By Ginny Paleg, MPT
Multiple studies are published each month supporting early supported ambulation in children with all levels of gross motor dysfunction. Evidence also supports supported and unweighted gait in adults with cerebrovascular accident (CVA), multiple sclerosis, total body irradiation, spinal cord injury, amputation, and orthopedic issues. Partial weight bearing treadmill training (PWBTT) devices and gait trainers offer therapists the opportunity to teach stepping and allow the patient to practice that skill in the community. Choosing a Gait trainer A gait trainer provides balance and postural control for individuals who cannot ambulate safely with a traditional walker. Third-party payors are the primary funding source for gait trainers. Most insurance companies that provide durable medical goods follow Medicaid and Medicare guidelines. New HIPAA guidelines mandate that the state codes match the federal codes. However, there are no codes for gait trainers. In a recent open meeting in Baltimore, I testified before a Centers for Medicare and Medicaid Services board in support of the issuance of a new code for gait trainers. I argued that the literature supported using a device that provided more support than a walker, specifically the ability to partially unweight the user. The code was denied, and instead gait trainers must be billed as “walker with trunk support.” The recommended reimbursement rate for this type of equipment is around $300. This means it may be difficult to provide these devices to our patients who rely on financial assistance. (See Figure 1 for a sample letter of justification.) The most important component of a gait trainer is the trunk support piece. If the patient can sit independently for more than 15 minutes, you may want to choose a less supportive design that will allow the patient to learn to shift their weight. The more flexible the supports, the more likely the patient will practice their righting, balance, and equilibrium reactions. If the patient has Level V cerebral palsy, a rigid, more supportive trunk support is probably your best choice. The pelvic prompt should be soft yet able to stop downward slippage. Systems with seats may encourage sitting and hip flexion, which is counterproductive to gait training. Make sure the armrests are capable of bearing weight so they can help you unweight the patient. Lastly, look at how the system controls scissoring. Some use straps to pull the legs out. Over time, this resistance to the adductors may actually strengthen them. Systems that have a solid plate between the legs may be the preferred setup. Many gait trainers now come with variable resistance for each wheel, directional locks, and rollback stops. This combination of options allows you to add resistance for strengthening or to slow down a patient, force the patient to go forward only, and allow all their energy to result in forward movement. Choosing a PWBTT Device
Sample letter of necessity and medical justification letter for a gait trainer.
