The way we view childhood disability is changing. As physiotherapists, we are being encouraged to shift our attention away from purely addressing a child’s body structure and function (that is interventions which focus on muscle length or strength) to a more holistic approach - one which understands how the child participates at home, at school and in their community. In 2012, Professor Rosenbaum and colleagues at CanChild in Canada pioneered the six ‘F-Words’ to encourage clinicians to consider the wider picture, taking emphasis away from the physical impairment. They suggested that ‘Function, Family, Fitness, Fun, Friends and Future’ should be the focus for those working with children with disabilities (View our F-words poster and goal setting worksheet). This refocus has yielded results, and in 2020 Novak et al (2020) noted that since their last review there had been an increasing interest in both interventions that encourage a child’s participation, and in approaches that addressed barriers to participation.
The use of walking frames/ gait trainers/ support walkers is an area of therapy that is continuing to gain pace. Traditionally, children who were unable to sit or walk unaided were denied the chance to walk using a supportive frame due to concern that the atypical gait pattern may negate any physical gain. Now, with advancements in equipment and changes in clinical thinking, more and more children can experience the numerous social, emotional and psychological benefits of walking. For physiotherapists, being able to evaluate the impact of these devices is key to whether that piece of equipment is appropriate for the child, and the choice of outcome measure chosen to assess impact will very much depend on the goals set.
In practice, the use of outcome measures can sometimes be seen as an overwhelming and time-consuming task which doesn’t contribute much to the clinical picture – most therapists would rather actively treat than spend time doing long, arduous measures. However, measuring the effectiveness of an intervention can be relevant to the child’s progress AND quick. For example, if the goal of using a walking aid is to increase the distance that they can mobilise, then simply recording steps/ distance over a set period, at set intervals e.g., every 3 months, can be a useful marker for the child and all who are involved in their care. Or if the goal is to increase the child’s aerobic activity, then recording their heart or respiratory rate before and after using a walking frame will indicate if effort has increased.
Increasingly, clinicians are being asked to conduct more formal outcome measures to show the validity and effectiveness of their interventions. Livingstone and Paleg (2016) completed an evaluation of the reliability, validity and clinical utility of outcome measures for gait trainers (walking frames that provide trunk and pelvic support). They found that The Paediatric Evaluation of Disability Inventory (PEDI) rated highest across all categories. Other measures, such as the Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling (GAS), Quebec User Evaluation of Satisfaction with assistive Technology (QUEST 2.0) and the Supported Walker Ambulation Scale (SWAPS) show potential for further gait trainer outcome measure research.
From watching children use their frames in home and school environments, we felt that some of these outcome measures missed a link between everyday functional walking tasks, e.g., active standing, turning, navigating a corridor, kicking a ball, and the child’s progress, and thus have developed a function-based Walking Skills Assessment to enable children, caregivers and therapists to quickly and easily chart progress with walking skills over time. This Walking Skills Assessment can be used
- as a descriptive indicator of where a child is at,
- to capture small gains in skills,
- and to show families the next steps to be working on.
Try it out and send comments and suggestions to firstname.lastname@example.org.
With regards to outcome measures for walkers, one thing is clear, encouraging children who cannot walk independently to use additional support will increase their participation, and being able to demonstrate and record progress, no matter how small, is a valuable tool for everyone.
- Livingstone, R.; Paleg, G. Measuring Outcomes for Children with Cerebral Palsy Who Use Gait Trainers. Technologies2016, 4, 22. https://doi.org/10.3390/technologies4030022
- Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, Langdon K, Namara MM, Paton MC, Popat H, Shore B, Khamis A, Stanton E, Finemore OP, Tricks A, Te Velde A, Dark L, Morton N, Badawi N. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3. doi: 10.1007/s11910-020-1022-z. PMID: 32086598; PMCID: PMC7035308.
- Rosenbaum P, Gorter JW. The 'F-words' in childhood disability: I swear this is how we should think! Child Care Health Dev. 2012 Jul;38(4):457-63. doi: 10.1111/j.1365-2214.2011.01338.x. Epub 2011 Nov 1. PMID: 22040377.