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