Introduction
Choosing a pediatric walker or gait trainer is a crucial decision in the path towards independent mobility of a child with motor disabilities. Every parent wants to make sure it will provide the best tool that enables therapy in an ideal way and enhances daily activities.

The evaluation of the available products prior to purchase should be based on the diagnosis of the client by a specialised physician and in consultation with an experienced physical therapist; assessing the condition, potential and environment of a user.

Is the individual ambulatory, semi-ambulant, or non-ambulatory? What are the particular physical and social needs? These are important initial points which should guide the evaluation.

There are many brands and models to choose from, but which one will be the most suitable for the individual child?

So much is at stake concerning the cognitive and physical development of the child. Activity-based therapies show important potential for restoration and gains in motor skill development. There is good evidence that pediatric walkers and gait trainers help the users improve their motor function.

Recent systematic review of the use of gait trainers in a total of 182 children demonstrated descriptive evidence of positive motor outcomes, especially in improving their stepping as well as walking distance.

Evidence shows also that gait trainers may have a positive impact on body structure and function as well as improved visual awareness. Independent mobility and walking improve the general strength, cardiovascular and bone health, bowl and bladder function, bone-mineral density, lung function and helps in the prevention of contractures.

Mobility plays a pivotal role in social development and psychological function of the child with better activity and participation outcomes including increased levels of overall independence, making gait trainers an extremely positive asset.

However, these outcomes will only be achieved if the right therapy is matched with the most suitable tools.

Condition and Age of the User

Of all selection parameters, the degree and way in which mobility is affected for the specific child is the most important. What is its balance, ambulation, strength, and endurance? Can it stand on its own with some support? Does it just require enhanced stability or is support required also for the upper body (e.g. by using arm rests)? Or would it require weight bearing trunk support to be able to stand even for short periods?

Whether the user is ambulatory, semi-ambulant or non-ambulatory will direct the type of pediatric/walker gait trainer which can be considered and the support elements which might be added.

An individual who is ambulatory can walk with or without minimal assistance; a semi-ambulant person is defined as someone who has experienced a permanent or temporary reduction in mobility yet is able to walk with assistance.

A non-ambulatory individual is unable to walk or stand without assistance, requiring comprehensive support or a wheelchair to move about.

There are typically trade-offs. Devices which offer more support for critical conditions, often referred to as gait trainer, tend to be bulkier and somewhat more inhibiting for free movement. They might also be harder to bring along in activities away from home. More flexible products with less adaptive features are often called pediatric walkers.

The most nimble, compact and light products will typically not provide the same level of support. What is important is to understand where the sweet spot is for the individual case is on this range, and which product corresponds to this sweet spot.

The Gross Motor Function Classification System (GMFCS) is a five-level clinical classification system that focuses on the voluntary movements of children with cerebral palsy (CP), with specialized focus on walking and sitting. It can be a rough guide for the type of mobility device to be considered.

For GMFCS Levels of 2 and 3 pediatric walkers are usually very suitable for support. GMFCS Levels of 4 or 5 will require more sophisticated gait trainers and standers to achieve standing position and some degree of mobility.

The age of the user is also a consideration, as not all products come in suitable sizes for pediatric, young adult, or adult.

Generally, it is recommended that a special needs walker should be introduced early, around 9 to 12 months of age when upright positioning and mobility can potentially impact the children’s motor, sensory, visual and social development.

It is not so much about whether a child could walk straight away with the selected device, which might often not be realistic, but whether it is the most suitable tool for it to progress towards it.

First it should enable the user to stand, then bear more of its body weight, make the first steps, to be followed by more and more of them. The aim for it is to support tasks which lead towards more movement, more activity and more autonomy.

Size and Weight Capacity

Size is a very essential parameter in the choice. Obviously, the walker needs to fit the size of the child well in all relevant dimensions after adapting all the adjustable features. It must be able to bear the users weight, now and for some future growth.

