Pediatric patients with mobility issues present unique challenges in rehabilitation. In the teen years, assessment and treatment are similar to those used in an adult population. Younger children may require playful approaches employing games and puppets to replace the straightforward analysis done with adults.
The goal of assessment for newborns to 18-year-olds remains the same: Pinpoint problems with gait in order to prescribe therapy and assistive devices to improve function. In the case of pediatric patients, developmental issues may be a factor and must be considered in prescribing appropriate treatment.
Conditions requiring rehabilitation and physical therapy among the pediatric population may include cerebral palsy, spina bifida, seizure disorders, dystrophic conditions, developmental delays, and brain tumors.
The order in which the evaluation is done depends on the child and what issues he may present. Often, the first step is to assess the range of motion for hips, knees, ankles, and trunk, followed by an assessment of muscle tone to see if the child has hyper- or hypotonicity. Next, strength is evaluated, either through formal manual muscle testing, if the child is able, or through functional strength testing. A posture assessment also will help to get a complete picture of the child.
Another important part of the pediatric patient’s evaluation involves reviewing the standing balance to determine which strategies, if any, are being used to maintain balance. The next step is a visual assessment of the child’s gait, observed in a variety of conditions, including with and without shoes and with and without braces and/or assistive devices. It is important to watch the child from the sagittal plane and the frontal plane. When doing a visual analysis, look at the position of each joint during each phase of the gait as well as the dynamic movements that occur with each step. The assessment also may include looking at gait velocity, abnormal joint stresses, asymmetries, endurance, step length, stride length, base of support, step time, single support time, and double support time.
TECHNOLOGY AS A TOOL
Video is often used in assessment. Having a video record of a child’s gait when they enter therapy is extremely useful later on because it provides a means of comparison. For example, comparing the gait before and after braces are prescribed can show if there is improvement and the degree of improvement. Video is helpful looking at a young patient’s progress over time and is something that most clinics can afford to add to their practice.
Computerized assessment devices for gait and balance can provide clinicians with a wealth of information in evaluating the pediatric patient. At Good Shepherd Rehabilitation Network (based in Allentown, Pa), we have the benefit of using computerized gait analysis. An electronic walkway system measures spatial and temporal gait parameters. As the patient walks across the walkway, the system captures the geometry and the relative arrangement of each step. This gives more concrete information regarding step and stride lengths, pressure mapping of each footprint, foot progression angles, as well as speed parameters.
For those without the advantage of this technology, using chalk or paint across the bottoms of a child’s feet can provide a similar set of results when the child walks across a long piece of paper. Information about step length, stride length, and pressure, similar to that recorded by computerized devices, can be obtained by this method.
Computerized balance devices allow clinicians to assess such issues as sensory organization, motor control, and limits of stability. Such devices collect information about the status of a child’s balance by having him stand on a platform in a variety of conditions. This information can assist a clinician in determining the cause of gait dysfunction. Larger hospitals may have gait assessment devices employing three-dimensional motion technology that can provide detailed and specific information on what each muscle is doing during each phase of the gait. Referring a child to a facility that has such technology can be helpful in confirming a diagnosis or if more detailed information is needed.
ASSISTIVE DEVICES AND OTHER TREATMENT
Once this information has been gathered, the impairments are analyzed to determine if anything has been identified that could be causing the gait dysfunction. After that connection is made, treatment can begin. We take all of the evaluation information and begin with treatment strategies to improve the child’s overall function and lessen their impairment. These may include activities for strengthening, balance training, facilitation, gait training, and stretching.
During an evaluation, the therapist determines whether a child would benefit from braces or orthoses to improve the gait pattern. This could be something simple, such as a shoe insert to improve alignment of the foot and decrease stresses on the hip, knee, and trunk. Or it might be more complex, such as a reciprocal gait orthosis that begins at a mid-trunk position and extends all the way down to the ankle, providing support to all of the joints and assisting the child in advancing each limb forward. Braces and orthoses also can be designed to provide support and stability to joints while a child is standing. For example, a child with Down syndrome who is very hypotonic and just learning how to stand and walk may benefit from solid ankle foot orthoses (AFOs) to provide support while standing. This bracing allows a child to improve his proximal strength and can be scaled back later to allow him to focus on improving his distal strength. Braces also can be designed to assist with joint movement. For example, an AFO can be used to support the ankle in a neutral alignment for a child experiencing foot drop during the swing phase of gait.
Another consideration in a pediatric gait evaluation is determining if an assistive device would enhance the child’s ability to walk. Appropriate devices could include a cane, crutches, walker, or even a traditional gait device such as a gait trainer. It is important to note that gait trainers, which may provide support for a child who is unable to hold herself up, can also facilitate an unnatural walking pattern. Using the information gathered from the gait analysis to determine the specific problems in a child’s gait pattern, it is possible to choose a gait trainer that compensates for deficiencies. For example, there are gait trainers available that allow for lateral pelvic movement and superior/inferior movement and also can be calibrated for anterior/posterior tilt trunk lean. Other devices allow for lateral weight shifting and can unweight the swing phase limb during gait. Care must be taken to recommend the appropriate device to address individual patient challenges.
At Good Shepherd, we also use a body weight support system that allows a child to practice typical walking patterns with partial weight support. The system uses an overhead suspension system and harness to support some of the child’s weight while the therapists help the child advance his limbs. Off-weighting can be accomplished via an adjustable gauge and facilitates upright posture. Using this system, a child can develop a typical pattern of walking without compensating before advancing to support his full weight.
CASE STUDY: ACCURATE ASSESSMENT, SUCCESSFUL OUTCOMES
Peter, a 5-year-old diagnosed with a brain tumor, benefited from assistive devices indicated during his evaluation. Peter’s tumor was resected, and he is receiving chemotherapy and radiation treatment. When he came to Good Shepherd for evaluation, he was in a manual wheelchair and needed moderate assistance for a sit-to-stand transfer. A preliminary range-of-motion assessment was significant for tightness in bilateral gastroc/solei and hamstrings. He also presented with weakness in bilateral hips, knees, and ankles, with grades between 3 and 3+ for all movements. He was not able to stand without upper extremity support during the evaluation and, even with the support, he presented with trunk sway and instability. He was able to take about 10 steps with support. His gait parameters were significant for foot flat initial contact bilaterally, short step lengths bilaterally, toe drag during swing phase, increased double limb stance phase bilaterally, and ataxic UE/LE/trunk movements. We ordered bilateral articulated AFOs to assist him with the stability phase of his gait and prevent toe drag during swing. We also introduced a posterior rolling walker to provide support and allow him to maintain an upright posture in standing. He is now able to walk up to 300 feet with these devices. He also has a heel first initial contact and increased single limb support time as well as longer step lengths.
Our goal with pediatric patients is to improve function that is appropriate for their age and developmental level. A thorough evaluation ensures that all factors affecting a child’s gait are addressed. Exciting advances in technology to assess and treat gait dysfunction help clinicians optimize results for pediatric patients.
Erin Sheeder, PT, DPT, PCS, provides pediatric mobility assessments at Good Shepherd Rehabilitation Network’s outpatient pediatrics program in Allentown, Pa. For more information, contact