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Guide walking

Promoting movement & active participation for rehab children

Walking is the basic form of human locomotion and our most important movement. When the ability to walk is impaired, our whole life changes.learning to walk is an impressive process, recognizable by the length of time it takes a child to do so. It requires not only strength, endurance and agility, but also coordination, balance and processing of all sensory impressions.

Children who cannot walk without help due to a disability or whose motor development is delayed therefore need our best possible support. Intensive therapeutic guidance and suitable aids enable these children to experience the sense of achievement of being able to walk themselves. What a great gain in quality of life and participation for children and their families.

Milestones of child development

On the way to crawling, sitting, standing up and finally walking, children develop very differently. But as great as the differences in time can be, there are some milestones that provide guidance in child development.

3 to 4 months

The baby can safely lift its head in the prone position and keep it free. To do this, it leans on its forearms and controls this movement.

3 to 7 months

Beginning to turn independently to both sides and roll over to prone position and back onto back.

7 to 10 months

The baby starts crawling - that is, moving on all fours on its own. In doing so, it has its own individual movement pattern.

9 to 10 months

Safe, free sitting with straight back and good head control, both hands are free to play.

9 to 15 months

The child pulls itself up to a safe standing position on chairs, tables or shelves. Then he learns to take his first steps along furniture and walls.

9 to 18 months

The child learns to walk freely, but still needs support from parents' hands or furniture and walls.

18 months

Free walking is now possible. In the playground, on the meadow, on field and forest paths, the child now tries out his abilities.

2 to 3 years

The child knows how to handle his body more and more confidently. He can already run and hop and learns to climb stairs.

2.5 to 3 years

Driving toys are very popular. The child learns to ride a tricycle or a running bike. It is also possible to race over shorter distances.

4 to 6 years

Children at this age are usually ready to master complex movement sequences. They want to and can learn to ride a bike on two wheels.

Important to know

Some children have impaired or significantly slowed motor development due to illness, disability or premature birth. They need professional support in their movement development.

Sought - found

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With walking trainers, children learn to walk in natural movement sequences and are supported in this. Which walking and running trainer supports your child's development and fits into your child's everyday life?


Recognize problems in the development of movement

The development of a healthy ability to move in children is of great importance for physical, mental and emotional development as well as body perception. Unfortunately, a disturbance in the development of movement is not always recognized immediately.

Due to illness or disability, children's movement development can be significantly delayed and impaired. Sometimes a disability is only recognized and diagnosed through a conspicuous and slow motor development.

In approximately 10% of children, pediatricians believe that these children do not reach their motor development milestones within the usual time frame. A Developmental delay is present. Early intervention and other therapeutic measures support children in learning the missing movements. Late effects are thus specifically prevented or reduced.

In about one third of children with developmental problems, there is an identifiable disease or development is so problematic without a specific diagnosis that a permanent disability results. In these children, there is no delay, but rather a Developmental disorder which manifests itself, among other things, in a permanent gait disorder.

In Germany, about 100,000 children and adolescents live with a severe gait disorder. This usually congenital movement disability accompanies the children throughout their lives. It should be treated early and permanently in order to train and maintain existing movement potential.

A disturbed motor development can be clearly recognized by "missed" milestones and thus by a too slow pace of development.

What is a gait disorder?

If the human musculoskeletal system is disturbed, abnormalities occur in the gait pattern. For example, gait unsteadiness, limping, stumbling, muscle weakness (flaccid muscles) or spasticity (spasmodically increased muscle tension), dystonia (excessive movements) or twisted leg positions may appear. These disturbed movement patterns have neurological, muscular or bony causes. If several forms of gait disorders occur simultaneously, a complex gait disorder is present.

Parents should be aware of these warning signs:

Weak muscle tension

Also called muscle tone, is in one or more areas of the body, the child is "floppy" and has difficulty holding himself upright.

Side differences

Distinct in posture and movement, the child can not center on his own body center.

Unusually high muscle tone

The child is "stiff" and cannot control muscle spasms.

Balance control

Problems with balance control, the child falls frequently and drops objects.

Movement patterns

Movement patterns and early childhood reflexes from the first months of life are retained, e.g. the grasping reflex when the inside of the hand is touched.

