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Gait Device Choice for Children with Spastic Diplegia Cerebral Palsy or Lumbar Level Spina Bifida

SAMSUNG CSC

Thank you for taking the time to view my Capstone. I appreciate any feedback, questions or comments.

Mae Langford, SPT

Background

This project is based on a recent experience working with pediatric patients in the field. Professionals have said, typically children are given posterior walkers while adults are given anterior walkers. This generic concept of assistive device prescription is largely based on research completed on children with various cerebral palsy diagnoses. Similar bodies of research have not been developed for the many other diagnoses seen in the pediatric physical therapy practice. If the goal of assistive device use with the pediatric population is to improve access to their environment and decrease energy expenditure, then the appropriate device is likely to change based on the individual. This is particularly important as children transition from a smaller preschool or home environment to a larger elementary school environment.

Project Purpose and Products

The goal of the project is two-fold. The first is to describe various assistive devices available for the pediatric population, from walkers to gait trainers, and their benefits, drawbacks and indications. This includes possible modifications available for the model and cost of the devices. The goal of the second portion of the project is to apply this information on devices to two pediatric populations who often benefit from their use, children diagnosed with spastic diplegia cerebral palsy and children diagnosed with lumbar level spina bifida. Two presentations were created to supplement course content in the Neuromuscular Assessment and Intervention courses in the UNC at Chapel Hill Doctorate of Physical Therapy program, one on gait device choice for children with spastic cerebral palsy and one on gait device choice for children with lumbar level spina bifida. Case studies were developed under each diagnosis to allow for practice applying gait device choices to patients with various levels of involvement.  

This project is designed for students in the entry level DPT program. While information about assistive devices is currently in the program curriculum, the information on gait trainers and walkers is primarily focused on the adult population. Within courses on development, pictures of pediatric gait trainers are displayed but there is little opportunity for students to think about and practice choosing a device for a child to address ambulation. These skills are important for the student planning to enter into the field of pediatrics but students who plan to go into other areas of practice can also utilize the concepts of gait device choice for their future patient populations.

Project Development

Completing my Critically Appraised Topic in Evidence Based Practice II helped to prepare me to create this project. My research focused on gait devices for children with lumbar-sacral level spina bifida. In working through that project, it became very clear that information on this topic is limited. Much more information is available regarding children with spastic diplegia CP. This prompted me to expand my topic to include that population. My evidence table was subsequently expanded to include information on gait in children with spastic diplegia cerebral palsy. To better develop my understanding of the various devices available, I worked with Kris Ledford, a seating and mobility specialist at Numotion in Cary, NC. I also worked with Cathy Howes, a pediatric physical therapist with a special interest in children with spina bifida and Melissa Scales, a school-based physical therapist in the Durham Public School System to improve my understanding of device choice for children and develop case studies for practice.

Evaluation

The project was developed to present to students in their second year of physical therapy school at UNC at Chapel Hill. Subsequently, this information has not yet been presented. I plan to present this information in person or over a voicethread to students in the fall semester of 2015 and the spring semester of 2016, schedule permitting. To assess the success of my presentations when they occur, I created a feedback form for the presentation on cerebral palsy and the presentation on spina bifida. In working with Cathy Howes who has presented to the second year students on cerebral palsy and spina bifida, and discussing the content of my presentation with Karen McCulloch who has taught the Neuromuscular Assessment and Intervention courses for many years, I feel confident these presentations will add useful content to the course material.

Self Evaluation

Creating this project has been a great learning experience for me. In working to develop course content for future physical therapy students, I greatly expanded my own understanding of the process and nuances of choosing gait devices for children. I also learned a lot about the diagnoses of spastic cerebral palsy and lumbar level spina bifida and how much variety there can be between children with the same diagnoses. Developing this project helped me learn to think critically about what the literature says and how that translates into living, dynamic patients who must interact with their environments. In working with a school-system physical therapist, an outpatient pediatric physical therapist and seating and mobility specialist, I developed relationships with area professionals and learned from their clinical experience. Working with those professionals, I was also able to get a diverse take on mobility devices for children.

The most difficult part of developing the project was creating presentations that are learner friendly and will be useful to future students. I hoped to limit my use of bullet points and allow for lots of time for class interaction. When it became clear my presentations may have to be delivered over voicethread, I felt a more traditional, bullet-point heavy presentation would be better able to convey the information. If I am able to give the presentations in person, I will plan to pause between slides to allow for class discussion and will use the bullet-point lists to briefly ensure all topics are covered. In this way, I hope my presentations will be more learner friendly. I feel confident the case studies will allow for learner interaction that should help with carry-over into clinical practice.

Finally, I learned a lot about the world of pediatric therapy by working to create case studies. Sickness, weather and school calendars do not always follow the deadlines I have set for myself. Coordinating between various settings, therapists and patients helped me practice patience and flexibility when things do not quite go my way. This project has helped to improve my ability to be adaptable, a skill necessary when working with children. This skill should serve me well in my future profession.

