Robert's Progress with the Pacer

By Ann Orcutt, PT KC Kids Early Intervention Reedley, CA

September 13, 2008

RobertArticleImage Robert was born in September of 2005, and had an accident when he was about 6 months old, resulting in brain injury and hemiparesis.

After approximately a year of therapy with another therapist, Robert came onto my caseload in August 2007, for early intervention physical therapy in the home. He was almost 2 years old. At that time he could not sit independently or move independently; he had no mobility while on the floor. He was reluctant to use his right arm, and had weakness in all extremities with significant extensor tone. In addition, his vision is limited, due to some resolving cortical visual impairment.

With the extensor muscle tone in his legs, he was able to stand briefly, and with a lot of support he could lean forward. But because of Robert’s extreme irritability at that time, any change in positioning was very difficult.

I decided to try the Pacer. In the Pacer, he was able to stand longer and he developed more strength. But it was really only in November of 2007 that he began to love it and discover independent movement. He would do a thrust motion with both legs together; the movement was backward or sideways at first, and then he accomplished forward movement.

His home has linoleum in their kitchen and then a little threshold piece where it goes to carpet. At Christmastime, Robert was finally able to make that transition. He kept trying and trying. His parents were wonderful - they wouldn’t help him and he continued to try. They filmed this on a little video with their cellphone. Robert pushed himself over that threshold and it was amazing – from then on, he developed his problem solving. That was what got him going.

The Pacer changed his whole status. When upright, he is able to see something and get to it; it has positively impacted his vision impairment. Being up off the ground has promoted his interest in his surroundings. Now Robert is completely independent in the Pacer and he goes everywhere in it. He has achieved a reciprocal gait. He can go from the kitchen area to the living area and down the hallway and turn. 

Now his parents see Robert as independent, plus he’s got attitude. They just love it when he can get away from them, or chase them. This really changed their relationship with him: the Pacer gave his parents a lot of hope. That is the really great part.

The gait trainer has been paramount in his development; it has been the most wonderful input for him. Once Robert was in the Pacer, his strength improved dramatically. On the floor, he began rolling everywhere, and demonstrated directionality of his movement. He can stand briefly. He can sit independently. He can transition from sitting to the floor. He is starting to combat-crawl. I believe a lot of this is from the strengthening of the core muscles and extremities that he gained while using the gait trainer.

Use of the Pacer has also helped the posturing of his right arm, which he uses more now. Because of the overall strengthening, particularly the core strengthening, Robert doesn’t have to fixate so much with his upper extremities when sitting and is able to use his hands more.

All this carried over to floor mobility. This was opposite to the sequence of NDT, where you try to get floor mobility before you get upright mobility. With the Pacer, we were getting the upright mobility and then because of the overall strengthening, his floor mobility and transitions were getting filled in.

I think he will still gain additional motor skills; it is just taking time. Because of the hemiparesis, Robert cannot yet assume an all-fours position, nor can he cruise at a sofa with lateral mobility, but he has certainly gained independent floor mobility. And with this independence, his directionality is down. He figures a lot out from the trial and error of his active movement; I believe it is stimulating his cognition. I believe without the Pacer all this would have taken twice as long, or perhaps he would never have gained it at all.

We do not use the arm prompts on the Pacer because of the retraction of Robert’s right arm – he resists being secured below the elbow. We use the hip positioner and the chest prompt. With the hip positioner secured well, we loosen up the chest prompt to encourage development of his core stability; he does not rely on it as much. Now we are removing the hip positioner for about 50% of the time that he is in the Pacer. We couldn’t have removed the hip positioner three months ago, because he was sitting on it while pushing himself to move. Now he really stands, with more strength of his legs. We are getting closer to removing the hip positioner entirely.

Robert’s excessive extensor tone has reduced quite a bit; this could be because of the overall strengthening, and perhaps also because of all the proprioceptive input he has with his floor mobility and his rotating while standing.

His parents are totally incredible with him; they are amazing. They really push him and encourage him. His dad brings the Pacer along in the front seat of the car to Robert’s daycare and family visits. 

His baby sitter has a big patio and a big open house, so when he is there in the Pacer, he is upright and completely mobile with his peers; he doesn’t have to be carried. It has promoted his socialization and interactions. Even his vocalizations have become longer. So his communication is evolving as well.

His sibling Anthony, of course, interacts with Robert while he is using the Pacer, and this has a huge impact as well, giving him motivation and making it more fun. They have developed a bond that you would have to see to believe.

Robert's use of the gait trainer has been the most wonderful work in progress; about nine months or so in the making.  A real success story.

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