Motor restlessness

The child shows uncontrolled, overactive behavior, characterized by general restlessness and inattention.

Promote movement in a targeted and successful manner

Children with movement disorders should also have the opportunity to live out their natural urge to move. This is supported by professional medical-therapeutic care and the provision of suitable aids.

Depending on the type and severity of the movement disorder, there are different treatment options. Targeted physiotherapy strengthens the muscles and trains movement sequences. Medications help to improve muscle tone and reduce cramps. Orthoses, i.e. splints, are effective for orthopedic problems; in some cases, malpositions are corrected by surgery. To get around in everyday life, children use walking aids with which they can learn and train to walk independently.

Goals of the standing and walking training

Being mobile means learning through movement and plays a central role in the treatment of physically disabled children. Being able to be active oneself, to feel one's own movement - this significantly promotes senso-motor and psycho-social development.

Sensory-motor goals:

(functional unit of perception and movement)
  • Preservation and training of muscle strength
  • Regulation of muscle tension
  • Reduction of joint and muscle contractures
  • Improvement of lung function
  • Strengthening the cardiovascular system
  • Stimulation of metabolism and regulated digestion
  • Promote bone growth and bone density
  • Optimization of motion sequences
  • Development of the natural (physiological) gait pattern
  • Improvement of body perception and position in space
  • Preservation and promotion of cognitive functions such as attention, concentration and orientation

Psycho-social goals:

  • Interaction with the social environment at eye level
  • experience upright position as easier to contact other people
  • independent, self-determined exploration of the environment
  • Experience the joy of movement
  • Enable participation in everyday activities
  • Strengthening self-confidence and self-esteem
  • gather new experiences

Use of aids for gait training

To use a gait trainer, the child and gait trainer should meet certain requirements to provide the child with a safe and successful mobility experience.

Child
Muscle strength and coordination available to learn and train alternating weight-bearing steps - Cognitive ability to direct and move the gait trainer toward a specific goal - Motivation to use a gait trainer.

Walking trainer
suitable for the respective developmental stage of the child - individually adjustable and growing - secure hold for the child | as little as possible, but as much as necessary - give the child sufficient freedom to be able to exploit movement potentials - enable and encourage togetherness (participation) in daily life


Which dimensions are decisive - and why?

In addition to the described abilities that children and adolescents must have for the use of a gait trainer, the following body measurements and data are also important for the selection of the appropriate aid. You should always keep an eye on your child's growth and adjust the gait trainer accordingly or change to the next size.

Step length

Many walking trainers are equipped with a saddle or other seating option. This allows the child to sit down for short breaks if the walking training has become too strenuous. A saddle provides additional safety so that the child does not immediately fall into the void in the event of exhaustion or stumbling.

To ensure that the saddle height fits well and does not interfere with gait training, the child's crotch or inner leg length is important. The measurement is taken on the inside of the leg from the crotch to the sole of the foot. The child can either stand or lie down while being measured, with legs extended as far as possible. Or it is measured in a sitting position on the inside of the leg from the crotch to the knee and further from the knee to the sole of the foot.

If the child wears orthotic or stability shoes during running training, the height of the shoe soles should also be taken into account.

Chest / thorax circumference

If children need a lot of support in the upper body during gait training, support rings or pads provide the necessary support and an upright posture. The thoracic circumference must be determined to ensure that these neither constrict the child nor provide too much clearance and thus instability.

Measure the circumference of the rib cage about a hand's width under the armpits. Depending on the upper body stability of the child, the support must fit tightly or can be somewhat wider.

In any case, it should allow the child in the gait trainer enough freedom of movement for training.

Body weight

Like rehab strollers or children's car seats, mobility aids can only bear loads up to a certain user weight. The design is tested and approved for this maximum load.

Make sure that your child is not too heavy for the walking trainer and choose the next size if necessary. If overloaded, connecting elements can break and your child can fall with the walking trainer. There is also a risk of tipping over if the maximum load is exceeded, especially with active children.

Many walking trainers have a Integrated suspension, which supports the walking movements of the child and cushions shocks. Here, too, make sure that the child's weight and the weight of the spring match. If the child is too light, the suspension is not effective and cannot provide support. If the child is already too heavy, the suspension will also not work optimally.

