Type of Article:  Original Research

Volume 5; Issue 5 (September 2017)

Page No.: 2294-2300

DOI: https://dx.doi.org/10.16965/ijpr.2017.194


Doaa Ahmed Mahmoud Sanad.

Lecturer, Department of Pediatric Physical Therapy, Faculty of Physical Therapy, Cairo University, Egypt.

Address for Correspondence: Dr. Doaa Ahmed Mahmoud Sanad, Ph.D, Lecturer, Department of Pediatric Physical Therapy, Faculty of Physical Therapy, Cairo University, Egypt. Telephone:+201007206392

E-Mail:  dr.doaa.sanad@gmail.com \ doaa.mahmoud@pt.cu.edu.eg


Background: A new way to increase the challenge of walking is to walk backwards. Backward treadmill walking may provide advantages by promoting improvement in balance, walking spatiotemporal parameters and quality that may reflect in improving walking speed. Information about the energy expended by the patient during ambulation could provide objective data to help guide the decision-making process.

Objective: To evaluate the effects of a backward treadmill training program in improving walking endurance in children with cerebral palsy.

Materials and Methods: Twelve children diagnosed with spastic diplegic cerebral palsy from both gender were included in this study. They were divided into 2 groups, group A  (control) received the regular therapeutic exercise program according to neurodevelopmental approach for such cases  and group B  (study) received the regular therapeutic exercise program for such cases along with 20 min backward treadmill walking using Biodex gait trainer equipment. Heart rate was monitored continuously each session for both groups. walking speed was assessed using The Biodex Gait Trainer 2TM and energy expenditure index was assessed by measuring heart rate using  pulsometer (Japan model Tunturi TPN-400) for both groups before and after three months of the treatment program.

Results: There was statistically significant improvement  in walking speed in the study group (P<0.05) with significant difference when comparing post treatment results between groups (p<0.05), but The change in mean EEI scores was not significant when comparing post treatment results between groups while there were  a significant improvement in  mean EEI scores within groups.

Conclusion: This study demonstrated an effective protocol using backward treadmill training to increase walking speed and endurance in children with CP. Although no significant change in EEI scores was noted and the sample size was small. This gait training method provides a safe and controlled environment for children to perform continuous walking at a cardiovascular training intensity to improve their gait and fitness.

KEY WORDS: Backward, Treadmill Training,  Energy Expenditure Index,  Diplegia,  walking speed, Cerebral Palsy.


