Woollacott,
ground gait training Apollo Medicine, 2009: 6(1): M. H., & Rocha, N. A. Assessment of postural
21-27 control in children with cerebral palsy: a review.
18. Lee JH, Sung IY, Yoo JY. Therapeutic effects Research in developmental disabilities, 2013;
of strengthening exercise on gait function 34(5): 1367–1375. https://doi.org/10.1016/j.
of cerebral palsy. Disabil Rehabil. 2008; ridd.2013.01.034
30[19]:1439-1444. 28. J Crompton,C. Imms,A T McCoy M Randall B
19. Kazon S, Grecco LA, Pasini H, Corrêa JC, Eldridge B Scoullar M P Galea, Group based
Christovão TC, de CarvalhoPde T, et al. Static task related training for children with cerebral
balance and function in children with cerebral palsy, A Pilot study, Physical and Occupational
palsy submitted to neuromuscular block and Therapy in Paediatrics 2007, 43-65.
neuromuscular electrical stimulation: study 29. Papale, A. E., & Hooks, B. M. Circuit changes
protocol for prospective, randomized, controlled in motor cortex during motor skill learning.
trial. BMC Pediatr. 2012; 16:12:53 Neuroscience, 2018; 368: 283–297. https://doi.
20. Johnston TE, Watson KE, Ross SA, Gates PE, org/10.1016/j.neuroscience.2017.09.010
Gaughan JP, Lauer RT, Tucker CA, Engsberg JR. 30. Wu, Y. W., Day, S. M., Strauss, D. J., &Shavelle,
Effects of a supported speed treadmill training R. M. Prognosis for ambulation in cerebral palsy:
exercise program on impairment and function a population-based study. Pediatrics, 2004;
for children with cerebral palsy. Dev Med Child 114[5], 1264-1271. doi: 114/5/1264 [pii]10.1542/
Neurol. 2011; 53[8]:742- 750. peds.2004-0114.
21. Norman, K. E., Pepin, A., Ladouceur, M., 31. Kurz MJ, Stuberg W, DeJong S and Arpin DJ.
& Barbeau, H. A treadmill apparatus and Overground body-weight-supported gait training
harness support for evaluation and rehabilitation for children and youth with neuromuscular
of gait. Archives of Physical Medicine and impairments. Phys OccupTherPediatr 2013; 33:
Rehabilitation, 1995; 76: 772–778. 353–365.
22. Goldberg, E. J., Kautz, S. A., & Neptune, R. 32. Wonsetler, E. C., & Bowden, M. G. A systematic
R. Can treadmill walking be used to assess review of mechanisms of gait speed change post-
propulsion generation Journal of Biomechanics, stroke. Part 1: spatiotemporal parameters and
2008; 41: 1805–1808. asymmetry ratios. Topics in stroke rehabilitation,
23. Harris-Love, M. L., Macko, R. F., Whitall, J., 2017; 24(6): 435–446. https://doi.org/10.1080/1
& Forester, L. W. Improved hemiparetic muscle 0749357.2017.128574