atmosphere to carry out therapeutic goals along with building confidence and having fun. Aquatic therapy is a great adjunct to traditional land-based therapy, improving such goals as range of motion, coordination, functional mobility, and a lifelong opportunity for fitness. There are many methods to use water for therapy and recreation with many different people developing recommendations and reporting what works and does not work (Tables R7 and R8).
7. Assistive Devices Mary Bolton, PT
Most children with CP will need assistive devices for standing and walking during their lifetime. There are many assistive device styles, accessories, and options in the durable medical equipment market. Choosing the walker that offers the appropriate support but allows the greatest degree of mobility is of utmost importance. Therefore, it is crucial to have several of these devices available for trial when evaluating a child for the use of assistive equipment.
When a child is being assessed for a walker, the initial evaluation is very extensive. The key factor is the child’s ability to weight bear on her lower extremities. When evaluating younger children, hold them upright with their feet in contact with the ground and note their ability to support themselves.
Noting the ability to take weight with transfers is key when evaluating older children. Information from the parents, therapists, teachers, and other care- givers will increase your understanding of the child’s needs and potential.
The ability to dissociate the lower extremities from each other is essential for walking, but is difficult for children with extensor tone. Stepping reactions should occur with the drive to stand and move. A thorough evaluation of the child’s range of motion is needed. Contractures of the lower extremity will have a significant effect on the child’s ability to stand upright. Evaluate the ability and strength used to hold the body upright with her arms. The arms may function in a variety of positions for weight bearing, such as extended elbows, or flexed with the arms supported on platforms.
The child’s functional mobility should also be assessed. Their usage of floor or upright movement enables the therapist to view weightbearing con- trol, weight-shifting ability, cognitive motivation, and problem-solving skills.
Observation of transfers from sit to stand, stand to pivot, and floor to stand is of value. The child’s use of a wheelchair, the style and maneuvering skills, provides further information about vision, strength, endurance, and cogni- tive and environmental awareness. Any durable medical equipment that is used to help the child’s positioning or ability to stand upright should also be used and evaluated.
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Table R7. Community resources.
American Red Cross 17th and D Streets, NW Washington, DC 20006 http://www.redcross.org
National Recreation and Park Association 3101 Park Center Drive
Alexandria, VA 22302 http://www.nrpa.org
Boys and Girls Club of America National Headquarters 1230 W. Peachtree Street, NW Atlanta, GA 30309
http://www.bgca.org
Table R8. Recommended reading.
Campion MR. Hydrotherapy in Pediatrics, 2nd Ed. Oxford: Butterworth-Heinemann, 1991.
Harris SR, Thompson M. Water as learning environment for facilitating gross motor skills in deaf-blind children. Phys Occup Ther Pediatr 1983;3:1:75–82.
Langendorfer S, Bruya LD. Aquatic Readiness: Developing Water Competence in Young Children. Champion, IL: Human Kinetics. 1995.
Routi RG, Morris DM, Cole AJ. Aquatic rehabilitation. Philadelphia: Lippincott-Raven, 1997.
Martin K. Therapeutic pool activities for young children in a community facility. Phys Occup Ther Pediatr 1983;3:1:59–74.
With their knowledge of the child’s equipment use at home and school, the parents are often able to provide additional background information for the assistive device evaluation. A history of the type of equipment the child has tried and how well she performed with it is helpful. You also will need to know what equipment is currently in use. Parents may have ideas about their child’s current needs and desires. In addition, determine if any surgeries or medical interventions (bracing, Botox injections, etc.) are proposed in the future, which may influence the recommendations for walking aids.
Many times the school or home therapists involved with the child’s care have important information regarding the assessment of the child’s walking needs, but they are limited by equipment availability and options. Access to the Internet often increases information about equipment, although it may not always be available to try with the child. Working with local durable medical equipment vendors and/or contacting the equipment manufacturers directly is always an option.
Standers are helpful for children who need significant postural support, lack ability or understanding of how to support themselves on their arms, and have limited cognitive understanding (by developmental age or actual limited cognitive development) of how to use a walking device. The first step is to determine if a supine, prone, or upright stander is most appropri- ate for the position desired. Children who need more extension strength in- cluding head control, arm weightbearing facilitation, and can actively engage in standing would benefit from a prone stander (Figure R5). Children with increased extension posturing or decreased postural control due to weakness or low tone generally benefit from initiating upright standing at a slower rate. A supine stander allows for a slower progression into the upright pos- ture and ease with blood pressure and circulation problems. The upright stander has many varieties from full trunk support to lower lumbar control.
They are often used with children who can move to standing with a stand
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Figure R5. Prone standers such as this are very useful but require measuring to fit the individual child. It is also ideal to have the equipment at the evaluation site so the par- ent can see how big it is and see how the child responds to the device.
transfer and need to increase their overall standing tolerance, whether it is due to limited range of motion, strength, or overall endurance. This type of stander with additional bracing can be used for lower extremity weakness.
All these different stander styles have a variety of options, accessories and special features. There are boundless possibilities limited only by the manu- facturer’s creativity.
When a child begins to show the ability to bear weight on her legs and attempts to weight shift as she steps, she is usually ready for a walking aid.
