CRE0010.1177/0269215514565947Clinical RehabilitationPaleg and Livingstone 565947research-article2014 CLINICAL Original Article REHABILITATION Clinical Rehabilitation 1 –15 Outcomes of gait trainer use © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav in home and school settings for DOI: 10.1177/0269215514565947 children with motor impairments: cre.sagepub.com A systematic review Ginny Paleg1 and Roslyn Livingstone2 Abstract Objective: To summarize and critically appraise evidence regarding use of gait trainers (walkers providing trunk and pelvic support) at home or school with children who are unable to walk independently or with hand-held walkers. Data sources: Searches were performed in seven electronic databases including EBM Reviews, CINAHL, Medline and EMBASE for publications in English from database inception to November 2014. Review methods: Included studies involved at least one child with a mobility limitation and measured an outcome related to gait trainer use. Articles were appraised using American Academy of Cerebral Palsy and Developmental Medicine criteria for group and single-subject designs and quality ratings completed for studies rated levels I-III. The PRISMA statement was followed with inclusion criteria set a priori. Two reviewers independently screened titles, abstracts and full-text articles. Results: Seventeen studies involving 182 children were included. Evidence from one small randomized controlled trial suggests a non-significant trend toward increased walking distance while the other evidence level II study (concurrent multiple baseline design) reports increased number of steps. Two level III studies (non-randomized two-group studies) report statistically significant impact on mobility level with one finding significant impact on bowel function and an association between increased intervention time and bone mineral density. Remaining descriptive level evidence provides support for positive impact on a range of activity outcomes, with some studies reporting impact on affect, motivation and participation with others. Conclusions: Evidence supporting outcomes for children using gait trainers is primarily descriptive and, while mainly positive, is insufficient to draw firm conclusions. Keywords Assistive devices, cerebral palsy, child rehabilitation, walking, mobility Received: 5 October 2014; accepted: 6 December 2014 1Montgomery County Infants and Toddlers Program, Corresponding author: Rockville, Maryland, USA Ginny Paleg, Montgomery County Infants and Toddlers 2Sunny Hill Health Centre for Children, Vancouver, BC, Program, Rockville, Maryland, 420 Hillmoor Drive, Silver Canada Spring, MD 20901 USA. Email: [email protected] Downloaded from cre.sagepub.com at University of British Columbia Library on January 31, 2015 2 Clinical Rehabilitation Introduction therapists hope to influence body structure and function components such as hip structure, cardio- The ability to move from one place to another inde- respiratory function and bone mineral density pendently appears to play a pivotal role in social through gait trainer use. Despite the apparent wide- development1 and psychological function.2 The spread and long-term use of gait trainers, to date transition from crawling to walking marks an there are no systematic reviews or published evi- important progression in overall development and dence-based clinical guidelines. The aim of this social interaction in infants.3 Children with cerebral systematic review is to evaluate the evidence for all palsy or complex developmental delays are often outcomes potentially impacted by use of gait train- less mobile and interactive than their peers.4This ers with children in home and school environ- lack of mobility and dependent positioning can ments. The specific question addressed is, “for have a negative impact on overall development, children with motor impairments, which outcomes social interaction and social status.5,6 are positively influenced by a gait trainer interven- The Gross Motor Function Classification tion?’ Secondary questions address “which popula- System7 classifies children with cerebral palsy (and tions benefit from gait trainer interventions” and similar/related conditions) according to their gross “at what age should they be introduced?” motor abilities. Children in levels IV and V are una- ble to use typical hand-held walkers due to impaired trunk control, strength, balance and range of motion. Methods Children with complex developmental delays also The Preferred Reporting Items for Systematic benefit from walkers that provide additional trunk Reviews and Meta-Analyses (PRISMA) statement and pelvic support.8 Children with visual impair- was used to structure this review.14 An electronic ment or profound cognitive limitations may lack database search was undertaken from database motivation to explore due to limited ability to engage inception to November 2014 and included: EBM in functional or stimulating activities.9,10 Supportive Reviews: Cochrane Central Register of Controlled walking devices or gait trainers may be used with Trials, Cochrane Database of Systematic Reviews, these populations to influence different types of out- Database of Abstracts of Reviews of Effects comes as defined by the International Classification (DARE), ACP Journal Club; CINAHL; Medline of Functioning, Disability and Health (ICF).11,12 and EMBASE. As noted in online supplementary The term gait trainer is used to describe a sup- material Appendix A, search terms included ‘gait ported walking device that provides trunk and trainer’, ‘support walker’, ‘walking device, ‘ring pelvic support. These devices are also known as walker, ‘infant walker”, ‘baby walker’, ‘body weight support walkers,13 posture control walkers or sus- support gait trainer’, ‘walker’, ‘supported ambula- pension body-weight support systems. Commonly tion’, ‘David Hart Walker’, and ‘supported walk- used examples include the Rifton Pacer, Mulholland ing’. Search terms were used in combination with Walkabout, Prime Engineering KidWalk, Ormesa the term ‘equipment’ or with diagnoses such as ‘cer- Grillo, and R82/SnugSeat Pony and Mustang. There ebral palsy’, ‘spina bifida’ or ‘muscular dystrophy’. is some confusion about the term gait trainers as No limits were placed on design methodology or they are not always used to ‘train gait’ or develop publication status in the initial search. independent, unsupported walking, but as a means Articles were included if they described primary to enhance activity and participation. In this paper, source studies using quantitative or qualitative the term gait trainer will be used since it has been methods to explore outcome(s) resulting from use established by US coding, is familiar to clinicians, of a gait trainer and involved at least one child aged and appears to be longest standing in the literature. 18 years or younger with a movement disorder or Gait trainers commonly unweight the body motor impairment. A gait trainer was defined as a through a solid or fabric ‘seat’, stabilize the trunk walker that is available with lateral and posterior and support the pelvis. Survey data13 suggests that components to stabilize or support the trunk and Downloaded from cre.sagepub.com at University of British Columbia Library on January 31, 2015 Paleg and Livingstone 3 pelvis as well as a rigid or flexible seat to provide Nine of the included articles were identified through body-weight support. Studies that did not provide manual searching.19-21,24-26,31,32 See online supple- sufficient description of the walker to determine if mentary material Appendix B for details of excluded it met criteria were included only if the population studies with reasons for exclusion. was described in sufficient detail to determine that Table 1 lists characteristics of included primary they would typically use a gait trainer or where it research articles. Evidence for effectiveness of gait was known that the intervention described involves trainers is limited as the majority of evidence is a gait trainer (e.g. Movement Opportunities Via descriptive, with only two studies achieving level II Education).15 Studies using swivel walkers (e.g. evidence. One,19 a single-subject concurrent multi- Orlau walker), typical ‘infant walkers’, robotic ple baseline design reports an increased ability to devices (e.g. Locomat), exoskeletons or mechani- step following introduction of the gait trainer. The cal stepping devices with external power sources, only randomized controlled trial, compared body stationary systems (confined to parallel bars or weight-support treadmill training and overground treadmill) or institutional-type gait trainers (e.g. walking and found a non-statistically significant Lite gait) too large to be used in a home or class- trend towards increased walking distance in the room environment were excluded as were non- overground group.33 Two non-randomized group English language and non-peer reviewed sources. designs were also identified. One, comparing the Bibliographies of electronically retrieved studies effectiveness of the Hart walker to standing22 found were manually searched to identify additional pub- a statistically significant increase in mobility skills lications. Both authors independently read all titles and significant improvement in bowel function in and abstracts and agreed on the list of articles to be the walking group. The other study compared the retrieved full-text. Following independent full-text Movement Opportunities Via