In the news this week is University of Limerick student, Jonathon O'Toole, for his design of an innovative treadmill - the ' Siul Skool' - to help encourage children with disabilities walk earlier.

Children are lowered on to the slow-running treadmill and held as a moving vertical screen with colourful footsteps in front of them encourages them to copy the moves.

The paediatric creation contains a speed controller, speed selector and brightness controller, with the rate set to the infant's ability.

Twenty-two yr old Mr O'Toole, who has just completed an industrial design degree, will now see his device compete against designs from 20 other countries to win a prestigious James Dyson Award.

In looking into this technology we came the pioneering work of Prof Dale Ulrich of the University of Michigan who believes you can start teaching children with Down Syndrome to walk from 11 months of age using the treadmill (11 months is when the genetic patterning for walking becomes accessible).

He also believes that motor development from birth should be emphasised, so as to minimise the developmental delays in motor development. When mobility is limited, the child's interaction with the environment is also restricted, reducinhg their learning opportunities. The child needs to be mobile - crawling or walking - to go after the pet cat, climb on top of a brother or sister, play with the tv or dvd or vcr buttons, explore the back yard or even the room he/she is in.

Here is a trascript of a radio interview which Dr Ulrich gave describing the positive effects of such training:

Dale Ulrich: Down Syndrome is a genetic condition that affects the 21st pair of chromosomes. There is extra material attached to that 21st pair, and with that extra material, the whole evolutionary process seems to be affected.

Interviewer: And how long, on average, does it take a child with Down Syndrome to learn to walk?

Dale Ulrich: Most of the research over the last 20 years would suggest that the average ages of onset of walking is very close to 24 months.

Interviewer: A year later.

Dale Ulrich: That’s correct. Right around a year later than what we see in typically developing children.

Interviewer: And the impact that has on the family and on a child?

Interviewer: Walking, just as any other form of locomotion, is very critical. We see a lot of other developmental milestones start to occur once locomotion occurs. For example, communication begins to be stimulated once the child is able to move away from Mom. They begin to look back over their shoulder to receive signals. Cognitive kinds of skills begin to develop as they’re able to manipulate objects in their environment.

Interviewer: So there’s a lot riding on the fact that you can walk?

Dale Ulrich: There is a lot of developmental behaviours that start to occur once locomotion occurs, yes.

Interviewer: And presumably there’s a fair bit of anxiety amongst parents too?

Dale Ulrich: If you follow the stress levels of parents of any child with a disability, including Down Syndrome, the longer they experience a delay in walking, we see the stress levels beginning to increase. And interestingly, once walking onset occurs, we see the reduction in stress. The child looks more normal once walking occurs.

Interviewer: So where did you get the idea that training might help?

Dale Ulrich: Back in the mid-‘80s, Esther Thelen at Indiana University, was doing some interesting basic science studies where she was using a small motorised treadmill, and they were asking basic science questions at that time. But as they were reporting the results –

Interviewer: This was with children with Down Syndrome?

Dale Ulrich: This was with normally developing babies, just to see whether or not at 3, 4, 5 months of age, whether or not if normal developing babies had this hidden ability to produce well-co-ordinated alternating steps on a treadmill, long before they could walk independently, and sure enough they do. And as I saw that research being published, it became very obvious that the treadmill may hold some promise for populations that are known to be significantly delayed in the onset of walking.

Interviewer: Meaning that it could help make the most of what’s there inbuilt?

Dale Ulrich: Yes, we know that there are many factors that contribute to when a child walks. For example, we know that leg strength is a critical factor. Balance control is a critical factor. We also know that in infants with Down Syndrome, they have an extreme amount of range of motion, of flexibility in the hips. And we know that all of those appear to constrain the child from walking any earlier.

Interviewer: So they’re weaker, wobblier and looser in the joints?

Dale Ulrich: They are much looser, and for example if you laid an infant down on their back and you abducted the leg away from the centre of the body, frequently the only thing that stops that leg is their shoulder, and so once they get upright, it takes them a long time to learn how to co-ordinate and control all that increased range of motion.

Interviewer: So they’re really working against it?

Dale Ulrich: They’re working against it, absolutely. And obviously all babies eventually with Down Syndrome do walk, but frequently they walk very much later.

