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NF-WALKERDOCUMENTATION

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NF-WALKER DOCUMENTATIONNo Study Scope Conclusion

1 Björg Gudjondottir et.al Pediatr Phys Ther 2002; 14:38-46

Effects of a dynamic versus a static Prone stander on bone mineral density and behavior in four children with severe cerebral palsy.

Both children who used the dynamic stander showed increases in bone mineral density, versus only one of the children who used the static stander.

2 Eisenberg S1, Zuk L, Carmeli E, Katz-Leurer M. Pediatr Phys Ther. 2009 Spring;21(1):79-85.

Contribution of stepping while standing to function and secondary conditions among children with cerebral palsy.

22 children with severe cerebral palsy was included in the study. 11 underwent treatment using a Hart Walker (HW) device, and the other 11 underwent a passive standing program. Children exposed to the HW improved bowel function, and were able to take steps independently in the device. Providing a child who is nonambulatory the opportunity to walk may be important both for participation in activities of daily living and social roles and for preventing secondary conditions.

3 Virginia Wright, Jeffrey W. Jutai, Disability and Rehabnilitation: Assistive Technology 2006; 1(3):155-166

Evaluation of the longer-term use of the David Hart Walker Orthosis by children with cerebral pasly: a 3-year prospective evalutation

A pre-/post- test prospective one-group study evalutated outcomes three years after receiving the David Hart Walker Orthosis. The Hart Walker Orthosis remained the sole walking device for 13 of 20 children at 3 years and demonstrated improved ability overall to manoueuvre it during functional ambulation. Six of seven children who discontinued use were over 12 years old and had outgrown its maximum size.

4 Chritoph Kuenzle, Reinal Brunner, Journal of prosthetics and orthotics 2009;21(3):138-144

The effects of the Norsk Funktion-Walking (NF-Walker) orthosis on the walking ability of children with cerebral palsy and severe gait impairment

78 children with CP with little or no trunk control were able to walk with the NF-Walker with moderate to no assistance. An increase in body function and activity according to the ICF was achieved.

5 Dr. med. Christel Kannegieß, Germany

The NF-Walker in the rehabiliation of children with a pronounced movement disorder

The NF-Walker helps children with multiple disabilities who, without the device, would need strong guidance and/or support from a helper to walk. The NF-walker enables the child to cover longer distances, as a result of which walking is increased and the walking sequence can more easily be automated. This intensive walking increases muscle strength in both legs and upper body. There is also a positive impact on hip mauration, as this requires standing and walking stimuli.

6 Physiotherapist S. Schneiders, Germany

Does early application of medical aid devices make sense. Based on the example of the NF-Walker.

Experience with the NF-Walker in an institution. The NF-Walker offers the safety the children need and enables progress both in their motor and their socio-emotional development.

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NF-WALKER DOCUMENTATIONNo Study Scope Conclusion

8 Idoia Gandarias Mendieta. El Mirado N ͦ 121 July 2008

Original NF-Walker: Bipedestador dinámico y desplazador Translated: NF-Walker: Dynamic and mobile standing orthosis

The NF-Walker offers children the possibility to experience standing independently, both still and moving. The device guarantees a correct body alignment, allowing the lower limb flexor muscles to stretch and improving head control and trunk stability.

7 Martín Gómez M.; laguna mena c.: Martín Maroto M.P.; Arroyo Riaño M.O. Jornadas Cientificas de la Sociedad Española de Rehabilitación Infantil, Volumen 2, Madrid Marzo 2012

Origninal -Evaluación del andador NF-Walker Translated - Evaluation of the NF-Walker

According to the results attained in our study, we find that the NF-Walker is a higly relvant helping aid for children with spastic CP, GMFCS V. There is a high degree of satisfaction amongst parents, related to technological aspects, adjustment to their needs and autonomy granted; therfore it is overall a good option to be prescribed by rehabilitation doctors for these patients.

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AbstractPurposeIn this case series, we examined how two types of prone stander affected bone mineral density and be-havioral variables in four children of preschool age with severe cerebral palsy.

MethodsIn phase one, four children of preschool age participated in an eight-week standing program, standing for 30 minutes a day, five days a week. Two children stood in a conventional stander, and two stood in a new type of motorized (dynamic) stander that provides intermittent weight bearing. Measurements of bone mineral density before and after the program revealed increases in bone mineral density in both children who used a dynamic stander and one child who used a static stander. In phase two, all four subjects stood in both types of stander during three separate test sessions.

