Evidence Based Practice

Evidence Update: Overground Supported Stepping in Individuals with Non-Ambulant Cerebral Palsy

October 09, 2023 by Elena Noble, MPT

A boy walks in a Rifton Pacer while his caretaker talks with him.Providing supported gait opportunities for individuals with multiple disabilities is a foundational therapy intervention. For those diagnosed with cerebral palsy (CP), assessing motor function and the use of adaptive mobility and positioning devices helps determine their level on the Gross Motor Function Classification Scale (GMFCS). Individuals with CP in GMFCS levels of IV and V are more severely involved and cannot walk independently; their lives are largely sedentary. They require extensive adaptive support for all mobility and positioning including gait trainers, standing devices and wheelchairs. Progressing musculoskeletal impairments such as contractures and windswept deformities are common in this group, along with pain, declining cardiovascular fitness and limitations in function.

For children in this group, targeted opportunities to be upright and actively use their muscles in functional tasks improves quality of life, benefits social interactions and offers necessary changes in position to reduce secondary impairments later on.

In tandem with a previous systematic review looking at supported stepping devices outcomes in children with multiple disabilities, another newly published scoping systematic review highlights the use of these devices in children, adolescents and adults with non-ambulant cerebral palsy. Some of the findings are note-worthy in a population and topic that is otherwise less researched.

Specifically, through expanding the scope of their search to include case studies, descriptive and grey literature, the researchers documented the successful use of supported stepping devices in over 700 individuals with non-ambulant CP. In combination with reports from families and therapists surrounding the benefits of gait training, this finding suggests the current provision and use of gait trainers in this population continues to be best practice.

Supported Stepping Devices and ICF Outcomes

Using the ICF and F-Words Model for Childhood Disability, this review reported the benefits of supported stepping devices across the domains of body function and structures (fitness), activity (function) and participation (friendships) from as early as nine months on into adulthood. Although some therapists prescribe gait trainers for improving mobility, the authors note that individuals with non-ambulant CP typically use powered wheelchairs for this functional mobility. Supported stepping devices are more appropriate to improve fitness and participation. Parents of children in GMFCS levels IV and V also tend to specify gait training goals focusing on physical activity, increasing independence and improving participation in activities of daily living.

The authors additionally reported on the utilization of supported stepping devices according to age, GMFCS level and outcome. The findings were diverse, making it hard to identify any clear trend. Thus, the prescription and choice of gait trainer continues to be highly individualized taking into account funding, availability, transfer capabilities, environment and postural support features.

This scoping review provides a comprehensive look at the literature pertaining to supported stepping in individuals with non-ambulant cerebral palsy. Clearly there are remaining research questions to be pursued in the future. Regardless, it still stands that providing individuals with CP in GMFCS levels IV and V opportunities to be upright and weight-bearing improves quality of life through the reduction of sedentary behavior and scope for increased participation.

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Livingstone RW, Paleg GS. Use of overground supported-stepping devices for non-ambulant children, adolescents, and adults with cerebral palsy: A scoping review. Disabilities. 2023; 3(2):165-195. https://doi.org/10.3390/disabilities3020012

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Susanna | October 10, 2023
I am a PT in the school system. I find that elementary school children love being in gait trainers. By middle school and definitely by high school students are rejecting their use even in PE. Any ideas on motivating older children are welcome. I do realize that these older students may regain an interest as they get older than high school as maybe they develop an interest in fitness. Thank you
elena | October 11, 2023
Hi Susanna, Thank you for your comment. Certainly it is best practice to keep the ICF's "F-Words for childhood disability" framework in mind when structuring any activity for children and young people. This framework guides us to think of interventions that are participatory (friendships), age appropriate, and fun. Here is an article with an associated webinar describing ideas for creating engaging physical activity opportunities for children using adaptive equipment. https://www.rifton.com/adaptive-mobility-blog/blog-posts/2020/november/physical-activity-disability-and-health