Always seek advice from therapists or rehab consultants when "measuring" your child. Then the new gait trainer will fit right from the start.


Where to go,
I now decide for myself!

Running as a sense of achievement is important for the development of all children. This is because intrinsic (inner) motivation drives children to move around independently - whether with or without an aid. The child's environment can provide further support.

What motivates children to run?

In addition to the internal (intrinsic) incentive, other external (extrinsic) influences motivate the child to run.

  • Getting from one place to another in a self-determined way
  • Feel joy through independent movement
  • Discover new things independently
  • Meeting other children at eye level and experiencing community
  • Facing new challenges

Support

Parents accompany the child on the way to independent walking with a walker. As with all children, they can support the learning process with the following tips:

  • Make the environment safe so that the child can move freely with the walker without obstacles
  • Observe proper fitting and adjustment of the walking aid
  • Set up small "stopovers" for a sense of achievement
  • Ensure sufficient breaks and rest to gather strength for the strenuous walking workout
  • Celebrate even small progress and successes and give the child self-confidence
  • Take physical, motor and cognitive characteristics into account
  • Retrieve and practice tips and exercises from therapy sessions
  • And last but not least: Have patience and do not slacken in the so important support for the child

Impulses forward

"Children with a strong tendency to walk backward need forward impulses for a forward leaning posture. A gait trainer with a special design that promotes a forward body posture or provides impulses for forward movement helps children walk forward."


What does anterior walker and posterior walker mean?

Anterior and posterior walkers are repeatedly mentioned in the provision of mobility aids. The terms "anterior" and "posterior" come from the Latin language, which is often used in medicine to designate something.

Anterior Walker

The term "anterior" is, among other things, an anatomical position designation and means "located further forward". (Latin: anterior, anterius - the anterior).

An anterior walker is a walking aid that can be BEFORE the child is located. The child pushes his walker in front of him. The senior rollator, for example, is also an anterior walker, which makes everyday life easier and safer for many older people.

The advantages

Walking aid for child visible
Since the child can see his walker in front of him, orientation is easier. The child can better estimate how much space it needs with its walker. The open access to the rear also makes it easier to transfer the child to the walker without having to turn around.

Brake system
Mostly, anterior walkers are equipped with lockable hand brakes that allow the child to brake independently. It can better control the walker itself.

more security
Having the walker in front of them gives the child more security, as they don't have an "empty space" in front of them. This helps especially insecure children who need a little more support.

The anterior walker is well suited for short-term use to quickly cover distances by themselves, e.g. at home, at kindergarten or at school. However, due to a stronger flexion of the hips and upper body, children often walk very far forward in this walker. Here, the caregiver should provide corrective support during walking training.


Posterior Walker

"Posterior" is also an anatomical positional designation and means "located further back" or "more posterior". (Latin: posterior, posterius - the posterior, following).

The child pulls the posterior walker behind him/her when moving around. The walking aid is therefore BACK the child.

The advantages

Freedom of movement
Due to the open space to the front, the child has full access to his environment in front of him (people, doors, tables, toys, etc.) Interactions and participation are actively encouraged.

better posture
When walking in the posterior walker, a better, more upright posture is possible. The child's shoulders are guided more backwards, which automatically ensures a more upright gait.

faster walking
With a posterior walker, the child can achieve a good gait speed and progress faster. A nice and motivating sense of achievement to be able to keep up with others.

The Posterior Walker gives children a sense of freedom and self-determination due to the open space to the front - no tube or hand arch restricts the view. By supporting good posture, it is a long-term solution for children with chronic neurological conditions such as spastic diplegia in cerebral palsy.

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Case study - Mille

A new walking aid gives MILLE a great deal of independence and plenty of motivation for their walking training and for improving their skills.

A new target

15-year-old Mille lives with a diagnosis of Rett syndrome. Mille can walk with the support of a VELA Meywalk 2000 and she is happy with her gait trainer. It gives her the freedom to decide for herself in which direction she wants to go - without Mille having to be guided by her parents or caregivers who might want to go in a different direction.