Interviewer: Now you didn’t just jump onto the treadmill with these kids, you did some work beforehand, leading you to think that this was really going to be a good idea.

Dale Ulrich: Yes, we did a series of studies. One suggested that infants with Down Syndrome, just like normally developing babies, have this hidden ability long before they walk, to produce well-co-ordinated alternating steps. If they’re supported on a small motorised treadmill.

Interviewer: But even when you lift a newborn baby, you can actually get a newborn baby almost to walk, but that’s a reflex reaction, that’s not necessarily natural walking steps.

Dale Ulrich: That’s correct. That’s the primitive stepping responsive reflex, and we’re actually very, very interested in pursuing that. It can be trained to actually last longer.

Interviewer: But is it this primitive reflex in the older baby with Down Syndrome, or is it a real stepping?

Dale Ulrich: It is a real step.

Interviewer: How do you know?

Dale Ulrich: Well because if you get them off the treadmill, if you stop the treadmill, if you stop the movement of the belt, they don’t step at all. So in other words, their feet are in contact with the belt, and the primitive stepping reflex, typically if they’re leaning forward slightly and they come into contact with a flat surface on their feet, is one that stepping response has elicited.

Interviewer: So what you found is that there’s a stepping response which is not a natural reflex, or not that early reflex if they’re supported on a walking treadmill. You’ve also found other things as well which led you to believe the training system might work.

Dale Ulrich: Yes, we did. And actually if you look at the developmental trajectory of treadmill stepping, and you compahre it to how any child eventually walks over ground, the actual parameters that we measure are very consistent to over ground walking. And so we really don’t think that it’s a reflex, we really think it’s part of the developmental continuum of independent walking.

Interviewer: So tell me about this study you did, because it wasn’t in a clinic, it was in people’s homes.

Dale Ulrich: Yes, on all of our early intervention research, we’d go to the parents. The parents were obviously extremely busy, so we’ve learned that we need to go to their home, and we take a treadmill, we show the parent how to position the child on the treadmill.

Interviewer: And this is a baby treadmill, this isn’t something that you would get in the gym?

Dale Ulrich: This is a small, very small miniature motorised treadmill, although we also have used subsequently, an adult-sized treadmill with a belt that moves very, very slowly. So I don’t think it’s the size of the treadmill that’s that critical. It’s that the treadmill belt goes very, very slowly.

Interviewer: Now we weren’t able to go into your lab today; we’ve got a picture here of it with a baby on it. This is not a treadmill where the baby is generating his or her own energy to move the belt, the belt is moving for you.

Dale Ulrich: That is correct. The treadmill belt is going a .2 metres per second, and so it goes very, very slowly, and we believe that it is the stretching of the muscles as the belt pulls the legs backwards, and the elastic properties of the muscles that actually help the legs to spring forward, and over time they begin to take many steps and they improve consistently.

Interviewer: Well let’s go back a bit: what did you tell the parents to do?

Dale Ulrich: We told the parents that they practice on the treadmill 8 minutes a day, 5 days per week. Any 5 days, depending on their schedule, depending on how they’re feeling, depending on how the child is feeling, any 5 days, but they have to do it for 8 minutes a day.

Interviewer: And the child’s in a harness suspended over the treadmill?

Dale Ulrich: We are holding them under their arms, they’re not in a harness. We’ve not figured out whether we really could use a harness, although it has been a question that has been posed by physical therapists. We’re holding them under their arms so that their feet are in contact with the treadmill, and again, they start off typically working on the treadmill for 1 minute intervals, and then they take a break for a minute, and then they’re back on for a minute, but eventually, over several months, they work up to 8 consecutive minutes.

Interviewer: And what age do they start this at?

Dale Ulrich: We started them rather than at a chronological age, we started them when they could sit independently for 30 seconds. In some of our earlier research we found that that motor behaviour occurred in all of our infants, just prior to when they displayed some sensitivity to the treadmill. And so in this clinical trial, most of the infants started anywhere from about 10 months to 12 months of age.

Interviewer: And compared to a control group, how much faster did they walk?

Dale Ulrich: Compared to our control group that received everything except for the treadmill experience, the infants who received the treadmill experience walked 101 days earlier, and that was approximately at 19-1/2 months.

