Project Objective: To design and develop a highly maneuverable mobility device for children with physical disabilities, which will allow a child to get within arms reach of objects and people. The Transitional Ortho-Therapeutic Walker (TOTWalker) will be designed for children from 1 to 6 years of age. It will be designed on the premise that young children need a means for hands free exploration in their indoor environment. The project will also assess the maneuverability of commercially available support walkers. The following presentation discusses the significance of encouraging early exploration for young children with disabilities by increasing access to the indoor environment through the use of self-initiated mobility devices, implications of using mobility devices and considerations for selecting and modifying them.
THOUGHTS
AND QUESTIONS TO PONDER
·
Isn’t
it interesting that we encourage the majority of children with disabilities
(1-3yrs) to stand (in standing positioning equipment) but don’t allow them to
move, and when we encourage them to move, it’s in a seated position.
·
When
is the magical moment we allow children to have access to their environment?
· How can young children with disabilities, during the critical stages of development, have more opportunities, like able-bodied peers, to explore?
· Does using a mobility device like a walking aid, reduce the likelihood of a child walking?
· Does sitting in a stroller/wheelchair for many hours reduce the likelihood of a child walking?
· Is a hand held push walker (rollator) the most optimal way to provide mobility for a child if it doesn’t provide hands free mobility or an optimal posture for ambulating?
· Infants in Mainland China, who for cultural and ecological reasons are not given an opportunity to move independently until they are able to walk, are delayed in the onset of spatial cognition, the socio-emotional domain, as well as the ability to develop mature reach, grasp and postural control. These skills significantly increase at the onset of ambulation. (Kermoian, Meng, Dong, 1992).
· Infants with a locomotor delay (spina bifida L4-5 or below) are delayed in the onset of the above skills until they begin to move, at which time they show a spurt in development in these domains (Telzrow, 1987).
· Assisted walking may not only improve the growing child’s mobility, but also make a difference in their ability to explore the environment and interact with their peers (Greineret al. 1993).
·
Treadmill Training with Partial Weight
Bearing Support – Numerous studies show that children with CP can benefit from
partial weight bearing training on a treadmill as early as they
demonstrate ability to bear weight on their feet. Schindl et al found subjects improved 47% in the standing section
of the GMFM and 50% on the walking section of the GMFM.
· Study examined balance differences between level of pathology and orthotic conditions: Solid AFOs compared to dynamic AFOs and wearing no brace. There was decreased activation of gastrocnemius muscles, disorganized muscle-response patterns, decreased use of ankle strategies and increased joint angular velocities at the knee compared with dynamic AFOs or with no AFOs (Burtner PA; Woollacott MH; Qualls C 1999).
· For some young children with severe motor impairments and developmental delay, use of a powered mobility device may increase self-initiated movement occurrences during free play (Deitz, 2002).
· To empower the child through self-initiated mobility.
· To increase the child’s ability to access the indoor environment.
MOBILITY DEFINED: Can mobility be defined according to its purpose?
·
Self-initiated Mobility: The child makes the decision
to physically move, and to control where, when and how they want to move.
·
Transitional Mobility (learning to move in space,
exploring, reaching, gaining sensory motor experiences, acquiring prerequisites
for other forms of mobility)
·
Functional Mobility (efficiently moving from one
place to another)
·
Mobility for Physiologic Function (building endurance and bone
density, improving respiratory and digestive function, stretching muscles)
· Sensorimotor activities based on physical interactions and experiences through play
(Push, pull, open, close, move under, around, bump, twist, turn, jump, move fast)
· Early spatial relations/visual experiences: Dynamic balance tasks place greater demands on visual and vestibular systems.
· Cultivating the mind: Greater problem solving and learning opportunities. The vast majority of the 1,000 trillion connections or synapses that the newborn’s billions of neurons will eventually make are determined by early experiences.
· Upper Extremity Motor Development: We have observed an increase in upper extremity use when children are able to explore and get close to objects and people.
· Social development and greater opportunities for peer interaction.
· Language development: We have observed an increase in language in some children as they explore their surroundings and an increase in verbalization in others.
· Physiological changes: In young adults we have seen weight reduction and increased endurance during walking with improved digestive function.
Push Walkers: (anterior & posterior) Hand held. Lightweight, easy to transport, no hands free position during gait, posture may be poor.
Support Walkers: Includes a seat, may include pelvic, trunk, head, arm supports.
- Front Leaning Support Walkers. May work for a child who can’t fully weight bear, has adjustable pitch, may be difficult to maneuver, may interfere with reaching, may encourage sitting.