Since Mille has been training with the walker, she has been able to walk considerably longer distances. This has also increased her desire to walk even further distances on her own. Her strength and endurance have also improved significantly - and if she does need to rest, she can sit on the seat. The goal of the training is for Mille to be able to walk herself to her father's work before she turns 16 - a distance of 4.6 km.


"Now we don't have to think about how much energy Mille has left before each walk - and whether we'll have to carry her home when she gets tired.

When we are out and about, Mille has both hands free. This gives her the opportunity, for example, to pick up the cat for petting, to pick flowers or to throw a stick for the dog - and Mille laughs when he rushes off to fetch the stick. Mille is happy, which in turn gives us energy for everyday life with her.

And we can look at each other at eye level when we talk or sing. That gives us great joy."

- Mille mother


Accessories for gait trainer

Once a gait trainer suitable for body size and weight has been selected, accessories are used to further adapt it to the child's different needs. Depending on the therapeutic objective, suitable accessories support gait training from the very beginning - from the first unsteady steps to successfully walking longer distances.

Upper body support

Good support in the upper body and pelvic area is a prerequisite for successful walking training. If the child lacks the necessary stability, the gait trainer must provide support here so that the child can focus better on walking. Accessories such as thorax rings, thorax pads, hip pads, abdominal cushions or belts hold and stabilize the child's upper body while allowing the legs and feet full freedom of movement.

Steering stop

Especially at the beginning of walking training, children still lack the practice to steer the walking trainer. It is difficult for them to concentrate on maneuvering as well as walking. An activated steering stop allows the wheels to roll in only one direction, which gives the walking trainer stability and the child is not unsettled by "spongy" driving behavior. With increasing practice, the child becomes more confident, now the steering stop can be deactivated to also train steering with full 360° rotation.

Backstop

Some children have difficulty getting into a forward movement. Their body's center of gravity tends to be shifted backwards due to their overall posture, which is why they tend to only walk backwards in the gait trainer. A backstop prevents the gait trainer from rolling backwards. So it only goes forward, or not at all. A backstop should ALWAYS be combined with a TIP PROTECTION.

Anti-tilt

The tilt resistance of a gait trainer is especially important for very active older children and adolescents. They should be able to exploit their movement potential with the greatest possible safety. For this reason, small "support wheels" are mounted on the rear wheels of the walking trainer with a distance of a few cm from the ground. Many are familiar with these "safety wheels" from wheelchairs. In both cases, the anti-tipper prevents tipping over backwards.

Grinding brake

Children with a lot of urge to move and exuberant movements often start running very quickly in the gait trainer. Such a lightning start makes it difficult for the children to keep control of the walking trainer. A sliding brake makes the walking trainer more sluggish, as the wheels are permanently braked slightly. Although this makes moving around a little more strenuous, it helps the child to walk in a controlled, purposeful manner. The strength of the braking effect can be individually adapted to the child and also changed.

Seat-brake system

Gait training is an enormous mental and physical effort for the child. For rest and more safety, many walking trainers have a saddle on which the child can sit. However, this also tempts the child to comfortably move forward with their feet while seated instead of walking independently. This is prevented in gait trainers with a seat-brake system. If the child sits on the saddle, it can rest - but at the same time, the weight on the saddle activates a brake. Only when the child gets up again does it continue.

Leg separation plate

When children cross their legs during running training, they are constantly getting in their own way, so to speak. The cause is often an inward rotational misalignment of the legs or feet. A leg separation plate underneath the seat prevents the legs from crossing and helps the child to move forward in the gait trainer.

Leg braces

Children with outward rotational misalignment of legs or feet repeatedly bump into the outer frame and wheels of their walker. Or their feet get trapped under the frame, causing them to trip. Leg splints near the floor on the right and left sides of the gait trainer can prevent this and guide the child's legs and feet safely forward.

Wall deflector

If the walking trainer is used indoors, children must be able to maintain the direction of travel and move from one room to the next by steering skillfully. This does not always work smoothly and the children bump into walls and door frames with their walking trainer. Bumper rollers" or wall deflectors above the wheels cushion and deflect the impact of the walking trainer. The children do not get stuck on the wall and find their way more easily - and walls and doors are also spared.

