Customized Walker Adaptions for a Child with Cerebral Palsy
TONI THOMPSON-RANGEL, MA, OTR/L, SANDRA B. SMITH, MS, PT, AND DANIEL E. GRINER, CO
Many children with Cerebral Palsy require the use of walkers for ambulation. Therapists involved in gait training of this population are aware of the importance of the ability to control lateral shift of the pelvis over the lower extremities as well as of upper extremity positioning on the overall ambulation gait pattern.
In 1975, Mathis1 identified improvements in the gait of a Cerebral Palsied child by incorporating arm troughs as walker handles, based on the theory of Bobath2 that a flexed upper extremity can contribute to decreasing. a total extensor pattern. Levangie3 et al, in 1989, discussed the effects of supination and of pronation upper extremity positions on the gait pattern. According to Patrick,4 research continues on more specific assessment of the gait of the Cerebral Palsied child.
Description of Problem
Shown in the photos is J.C., a five year old male with spastic diplegic Cerebral Palsy. In his initial attempts to ambulate with a walker with horizontal handles (Fig. 1 ) or vertical handles, he demonstrated:
asymmetrical distribution of tone,
unequal weight-bearing in the lower extremities,
poor ability to shift weight across pelvis onto right lower extremity,
forward displacement of center of gravity,
shoulders forward of pelvis,
trunk and hip flexion during all phases of gait,
asymmetrical upper extremity position, increasing amount of ulnar deviation in the left upper extremity (Fig. 2 ).
Instead of an even distribution of weight-bearing across the proximal palmar arch and thenar and hypothenar eminences with active use of left triceps, the left hand slides inferiorly and resulted in pressure across the distal palmar arch. J.C. used a pulling flexion action rather than a pushing motion to hold the walker and to maintain upright posture. This, in turn, resulted in increased upper extremity tone, uneven tone distribution, upwardly rotated scapuli, increased shoulder internal rotation, adduction, and a flexion pattern that contributed to a mild ATNR posturing.
As a result, J.C. demonstrated the onset of a vicious cycle of increased tone and less functional positioning that contributed to decreased maneuverability and inefficiency in ambulation. He was able to ambulate only in a circle, neither forwards nor backwards, at a slow rate of speed, with a high level of energy devoted to trying to maintain upright posture.
To improve functional lower extremity posture, a hip guard was added to the walker (Figs. 3 and 4 ). The Orthotist fabricated the guard of high-temperature polypropylene and affixed it to the posterior bar of the walker with hose clamps. This guide maintained the hips in a more midline position instead of serving as a weight-bearing surface (Fig. 5 ). As a result, the lateral excursion of the pelvis during the weight shift in the gait process was reduced, allowing him to more efficiently shift weight from the right to the left lower extremity.
His left hand, however, continued to slide medially and inferiorly on the walker handle resulting in asymmetry in upper extremity position, increased ulnar deviation, reinforcement of a mild ATNR posture, and increased as well as uneven tone distribution.
Neither Moleskin nor Dycem attached to the left walker handle provided adequate hand stability. An adaptive handle was fabricated of the lowtemperature splinting material Aquaplast (Fig. 6 ). The anterior stop component prevented his fingers from sliding forward and off the handle (Fig. 7 ). A medial thenar eminence block helped to support the appropriate wrist position, and assisted in more even distribution of weight-bearing across the proximal palmar arch and eminences.
Utilizing the walker with adaptive handle and hip guard, J.C. shows:
more symmetrical posture,
increased functional use of left triceps,
more efficient and effective weight-bearing through proximal palmar area of left upper extremity, increased ability to shift weight across pelvis (Fig. 8 ).
With these positive changes contributing to more postural security, LC. demonstrated the ability to ambulate with similar stride length on both lower extremities and with increases in efficiency and velocity. He is now able to ambulate with a Strider walker in a straight line and change directions as a functional household ambulator.
The use of a hip guide attached to the walker resulted in improved alignment for a five-year old male spastic diplegic. A custom-molded walker handle provided improved upper extremity position and stability during ambulation. The child demonstrated a more functional pattern of ambulation with the walker adaptations.
Shriners Hospital, 12502 North Pine Drive, Tampa, FL 33612-9499,
- Mathis, HJ: Adaptive Walker for Child with Cerebral Palsy, Suggestions from the Field. Phys Ther 55:1344-1345, 1975.
- Bobath, K, Bobath, B: The Facilitation of Normal Postural Reactions and Movements in the Treatment of Cerebral Palsy. Physiotherapy 50:264-267, 1964.
- Levangie, PK, Guihan, MF, Meyer, P, Stuhr, K: Effect on Altering Handle Position of a Rolling Walker on Gait in Children with Cerebral Palsy. Phys Ther 69:130-134, 1989.
- Patrick, J: Cerebral Palsy Diplegia: Improvements for Walking. BMJ 299:1115-1116, 1989.