Effect of Altering Handle Position of a Rolling Walker on Gait in Children with Cerebral Palsy

Transcription

1 Effect of Altering Handle Poition of a Rolling Walker on Gait in Children with Cerebral Paly The purpoe of thi tudy wa to determine whether altering the handle poition on a rolling walker would affect the gait pattern of children with patic cerebral paly (CP). Sixteen children with CP (2-10 year old) performed ix gait trial, three with the handle on the rolling walker poitioned horizontally and three with the handle poitioned vertically. Uing the footprint-on-paper method, gait characteritic of right and left tep width, tep length, and tride length; cadence; and velocity were determined. A two-way analyi of variance for two repeated meaure indicated no ignificant difference in the meaured gait characteritic between handle poition. Significant difference between the firt trial and ubequent trial for both horizontal and vertical handle poition were found uing Duncan' multiple comparion tet Thi tudy ugget that in thi ample of children, altering the handle poition did not lead to any immediate tatitically ignificant change in the gait characteritic meaured. Reult ugget that walker with vertical handle hould not be precribed under the aumption that the gait characteritic of the child uing the walker will be changed. Thi tudy doe not rule out other change that might occur with the ue of vertical-handled walker. [Levangie PK, Guihan, eyer P, et al Effect of altering handle poition of a rolling walker on gait in children with cerebral paly. Phy Ther 69: 1-4, 1989.] Pamela K Levangie ichele ord Guihan Pamela eyer Krita Stuhr Key Word: Ambulation aid, walker; Cerebral paly, equipment/gait; Pediatric, equipment. Phyical therapit who precribe walker for their young patient with cerebral paly (CP) commonly adapt the handle poition of the walker from it uual horizontal poition to a vertical handle poition. In 1977, P Levangie, S, PT, i Aitant Profeor and Coordinator of Entry-level Program, Department of Phyical Therapy, Sargent College of Allied Health Profeion, Boton Univerity, 1 Univerity Rd, Boton, A 022 (USA). Guihan, S, PT, i Staff Phyical Therapit, New England Rehabilitation Hopital, Two Rehabilitation Way, Woburn, A P eyer, S, PT, i Senior Phyical Therapit, Santa Clara Valley edical Center, 751 S Bacom Ave, San Joe, CA K Stuhr, S, PT, currently ha a part-time private practice in Ventura, CA. Guihan, eyer, and Stuhr were tudent in the mater' degree program, Department of Phyical Therapy, Sargent College of Allied Health Profeion, Boton Univerity, when thi tudy wa completed in partial fulfillment of the requirement for their ater of Science in Phyical Therapy degree. Thi tudy wa partially upported by the Dudley Allen Sargent Reearch und, Sargent College of Allied Health Profeion, Boton Univerity. Thi article wa ubmitted October 9, 1987; wa with the author for reviion for 25 week; and wa accepted Augut 16, Bergen in Selected Equipment for Pediatric Rehabilitation noted that The adapted rollator encourage forearm upination, elbow extenion and humeral abduction and external rotation. Once the flexor predominance or habitual poition i corrected, truncal ymmetry and back extenion are coniderably improved. Similarly, lower extremity alignment i demontrably improved. 1 Ue of the vertical-handled walker ha become widepread enough that ome manufacturer offer a walker that include both horizontal and vertical handle or model where the option are eaily interchangeable. Bergen' 1 comment mirrored the principle epoued by the Bobath, Phyical Therapy/Volume 69, Number 2/ ebruary /47

2 ethod Table 1 Decriptive Information on Subject Teted Subject Age (yr/mo) 2/ /4 8/8 7/9 8/7 2/8 8/7 5/2 8/ / 4/ 5/2 9/7 8/4 Sex a PCW = poture control walker. Aitive Device PCW a b independent VHRW C PCW PCW VHRW b = horizontal-handled rolling walker. C VHRW = vertical-handled rolling walker. Duration of Ue (mo) Locomotion Time Ued (%) at chool The 16 ubject in thi tudy were identified by contacting outpatient clinic and chool for handicapped children in eatern aachuett and northern Rhode Iland. Phyical therapit at thee facilitie received a tudy propoal approved by the Sargent College of Allied Health Profeion Human Subject Committee and were aked to identify any children under their care who might be appropriate for the tudy. All ubject met the following incluion criteria: 1) be between 2 and 10 year of age, 