Interviewer: They were what? three or four months faster?

Dale Ulrich: Yes, approximately 3 to 4 months faster.

Interviewer: Have you followed these children through, to see whether that actually really does pay off? If these children who are walking early, does everything else happen sooner too?

Dale Ulrich: In that particular clinical trial, we were unable to follow them for 2, 3, 4 years after the fact. In our current research we have built that question into the proposal, where we’re actually following them for a period after they begin to walk. And so we’re looking at whether for example, that they’re more physically active, whether they actually explore their environment more frequently, whether they interact with other children more frequently, and so we are looking at some other developmental outcomes besides just the onset of walking.

Interviewer: I suppose the attraction here is there is only 8 minutes, 5 or 6 days a week, compared to some of the other so-called neural programming techniques, which have been rather infamous, like Doman-Delacato, where the parents are working 12, 14, 15 hours a day on the child.

Dale Ulrich: Yes, and we frequently get that question from a curious parent. Are we talking about trying to pattern the child into this alternating leg activity? And certainly we’re not. In our case, the infant is a very active participant. They’re sensing the sensory information that’s being generated from their muscles, and we believe that that’s a very important element, that they can use that information to help them learn how to co-ordinate and control those legs.

Interviewer: And is their walking normal when they actually walk, because you could be actually patterning them into an abnormal gait.

Dale Ulrich: We had some physical therapists who are very well-known here in the United States, suggest that they thought it was a bad idea, that they thought that it might actually facilitate an inappropriate walking gait pattern, but we found just the opposite, that of those infants that were trained on the treadmill were seeing less toe-ing out, we’re seeing longer step lengths and stride lengths, and we’re also seeing that their feet are more closely aligned to the pathway with which they’re walking.

Interviewer: Now Down Syndrome is probably, compared to other problems, only a minority problem with children not walking later in life, with the advent of neo-natal intensive care, a lot of premature babies, we have increased the number of children in the community with cerebral palsy, such as there are really large numbers, and I’m sure the outnumber children with Down Syndrome vastly. Could this help children with cerebral palsy?

Interviewer: We’re hopeful. I cannot say for sure at this point. We have initiated a new clinical trial. Obviously we don’t just jump in to a new population thinking that we’re going to start training them. We have been funded by the United States government to begin to ask that question, whether the treadmill holds some potential for our early intervention to speed up the onset of walking, but our first question is, we’re going to be starting to follow infants beginning at 8 months of age every other month until they’re 24 months of age, to see if, when and how they respond to the treadmill, and if we can find a developmental period sometime within that age span that a large percent of the children respond to the treadmill, then that would make more logical sense, that that would be the time period with which you’d start the treadmill training.

Interviewer: How does this fit into the modern approach to intervening as early as possible with children with disabilities such as Down Syndrome?

Dale Ulrich: I think what we’re going to see is that especially if we’re thinking about the importance of walking and locomotion, and the facilitation of experience with locomotion on many other developmental domains, is I think that one of the things that we’re going to find, I’m very confident, is that we need to get infants with Down Syndrome as well as other disabilities upright much earlier than what we’re traditionally doing. It’s very common that parents are discouraged from getting their child upright until they can crawl. Although crawling contributes to upper body strength, it does not contribute a lot to the onset of walking.

Interviewer: So you’re happy to leap over the fence, not wait for crawling, and get straight to the walking?

Dale Ulrich: That’s correct, and I think that that is really where I think we’re going to find some important developmental gains is if we can get those infants who have disabilities, and have serious delays upright much earlier, I think that we’re going to find that we’re going to be able to develop leg strength, postural control and also critical, a motivation from the child to want to be upright.

REFERENCES:

Ulrich B.D. et al. Alternating Stepping Patterns: Hidden Abilities Of 11-Month-Old Infants With Down Syndrome. Developmental Medicine and Child Neurology 1992, 34, 233-239

Ulrich B.D. and Ulrich D.A. Spontaneous Leg Movements of Infants with Down Syndrome and Nondisabled Infants. Child Development, 1995, 66, 1844-1855

Ulrich D.A. et al. Treadmill Training of Infants with Down Syndrome: Evidence-Based Developmental Outcomes. Pediatrics Vol. 108 No.