ResultsMeasures of behavioral variables, including behavioral state, reactivity, goal directedness, and attention span, indicated little or no effect of type of stander on behavior.

Conclusions These results suggest there is potential value in additional research concerning the effects of static and dynamic standers on bone mineral density and behavior in children with cerebral palsy.

Effects of a dynamic versus a static prone stander on bone mineral density and behavior in four children with severe cerebral palsy.Pediatr Phys Ther. 2002 Spring;14(1):38-46.Gudjonsdottir B1, Stemmons Mercer V.

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AbstractPurposeTo explore the feasibility and efficacy of stepping while standing and its effect on function and preva-lence of secondary conditions among children with severe cerebral palsy.

MethodsOf 22 children with severe cerebral palsy, 11 underwent treatment using a Hart Walker (HW) device, and the other 11 underwent a passive standing program. Constipation prevalence and adverse events were recorded. Bone quantitative ultrasound was performed for the tibia. The Pediatric Evaluation of Disabili-ty Inventory was used to assess activities of daily life.

ResultsChildren exposed to the HW improved bowel function, but no added quantitative benefit to bone was observed when compared with passive standing. Children using the HW were able to take steps inde-pendently in the device, but did not reach a functional walking level.

Conclusions Providing a child who is nonambulatory the opportunity to walk may be important both for participation in activities of daily living and social roles and for preventing secondary conditions.

Contribution of stepping while standing to function and secondary conditions among children with cerebral palsy.Pediatr Phys Ther. 2009 Spring;21(1):79-85. doi: 10.1097/PEP.0b013e31818f57f2.Eisenberg S1, Zuk L, Carmeli E, Katz-Leurer M.

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AbstractPurposeTo evaluate a walking device, the David Hart Walker Orthosis (HW), that was designed to allow children with severe cerebral palsy to ambulate with hands-free support.

MethodsA pre-/post-test prospective one-group study evaluated outcomes three years after receiving the HW. Physical therapy assessment, parent interview and satisfaction questionnaire provided details on out-comes.

ResultsChildren exposed to the HW improved bowel function, but no added quantitative benefit to bone was observed when compared with passive standing. Children using the HW were able to take steps inde-pendently in the device, but did not reach a functional walking level.

Conclusions Sixty-five percent of the children continued to use the HW as their sole walking device, and demonstrat-ed improved ability overall to manoeuvre it during functional ambulation. The primary reason for discon-tinuation was inability to accommodate taller children.

Evaluation of the longer-term use of the David Hart Walker Orthosis by children with cerebral palsy: a 3-year prospective evaluation.Bloorview Kids Rehab, Toronto, Ontario, Canada. VWright@bloorviewmacmillan.on.caWright FV1, Jutai JW.

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AbstractThe purpose of this study was1) to test whether an orthosis, which provides postural stability of the trunk and guides the leg movements during walking (Norsk Funktion-walker orthosis [NFWO]), would enable nonambulant children with cerebral palsy with poor or no leg coordination and with little or no trunk control to walk on their own,

2) to investigate if there is an increase in motor function and activity while using a NFWO, and 3) defining requirements for a successful provision. Ninety-three children (39 girls, 54 boys; mean age 7.6 years; 67 with bilateral spastic, 10 with dyskinetic, 10 with mixed, 6 with ataxic cerebral palsy; Gross Motor Function classification System level 4: 45, level 5: 48) were provided with a NFWO. The following assessments were carried out immediately before and 3 months after using the NFWO: WeeFIM walking score; independence rating by parents or caregivers; aims or expectations of parents or caregivers; at a mean interval of 265 days after provision: mean daily walking distance (meters). With the NFWO, 78 children (84%) became ambulatory, 10 children (11%) used it exclusively as a dynamic standing frame only, and 5 children (5%) returned the NFWO. The mean daily walking distance was 99 m (2–463 m). The mean WeeFIM walking score of 1.99 (SD 0.83) without the NFWO increased to 4.42 (SD 1.00) with the NFWO indoors and to 3.71 (SD 1.24) (p < 0.001) outdoors. Independence rating by parents or caregivers reflected a highly significant increase in independent mobility with the NFWO compared with locomotion without ambulatory aides (p < 0.001) and of bilateral hand function (p < 0.001). No significant increase in the mobility was found when comparing former mobility aides (wheelchair, tricycle) with the NFWO. The ability to cross obstacles did neither significantly increase with the NFWO. Successful indication for a NFWO depends on

