Skip to main content

Immediate effect of maximal treadmill walking on muscle fatigue and postural stability in children with cerebral palsy



Postural instability and muscle fatigue are from elementary causes of deteriorations in children with cerebral palsy (CP). The aim of this study was to investigate the immediate effect of maximal treadmill walking on muscle fatigue and postural stability in children with hemiplegic CP.

Patients and methods

Thirty (17 boys and 13 girls) children with hemiplegic CP of both sexes, aged from 5 to 11years, participatedin this study. Muscle fatigue and postural stability were assessed for every child by using isokinetic dynamometer and pediatric reaching test, respectively, before and after maximal treadmill walking at two separated sessions.


The results showed that there were no significant differences in fatigue index (P=0.33 and 0.1), peak torque of quadriceps and hamstring muscles (P=0.52 and 0.14), and anterior and lateral reaching tests of postural stability (P=0.46 and 0.63) before and after maximal treadmill walking.


Maximal treadmill walking does not cause muscle fatigue or postural instability in children with hemiplegic CP.


  1. 1

    Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 2013; 55:885–910.

    PubMed  Google Scholar 

  2. 2

    Nooijen C, Slaman J, van der Slot W, Stam HJ, Roebroeck ME, van den Berg-Emons R, et al. Health-related physical fitness of ambulatory adolescents and young adults with spastic cerebral palsy. J Rehabil Med 2014; 46:642–647.

    PubMed  Google Scholar 

  3. 3

    Kulak W, Sobaniec W. Comparisons of right and left hemiparetic cerebral palsy. Pediatr Neurol 2004; 31:101–108.

    PubMed  Google Scholar 

  4. 4

    Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsyApril 2006. Dev Med Child Neurol Suppl 2007; 109:8–14.

    PubMed  PubMed Central  Google Scholar 

  5. 5

    Duarte M, Freitas SM. Revision of posturography based on force plate for balance evaluation. Braz J Phys Ther 2010; 14:183–192.

    Google Scholar 

  6. 6

    Hadders-Algra M, Carlberg EB. Postural control: a key issue in developmental disorders. London: Mac Keith; 2008.

    Google Scholar 

  7. 7

    Näslund A, Sundelin G, Hirschfeld H. Reach performance and postural adjustments during standing in children with severe spastic diplegia using dynamic ankle-foot orthoses. J Rehabil Med 2008; 39:715–723.

    Google Scholar 

  8. 8

    Kenis-Coskun O, Giray E, Eren B, Ozkok O, Karadag-Saygi E. Evaluation of postural stability in children with hemiplegic cerebral palsy. J Phys Ther Sci 2016; 28:1398–1402.

    PubMed  PubMed Central  Google Scholar 

  9. 9

    Leunkeu A, Keefer D, Ahmaidi S. Electromyographic (EMG) analysis of quadriceps muscle fatigue in children with cerebral palsy during a sustained isometric contraction. J Child Neurol 2010; 25:287–293.

    PubMed  Google Scholar 

  10. 10

    Stackhouse SK, Binder Macleod SA, Lee SC. Voluntary muscle activation, contractile properties, and fatigability in children with and without cerebral palsy. Muscle Nerve 2005; 31:594–601.

    PubMed  PubMed Central  Google Scholar 

  11. 11

    Lindström B, Lexell J, Gerdle B, Downham D. Skeletal muscle fatigue and endurance in young and old men and women. J Gerontol A Biol Sci Med Sci 1997; 52:B59–B66.

    PubMed  Google Scholar 

  12. 12

    Van der Dussen L, Nieuwstraten W, Roebroeck M, Stam H. Functional level of young adults with cerebral palsy. Clin Rehabil 2001; 15:84–91.

    PubMed  Google Scholar 

  13. 13

    Jahnsen R, Villien L, Stanghelle JK, Holm I. Fatigue in adults with cerebral palsy in Norway compared with the general population. Dev Med Child Neurol 2003; 45:296–303.

