November 2001

Beyond Wheelchairs

By Ginny Paleg, MPT

This device converts from a table and chair to a stander.

Beyond Wheelchairs
Using standers, walkers, and gait trainers to improve mobility problems.

With independence as the goal, a variety of assistive devices must be considered when patients experience mobility impairments. Clinicians must not only consider wheelchairs—standers and walkers can also be effective options.

Standers
Mobile prone standers can be used to stand patients as well as teach the skills needed for standing without the device. The trunk supports can be lowered so that the patient has to work to maintain postural control. In order to push the wheels, the patient has to weight shift. This skill may transfer to other functional activities. The camber or angle on the wheels of these standers makes them easier to propel than traditional wheelchair wheels. Often, patients who cannot propel their own wheelchairs begin to learn the skill of independent mobility in mobile prone standers. There are standers that are designed so that adults can get themselves up and down without help.

Self-propelled standers allow individuals to stand with the opportunity to explore their environment. These devices may help to strengthen accessory breathing muscles, upper trunk musculature, and upper extremities, as well as improve head control. These standers may be used for patients who can tolerate an upright position and have (even the most remote) potential to push the wheels. All of these standers have placed their large wheels high and in front of the patient to make pushing much easier. Children, who are too weak to push a wheelchair when the wheel rims are placed below and behind their bodies, can easily move the wheels on these standers. The movement of the self-propelled stander will stimulate the vestibular system, cerebellum, vision, and righting responses.

Self-propelled standers offer a new way to help kids with gross motor dysfunction and developmental delays to improve their postural control, strength, range of motion, and understanding of how their bodies interact with their surroundings. For children who have tight hamstrings, heelcords, or hip flexors and need prolonged stretching, self-propelled standers offer an excellent option. These devices also benefit children who cannot yet stand independently or have poor trunk control. Simply lower the trunk support as much as is safely possible and encourage the child to use the trunk muscles by leaning, weight shifting, and pushing the wheels. Of course, the most important factor in choosing self-propelled standers over traditional stationary standers is that they are fun.

Standers should be a daily part of a non-ambulatory patient’s program. If a patient is medically stable and can tolerate being partially upright, a daily standing program can help with bone density and tight muscles.

This stander can also be self-propelled.

Prone and supine standers have been around for a long time. Patients who have absent head control, tracheostomies, or medical issues most commonly use supine standers. Supine standers or tilt tables are flat and easy to use. The patient can be transferred directly from a bed. Patients lie flat while you stabilize them, then you elevate them as much as they can tolerate. You can do this as slowly as you need to. For patients with flexion contractures, supine standers may be easier to use than prone standers, because the pressure is taken up by the extensor surfaces.

Prone standers are traditionally used for patients that need to strengthen their extensors, have good head control, and are functionally and developmentally more advanced than a supine stander user. This view has been challenged lately. Clinical observations and experience led some therapists to use prone standers for lower functioning patients. The results were beneficial. Since a prone stander offers less support for the head, some patients developed head control faster. Because therapists tend to use a prone stander in a more upright position, more weight is taken through the long bones. This loading may result in increased bone density.

The big leap came when manufacturers began incorporating independent mobility with standers. Both power and manual mobility have been shown to improve a patient’s spatial awareness and may actually facilitate gains in cognition and language. Mobile prone standers are available from many different manufacturers and offer many different options. One model offers wheel covers, to protect fingers from getting caught, and an activity bucket and tray. Another model offers extensive adjustments in the footplates to accommodate leg length discrepancies and foot deformities/contractures.

If your pediatric patient needs to work on floor mobility, consider a crawler. One model can also be used as a stander, gait trainer, or a partial weight-bearing system that goes over a treadmill to teach a child how to walk better.

Therapists, parents, teachers, teacher assistants, families, and other professionals understand that using a gait trainer or self-propelled stander is hard work for everyone. Equipment cannot be used in isolation. The home and school team must be on the same page and share common goals and objectives. The most helpful ingredient for success is a well-thought-out plan. A functional-based program works best and can guide the team through the entire continuum from children who are maximally dependent to those who are independent ambulators. The Mobility Opportunities Via Education curriculum (MOVE) is an excellent resource. Conductive education also offers a good program of progressing children with gross motor dysfunction.