1) the child’s motivation to walk and the support of the environment to achieve independent walking mobility through the use of this assistive tool, 2) the ability for selective reciprocal leg movements, and 3) no flexion contractures of hips and knees above 20° and a foot dorsiflexion of at least neutral-0°. The NFWO proved to be a useful ambulatory aid in the children with cerebral palsy with severe gait impairment to increase independent mobility.( J Prosthet Orthot . 2009;21:138– 144. )

The Effects of the Norsk Funktion-Walking Orthosis on the Walking Ability of Children With Cerebral Palsy and Severe Gait ImpairmentChristoph Kuenzle, MD Reinald Brunner, MD

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“If you want to learn to walk, then you must walk.” This fundamental of locomotion therapy (walking training using a special treadmill, also known as a “lokomat” (1)) applies in general terms irrespective of which aid is being used and even in the case of walking training without an aid.

Nevertheless, there are a number of things to be taken into consideration. The decisive question in the treatment of a child with severe multiple disabilities is often at what point the child can or may be introduced to supported standing and walking. The individual therapy areas have widely differing views on this question. While placing a child on his or her own feet or verticalisation at a very early stage carries the risk of scoliosis, delaying this stage runs the risk of disturbance of hip maturation to the point of dislocation, as the hip requires corresponding stimuli to achieve correct maturation. In this respect each child must be tested individually to determine from when verticalisation, i.e. placing upright in the vertical position, may be started (2). One factor frequently given far from adequate consideration here is the opinion of the child. Only someone who has experienced how a child who either cannot walk at all, or only with great difficulty and supported by helpers, reacts on taking his or her first independent (more or less cautious or assertive) steps in a walking training aid, can understand why ‒ to me ‒ the opinion of the child in this matter is so important. Even children with such severe disabilities that they are unable to express themselves verbally with phrases such as “I can do that on my own” or “walk like the others” sense the independence they have achieved and react accordingly with delight.

However, standing upright and walking training require an appropriate aid. This should support the child in standing upright and support the child’s own movements when walking as much as possible but not more than necessary. Anyone who is more interested in the exact structure of the NF-Walker and how it works, which has been investigated in a study, is referred to the corresponding literature (5, 3).

Instead, I would like to describe in the present article the experience of my patients in using the NF-Walker in therapeutic and everyday family settings. In my practice I use the system of psychomotor holistic therapy (2) I have developed and, among other things, draw up therapy programmes for children with multiple disabilities that the family use at home for regular training with their child. As a very large number of my patients are severely restricted in their motor activity, I use the NF-Walker relatively frequently with these children, and rate the opportunity it offers for flexible adjustment particularly highly.

I must stress here that the decision as to which walking training aid should be used for which child must always be a completely individual one, for example in the case of Nico. Nico is almost four years old and has been my patient since 2009. He was born 10 weeks premature, which led to a disturbance inpsychomotor development with pronounced tetra spasticity. Other areas are affected to a significantly

The NF-Walker in the rehabilitation of children with a pronounced movement disorderDr. med. Christel Kannegießer-Leitner, Sibyllenstr. 3, 76437 Rastatt, Germany

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lesser degree, for example he has made enormous progress in language in recent months.At home he undergoes a therapy programme within the framework of psychomotor holistic therapy that covers all areas. Particularly worth mentioning here are the exercises to help him crawl, as these work towards walking, on the one hand, and, on the other, represent important exercises to strengthen the back musculature and for hip maturation.

Not only were the overall programme and special aids such as a Mancini orthosis/hip abduction orthosis to counter adductor spasm (2) able to pick up the onset of partial dislocation, but hip maturation has improved to the extent that the hip is well covered and there is no longer any partial dislocation.As the hip requires standing exercises to achieve maturation, I suggested additional walking in a walking training aid.

The parents not only found out about the different walking training aids that were appropriate for Nico but we arranged for Nico to be able to try several of these devices for a couple of weeks at a time. Points to observe were Nico’s posture, how upright his upper body was, the position of the legs and feet, and the ease with which he walked. It was clear that Nico was best able to hold himself upright in the NF-Walker.

Figs. 1 to 3: Nico loves walking. Without an orthosis, adductor spasm means that he holds his legs crosswise and walks with the typical spastic foot drop and additional inward rotation of the legs, making guided walking impossible. There is a slight improvement using Nancy Hylton orthoses (2, 4) and the Mancini orthosis (2), but it is still extremely strenuous for the helper. The NF-Walker enables Nico to hold himself in a stable position and walk independently, going a little further every day. He clearly enjoys this. The guide bands support him in the alternating leg movements.