    PubMed  Google Scholar 

  14. 14

    Hilberink SR, Roebroeck ME, Nieuwstraten W, Jalink L, Verheijden J, Stam HJ. Health issues in young adults with cerebral palsy: towards a life-span perspective. J Rehabil Med 2007; 39:605–611.

    PubMed  Google Scholar 

  15. 15

    Verschuren O, Ketelaar M, Keefer D, Wright V, Butler J, Ada L, et al. Identification of a core set of exercise tests for children and adolescents with cerebral palsy: a Delphi survey of researchers and clinicians. Dev Med Child Neurol 2011; 53:449–456.

    PubMed  Google Scholar 

  16. 16

    Armstrong N, Welsman JR. Aerobic fitness: what are we measuring. Med Sport Sci 2007; 50:5–25.

    PubMed  Google Scholar 

  17. 17

    Hoofwijk M, Unnithan V, Bar-Or O. Maximal treadmill performance of children with cerebral palsy. Pediatr Exerc Sci 1995; 7:305–313.

    Google Scholar 

  18. 18

    Lauglo R, Vik T, Lamvik T, Stensvold D, et al. High-intensity interval training to improve fitness in children with cerebral palsy. BMJ Open Sport Exerc Med 2016; 2:1–6.

    Google Scholar 

  19. 19

    Paulson A, Vargus-Adams J. Overview of four functional classification systems commonly used in cerebral palsy. Children 2017; 4:30–40.

    PubMed Central  Google Scholar 

  20. 20

    Yam WKL, Leung MSM. Interrater reliability of Modified Ashworth Scale and Modified Tardieu Scale in children with spastic cerebral palsy. J Child Neurol 2006; 21:1031–1035.

    PubMed  Google Scholar 

  21. 21

    Hong WH, Chen HC, Shen IH, Chen CY, Chen CL, Chung CY. Knee muscle strength at varying angular velocities and associations with gross motor function in ambulatory children with cerebral palsy. Res Dev Disabil 2012; 33:2308–2316.

    PubMed  Google Scholar 

  22. 22

    Carusoa J, Brownb L, Tufanob J. The reproducibility of isokineti dynamometry data. Isokinet Exerc Sci 2012; 20:239–253.

    Google Scholar 

  23. 23

    Moreau N, Li L, Damiano DL. A feasible and reliable muscle fatigue assessment protocol for individuals with cerebral palsy. Pediatr Phys Ther 2008; 20:59–65.

    PubMed  Google Scholar 

  24. 24

    Bartlett D, Birmingham T. Validity and reliability of a pediatric reach test. Pediatr Phys Ther 2003; 15:84–92.

    PubMed  Google Scholar 

  25. 25

    Volkman KG, Stergiou N, Stuberg W, Blanke D, Stoner J. Methods to improve the reliability of the functional reach test in children and adolescents with typical development. Pediatr Phys Ther 2007; 19:20–27.

    PubMed  Google Scholar 

  26. 26

    Deshmukh AA, Ganesan S, Tedla JS. Normal values of functional reach and lateral reach tests in Indian school children. Pediatr Phys Ther 2011; 23:23–30.

    PubMed  Google Scholar 

  27. 27

    Eken MM, Dallmeijer AJ, Houdijk H, Doorenbosch C. Muscle fatigue during repetitive voluntary contractions: a comparison between children with cerebral palsy, typically developing children and young healthy adults. Gait Posture 2013; 38:962–967.

    CAS  PubMed  Google Scholar 

  28. 28

    Van der Cammen-van MH, IJsselstijn H, Takken T, Willemsen SP, Tibboel D, Stam HJ, et al. Exercise testing of pre-school children using the Bruce treadmill protocol: new reference values. Eur J Appl physiol 2010; 108:393–399.

    Google Scholar 

  29. 29

    Gumming GR, Everatt D, Hastman L. Bruce treadmill test in children: normal values in a clinic population. Am J Cardiol 1978; 41:69–75.

