The Clinical Use of Passive Standers and the Reciprocal Gait Orthosis In Children
John F. Schulte, CPO, FAAOP
Children want to be Children regardless of the Congenital Anomaly, SCI Lesion or as the result of Trauma. That being said, they all want to be like the other 'Kids' in their circle of friends, classmates or persons that they admire.
Parents being parents, will undoubtedly ask you as their Medical Practitioner, Therapist or Caregiver what can be done to help their child reach their goals to be as much like 'Others' as possible.
All children have an inner desire move. This happens within the first few months of life when they learn to lift their head, using their arms to help push themselves off their chests (actually, an inner sense to enable them to breathe more effectively, thus better oxygenating the blood and helping them during those all-important first months of growth). Once the child exhibits the desire to move and pull themselves erect, it is important in the growth milestone to allow them to load the Epiphyseal Plates in the long bones of the skeleton to Stand and Walk is paramount in children of all ages.
The first stage in allowing the physically challenged child to reach the sense of independence is to encourage standing. The Standing frame (Left) and Parapodium (Right) are excellent tools to help the child reach this goal.
The Clinical indications for the Stand is intended for the very young child who lacks sufficient muscle power in the lower extremities and trunk to stand. A child of 12 months or older with good head control in the vertical position and who is commando crawling (drag crawling) in prone, who appears to be trying to pull herself/himself up to standing at a low table, is ready for fitting. Children older than two years who are not able to commando crawl may be appropriate candidates for a standing frame to provide hands free standing. The frame can also be used as a training tool to help the parents and the therapist develop the child's physical abilities so that she/he can progress to other types of assistive devices. Upright positioning will benefit the child both physically and socially, but in all cases, the child should be properly assessed by the rehabilitation team prior to the prescription of the frame.
The criteria used for ParaPod considerations are:
- The child does not have sufficient muscle power in the lower extremities and trunk to ambulate and stand without crutches.
- The child has either gone through the Standing Brace stage or is physically and mentally ready to move into the ParaPod directly.
- The child is of such size that comfortable sitting can only be accomplished by flexing knees and hips.
Evaluate upper extremity coordination and strength to determine if the child can utilize crutches or walkers effectively.
Evaluate the condition of the feet and determine if there is room for custom shoes, special padding and plantar flexion wedges. Check the condition of the skin, bones and joints for good weight bearing capabilities. A physical therapy program may be required to prepare the child for weight bearing activities.
Using a Swivel walker base is an ideal way to introduce ambulation to a paralyzed child.
Side Bar information: Treatment Schedule for the Reciprocal Gait Orthosis Candidate
Week One: It all starts with The Plan!
- Intital Exam
- Plan of Treatment
- RGO Ordering
- RGO Fitting
- Peer Interaction
Week Two: Focus on Upper Extremity Musculature Strengthening
Goal: Strengthening of Core Muscle Groups and reaching desired outcomes
- Wrist exercises
- Crutch Push-ups
- Biceps strengthening
- Triceps strengthening
- Push-up blocks
- Contracture management
Order the RGO the end of Week Two
Week Three: Focus on Lower Extremity Musculature
Goal: Contracture Management, Prevention and bone strengthening
- ROM Modalities
- Diagonal Weight Shift
Week Four: Lower Extremity Musculature (This is a Busy Week!)
Goal: Self Transfer RGO Fitting and Use ADL
- Cardio Pulmonary Endurance
- Bed to Chair
- Chair to Commode
- Floor to Chair
- Strengthening exercises; ALL Groups
Diagonal Weight Shift = SHIFT
Trunk and Hip Extension = TUCK
Push Down = KICK THROUGH
Work with OT this week to maximize patient's ability to donn and doff device.
Patient needs to learn to trust the RGO device.
- How to build trust in the device?
- Treatment exercises in parallel bars
- Treatment outside the parallel bars
- Easily attaches to standing brace or other standing devices
- Easy to attach or detach from standing brace
- Allows hands-free ambulation
- Swivel base recommended for patients no taller than 40"
Evaluate for deformities and contractures to determine if device modification may be required. Check the legs, pelvis, and spine for severe deformities. Orthopedic surgery and physical therapy can be of great assistance.
Evaluate the skin condition while checking for sores and hypersensitive areas around the chest panels (front panel area), sacral area (buttocks support) and patellar tendon and knees (knee pads).
Protruding Myelomeningocele and Spinal Deformities should be evaluated to determine if there is enough clear area over the sacrum to have a good buttocks support (purchase) panel and if an (LSO / TLSO body jacket) can be used if necessary.
Once it is determined that the child can stand and is motivated to stand, the Therapist should now begin their treatment modalities to strengthen the Upper Extremity strengthening in anticipation of beginning the RGO fitting and training program. Therapeutic Treatment Modalities at this stage are focused on Balance, UE and Trunk modalities in preparation for RGO fitting. (See sidebar for suggested schedule.)
Child Standing with the RGO The Reciprocal Gait Orthosis enables the Child to Stand Unassisted, Load the Long Bones to promote growth, Increase Situational Awareness and offer Increased Self Esteem by enabling Eye to Eye with Peers. Additional benefits are decreases in Obesity through exercise, Reduction of Contractures through Reciprocal ambulation and Bladder infections through more efficient bowel and bladder drainage while upright. Sitting Balance is enhanced with the RGO by allowing the child to sit and play unassisted through the use of the Abduction joints at the hip, then return to normal positioning, stand and ambulate with beneficial Reciprocal gait.
Enabling a Child to be fitted with the RGO and seeing them leave the confines of the wheelchair and walk independently not only gives them the physiological sense of normalcy but is one of the most rewarding treatments we as Medical Practitioners can be involved with. The day that the Child (or Adult) is fitted with their RGO, is truly one that we will remember throughout our career!
NOTE: The RGO device is clinically applicable to Children from the age of 3 with Spinal disorders such as Spina Bifida, Spinal disorders, Trauma and Disease and is adjustable throughout their Growth cycle.
The Fillauer Companies, Inc. is the World's largest provider of the Reciprocal Gait Orthosis. www.fillauer.com
Summary of RGO Treatment Plan and transition to Discharge
How do you build trust in the RGO device?
Within the confines of the parallel bars:
- Master the ability to stands hands free
- Builds Trust in the Device
- Weight Shift side to side with feet even
- Teaches Balance while Standing
- Weight shift front to back with one foot in front of the other
- Begins the Ambulation re-training
- Weight shift Front to Back with feet even
- Begins the learning phase of fall /trip recovery
- Retrieve object in Front
- Retrieve object to the Side (L & R)
- Retrieve object to the Rear
- Allows the user to use the UE and Trunk Musculature effectively
- Ball Toss
- Focuses on all the above
John F. Schulte CPO FAAOP has 40 years Clinical Experience as a Certified Prosthetist Orthotist, is a Published Author, Clinical Educator and Consultant with the Fillauer Companies, Inc. Chattanooga, TN. He is the Product Specialist for the Reciprocal Gait Orthosis. He can be reached at JSchulte@fillauer.com.