Thanks to the runner system and the attachment of these runners to the shoes, he is also best able in the NF-Walker to place his legs side by side and – without crossing them over – move them past each other. He still uses the Mancini orthosis when not in the NF-Walker; this would not be required in combination with the NF-Walker but he keeps it on to avoid having to constantly take it on and off. I have trained his parents in a special technique for getting Nico into the NF-Walker as easily as possible because, although Nico is only four years old, the standard method of first attaching the runners to the child while he or she lies on the floor and then placing him or her in the walking frame is extremely strenuous and not easy for the mother to manage on her own.

Nico is now placed in the ready-assembled device and the chest strap fastened, then the leg runners are

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placed in the catches on the shoes, the screws tightened and, finally, the knee strap fastened.This method is simpler and takes only a few minutes, so that there is still plenty of time left for walking, which incidentally Nico enjoys very much. He can already walk independently and is enthusiastic about extending how far he walks each day. And the NF-Walker had to go on holiday with the family to the Baltic – Nico insisted!

The NF-Walker can also be adjusted so that the child must largely stabilise the upper body him- or herself when walking. This is helpful if the child tends to want to lean, without needing to do so. This is the case with Christoph, for example. Christoph has a global disturbance of psychomotor development, the origin of which is unclear.

He was already able to walk on his own, but lost this skill as a result of an enormous increase in the frequency of epileptic seizures and the anti-epileptic medication administered as a result. In the meantime his condition has improved again, and the dosage of anti-epileptics was able to be reduced. Christoph has become more cheerful and lively again. He would very much like to walk, but also has a tendency to make it easy for himself by “hanging” in the strap. Without the top strap, he holds himself upright, places his legs independently and does better every day.

Exactly the same applies to Frank-Udo. Frank has Angelman syndrome, which involves severe impairment in all areas. He is now 22 years old and 1.80 m tall, which certainly doesn’t make handling any easier. For Frank, too, the top strap is left unfastened if he “hangs” in the strap system, and an extra strap is used at the waist for safety. Of all the children and young people described here, Frank- Udo is naturally the one I know the best: he is my son.

For many years our regular daily training (2) has included – alongside several other exercises –intensive walking training, either guided or on the treadmill. Frank became increasingly less willing to take part and often sat down after 20 m, although no one could explain why.

Fig 4 Christoph after approx. 3 weeks with the NF-Walker. The intensive training helps him to walk better and a bit further in it each day, if the top strap is left unfastened.When village life on the island proves particularly interesting during the holidays, Frank even manages to stand up straight with the upper strap fastened Figs 5 and 6. The kilometre he has already covered doesn’t show on him. Previously, we walked

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this stretch into the village centre without NF-Walker, but both of us were completely exhausted on arrival (I scarcely less than him). The adjacent photo of everyday training at home clearly shows that the upper strap is left unfastened, necessitating an extra strap at waist height for safety reasons, as is planned for Christoph.

What I was looking for was a way to prevent this sitting down. Luckily, it was right at this time that the NF-Walker was developed in a larger size. Everyone involved was highly sceptical as to whether it would be possible to get this extremely tall young man into an NF-Walker.

The method using a hoist didn’t appeal to me personally, as I wanted to remain able to move freely. So I was left with no choice but to develop a method other than the standard one – and I was successful in this to the extent that it now takes only three minutes and I no longer require a helper.

I have already described this method in relation to Nico. Frank enjoys his walking training in the NF-Walker so much that he perceives it as an outing rather than exercise and it is now no problem to motivate him to cover 2 to 4 km a day. Our radius is steadily increasing, becoming more interesting for Frank as a result. Looking back, I think he simply could no longer bear being guided by me. In the NF-Walker he clearly does not feel he is being guided, because I am not holding either the device or him.

The NF-Walker can also be used when head control is impaired, for example by using an extra neck or shoulder support. One must in any case not expect every child to be able to walk in the NF-Walker straight away. With some children, particularly those with very pronounced spasticity, the device will initially only be used to train them to stand, and only little by little for walking training.

Teresa, who has been my patient since 1998 and is now 16 years old, shows what a child with pronounced tetra spasticity can achieve. Despite her severe tetra spasticity, she enjoys movement and does regular and intensive training within the context of psychomotor holistic therapy. Walking training in the NF- Walker is a fixed part of her everyday routine (2, 5). As well as tetra spasticity, she also has significant speech disorders, such that it is often difficult for people other than her family to understand her. Since being provided with an appropriate electronic communication aid, she has been much more able to communicate to those around her all she can do, all she knows (e.g. reading, writing and arithmetical skills and knowledge of special subjects) – and what she would like. Her mother has now programmed the communication aid to enable Teresa to ask in the mornings at school when she can walk in her NF-Walker.