  1. Facts about cerebral palsy (2015, January 12). Retrieved February 28, 2015, from http://www.cdc.gov/ncbddd/cp/facts.html.
  2. Smania N, Bonetti P, Gandolfi M, et al. : Improved gait after repetitive locomotor training in children with cerebral palsy. Am J Phys Med Rehabil, 2011;90:137–149. [PubMed].
  3. Richards CL, Malouin F, Dumas F, et al. : Early and intensive treadmill locomotor training for young children with cerebral palsy: a feasibility study. Pediatr Phys Ther, 1997;9:158–165.
  4. Takao T, Tanaka N, Iizuka N, et al. Improvement of gait ability with a short-term intensive gait rehabilitation program using body weight support treadmill training in community dwelling chronic post stroke survivors. J Phys Ther Sci, 2015;27:159–163. [PMC free article] [PubMed].
  5. Grasso R, Bianchi L, Lacquaniti F. Motor patterns for human gait: backward versus forward locomotion. J Neurophysiol 1998;80:1868–85.
  6. Hooper TL, Dunn DM, Props JE, Bruce BA, Sawyer SF, Daniel JA. The effects of graded forward and backward walking on heart rate and oxygen consumption. J Orthop Sports Phys Ther 2004;34:65–71.
  7. Winter DA, Pluck N, Yang JF. Backward walking: a simple reversal of forward walking? J Mot Behav 1989;21:291–305.
  8. Thorstensson A. How is the normal locomotor program modified to produce backward walking? Exp Brain Res 1986;61:664–8.
  9. Katsavelis D,Mukherjee M, Decker L, Stergiou N. Variability of lower extremity joint kinematics during backward walking in a virtual environment. Nonlinear Dynamics Psychol Life Sci 2010;14:165-78.
  10. Flynn TW, Connery SM, Smutok MA, et al. Comparison of cardiopulmonary responses to forward and backward walking and running. Med Sci Sports Exerc, 1994;26:89–94. [PubMed].
  11. Rose, J., Medeiros, J.M., & Parker, R. Energy cost index as an estimate of energy expenditure of cerebral–palsied children during assisted ambulation. Developmental Medicine and Child Neurology, 1985;27:485-490.
  12. Eagleton, M., Iams, A., McDowell, J., Morrison, R., & Evans, C.L. The effects of strength training on gait in adolescents with cerebral palsy. Pediatric Physical Therapy, 2004;16:22-30.
  13. Schlough, K., Nawoczenski, D., Case, L.E., Nolan, K., & Wigglesworth, J.K. The effects of aerobic exercise on endurance, strength, function and self– perception in adolescents with spastic cerebral palsy: a report of three case studies. Pediatric Physical Therapy, 2005;17:234–250.
  14. Cooper DM, Weiler- Ravell D, Whipp BJ and Wasserman K. Growth related changes in Oxygen uptake and heart rate during progressive exercises in children. Pediat Res 1984;18:845-51.
  15. Dal U, Erdogan T, Resitoglu B, Beydagi H. Determination of preferred walking speed on treadmill may lead to high oxygen cost on treadmill walking. Gait Posture. 2010;31:366–369. [PubMed].
  16. Rose, J., Gamble, J.G. and Lee, J. The energy expenditure index: a method to quantitate and compare walking energy expenditure for children and adolescents. J Pediatr Orth., 1991;11:571-578.
  17. Hesse SA., Bertlt CM., Schaffrin A. Restoration of gait in non ambulatory hemiparetic patients by treadmill training with partial body-weight support. Arch. Phys. Med. Rehabil. , 2009;75(10):1087-1093.
  18. Maher CA, Williams MT, Olds T, Lane AE. Physical and sedentary activity in adolescents with cerebral palsy. Dev Med Child Neurol., 2007;49:450–457. [PubMed].
  19. Durstine JL, Painter P, Franklin BA, Morgan D, Pitetti KH, Roberts SO. Physical activity for the chronically ill and disabled. Sports Med. ,2000;30:207–219. [PubMed].
  20. Verschuren O, Takken T. Aerobic capacity in children and adolescents with cerebral palsy. Res Dev Disabil. ,2010;31:1352–1357. [PubMed].
  21. Dahlback, G. O. and R. Rorlin. The effect of corrective surgery on energy expenditure during ambulation in children with cerebral palsy. Eur. J. Appl. Physiol., 1985;54:67-70. Full Text Internet Resources Bibliographic Links [Context Link].
  22. Sutherland, D. H., R. Olshen, L. Cooper, and S. Woo. The development of mature gait. J. Bone Joint Surg., 1980;62A:336-353. Internet Resources Bibliographic Links [Context Link].
  23. Schindl MR, Forstner C, Kern H, Hesse S. Treadmill training with partial body weight support in nonambulatory patients with cerebral palsy. Arch Phys Med Rehabil., 2000;81:301–306. [PubMed].
  24. Duffy CM, Hill AE, Cosgrove AP, Corry IS, Graham HK. Energy consumption in children with spina bifida and cerebral palsy: a comparative study. Dev Med Child Neurol. ,1996;38:238–243. [PubMed].
  25. Reisman DS, Wityk R, Silver K, Bastian AJ. Split-belt treadmill adaptation transfers to overground walking in persons poststroke. Neurorehabil Neural Repair , 2009;23:735–744. [PMC free article] [PubMed].
  26. Green, M. A. and C. Foster. Effect of magnitude of handrail support on prediction of oxygen uptake during treadmill testing (Abstract). Med. Sci. Sports Exerc., 1991;23:S166. Internet Resources Bibliographic Links [Context Link].
  27. Rose, J., W. L. Haskell, and J. G. Gamble. A comparison of oxygen pulse and respiratory exchange ratio in cerebral palsied and nondisabled children. Arch. Phys. Med. Rehabil.,1993;74:702-705. Full Text Internet Resources Bibliographic Links [Context Link].
  28. Berger, W., J. Quintern, and V. Dietz. Pathophysiology of gait in children with cerebral palsy. Electroencephalogr. Clin. Neurophysiol. , 1982;53:538-548. Full Text Internet Resources Bibliographic Links [Context Link].
  29. Gatev, V. Role of inhibition in the development of motor coordination in early childhood. Develop. Med. Child Neurol. 1972;14:336-341. Internet Resources Bibliographic Links [Context Link].

Cite this article: Doaa Ahmed Mahmoud Sanad. CONDITIONING EFFECTS OF BACKWARD TREADMILL TRAINING IN CHILDREN WITH SPASTIC DIPLEGIC CEREBRAL PALSY. Int J Physiother Res 2017;5(5):2294-2300. DOI: 10.16965/ijpr.2017.194