Peanut butter or chocolate? Both! Stander or gait trainer? Both!
Perhaps I’m indecisive. Perhaps I’m selfish. Perhaps I just know a good thing when I see it.
Unfortunately, as the great philosophers Jagger and Richards wrote, “You can’t always get what you want.” Especially when it comes to insurance funding for durable medical equipment. You have to choose one.
As the New York Medicaid Program puts it, “Provision of both a standing system and walker/gait trainer is typically considered a duplication of service, as both address weight bearing.” That is not what I say, but that’s what they say, and they’re the ones with the health care dollars.
So, for those who have enough lower extremity function to consider a gait trainer, but who still need plenty of extra support for good standing alignment, some problem-solving needs to happen to determine which equipment will best meet their needs.
First and foremost, what are the therapeutic goals?
Many people want to walk. Many parents want for their children with mobility impairments to walk. Ensuring quality standing before walking is not sentencing an individual to be stationary. It is an important part of neuromotor learning. Ultimately, do we want mobility? Improved cardio-respiratory function? Pressure relief? Participation in play, education, work, self-care? Treatment or prevention of joint contractures? Decreased muscle tone?
Where is the equipment going to be used, and how can its use be maximized?
Home? Work? School? Daycare? Does the equipment need to be moved between locations? A folding gait trainer fits into the trunk of a patient’s family vehicle to move from home to daycare to Grandma’s house to the hospital to visit a newborn brother, etc. A high school student who splits his time between Mom’s house and Dad’s house uses his stander at school and the PCA is able to bring it home in the family’s adapted minivan during the summer months and longer breaks.
How much space is there for using the equipment?
In order to maintain balance and safety, standers and gait trainers need to have a substantial base of support. Even standers made for infants and toddlers, such as the EasyStand Bantam, may be expected to take up approximately 24 by 36 inches (62cm x 93cm) of floor space. Is there enough room in the intended space for a gait trainer to be used for the user to walk, turn, move through doorways, and participate in meaningful and motivating activity? Can the stander be moved through the desired areas of the living environment?
What kinds of surfaces will the equipment be used on?
Thick carpeting and transitions between flooring can create challenges for moving a stander or gait trainer around.
How often – honestly and realistically – will the equipment be used?
Which piece of equipment can be utilized for more longer-duration functional tasks during the course of the day? More is usually going to be better.
Which equipment is easiest to transfer in and out of?
Ease of use generally increases satisfaction with and frequency of use.
Which piece of equipment offers better positioning?
The full support of a stander is typically going to yield the best posture, but one of my patients achieves good alignment and weight bearing in her gait trainer with brakes locked and knee immobilizers and AFOs on. Gait trainer use as a primary weight bearing activity would not be recommended for individuals with lower extremity joint contractures.
What other resources are available?
If you choose a stander, there are likely still opportunities to practice walking. If you choose a gait trainer, there may still be ways to access a stander. Talk to your clinic, school, and early intervention therapists. You may be able to borrow adaptive equipment or ensure that your child has access to adaptive equipment as part of his or her educational plan. You may also be able to rent equipment through your health insurance provider. Needs may change over time, so you and your medical team can always make a case to insurance if they do.
If stander use and gait trainer use are both beneficial to you, then I warmly wish you “Both!”
How have you dealt with accessing a combination of standing and gait training equipment?