At home this isn’t an issue, because her parents know how much Teresa likes going for walks in the countryside. Teresa has a short rest after school and then enjoys a regular daily walk of 1.5 to 2 km across the fields with her mother.

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Fig. 7: Teresa is already able to raise her head with good control when standing but finds this more difficult when walking. Her NF-Walker has a neck support, which she prefers to lean her shoulders against rather than her head: the support canhowever also prevent Teresa’s head inadvertently falling backwards.Teresa also benefits from the special guide bands on the NF-Walker, as without these bands her steps become too long. Now, in summer 2011, Teresa can place her heels on the ground and move the knee much more easily.

As Teresa’s leg muscles were increasingly contracting as a result of the spasticity, and this was also preventing her from walking in the NF-Walker, a fasciotomy was performed in 2010 (2). Post-operative healing was good, such that Teresa was relatively quickly able to use her NF-Walker again, and much better and more purposefully than before. This is because both adductor spasm and contraction of the patellar ligaments have been reduced, enabling her to stand and support her weight more purposefully and with better stamina, which benefits Teresa in all areas.

Summary:The NF-Walker also helps children with multiple disabilities who, without this device, would need strong guidance and/or support from a helper to walk. This guided walking without a walking aid can be extremely strenuous for parent and child, depending not only on the motor stability but also the size of the child. The NF-Walker, on the other hand, enables the child to cover longer distances, as a result of which walking is increased and the walking sequence can more easily be automated. This intensive walking increases muscle strength in both the legs and upper body. There is also a positive impact on hip maturation, as this requires standing and walking stimuli. The flexible system of the NF-Walker means the support can be precisely tailored to the needs of the child. Other people more readily perceive children using the NF-Walker as individual personalities, as they are walking and are at “eye level”. And the children themselves enjoy the feeling, and are proud to be standing and walking on their own feet in the NF-Walker.

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References:1) HESSE, S.: Lokomotionstherapie: Ein praxisorientierter Überblick [Locomotion therapy: a practice-oriented overview], Hippocampus Verlag 2007

2) KANNEGIESSER-LEITNER, C.: Psychomotorische Ganzheitstherapie – ein Therapiekonzept für zu Hause bei Kindern mit Cerebralparese oder Mehrfachbehinderung [Psychomotor holistic therapy – a home treatment concept for children with cerebral palsy or multiple disabilities], Sequenz Medien Produktion 2010

3) KÜNZLE, C., BRUNNER, R.: Die Wirkungsweise der Geh-Orthese von Norsk Funktion auf die Gehfähigkeit von Kindern mit Zerebralparese und schwerer Gehbehinderung [How Norsk Funktion’s walking orthosis works on the walking ability of children with cerebral palsy and severe walking impairments], Copyright © 2009 American Academy of Orthopedic Surgeons and Orthopedic Technicians.

4) KANNEGIESSER-LEITNER, C.: Dynamische Orthesen bei Kindern/ Spitzfußbildung und /oder spastische Supination der Füße [Dynamic orthoses in children/ foot drop and/or spastic supination of the feet], BIG-Heft No. 34 /2003

5) BLACK, J.: Stand to be Proud: Standing and Walking for Children with Movement Disorders, Motico – Motion Communication, 2010, Scotland.Dr. med. Christel Kannegießer-Leitner

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Does early application of medical aid devices make sense? Based on the example of the NF Walker.By S. Schneiders, Physiotherapist