2) have a diagnoi of patic diplegia or quadriplegia, and ) be able to ambulate with aitive device and no more than minimal contact guarding. No attempt wa made to control for the uual form of aitive device ued by ubject becaue the number of ubject wa anticipated to be mall. Informed conent were igned by a parent or guardian. Information on the age, ex, and aitive device ued by the ubject i provided in Table 1. who held that modifying joint poition could reduce abnormal pattern of movement throughout the body. 2, Delwaide et al were able to demontrate on a healthy ubject population that paive poitioning of the upper extremitie could influence what they noted a "tone" in the lower extremitie. 4 Although one therapeutic goal for precribing the rollator walker with vertical handle would be, a Bergen uggeted, 1 to improve the lower extremity alignment and gait of the child with CP, there i little, if any, ubtantiation in the literature of change in gait produced by modifying the handle poition of the walker. 5 The uual gait of the child with patic CP ha been documented, a marked by decreaed tep and tride length, decreaed angle of toe-out, variation in tep width, and decreaed cadence and velocity. 6,7 Improved gait for thee children would generally imply increaed value for thee gait characteritic, each of which can be meaured by or during the footprint method of gait documentation originally decribed by Ogg 8 and Boenig. 9 The reliability and validity of the footprint method of gait analyi ha been demontrated by numerou invetigator on a variety of population The purpoe of thi tudy wa to document among a mall ample of children with CP whether uing rollator walker with horizontal and with vertical handle would create any immediate change in the gait characteritic of velocity; cadence; and right and left tride length, tep length, and bae of upport. The hypothei of thi tudy wa that there would be ignificant change in the deignated gait characteritic of the child with patic CP when ambulating with the vertical-handled walker (forearm neutral) a compared with ambulating with the tandard horizontal-handled walker (forearm pronated). All children were teted in their own chool or clinic. The children wore their own hoe and any orthoe normally worn during ambulation. Opara et al howed that ankle-foot orthoe have a ignificant effect on gait characteritic. The orthoe were not a factor in thi tudy, however, becaue they were worn in both treatment condition (walker with vertical handle, walker with horizontal handle). We requeted that each child bring with them to the teting eion their uual aitive device o that the height of both rollator walker variation could be adjuted a cloely a poible to the height of the child' own walker or crutch handle. Procedure Subject were eated in a chair poitioned at the end of a 4.0- x 0.7-m path of newprint that wa ecured to the floor with making tape. On the ole of each hoe, adheive molekin trip (1. cm wide) were applied horizontally through the widet portion of the forefoot (line A) and vertically 48/1 Phyical Therapy/Volume 69, Number 2/ ebruary 1989

3 ig. 1. olekin marking placed on bottom of each hoe. along a line projected to be through the econd metataral and the midpoint of the heel (line B) (ig. 1). The interection of the two trip of molekin on each foot wa called point C. Each child wa given the ame minimal intruction in the ue of each walker. The children were aked to walk at a comfortable peed in their uual way. Each ubject performed three trial with each of the two handle poition for a total of ix trial per ubject. The handle poition for the initial trial wa randomly elected and wa alternated for each trial thereafter. A brief ret period between trial wa ued to change paper path and to re-ink the molekin for the next trial. Data Reduction Each 4-m path of paper wa marked with a line 0.5 m from either end. Data on footprint were collected only in the -m length in the middle to eliminate thoe tep taken at the beginning and end of the trial. Time meaurement began and ended a the toe of the ubject' hoe croed the marked line. centimeter (ig. 2). Point C, rather than the more traditional midpoint of the heel, wa ued a the referent on each foot becaue the initial contact in many children with CP i toefirt,rather than heel-trike. Velocity wa calculated a the number of econd taken to cro the central -m ditance. Cadence (in tep per minute) wa calculated a the number