For that reason, most manufacturers make their products adjustable and offer several sizes. However, the walker should also be sufficiently adaptable to be able to grow for some time with the child.

Besides the economic considerations of catering for some significant growth, being able to keep the same device for a longer period is also reducing disruption in the mobility progress of the user.

Once a walker suits a child really well, changing to another one (even of the same type) can become an additional challenge. The Voyar FROG has larger adjustability ranges then most products in the market. It is also the only one which is adjustable in width.

The releveant measurements for fitting a pediatric walker or gait trainer are:

Hip height – corresponds frame height of a walker

Elbow height – are the forearm support / armrests adjustable to this height and higher

Chest width/circumference & thigh width/circumference – relates to frame width

Weight – relative to the weight limit of the product

Based on these measurements a suitable frame size can be selected.

Frame Configuration

Generally, there are three common main configurations which can be distinguished for the common walker frames in the market:

Anterior walker

The frame is in front of the child, like a rollator for elderly. These devices are easy to engage. Their use seems quite natural, in particular for children who adopt a forward leaning posture during walk, since it will stabilise the forward momentum.

However, these types of walkers can have a tendency to reinforce that posture, which can come at the detriment of balance and turning ability.

Posterior walker

The posterior walkers with the frame around the child from behind. They are a bit more difficult to transfer into. However, this configuration generally leads to a more correct upright posture and allows the therapist to teach good posture using cues from body contact with the frame or parts of the walker.

A more upright posture induced by this type of walker also improves manoeuvrability. Enhancing the support with armrests is quite straightforward for these frame configurations. The Voyar FROG is a posterior walker which comes with an armrest option.

Full Frame Walker

These models are often hybrids allowing anterior or posterior positions with a lot of flexibility to reconfigure for support with harness systems and saddles. They have a high degree of adjustability to accommodate the user’s posture and offer support and additional features for more critical cases.

Hands-free walkers also fall under this configuration. They contribute to arm swing and trunk rotation as well as increased participation and inclusion. However, for children with spasticity versions with arm rests will allow them to relax more and walk steadier.

Full frame walkers tend to be also bigger, heavier and more costly. They are the right choice when such high degrees of adjustability, support and customisability are required in function of the mobility challenge of the child.

Features & Accessories

The pediatric walker should fit well the condition, the type of activities and preferences of the user.

Where will the device mostly be used; in therapy, or also at home, in school, outdoors (playgrounds and parks), on the move (shopping)? How is it transported; in a car, perhaps together with other equipment such as stroller or wheelchair? How can it support these activities and suit its constraints?

Required adaptations can often be achieved with accessories. These could be additional support features, such as armrests, trunk support and harnesses.

Some users will require devices to prevent the crossing of feet and legs. Or it can be activities related elements such as guide bars, seats and even sunshades which can enhance the product.

For a walker to be used in daily life it is important to be foldable with a small collapsed envelope, to fit in car trunks and to be conveniently stored away.

A tote bag or features to attach bags or baskets are very popular among the children and can allow to integrate the walker better into real life activities. A communication tray provides a secure spot for most types of communication system to be placed.

Brakes can be an important feature either because of gait disturbances (providing continuous adjustable friction to stabilise gait), or to prevent a runaway walker (particularly with seat) used in uneven and sloping terrain.

Such a ‘parking brake’ or wheel lock is part of the standard version of the Voyar FROG. Most walkers have anti-reverse ratchets or one-directional rear wheels. For many users it is useful if these have an option to be disengaged for better manoeuvrability.

For children who do not have a good directional control with the walker yet, a feature to lock the swivel of the front casters, either both or only one, is beneficial. Locking the caster wheels allows to practise the gait without having to deal with directional movements straight away.

The Voyar FROG has a unique caster control which permits to limit and release the travel in increments for each side and each wheel, providing opportunities for a very progressive therapy program in terms of directional control.