These walking devices vary from maximum assistance control, as in a gait trainer, to walkers, canes, and crutches.
A gait trainer is usually most appropriate for a child with increased pos- tural tone, limited pelvic and lower extremity dissociation, and the inability to weight shift with caregiver support. Such children have a desire to move and interact with their environment but are limited by their ability to do so independently. Gait trainers align the body’s center of gravity over the feet, prevent trunk lateral flexion, and offer weightbearing support through a seat. The gait trainer helps to stabilize the trunk and pelvis so the legs can move independently for stepping. For the child that adducts her legs, step- ping straps can assist in abducting the legs. Arm supports are optional. The child is able to propel the device by stepping. The trunk is aligned with trunk/hip guides, straps, or pads. Gait trainers are like ring walkers or baby walkers that offer more support, have variable sizes, and the capability for limited wheel direction. For safety of the older and more mature child, the gait trainer’s base of support is much larger, but this is often found to be large and cumbersome in a home setting. Also, the large child needs to be lifted or moved into the trainer making it difficult for a single caretaker to manage safely. Although not functional for the older child, the trainer is ideal for the younger one who needs stabilization and is beginning to demonstrate am- bulation skills.
A walker is usually beneficial when a child shows potential for weight bearing, is initiating stepping, but has limited weight shift, balance, muscle endurance, or coordination. There are a variety of walkers to use for assess- ment. Forward and posterior walkers are available and include many acces- sories and options. The most important determinant in choosing a walker is how the child actually functions with it. It is valuable, as with all equipment, to have a large selection of walker styles, sizes, and upper extremity support devices to try. Additional items such as wheels, brakes, seats, and pelvic guides can be added or interchanged later. Generally, watching the child’s emotional reaction and movement ability will guide the therapist in narrowing down the style of walker that is most appropriate for that child. Some children need multiple sessions or extended periods to adjust to the equipment, especially if it is their first time using it. The younger child may be more accustomed to walking with their arms in a variety of positions including hands held high, leaning on furniture, or pushing walking toys. A child with this expe- rience may accept the posterior walker easier than an older child who has become accustomed to using a front walker. The larger child also has an easier time with maneuvering the forward walker, because the base of support on the large-size posterior walkers becomes too cumbersome. A posterior walker is most suitable for a child who advances the supportive device too far forward or has excessive trunk flexion. A forward walker is appropriate for children who need less upper extremity support for postural alignment and have more fluent weight shift patterns. These walkers generally are lighter and more compact.
Children who need relatively little assistance for balance, fall occasion- ally, and have difficulty with longer community distances or unleveled sur-
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faces may benefit from the assistance of a cane or crutches. The child is usually 6 years or older, and reports using their walker less often, leans on furniture for assistance, or prefers to be mildly supported by another person.
Canes and crutches come in a variety of styles and designs. Canes are bene- ficial for children who have occasional falls, and are gradually getting slower than their peers and entering their teenage years. The therapist will need an array of sizes, base options, and grip styles to determine the most appropri- ate equipment for the child’s comfort level and need. Some individuals use canes for safety in larger school settings and community outings; however, forearm crutches are by far the most useful assistive devices for individuals with CP.
Determining the best assistive equipment should not be a rushed decision.
It will impact on the child’s continued development and ability to interact and move in her world. Sometimes more than one device is necessary, per- haps a walker for school distances and a cane for the smaller crowded home.
Selecting the best equipment for the child should not be limited by evalua- tion time. Remember, the goal is walking with the best postural alignment, convenience for usage, efficiency, and walking speed. The parent and child should be satisfied and confident with the recommendation.
8. Seating Systems
Denise Peischl, BSE, Liz Koczur, MPT, and Carrie Strine, OTR/L
No other area of technology for children with CP has shown any greater growth than that in mobility systems and seating components. There is no facility where you will not find consensus among the caregivers that an ap- propriate prescription for a seating device needs to include the family, the treating therapist, the physician, the equipment vendor, and, for the com- plex cases, a rehabilitation engineer. Guidelines for seating systems are out- lined in Tables R9 through R17. Because wheelchairs are always large devices
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Table R9. Seating systems.
Laterals (trunk supports mounted on the backrest) (+) Support patient in an upright posture (+) Lateral support for safety in transport (+) Proximal stability to enhance distal mobility (−) Decreases amount of lateral mobility patient has Curved laterals
(+) Curve around patient’s trunk to help decrease forward flexion of the trunk (−) May make transfers difficult
(−) Requires swing-away hardware for transfers Straight laterals
(+) Easier for patient to move in and out (+) Easier for transfers
(−) Does not block forward flexion of the trunk
Summer/Winter Bracket Hardware (Slide adjustment on back of chair allows caregiver to move lateral in and out for heavier clothing); user is unable to access
(+) Easy to use: no tools required
(+) Allows width adjustability for changes in season (i.e., winter coat) (+) Allows for growth adjustability without tools
(−) Extra parts to chair that could be removed and lost
Swing-away hardware (Push lever on side of lateral, allows it to open at an angle) (+) Moves lateral out of the way for ease of transfers
(−) Additional hinge; creates a weak spot for potential break (−) Not considered heavy duty for aggressive support