- Upright Support Walker, (no dynamic movement): May require use of arms to maneuver no vertical movement available during ambulation if trunk pads are tight.
- Dynamic Support Walkers: Vertical movement for ambulating, hands free.
Custom Orthotic Walkers: Good alignment, encourages reciprocal movements, turning may be difficult, cannot be easily used in side by side trials, not easy to put on child.
Self-propelled Standers: Dual function, good alignment, difficult to get close to objects.
Powered Indoor devices: Get close to objects, explore using switches/joystick, may need unobstructed area
Powered Outdoor devices: Battery operated toy vehicles, Go-Karts,
MODIFICATIONS OF
WALKING AIDS TO IMPROVE PERFORMANCE
· Seat: More padding for comfort in weight bearing, wider for children who adduct, longer and deeper for children who scissor.
· Trunk/Pelvis: pelvic wedge for prone support walkers to keep feet behind pelvis
· Headrests: most frequently added to forward leaning walkers. May require more padding
·
Functional
Turning Radius: 31-56”. Smallest radius: Pacer, Pony, Pommel
·
Initiation
of Movement: Carpet: 5-9.2lbs. Least resistance: Gator, Miniwalk, Pommel,
Walkabout, Cricket
·
Initiation
of Movement: Linoleum 0.3-2.2lbs. Least: Pommel, Walkabout, Miniwalk
·
Resistance
to turning: Carpet: 7-14lbs. Least: Pommel (3”), Gator, Walkabout, Miniwalk
·
Resistance
to turning; Linoleum 0.8-3.5 Pommel
(3”), Walkabout, Miniwalk, Arrow
·
Resistance
to threshold: 8-24lbs. Least: Spee Dee, Bronco, Miniwalk, Walkabout
CONSIDERATIONS FOR
DESIGNING AN INDOOR MOBILITY DEVICE FOR INTERACTIVE EXPLORATION
Should
work on carpet, have a small turning radius, be adjustable without various
tools, no hardware which interferes with the body, no hardware in front of the
child which would prevent moving close to objects, hands free.
·
Things
take time: Average length of time for project team to evaluate 3 mobility
devices from evaluation to report was 6 hours of OT or PT and 6 hours of a
rehab technologist.
· What is the purpose? Exploration, access to environment, exercise, walking?
· Where is it to be used? Evaluate in a similar environment (carpet, linoleum, playground)
· Does it need to be folded or disassembled for transport?
· Can the child stand for at least 5 seconds without sinking or flexing? No? Relieve weight.
· Can the child independently move his legs and reciprocate in an upright position?
(No? Try treadmill training first, i.e. LiteGait)
· Is child reported by care provider to be stiff in AFOs? Try without AFOs first.
· Can child weight bear? If no, relieve weight in a light device or MiniBot.
· Children with head flexion, stiff arms and stiff legs (STNR?) tend to do better in forward leaning support walkers, GoBot or Mini-GoBot. Supporting arms may assist in head extension so legs are less extended and stiff.
· Children who reciprocate do better in upright walkers like Walkabout, Pommel (not pitched).
· Children who are ‘developmentally delayed’ with normal muscle tone, have walked independently within 3-4 months of using a support walker on a daily basis.
· Children who have a significant visual impairment don’t respond to self-initiated mobility opportunities as quickly as those without visual impairment.
· Children whose parent’s reported increased leg stiffness in braces (AFOs), moved more efficiently without wearing their AFOs during the initial use of the mobility device.
· Children who do not immediately move in a mobility aid, especially in a clinical situation, may need a more motivating reason to move or the device or fit is not appropriate.
· If vision and motivation to move are not restricted, the child should demonstrate an ability to move a walker within 5-10 minutes. If not, you may need to adjust it or use another type.
1. Kermoian R., Meng, Dong. How cultural practices mediate the onset of crawling. Proceedings of the Eighth International Conference on Infant Studies, Miami, FL: 1992.
2. Greiner BM. Czerniecki, JM. Deitz J. Gait parameters of children with spastic diplegia: a comparison of effects of posterior and anterior walkers. Archives of Physical and Medicine Rehabilitation 1993; 74: 381-5.
3. Telzrow, R.W., et al. Spatial understanding in infants with motor handicaps. In KM Jaffe, Childhood powered mobility: Developmental, technical, and clinical perspective: Proceedings of the RESNA 1st Northwest Regional Conference. Washington DC, RESNA p62-69.
4. Schindl et al. Treadmill Training with Partial Body Weight Support in Nonambulatory Patients with Cerebral Palsy. Arch Psy Med Rehabil 1999; 81: 301-306.