Rigid or swiveling wheels?

"For children with ataxias whose movement coordination is severely impaired due to uncontrolled and excess movements, the gait trainer should have rigid wheels or the steering stop should be used with swivel wheels. This makes it easier for children to walk straight with their gait trainer."


Status survey - What assistive devices does my child need?

A needs assessment form makes it easier for parents, caregivers, and providers to clearly describe and document a supply of assistive technology.

Many stakeholders are involved in the provision and use of assistive devices. In order to find the best possible aid for the child's development and participation in the respective environment, it is advisable to clearly document and describe the need.

For example, the following information is gathered:

  • general information about the child
  • accompanying therapeutic measures
  • Classification of the degree of disability (e.g. according to GMFCS)
  • Body functions (physical and mental)
  • Activities and participation

The classification of motor impairments in children with cerebral palsy is based on the Gross Motor Function Classification System (GMFCS for short) of the ICF. The GMFCS system includes five levels. The classification is based on the ability for independent mobility and the need for assistive technology support. Parents can help with the classification, as they can usually assess their child well. GMFCS is simple and quick to use, requiring only about 15 minutes for experienced professionals.

Stage I

Free walking without limitation; limitation of higher motor skills.

Stage II

Free walking without walking aids; limitation in walking outside the home and on the street.

Level III

Walking with walkers; limitation in walking outside the home and on the street.

Stage IV

Independent locomotion limited; children are pushed or use e-wheelchair for outdoors.

Stage V

Independent locomotion severely limited even with electrical aids.


Illustrations taken with kind permission from: "GMFM and GMFCS - Measurement and Classification of Motor Functions", Dianne Russel et al. Verlag Hans Huber, Hogrefe Verlag, CH-Bern, Ill. Prof. Kerr Graham, AUS-Melbourne.

Status survey to determine the need for aids

Use the survey form from rehaKIND e.V. to document the provision of aids.


What is the ICF
and why is it so important?

The basis for the provision of assistive devices is not only legal requirements such as the entitlement to benefits for assistive devices, self-determination and participation in SGB XI. The ICF must be taken into account when assessing and justifying the provision of aids.

ICF means "International Classification of Functioning, Disability and Health". (The ICF is a classification of the World Health Organization (WHO), which was first created and published in 2001 and is considered a globally recognized standard. It describes the current functioning, activity and participation of a person in order to derive participation goals, support measures and process recommendations.

Significance of the ICF for the provision of assistive devices

Aids are intended to ensure the success of medical treatment, prevent an impending disability or compensate for a disability. For the successful provision of an aid, an individual care concept must be created for the child.

For this purpose, the classification according to the bio-psycho-social model of the ICF is included. This model describes a current state of health and the interaction between the components. With the help of the ICF it is described what the child can do and what help and support he needs.

Objective: Assistive device supply walker

With the help of the ICF classification, for example, a supply of a walking frame for children is requested. The goal-oriented justification of the supply is always better than having to formulate an objection later. Example:

Significance of the ICF for the provision of assistive devices

Health issue: ataxic cerebral palsy

Body functions and structures:

  • Increase low muscle tension (hypotension)
  • Strengthening of the trunk and leg muscles
  • Improvement of vital functions

Activity: purposefully and in a controlled manner master 100 meters with an indoor walking trainer

Participation: participate independently in school presentations directly on the blackboard or whiteboard

Environmental factor: barrier-free room change in the kindergarten possible, suitable aid (walker for children) available

Person-related factor: Create motivation to walk independently with an assistive device, cognitive ability to steer available

The right to participation

"Again and again there is talk of the right to "participation," that is, "being included in a life situation."

For people with disabilities, there is even a legal entitlement to participation in SGB IX and thus also to aids such as gait trainers. This is because they promote self-determination and equal participation in social life. This active participation is an important building block in child development."

You can also find more important and exciting information on the topic of "participation" in our children's rehab podcast.


FAQ - Frequently asked questions

New concept of disability since 2018

The ninth Social Code (SGB IX) defines the rehabilitation and participation of people with disabilities. Since 01.01.2018, the legal definition of "disability" has been changed in this Federal Participation Act. It is no longer physical, psychological or mental "functional impairments" that are a prerequisite for the existence of a disability, but social contextual factors (personal and environmental) that are associated with impairments.