The biggest hurdle for the team is to meet and agree on just a few objectives and decide how to accomplish them. The team must make sure that their assistance is decreased over time so that the child is allowed to gain more and more independence. Gait trainers and/or self-propelled standers are excellent assistive devices for this. Most of the models available allow the user to decrease the supports (remove pieces) over time so that the child may eventually be able to use a regular walker or even be independent for short distances.

WALKERS
Platform walkers are great for patients who cannot support enough of their weight through their hand and wrists. When the forearm is fully supported and weight bearing, the patient uses less energy for walking and is more stable. The width of the elbows determines the base of support and can make the patient feel very secure.

What about a patient that is not safe or independent in a walker? What comes next? Gait trainers. They are a whole new breed of walking devices made for patients who need more postural control and support. They are for the child who crosses her legs and the elderly man in the assisted living center who is scared of falling.

GAIT TRAINERS
When pediatric patients do not have the postural control to learn to walk independently by age 12-24 months, we may consider a gait trainer. Independent mobility drives the development of cognition and learning. In children who may have global developmental delays, speeding up the onset of independent ambulation may be crucial. Gait trainers offer varied levels of trunk, head, pelvis, and leg control to allow some children to learn to take steps.

Many children who are not walking independently by age 2 will benefit from the strengthening and cardiopulmonary conditioning that upright mobility offers. The best way to strengthen the muscles needed for walking in a minimally involved child may, in fact, be walking. Upright mobility may also be important in spatial awareness, exploration of the environment, peer interaction, and communication.

Most of the models of gait trainers available in the United States are made of many supports or components that easily come off and on. This system makes it easy for the therapist to provide each patient with just the right amount of support. The key is to make the patient comfortable and functional, but not to provide so much support that the patient does not move or exercise.

Using a stander can help a medically stable patient with bone density and tight muscles.

Children with severe gross motor dysfunction who are not expected to walk until age 5 or later, if at all, could benefit from using a gait trainer as early as 9-12 months of age. Very young, severely involved children learn to take some of their body weight through their legs as a precursor to assisting with stand pivot transfers, toileting, and perhaps assisted ambulation in later years.

For older children who have never been exposed to a gait trainer, begin by placing them upright and make sure that they can tolerate this. If the team has any concerns, a medical consultation should be obtained. If the child has any musculoskeletal deformities (back, hips, knees, and ankles), the orthopedist should be consulted before beginning the program. Once the child has medical clearance and can tolerate being upright for 5-10 minutes, then we begin to teach the child to take steps. This is accomplished by getting on the floor and moving the child’s feet (gently) with your hands. Some people believe that children should begin this process in the upright (vertical) position. Forward leaning is another option.

In the forward-leaning position, children are able to place most of their body weight on the balls of their feet. This may stimulate some basic reflexes that assist in the performance of stepping reflexes. When normal infants are tipped forward, they take steps. This is called the stepping reflex. Many children with severe gross motor dysfunction still have this reflex and it may be useful for this initial stage of learning.

Forward leaning may also produce a stretch on the hip flexors and help them to activate. The shortened position of the hip flexors and hamstrings may help very weak muscles to be able to begin to produce enough muscle force to move. Forward leaning also allows the user to be positioned so that some weight is taken through the forearms. This lessens the load taken through the trunk support and ensures that weight bearing does not occur between the legs (not a traditional place to weight bear). Weight bearing through the forearms may increase sensory input to the neck, arms, and spine, and should result in improved motor control.

The long-term goal of gait training can vary from reducing flexion contractures and increasing alertness and head control to achieving independent ambulation. By choosing an appropriate gait trainer and teaching the skill of walking, independent functional ambulation can become a reality for many people.

Some gait trainer models come with an electric lift option. A power lift gait trainer allows you to wheel up to a person sitting in a wheelchair or on a mat table or bed and get him upright without having to lift him. If you are dealing with a large person, this is a great back-saving option.

Following are some tips on using gait trainers:

• People should never hang, especially from the armpits. This can put pressure on the brachial plexus and occlude the artery. Alleviate all pressure areas.
• Avoid crouch gait (walking with bent knees). Hips and knees should be maximally extended at the proper times during the gait cycle. Facilitate a gait pattern that is as close to normal as possible.
• Do not block the pelvis. The pelvis should be free to move independently of the spine. A mild posterior or neutral tilt may work best in the initial skill-acquisition phase.
• Do not park the kids. There is little benefit to placing a child in a gait trainer and leaving her to figure it out on her own. With supervision, teach standing and weight shifts with the seat or sling removed.