Acknowledgements

I would like to thank my committee members, Cathy Howes and Melissa Scales for working with me to develop these capstone materials. I would also like to thank my capstone advisor, Karen McCulloch who helped me create a project idea and scope appropriate for supporting the education of students in the physical therapy program at UNC at Chapel Hill.

Capstone References

  1. Anthem Blue Cross Blue Shield. Clinical UM guideline: Pediatric gait trainer. Anthem Web site. http://www.anthem.com/medicalpolicies/guidelines/gl_pw_c174202.htm. Updated 2014. Accessed 02/22, 2015. Shaer CM. The infant and young child with spina bifida: Major medical concerns. Infants and young children. 1997;9(3):13.
  2. Bare A, Vankoski SJ, Dias L, Danduran M, Boas S. Independent ambulators with high sacral myelomeningocele: The relation between walking kinematics and energy consumption. Dev Med Child Neurol. 2001;43(1):16-21.
  3. Bartonek A, Saraste H. Factors influencing ambulation in myelomeningocele: A cross-sectional study. Dev Med Child Neurol. 2001;43(4):253-260.
  4. Campbell SK, Orlin M, Palisano RJ, eds. Physical therapy for children. Fourth ed. St. Louis, Mo.: Elsevier/Saunders; 2012.
  5. Darbee JC, Franks CA, Palisano RJ. The effect of walking with an assistive device and using a wheelchair on school performance in students with myelomeningocele. Phys Ther. 1991;71(8):570.
  6. David KS, Sullivan M. Expectations for walking speeds: Standards for students in elementary schools. Pediatric physical therapy. 2005;17:120-127.
  7. Gagnaire N, Gawron A, Hogue J, et al. Abstracts of platform and poster presentations for the 2005 combined sections meeting: Growth related factors and gait in children with cerebral palsy. Pediatr Phys Ther. 2005. Park. Comparison of anterior and posterior walkers with respect to gait parameters and energy expenditure of children with spastic diplegic cerebral palsy. Yonsei Med J. 2001;42(2):180.
  8. Kelly S. Oxygen cost, walking speed, and perceived exertion in children with cerebral palsy when walking with anterior and posterior walkers. Pediatric physical therapy. 2002;14(3):159-161.
  9. Lephart K, Utsey C, Wild DL, Fisher SR. Estimating energy expenditure for different assistive devices in the school setting. Pediatric physical therapy. 2014;26(3): 354-359.
  10. Levangie PK, Brouwer J, McKeen SH, Parker KL, Shelby KA. The effects of the standard rolling walker and two posterior rolling walkers on gait variables of normal children Phys Occup Ther Pediatr. 1989;9(4):19-31. doi: 10.1080/J006v09n04_02.
  11. Levangie PK, Chimera M, Johnston M, Robinson F, Wobeskya L. The effects of posterior rolling walkers vs. the standard rolling walker on gait characteristics of children with spastic cerebral palsy Phys Occup Ther Pediatr. 1989;9(4):1-17. doi: 10.1080/J006v09n04_01.
  12. Littlewood RA, Trocki O, Shepherd RW, Shepherd K, Davies PS. Resting energy expenditure and body composition in children with myelomeningocele. Pediatr Rehabil. 2003;6(1):31-37. doi: 10.1080/1363849031000097817.
  13. Logan L, Byers-Hinkley K, Ciccone CD. Anterior versus posterior walkers: A gait analysis study. Developmental Medicine and Child Neurology. 1990;32:144-148.
  14. Low SA. Abstracts for the 2004 combined sections meeting: Comparison of two support walkers on the gait and mobility of a child with cerebral palsy: A case report. Pediatric physical therapy. 2004:49-68.
  15. Low SA, McCoy SW, Beling J, Adams J. Pediatric physical therapists’ use of support walkers for children with disabilities: A nationwide survey. Pediatric physical therapy. 2011(23):381-389.
  16. Moen T. Crouched gait in myelomeningocele A comparison between the degree of knee flexion contracture in the clinical examination and during gait. Journal of pediatric orthopaedics. 2005;25(5): 657-660.
  17. Noble E. Medicaid reimbursement making the case for a gait trainer. Rifton.com Web site. http://www.rifton.com/adaptive-mobility-blog/blog-posts/2011/october/pediatric-walkers-medicaid-funding. Published October 18, 2011. Updated 2011. Accessed 02/07, 2015.
  18. North Carolina Division of Medical Assistance. Durable medical equipment and supplies. Medicaid and Health Choice Clinical Coverage Policy No: 5A. 2013:1-115. Anthem Blue Cross Blue Shield. Clinical UM guideline: Pediatric gait trainer. Anthem Web site.
  19. O’Neil ME, Fragala-Pinkham MA, Westcott SL, et al. Physical therapy clinical management recommendations for children with cerebral palsy – spastic diplegia: Achieving functional mobility outcomes. Pediatr Phys Ther. 2006;18(1):49-72. doi: 10.1097/01.pep.0000202099.01653.a9.
  20. O’Sullivan, Susan B. Schmitz, Thomas J Fulk, George D, ed. Physical rehabilitation. 6th ed. F.A. Davis Company; 2014.
  21. Ounpuu S, Thomson JD, Davis RB, DeLuca PA. An examination of the knee function during gait in children with myelomeningocele. Journal of Pediatric Orthopaedics. 2000;20(5):629-635.
  22. Park ES, Park CI, Kim JY. Comparison of anterior and posterior walkers with respect to gait parameters and energy expenditure of children with spastic diplegic cerebral palsy. Yonsei Med J. 2001;42(2):180-184.
  23. Williams EN, Broughton NS, Menelaus MB. Age-related walking in children with spina bifida. Dev Med Child Neurol. 1999;41(7):446-449.