A unique feature of the Voyar FROG is its innovative lift seat. It addresses fatigue and eliminates the need for frequent assisted transfers out of the walker in therapy. The resting seat with integrated, patented weight-compensation mechanism enables easy and autonomous transition from sitting to standing and vice versa.

When seated, the compensation mechanism exercises an adjustable counter force against the weight of the child, assisting it in standing up and reducing the strength required. The mechanism provides space for walking with seat folded up and easy access for the next deployment, stabilizing the child also in transition to sitting from standing position.

Usage & Handling

Gait trainers and pediatric walkers come in a wide range in terms of weight. Generally, a heavier device will stabilise the gait and movements of the user more. It will thus be beneficial in particular to users with challenges in directional control and steadiness.

However, such a higher weight comes with a penalty in terms of ease of use in daily life; hauling a heavier device in and out of car booths, in public transport, up and down stairs, and pushing them uphill in outdoor activities is more tiring and cumbersome for parents and caregivers.

For ease of handling in these situations, families might prefer a lighter model. Here as well, the best trade-off should be sought based on the individual case, how much stability the walker should provide, or how nimble it should be, based on the capabilities of the user.

And concerning its size, does it actually fit through the doors at home and can it be stored away in a space available for that? Is it easy to fold and small enough in collapsed condition for transport and storage?

Extensive outdoor use is probably the ultimate goal, and therefore the suitability for such a setting should be given serious thought. Wheel size becomes is a key factor the more rugged the terrain. Even pneumatic tires can be a consideration in this context.

It is important to consider the actual environment and activities in which the device will be used: from feeding to dressing, from learning to playing and interacting with peers. The better it integrates into these, the more often it will be used and therefore the most developmental benefits will be reaped.

Child’s Preferences

One aspect which is often somewhat neglected is the preference of the child itself. Children can be actually very decisive in the choice products and also their aesthetic preferences. For a product which has such an essential role in their life, it is very important that they can identify with it also on an emotional level.

Such an identification can elevate the device to become a source of motivation rather then a symbol of chores. Look and feel of the product is more important then typically acknowledged in very rationally based considerations.

It seems very obvious that most children have strong preferences and affinities in personal products like sneakers, scooters and bicycles, however for walkers the same level of engagement is not always considered an important factor in the decision making.

But the walkers and gait trainers represent in most cases a much more intensive and essential use for them. It should be OK if a such a serious therapeutic product is at the same time cheerful and fun.

If the child likes its walker and identifies with it, that is a great start for the battle of mobility to be won.

Price and Reimbursement

Special needs families can be under significant financial constraints. Therefore, it is important that assistive equipment is affordable. Whether equipment is reimbursed or not, or how it can be funded are important real-world factors which can weight in on the selection.

Unfortunately special needs equipment manufacturers do not operate in a low cost environment, due to regulatory costs, relatively low production volumes and high quality expectations.

Assistive equipment represents a real investment into the future of the child. A realistic view on the affordability is required which also looks beyond the sticker price at total cost over the usage period.

The distribution of these products is evolving. While in most countries with reimbursement for such products specialised distributors work closely with hospitals and therapy centers, eCommerce has entered the field with some large distributors marketing to users and healthcare providers.

Manufacturers are also offering their products directly over their websites. This has the positive aspect of enlarging the potential offer for the clients; however, at the same time this increased variety in the offer has also sometimes made the choice more difficult.

Summary
Each user is unique in its condition, environment, preferences and aspirations. The best product match should be sought by analysing and balancing carefully these individual parameters and looking beyond what could be just the most established and conventional choice.

Unfortunately, in many cases the decision-making process can be guided too much by familiarity or availability. Therapists will feel comfortable with what products they are familiar with and can have sometimes only limited resources to explore new solutions.

Parents have an important role to discuss with the therapists and suppliers what considerations guide their specific recommendations. They should bring particularly the social and environmental aspects into the evaluation, which is the part they are most familiar with.