of tep within the marked area divided by the time taken to cro the area. Two invetigator (G and KS) were reponible for obtaining and recording all meaurement. Intrateter and interteter reliability for each variable were determined by having the invetigator analyze the ame trip of footprint from two different ubject on eparate occaion. Data Analyi ean value for each gait characteritic for each trial were obtained. or each gait characteritic under tudy, the mean value for all trial were ued in a two-way analyi of variance (ANOVA) for two repeated meaure. Where -tet ratio for the ANOVA were found to be ignificant (p <.05), a Duncan multiple comparion tet wa performed to locate difference. Pearon product-moment correlation were alo performed, with a correlation of.90 conidered acceptable. Reult The randomized order of walker preentation reulted in even ubject uing the walker with the horizontal handle poition firt and in nine ubject uing the vertical handle poition firt. Interrater and intrarater reliabilitie were determined to be.98 and.99, repectively. The two-way ANOVA for two repeated meaure indicated no ignificant difference in any of the meaured gait characteritic either between the two handle poition or in the interaction of handle poition and trial order. Significant difference, however, were found for all variable except right tep length between firt, econd, and third trial (Tab. 2). Line of Progreion Step Width Step Length Stride Length Step length, tride length, and tep width (bae of upport) were obtained from the deignated -m area in the center of the path. Each variable wa meaured and recorded to the nearet ig. 2. eaurement of ditance characteritic from recorded footprint. Phyical Therapy/ Volume 69, Number 2/ ebruary /49

4 Table 2. -Tet Ratio Reult rom Two-way Analyi of Variance for Two Repeated eaure Handle Trial Order Handle x Trial Order Variable Step width (L) Step width (R) Step length (L) a 6.94 a 5.55 a Step length (R) Stride length (L) Stride length (R) Cadence Velocity a a 4. a 5.56 a a p <.05. Table how the mean and tandard deviation for each of the variable and indicate the reult of the Duncan multiple comparion tet. Although reult of the ANOVA indicated cadence varied between firt, econd, and third trial, the multiple comparion tet did not how evidence of any difference. Dicuion Data led to a rejection of the hypothei that altering the handle poition on a rolling walker between horizontal and vertical poition would how difference in the gait characteritic of tep length, tride length, bae of upport, velocity, and cadence among a ample of children with patic CP. Difference in meaured gait characteritic between the two verion of rollator walker teted did not reach a level of ignificance of.05. Although gait pattern varied coniderably from child to child, the repeated meaure deign ha the advantage of both being more efficient and controlling for ubject heterogeneity. 16,17 The variation in initial gait among the children, therefore, hould not account for the lack of tatitically ignificant difference between the walker variation. Adapting the handle poition on the walker from a horizontal to a vertical poition altered the poition of the forearm from pronation to neutral but did not appear to be accompanied by the increaed elbow extenion or houlder abduction and lateral (external) rotation uggeted by Bergen. 1 The change in forearm poition produced by altering handle poition by themelve may not have been adequate to effect change in lower extremity function een clinically by Bergen. 1 Although the order effect of trial were not of primary interet in thi tudy, difference between and one or both of the ubequent trial reached tatitical ignificance for each variable except right tep length and cadence (where the multiple comparion tet wa unable to locate the difference indicated by the ANOVA). Viual inpection of the mean value for each gait characteritic except tep width indicated a trend toward increaing value from to, even when difference were not found to be ignificant. There wa no obviou trend for tep width. It hould be noted that our ample ize in thi tudy wa mall. The mall number of ubject and the large variance een in the gait characteritic may have affected the power of the tudy to find tatitically ignificant difference. Significant difference, however, were found between trial for thee ame ubject. A larger number of ubject would alo have permitted a ubgroup