    Google Scholar 

  30. 30

    Bruno Messmer B, Bernuth G. Results of the Bruce treadmill test in children after arterial switch operation for simple transposition of the great arteries. Am J Cardiol 1998; 81:56–60.

    Google Scholar 

  31. 31

    Gorter H, Holty L, Rameckers EE, Elvers HJ, Oostendorp RA. Changes in endurance and walking ability through functional physical training in children with cerebral palsy. Pediatr Phys Ther 2009; 21:31–37.

    PubMed  Google Scholar 

  32. 32

    Armstrong N, van Mechelen W. Paediatric exercise science and medicine. 2nd ed. New York: Oxford University Press; 2008.

    Google Scholar 

  33. 33

    Ratel S, Duché P, Williams CA. Muscle fatigue during high-intensity exercise in children. Sports Med 2006; 36:1031–1065.

    PubMed  Google Scholar 

  34. 34

    Peterson MD, Gordon PM, Hurvitz EA, Burant CF. Secondary muscle pathology and metabolic dysregulation in adults with cerebral palsy. Am J Physiol Endocrinol Metab 2012; 303:E1085–E1093.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. 35

    Riner WF, Sellhorst SH. Physical activity and exercise in children with chronic health conditions. J Sport Health Sci 2013; 2:12–20.

    Google Scholar 

  36. 36

    Smith LR, Lee KS, Ward SR, Chambers HG, Lieber RL. Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length. J Physiol 2011; 589:2625–2639.

    CAS  PubMed  PubMed Central  Google Scholar 

  37. 37

    Booth CM, Cortina-Borja M, Theologis T. Collagen accumulation in muscles of children with cerebral palsy and correlation with severity of spasticity. Dev Med Child Neurol 2001; 43:314–320.

    CAS  PubMed  Google Scholar 

  38. 38

    Fridén J, Lieber R. Spastic muscle cells are shorter and stiffer than normal cells. Muscle Nerve 2003; 27:157–164.

    PubMed  Google Scholar 

  39. 39

    Stephenson DG, Lamb GD, Stephenson GM. Events of the excitation-contraction-relaxation (E-C-R) cycle in fast- and slow-twitch mammalian muscle fibres relevant to muscle fatigue. Acta Physiol Scand 1998; 162:229–245.

    CAS  PubMed  Google Scholar 

  40. 40

    Grecco LA, Tomita SM, Christovão TC, Pasini H, Sampaio LM, Oliveira CS. Effect of treadmill gait training on static and functional balance in children with cerebral palsy: a randomized controlled trial. Braz J Phys Ther 2013; 17:17–23.

    PubMed  Google Scholar 

  41. 41

    Damiano DL, Alter KE, Chambers H. New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy. Phys Med Rehabil Clin N Am 2009; 20:469–491.

    PubMed  PubMed Central  Google Scholar 

  42. 42

    Smith GV, Forrester LW, Silver KH, et al. Effect of treadmill training on translational balance perturbation response in chronic hemiparetic stroke patients. J Stroke Cerebrovasc Dis 2000; 9:238–245.

    Google Scholar 

  43. 43

    Dimitrijevic MR, Gerasimenko Y, Pinter MM. Evidence for a spinal central pattern generator in humans. Ann N Y Acad Sci 1998; 860:360–376.

    CAS  PubMed  Google Scholar 

  44. 44

    Silva MS, Daltrário SM. Cerebral palsy: functional performance after gait training treadmill. Fisioter Mov 2008; 21:109–115.

    Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Walaa A. Abd El-Nabie PhD.

Additional information

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Abd El-Nabie, W., Attia, M. Immediate effect of maximal treadmill walking on muscle fatigue and postural stability in children with cerebral palsy. Bull Fac Phys Ther 24, 79–84 (2019).

Download citation


  • cerebral palsy
  • hemiplegia
  • maximal treadmill walking
  • muscle fatigue
  • posture stability