I am a physiotherapist working at an institution that provides 24-hour care and fostering re-education for some 50 children of ages ranging between a few months and young adulthood, all of whom suffer from multiple severe disabilities. In addition to the nursing personnel, educators and teachers, our team includes representatives of all professional rehabilitation and re-education health care provider groups. The majority of these children and young people have an ICP (usually GMFCS Level V, more rarely Level IV), while the other children have rare syndromes or progressive diseases requiring close care and monitoring.ICP is characterised by being an acquired, non-progressive, incurable, but symptomatically changing posture and motor dysfunction caused by damage to the immature brain.It can vary in type and severity and, in addition to motor disorders, also encompasses other symptoms.As a Bobath therapist, the focus of my work is on enabling participation, in some cases by means of an appropriate environmental setting, thus improving quality of life (with ICF-CY being the guideline).Treatment must always be based on a detailed anamnesis, an intensive parent interview, careful analysis of doctors’ reports, interdisciplinary case discussions with care and therapy provider colleagues and, of course, first and foremost, an assessment of the child as an individual. Parents often wish for the child to become autonomous, the nursing personnel takes care of the breathing function and digestive problems such as constipation, the orthopaedists tend to consequential symptoms resulting from muscular imbalance, such as muscle contractions, shrinkage of fascia and ligaments, joint misalignments, instability and deformities (e.g. hip dislocation, scoliosis, contractures and many others) and the pain most certainly accompanying them.Especially in the most severely disabled children and those with multiple disabilities this is unavoidable, but I am of the opinion that early mobilisation, close to the timeline of normal development, can be a good opportunity to delay such problems or even to keep them in check, thus improving quality of life.I have used the NF Walker with a number of children aged approximately 18 months after having mobilised them into the standing frame at approximately 12 months of age, at first on a three-month trial basis.

I was able to make the following observations:▪ Patients can alternate between active and passive standing, thus strengthening their muscles and preventing muscle imbalance▪ By alternating between active and passive standing, they receive proprioceptive stimuli, which changes their perception (these legs are part of me) and contributes to the maturation of the hip joints▪ The lower extremity joints can freely and actively be moved within one plane▪ Because of their upright posture, they perceive space and themselves in a different way

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▪ They are perceived more positively by others, especially by other children, and are more frequently integrated into play activities▪ The field of view increases with better spatial head motion▪ The lungs are ventilated in greater depth▪ There is an improvement in the blood flow through the body▪ The diaphragm muscles are stimulated and strengthened▪ The pelvis becomes more stable, bringing about a gain in upright posture; the children also develop more strength to help them expectorate▪ A more erect posture also changes the perspective on the child; it can thus leave the role of the “baby” and, unconsciously, signal other needs Even if the children did not simply walk off as had been hoped for, the majority of these positive effects could quickly be recognised.After some time spent standing and trying things out, the children started lifting a foot, shifting back and forth, moving their feet, watching themselves in the mirror, and quite soon the first, even though strenuous, steps were taken. Each of these steps is a huge step forward in these children’s self-determination; they can go from A to B, leave things behind, approach people and toys, withdraw from any situation, thus signalling a “No” through their motor function, a development that normally takes place at around 18 months. In some children, this developmental step can however prove to be applied too early. Then, the aids can be provided in intermediate steps (e.g. longer periods in the standing frame or on the tilt table) to ensure that no excessive demands are made on the child. The NF Walker offers, on the one hand, the safety the children need, but on the other hand it enables progress both in their motor and socio-emotional development.Early provision of aid devices became even more important for me when I approached the topic of “Neuroplasticity, or the plasticity of the brain”, as this is exactly what constitutes the foundation of learning. It is however largely dependent on activity and utilisation, and as the children with the most severe disabilities are often not autonomously able to target their own cognitive and motor stimuli, we, the therapists and device designers and manufacturers, are required to find out what we can and must offer these children. Here, too, it is essential to involve and provide guidance to the parents. I find this topic to be of enormous importance especially in those children who come to us for therapy as a result of brain damage, as the intensive utilisation and training of cognitive and motor functions can help compensate lost function. Even children who have had an entire hemisphere removed can compensate certain functions by means of the remaining hemisphere. In addition to pure function training it is also important to include the child’s emotions in the therapy. The child must have fun with what it is supposed to do and learn. Without fun, motivation and social connections, the brain’s plasticity appears to present a lesser degree of development, thus hindering re-education. It would therefore seem to be certain that early, intensive support can achieve significant results; however, as the extent of such results is never known in advance, the therapist should, from the very beginning, not set limits, but, rather, stimulate children intensively and at an early stage.