analyi of thee data by the uual aitive device of the child. That i, change in gait characteritic may have been influenced by whether the child uually ued a tandard rollator walker and, if o, whether that walker had vertical or horizontal handle. Reult of thi tudy do not rule out change in poture or gait that may be een with other concomitant walker adjutment or with walker ue over time. Similarly, adjutment of the walker handle poition may have beneficial effect to upper extremity function. Concluion Two concluion can be drawn from the data in thi tudy. irt, altering handle poition alone did not create immediate tatitically ignificant change in the gait characteritic meaured in thi tudy. Second, data in thi tudy ugget that the initial gait trial for each treatment condition hould be excluded from data analye or carefully aeed a to whether it i typical of ubequent trial. The purpoe of thi tudy wa to examine difference produced by vertical- and horizontal-handled walker on the gait characteritic of tep length, tride length, bae of upport, velocity, and cadence among a ample of children with patic CP. Thi tudy identified that, in thi retricted ample of children, changing handle poition on a rollator walker in iolation did not influence meaured gait characteritic. A vertical-handled walker probably hould not be precribed for a child with patic CP if the goal i to obtain 50/ Phyical Therapy/Volume 69, Number 2/ ebruary 1989

5 Table. Gait Characteritic Acro Trial Uing Vertical-Handled and Horizontal-Handled Walker Vertical Handle Horizontal Handle Right Left $ Right 5 Left Step width (cm) a a a a Step length (cm) * b Stride length (cm) b b b *.7.1 Velocity (m/ec) c C Cadence (tep/min) d a Significantly different (p <.05) from. b Significantly different (p <.05) from Trial 2 and. c Significantly different (p <.05) from. d Significant difference were not identified by Duncan multiple comparion tet. immediate and obervable effect on thee gait characteritic. Thi tudy, however, did not attempt to draw concluion about the poitive effect that a vertical-handled walker might have on uch variable a hand or writ poition or on overall potural alignment. Similarly, change over time or with experience uing the walker were not aeed. Thee and other effect of the modified rollator walker hould be the topic of further tudy. Acknowledgment We acknowledge Cambridge edical Supply, Cambridge, A. Newprint wa donated by The Boton Globe, Boton, A. Reference 1 Bergen A: Selected Equipment for Pediatric Rehabilitation, ed. Valhalla, NY, Blythedale Children' Hopital, 1977, pp -4 2 Bobath B: The treatment of neuromucular diorder by improving pattern of coordination. Phyiotherapy 55:18-22, 1969 Bobath K, Bobath B: The facilitation of normal potural reaction and movement in the treatment of cerebral paly. Phyiotherapy 50: 4-7, Delwaide PJ, igiel C, Richelle C: Effect of potural change of the upper limb on reflex tranmiion in the lower limb: Cervicolumbar reflex interaction in man. J Neurol Neurourg Pychiatry 40: , athi HJ: Adaptive walker for child with cerebral paly: Suggetion from thefield.phy Ther 55:44-45, Skrotzky K: Gait analyi in cerebral palied and nonhandicapped children. Arch Phy ed Rehabil 64: , Perry J: Cerebral paly gait. In Samilon R (ed): Orthopaedic Apect of Cerebral Paly. Philadelphia, PA, J B Lippincott Co, 1975, pp Ogg HL: eauring and evaluating the gait pattern of children. J Amer Phy Ther Aoc 4: , Boenig DD: Evaluation of a clinical method of gait analyi. Phy Ther 57: , Little H: Gait analyi for phyiotherapy department: A review of current method. Phyiotherapy 67:4-7, Andriacchi TP, Ogle JA, Galante JO: Walking peed a a bai for normal and abnormal gait meaurement. J Biomech 10:1-8, Wadworth JB, Smidt GL, Johnton RC: Gait characteritic of ubject with hip dieae. Phy Ther 52:829-87, 1972 Shore : ootprint analyi in gait documentation An intructional heet format: Suggetion from the field. Phy Ther 60: , Holden K, Gill K, agliozzi R, et al: Clinical gait aement in the neurologically impaired: Reliability and meaningfulne. Phy Ther 64:5-40, 1984 Opara CU, Levangie PK, Nelon DL: Effect of elected aitive device on normal ditance gait characteritic. Phy Ther 65: , Volicer BJ: ultivariate Statitic for Nuring Reearch. Orlando, L, Grune & Stratton Inc, 1984, pp Keppel G: Deign and Analyi: A Reearcher' Handbook. Englewood Cliff, NJ, Prentice-Hall Inc, 197, p 9 Phyical Therapy/ Volume 69, Number 2/ ebruary /51