5. Burtner PA, Woollacott MH, Qualls C. Stance balance control with orthoses in a group of children with spastic cerebral palsy. Developmental Medicine & Child Neurology 1999, 41: 748-757.
6. Deitz, J. et al. Powered Mobility and Preschoolers with Complex Developmental Delays. American Journal of Occupational Therapy 2002; 56:86-96.
Arrow by Triaid Inc. 800-306-6777
Children’s Walking Table by SamHall, 800-882-0098
Cricket by Sammons Preston 800-323-5547
Gobot, MiniBot by Innovative Products, 800-950-5185
Pacer by Rifton Equipment, 800-777-4244
Pommel Walker, Rehab Centre for Children, Canada, 204-452-4311
Pony, Bronco, Gator: Snug Seat, 800-336-7684
Spee Dee by Otto Bock. US 800-328-4058. Canada 800-665-3327
WalkAbout, MiniWalk by Mulholland Positioning Products 800-543-4769
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Support Walkers and
Mobility Companies (* List not inclusive of all walkers on
the market) |
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ARROW |
GOBOT - MINIBOT |
SMART WALKER |
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Triaid Inc. |
Innovative Products |
Advanced Orthotic Designs Inc. |
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PO Box 1364 |
830 South 48th Street |
3995 Sladeview Cres., Unit #4 |
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Cumberland, MD 21501-1364 |
Grand Forks, ND 58201 |
Mississauga, ON, Canada
L5L5Y1 |
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301-759-3525 or 800 306 6777 |
800-950-5185 |
905-607-4022 |
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301-759-3525 FAX |
701-772-5284 |
905-607-9099 FAX |
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www.triaid.com |
www.iphope.com |
walk@aodmobility.com |
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www.aodmobility.com |
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BRONCO - PONY - GATOR |
HART WALKER |
SPEE-DEE |
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Snug Seat Inc. |
The Hart Walker Program |
Otto Bock |
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12801 E. Independence Blvd. |
189 Allambie Road |
Two Calson Parkway Suite 100 |
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Stallings, NC 28105 |
Allambie Heights, NSW
Australia |
Minneapolis, MN 55447-4467 |
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800-336-7684 |
02 9972 8109 |
US 800-328-4058 |
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704-882-0751 FAX |
02 9975 6195 FAX |
FAX: US 800-962-2549 |
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www.snugseat.com |
www.thespasticcentre.org.au |
www.ottobockus.com |
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CHILDREN'S WALKING TABLE |
MOTILO |
THERATREK 1000 |
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Sam Hall |
JANTON |
UltiMedCo, Inc. |
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400 Long Beach Boulevard |
Zone Industrielle |
2506 Zurich Drive |
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Stratford, CT 06615-7152 |
37120 Richelieu, France |
Fort Collins, CO 80524 |
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800-882-0098 |
(332)47936666 |
800- 377-9658 |
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203-308-1780 FAX |
(332)47581047 FAX |
970-221-2274 |
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janton@wanadoo.fr |
www.ultimatesupport.com |
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CRICKET |
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Sammons Preston |
PACER |
WALKABOUT - MINIWALK |
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P.O. BOX 5071 |
Rifton Equipment |
Mullholland Positioning Products, Inc. |
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Bolingbrook, IL 60440-5071 |
Rte 213, PO Box 901 |
215 North 12th St. |
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800-850-8602 |
Rifton, NY 12471-0901 |
Santa Paula, CA 93060 |
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800-547-4333 FAX |
800-777-4244 |
800-543-4769 |
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www.samonspreston.com |
800-336-5948 FAX |
805-933-1082 FAX |
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www.rifton.com |
www.mulhollandinc.com |
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DYNAMICO |
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ORMESA |
POMMEL WALKER |
WALKABLE |
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di MENICINI LUIGI & C. snc |
Rehabilitation Centre for Children |
LiteGait MOBILITY
RESEARCH |
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Via A. da Sangallo, 1 |
633 Wellington Crescent |
P.O. Box 3141 |
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PACIANA 06034 FOLIGNO (PG)
ITALY |
Winnipeg, MB, Canada R3M0A8 |
Tempe, AZ 85280 |
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0742 22927 (r.a.) 0742 22637 |
204-452-4311 |
800-332-walk |
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ormesa@mail.caribusiness.it |
204-477-5547 FAX |
www.litegait.com |
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GET AROUND GAIT TRAINER |
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Freedom Designs,
Inc. |
800-331-8551 |
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2241 Madera Road
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800582-1509 |
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Simi Valley, CA
93065 |
www.freedomdesigns.com |
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