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Evaluation of the NF-Walker*Martín Gómez M.; ***Laguna Mena C.; **Martín Maroto M.P.; **Arroyo Riaño M.O.*Specialty Registrar and **Specialist. H. G. U. Gregorio Marañón [Gregorio Marañón University Hospital].C/Doctor Esquerdo, 46. Madrid 28007. Tel.: 915868438 ***Specialist, C. Hospitalario de Ourense [Ourense General Hospital].Email: miriammgsonse@hotmail.com

IntroductionCerebral palsy (CP) is the primary cause of disability in developed countries, with an incidence of 1.5-3/1000 live births. Bipedal locomotion in children with CP (especially GMFCS Levels IV or V), or other diseases which are characterised by severe psychomotor development delays, is a skill which is difficult to achieve. The Norsk Funktion-Walking Orthosis (NF-Walker) is a standing frame system with partial suspension of body weight. It consists of a 4-wheel system, from which HKAFOs (hip- knee-ankle-foot orthoses) are hung, connected to a hip and chest belt. At the bottom of the device, special orthopaedic shoes can be fitted. The suspension of body weight allows the patient to activate ambulation and initiate alternating movements.The purpose of our work is to obtain knowledge of the clinical and functional characteristics of the NF-Walker user, outside the firm’s intended indications. We also wish to evaluate satisfaction and effica-cy based on parents’ or carers’ opinions regarding use of the NF-Walker. Material and methodsFrom December 2011 to February 2012, a retrospective descriptive study involving 26 users of the NF-Walker was conducted using a survey. Epidemiological, clinical, rehabilitation therapy, and NF- Walker use data, as well as data on the level of satisfaction regarding technological aspects and purpose were collected, using the Children’s Version of the scale to evaluate technical assistance, The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.1). In addition, mobility data from the GMFCS Family Report Questionnaire and the Pediatric Evaluation of Disability Inventory (PEDI) scale were recorded. ResultsA total of 26 patients were included. Of these, 61.5% were female and 38.5% were male, with a mean age of 10.2 years. 84.6% had CP, with spastic cerebral palsy being the most common type (50%). 73% were GMFCS Level V.All were receiving an average of 3.8 hours/week of rehabilitation treatment. The NF-Walker was used 8.5 hours/week on average, and the development time median was 25.5 months. In 7.7% of cases it was recommended by a rehabilitation doctor. Around 80% of the parents thought it was “very satisfactory” in all the items evaluated in the QUEST scale. Discussion and conclusionsThe study has limitations with respect to losses and because no comparison can be made with another type of walker to identify clinical improvements and independence offered by the NF-Walker, since it is indicated for children who cannot walk with any other type of walker.According to the results obtained in our study, the “typical patient user” of the NF-Walker is a child with

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spastic CP, GMFCS Level V. There is a significant level of satisfaction of parents regarding the technological aspects, in that it meets their needs and provides greater independence. The NF-Walker is a good prescription option for rehabili-tation doctors and these patients. This is a translated version of the original article: EVALUACIÓN DEL ANDADOR NF-WALKER published in Jornadas Cientificas de la Sociedad Española de Rehabilitación Infantil, Volumen 2, Madrid Marzo 2012

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NF- Walker: dynamic and mobile standing orthosisIdoia Gandarias Mendieta. El Mirado N ° 121 July 2008

The NF-Walker offers children the possibility to experience standing independently, both still and moving. This device guarantees a correct body alignment, allowing the lower limb flexor muscles to stretch and improving head control and trunk stability. It consists of a system of braces and supports which allows children to load around 80- 90% of the corporal weight on their feet whilst the remaining 10-20% is taken by the thoracic, pelvic and tibial supports. The child is slightly degravitated making it easier for him or her to be able to take a step.NF-Walkers adapt individually to each user, so that two different children cannot share a device. It is also necessary to have regular follow-ups (every 3 months) to modify the positioning and movement components, as the child grows, so that they always have a physiological upright posture. This is a prerequisite for the child to learn a correct movement pattern.

Therapeutical effectsThe NF-Walker is a combination of a dynamic standing brace and a walker. This device needs to be adapted individually to each user, according to height, weight, muscle strength and movement patterns. The main feature of this product is that it keeps the child completely straight and loads the body-weight on the feet in an equal manner.

The therapeutic effects that the NF-Walker offers vary a lot from one person to another. After 10 year of experience in Europe, it has been proved that this device only offers the possibility to experience what standing for short periods of time for some patients, whilst for others it helps learn to walk independently.

The main benefit of this device is for children who cannot walk unaided, offering them the possibility to walk independently in their environment. It does not generate a perfect walking pattern, but once the child adapts to the device, they are able to maintain a correct upright posture whilst having their hands free to play. This allows the child to progressively regulate tone, and, in some cases, they can manage to move considerable distances.