 

 

5 Responses to “Gait Device Choice for Children with Spastic Diplegia Cerebral Palsy or Lumbar Level Spina Bifida”

  1. Mae

    Hi Christine and Brittany,
    Thank you for taking the time to look through my capstone! I am glad you both found the information pertinent to clinical decision making. I ended up calling the Medicaid office trying to find more information and what is covered seems to definitely be on a case-by-case basis with a bent towards saving money. I hope more information about why a device is chosen can assist clinicians in writing letters of medical necessity that are successful in getting the appropriate device.

    Thanks,
    Mae

    Reply
  2. Christine Lysaght

    Mae,
    I found your presentation to be pertinent and informative. Your information also points to the need for practicing PTs to rely on specialists in seating and equipment. I recently attended the international seating symposium, where all types of equipment was on display. Even within the category of “gait trainer” there a multitude of options. Unfortunately Medicaid has started to deny children gait trainers. But our decision to recommend treatment must be based on the individual patient as you eloquently point out. Thanks again for your well written and clinically relevant capstone.

    Reply
  3. Brittany Stapleton

    Hey,
    I definitely find this information helpful. We are exposed to the different assistive devices for kids during the curriculum, but we not in detail. On my peds rotation, my CI wanted me practice prescribing equipment so I would treat a patient then choose a device then I would tell her why. I wished I had your information earlier. I think you did a good job outlining the material for the assistive devices and your evidence table was easy to digest.
    Brittany

    Reply
  4. Mae

    Hi Laura,

    Thanks for the great feedback and for sharing that case example! I think we often wish there was just one right way to do something or one right gait device to choose but I think your case illustrates that the “right” choice will likely change over time. We must be prepared to reassess. It sounds like the child you worked with was much safer even if she was less mobile in an anterior walker. I think the most important thing to remember is even though there is research on children with CP and which walker is appropriate, each child will present differently. My hope is that my presentations provide a starting point to guide therapists to making a safe, appropriate choice for a patient whether that be an anterior or a posterior device.

    Thanks so much, Laura!!

    Mae

    Reply
  5. Laura Rapp

    Mae,

    Excellent job with your capstone!! I completely agree that the world of walkers and gait trainers within the pediatric population seems fairly generalized in that, based on my limited pediatric experience on rotation, most children do tend to receive the same sort of walker regardless of diagnosis and individualized needs. I found your descriptive table categorizing the various types of gait devices to be extremely helpful – particularly since you included pictures and items such as various uses, drawbacks, and cost estimates. That is an excellent supplement to the material in the second year Neuromuscular course, and it is something that will likely be beneficial for me in my upcoming pediatric clinical rotation as well!

    Furthermore, your PowerPoint presentations are clean, easily understood, and make use of helpful visuals like Venn diagrams and side-by-side comparisons. I also love that you added in case studies to help integrate the information into a real situation that may be encountered. The two PowerPoint presentations on lumbar level spina bifida and spastic cerebral palsy additionally have just enough in common in terms of format to allow for better comparison while highlighting the differences later in the characteristics and case study portions of the presentations.

    I was particularly interested in the case study you presented in the PowerPoint on spastic CP – the 12 year-old male who switched from a posterior walker to an anterior walker. I had always assumed that a posterior walker is generally better for children with cerebral palsy for all the reasons you mentioned: decreased hip flexion, longer step length, increased vertical alignment, and facilitation of forward motion. However, when I was reading your case study I was reminded of a 6 year old with CP with whom I worked on my pediatric rotation in the school system. She was extremely outgoing and wanted nothing more than to run and keep up with her classmates – which she did. Unfortunately, she also fell very often, requiring her to wear a helmet any at all times during ambulation. To better explain her vigor for running and keeping up with her peers, she actually broke two different pairs of solid-ankle AFOs! A few weeks into working with her, my CI and I switched her from the posterior walker she was using to an anterior walker, and – along with the use of articulating AFOs, she had improved trunk control, foot contact, and fewer falls. It also slowed her down a bit, which she wasn’t thrilled about, but it ultimately improved her gait.

    That one example just goes to show that the information you present in your capstone is most certainly something that is useful to learn! Gait devices and individuals are unique, and so we as physical therapists need to help match them as well as possible in order to improve the patient’s function and meet the goals of the patient and family.

    Again, great job!

    Thanks,
    Laura

    Reply

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