Section 2 (1) sentence 1 SGB IX states:
People with disabilities are those who have physical, mental, intellectual or sensory impairments, which, in interaction with attitudinal and environmental barriers, are likely to prevent them from participating equally in society for longer than six months. An impairment according to sentence 1 exists if the physical and health condition deviates from the condition typical for the age of the person. People are at risk of disability if an impairment according to sentence 1 is to be expected.

Why must the maximum permissible body weight for rehab aids be taken into account?

Please always observe the maximum permissible body weight for the use of a walking trainer. In the event of overloading, connecting elements could break and subsequently cause your child to fall. You will find information on this in the operating instructions or on the type plate on the frame of the gait trainer.

Can my child fall over with the walking trainer?

Walking trainers are tested for tipping stability and are only approved for use if they pass the required tipping test. However, you should not let your child walk with a walking trainer unsupervised. Furthermore, you should not use walking trainers on very uneven or steeply sloping surfaces.

Can I customize the walking trainer myself to meet my child's needs?

The adjustments and adaptations of the gait trainer to the abilities and growth of your child must always be carried out by trained or instructed specialists (e.g. medical product consultants from the medical supply retailer or therapists).

(We will gladly give you the name of a specialist in your area: 04761 8860)

What is the difference between a gait trainer and a walker?

Walking aids are aids in which the child does not need any further attachments, but above all need a securing function for support. The best-known example is a "rollator", which many are familiar with from rehab care for seniors.

Gait trainers are aids in which individually adaptable accessories and support functions enable children with greater motor deficits to walk.

How many years may gait trainers be used?

Walking trainers are suitable for reuse, which means that your health insurance company may also provide you with a used walking trainer. However, these rehab products are subject to exceptional wear and tear. Based on market observations and the state of the art, the manufacturer calculates and determines a product service life and a number of reuses when used properly and taking into account service and maintenance work. Times of storage at the specialized trade are already taken into account in the service life.

Does prescribing gait trainers put a strain on my doctor's budget?

In contrast to medicines and remedies, the prescription of medical aids does NOT burden the physician's budget. Aids are paid for by the health insurance fund. That is why the provision of an aid must be approved by the health insurance company in advance. Info for differentiation:

  1. Drugs are substances intended for the cure or prevention of diseases (medicines)
  2. Remedy are all personal medical services, e.g. physiotherapy, medical treatment
  3. Auxiliary means are all material medical means that serve the treatment of the sick.
What is the list of aids?

 

The list of medical aids of the statutory health insurance in Germany contains a list of those medical aids whose costs must be covered by the German statutory health insurance according to the Medical Aids Guideline of the Joint Federal Committee.

New products are included after the Medical Service of the National Association of Health Insurance Funds (MDS) has examined the prerequisites.

However, aids that are not listed in the list of aids can also be covered by the statutory health insurance. This applies if an aid corresponds to the generally recognized state of medical knowledge and is necessary, sufficient, appropriate and economical.

The list of therapeutic appliances is thus not an exclusive "positive list", but rather summarizes relevant information on therapeutic appliances in the form of a list and provides an overview suitable for comparison purposes.

Where can I find walking trainers for children in the list of aids and how are they described?

The product group "Walking frames for children" is included in the scope of

10.46.02.3xxx of the list of medical aids.

Description:

Walking frames for children usually consist of a tubular frame with four castors or wheels. They can be equipped with seats, back and pelvic pads, and various holding systems that give the children as much freedom of movement as possible to move around the living area independently or with the help of an accompanying person.

Some products can also be equipped with various optional accessories such as splay seats or leg rests, height-adjustable underarm supports and height-adjustable underarm supports.

Indication:

  • Impairment of mobility in the case of damage to movement / coordination / balance in children (e.g. in the case of damage to the CNS).
  • For maintaining / promoting / securing walking and standing / movement development / stabilizing posture (walking or learning to walk training), also with partial or complete weight relief

(Service area according to the recommendations § 126 SGB V: 10B)