Advantages of the NF-Walker with respect to other standing devicesThe therapeutic effects of standing – preventing joint retractions and muscle shortening, osteoporosis and pathological fractures, helping regulate postural tone, improving cardiopulmonary function, renal function and gut regulation, as well as improving coordination and balance in general – are common to all standing devices currently in the market.Below we describe the features that set the NF- Walker apart from other standing devices:

• Ensuring a correct posture with all of the articulations well alignedThe NF-Walker has a unique brace system that avoids the child adopting incorrect postures. It is made up of orthopaedic footware to correct postural deformities of the feet (such as postural equinovalgus) which is attached to a set of braces to a pelvic support, and another two vertical bars join the pelvic

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support to a thoracic support. There are also two further supports which are adjusted below the knee to avoid genu valgus and genu varus. It also has other accessories for the head when needed, so as to control an extensor pattern.

• It allows the child to experience slight movements.Other standing devices keep the child bound to a flat wooden structure or a plaster mould, whereas with the NF-Walker the child has practically the whole body free to move and is able to move both upper and lower limbs freely. This allows them to learn different movements after experiencing them several times.

• It helps increase trunk stability.The thoracic support can be height-regulated depending on the trunk support that the child has. As trunk stability improves the support can be moved down (closer to the pelvic support) allowing the user to actively improve trunk stability, moving away from the midline and moving back to recover the correct posture.

• Greater stabilityThe NF-Walker has a wide base with four wheels. The back wheels are fixed in place whilst the frontwheels are free to turn, in such a way that it is not possible to tip over the device, so long as the brakes are not activated. Both if the user pushes himself against a surface or even if he were pushed by one of his friends from one place to another, the device would turn around itself or it will move in some direction but it would not tip over.

• It helps the child to integrate with his peers.When the child is in the NF-Walker, the child has his feet placed on the ground and is at the same height as his peers (as opposed to other devices which place the child at an adult’s height by placing a platform underneath). Even though it has four wheels the p can come close to the patient and touch him, hug him, or hit him as they would with any other child. It also allows the child to participate actively in games like kicking a ball.

• Physical and emotional wellbeingAs discussed earlier, standing has many therapeutic effects. The fact that the NF-Walker allows children to stand without having to stand in a corner - either because the device is not stable enough to allow others to come close by or because they are too large and cannot be placed in the middle of the classroom - means it makes practising standing fun because they feel equal to their friends, helping their self-esteem.

• Advantages of the NF-Walker over other walkersThe main differences between the NF-Walker and the other walking devices that are in the market today are:

• Aligned postureThe child is well-aligned and held by a pelvic support and another support across the chest, two bars that work like long braces, connecting the pelvic support to the footware. This system does not allow the patient to sit. Other walking devices allow the child to “hang” on a pelvic harness, adopting a poor posture once he tires.

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• Reciprocal gaitThis device has elastic straps which help reciprocal gait, making it impossible to step forward with both legs at once (when one knee flexes the other one gets pulled into extension).

• SizeThe NF-Walker has a wider base than other walking aids, offering a greater stability. The base is distributed in four points forming a square as opposed to a triangle, which helps going through doors and other narrow spaces.

• Going around cornersThe greatest inconvenience about the NF-Walker is that it is very difficult for the user to turn left or right. It has an accessory that works like a steering wheel, allowing the user to turn, otherwise, it takes a great deal of dexterity to be able to turn using only the lower limbs.

ContraindicationsThe NF-Walker is contraindicated in the following cases:• Structured joint deformities, such as hip/knee/ankle flexion contractures of more than 20o• Children without enough cognitive capacity to identify dangers (such as stairs, busy roads, etc.)

unless they are under continuous surveillance.When addressing children with very poor head control that necessarily leads to them being completely supported, not allowing them to feel any free movement, the use of an NF-Walker is not contraindicated, but it does not have any additional benefits to conventional standing devices. Therefore, when children are in this phase it is preferable to use a standing frame that offers the same therapeutic effects for a more economic price when funding is an issue.In the same way, children that are able to walk with a posterior walking frame or holding hands with an adult, as well as the children who have enough balance to stand unassisted are not candidates to use this device, because it would make walking harder for them, especially turning.

BibliographyCarr, J. Shepherd, R. (2000)Rehabilitation: Optimizing Motor Performance; Oxford, GB: Butterworth Heinemann.

Finnie, N.R. (2001) Handling the Young Child with Cerebral Palsy, Oxford, GB: Butterworth Heinemann

Campbell, S.K. (1999) Decision Making in Paediatric Neurologic Physiccal Therapy, Pennsylvania, EEUU: Churchill Livingstore.

Levitt, S. (2004) Treatment of Cerebral Palsy and Motor Delay, Oxford, UK: Blackwell Publishing.