Effects of backward-downhill treadmill training versus manual static plantarflexor stretching on muscle-joint pathology and function in children with spastic Cerebral Palsy

Gait Posture. 2018 Sep:65:121-128. doi: 10.1016/j.gaitpost.2018.07.171. Epub 2018 Jul 22.


Background: Patients with spastic Cerebral Palsy are prone to equinus deformities, likely affected by short and inextensible plantarflexor muscles. Manual stretching is a popular treatment but its effectiveness concerning joint mobility, muscle-tendon morphometrics and walking function is debated. Eccentric exercise by backward-downhill treadmill training could be a therapeutic alternative for ambulatory patients improving gait and muscle function.

Research question: What are the effects of eccentric training by backward-downhill treadmill training and plantarflexor stretching concerning gait and muscle function in patients with spastic Cerebral Palsy?

Methods: 10 independent ambulators with spastic Cerebral Palsy (12 [SD 4] years old, 2 uni- and 8 bilaterally affected) participated in a randomized crossover-study. One group started with manual static stretching, the other one with backward-downhill treadmill training. Each treatment period lasted 9 weeks (3 sessions per week). Pre and post treatments, 3D gait was assessed during comfortable and during fastest possible walking. Ultrasonography and dynamometry were used to test plantarflexor strength, passive joint flexibility, as well as gastrocnemius morphometrics, stiffness and strain on muscle-tendon and joint level.

Results: When comparing both treatments, backward-downhill treadmill training lead to larger single stance dorsiflexion at comfortable walking speed (+2.9°, P = 0.041) and faster maximally achievable walking velocities ( + 0.10 m/s, P = 0.017). Stretching reduced knee flexion in swing, particularly at faster walking velocities (-5.4°, P = 0.003). Strength, ankle joint flexibility, as well as stiffness on muscle-tendon and joint level were not altered, despite similar increases in passive muscle and fascicle strain with both treatments (P ≤ 0.023).

Significance: Backward-downhill treadmill training can be an effective gait treatment, probably improving coordination or reducing dynamic stretch sensitivity. More intense BDTT might be necessary to further alter muscle-tendon properties. Manual static plantarflexor stretching may not be optimal in Cerebral Palsy patients with high ambulatory status.

Keywords: Backward walking; Cerebral palsy; Muscle architecture; Muscle contracture; Stretching; Ultrasound.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Biomechanical Phenomena
  • Cerebral Palsy / physiopathology
  • Cerebral Palsy / rehabilitation*
  • Child
  • Child, Preschool
  • Cross-Over Studies
  • Exercise Therapy / methods*
  • Female
  • Gait / physiology*
  • Gait Analysis / methods
  • Gait Disorders, Neurologic / physiopathology
  • Gait Disorders, Neurologic / rehabilitation*
  • Humans
  • Male
  • Muscle Strength Dynamometer
  • Muscle, Skeletal / physiopathology
  • Range of Motion, Articular / physiology
  • Treatment Outcome
  • Ultrasonography
  • Walking / physiology*
  • Walking Speed / physiology
  • Young Adult