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INNOWALKDOCUMENTATION

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INNOWALK DOCUMENTATIONNo Study Scope Conclusion

1 Article in”Barnestafetten” Issue 56/2009

Innowalk – Experience from two counties in Norway

Experiences so far has shown that Innowalk can improve or maintain endurance, stomach functioning and posture control. In addition several users improved joint movement and for one user, Botox treatment was no longer indicated after the trial period ended.

2 Poster at European Seating Symposium

Assisted movement Effect of assisted movement in a standing position on children with former disabilities over a period of one year. To provide assisted movement the helping aid Innowalk was used. 13 children was involved in the project. All children were tested before they started up with the helping aid, after 4 weeks, 4 months and 12 months of use.

3 Poster at 28th International Seating Symposium Vancouver, Canada. March 2012

Improved gait and gastrointestinal function following Innowalk trial

Evaluation on gait and gastrointestinal function in a 13 year old child with CP GMFCS III. Improvements was seen in range of motion on the hip, gastrointestinal function, resistance against rapid passive stretch, and walking function.

4 Poster at 30th International Seating Symposium, Vancouver, Canada. March 2014

Effect of a motion therapy device on the hip joints of children with bilateral spastic CP GMFCS IV/V

The study show that the motion therapy device(Innowalk) have direct effect on the hip joint of children with CP. Effects on the range of motion and mucle tone was documented. Duration of the intervention (3 months) was a determining factor.

5 By Hege M. Hansen, manual therapist. The text is a summary of a Master’s thesis in Manual Therapy at the University of Bergen, 2014

An investigation of whether gross motor function, joint mobility and spasticity in the lower limbs of children with CP can be affected by using the “Innowalk” motorized training and stimulation aid.

The approach of the study was to investigate how gross motor function, joint mobility and spasticity in the lower limbs of a child with CP can be affected by using a motorised training and stimulation aid. The results from GMFM-66 and measurement of joint mobility show that it is possible to achieve a positive change in both gross motor function and joint mobility using the aid in question.

6 By Britt-Marie Rydh Berner og Lotta Ahlborg, Physiotherapist’s Danderyds sjukhus AB, Stockholm

Evaluation of the use of Innowalk by two patients, 4-6 times a week respectively

The two test subjects were people with CP GMFCS III. In a short time, we were able to record measureable results and could see that our motivational talks were no longer required to get the patient to do their traning.

7 Case report (Ulrik) CP GMFCS IV The aim of using the Innowalk was to increase his activity level, and achieve more movement and increased muscle strength. They experience that he has become stronger and has better posture, which has led to increased stability and control in the upper body.

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INNOWALK DOCUMENTATIONNo Study Scope Conclusion

8 Case report (Ada) CP GMFCS IV

9 Case report (Peter) CP GMFCS IV after hip surgery

The Innowalk has been a central element of the rehabilitation. The aim of using the Innowalk was to get Peter into a safe standing position with weight bearing as soon as possible after the plaster was removed.

10 Case report (Marla) Rett Syndrome The doctor recommended Innowalk after a hip operation. Today, the Innowalk is an important training aid that she uses at home. Without the Innowalk, Marla’s opportunity for movement would be severely limited. She would miss out on important mental stimulation. We find that the Innowalk meets a fundamental need for movement

11 Case report (Jonathan) Brain Tumor The aim with the Innowalk was to increase his activity level, and see how activity with weight bearing and repeated movements would affect his motor functional level. Today, he takes a greater part in transfers . His trunk stability has improved significantly, and he clearly enjoys the sensation of movement in the Innowalk. His mood improves and those around him find it is easier to motivate Jonathan to take part in other activities

12 Case report Report written by Physiotherapist at a clinic in Germany after Innowalk trial on a patient.

Continuous training with the Innowalk will provide the patient with decisive support in the attainment of the therapy goals. Such as improvement of the joint mobility, muscle strength, sensitivity normalization, improved cardiovascular situation and better tolerance of a standing position.

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Case report

Article in Barnestafetten,November 2015 no. 76- 33

Physiotherapeutic evaluation after Innowalk trial on a patient in Germany

Innowalk – bene cial effect in spinal muscular atrophy

It is extremely important from a physiotherapeutic point of view that the patient should over the long term achieve target oriented and high quality muscle tone regulation in order to prevent consequential damage such as server hip dislocation or a scoliosis. Innowalk outstandingly supplement the patients therapeutic treatment.

The case report has shown that for Martin, who has SMA, training in Innowalk has produced positive results in a short time in the form of better walking function, more energy and a genuine sense of moving more easily. If the training is adapted to the individual child, takes account of his/her particular needs and requirements, and is closely monitored to avoid over-training, I think that Innowalk can be recommended for this user group.

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INNOWALK – Experience from two counties in Norway

Experience so far has shown that Innowalk can improve or maintain endurance, stomach functioning and posture control. In addition, several users improved joint movement and for one user, Botox treatment was no longer indicated after the trial period ended. Innowalk is a new aid designed for children with physical limitations who can benefit from increased movement. On request by government department responsible for special aids for people with disabilities in Norway, the rehabilitation services in the two counties in Norway together with EO Funktion, carried out a trial project with Innowalk.The objective of the project was to defensibly show that it is possible to give assisted movement to children who have little or no ability to move on their own. At the same time, there was also a desire to record changes in the child related to increased movement and activity. The trial project is designed in collaboration with rehabilitation services in the two counties.

MethodThe trial period was set at 4 weeks. The 5 children were chosen by rehabilitation services. During the trial, the children had to use Innowalk a minimum of 5 times per week, for a minimum of 30 minutes per day. The date, heart rate and length of time in movement was recorded. In addition, comments were written about each session. It was desirable to record the heart rate, measured by a heart rate monitor, in order to evaluate the effect on endurance, seen in relation to Innowalk’s speed and the child’s own level of activity.

Stomach functioning, sleep pattern and presence of pain were systematically recorded before and during the trial period with a view to assess possible changes related to an increase in activity level. Specific functions, in accordance with individual goals, were videoed before and after the trial period in order to document possible changes.

The thigh and calf circumferences were measured before and after the trial period, along with recording of the joint movement and spasticity.

Both carer and therapists gave an overall evaluation of the child after the trial period. This overall evaluation included a description of how movement in Innowalk, in combination with the treatments already in place for the child, effected the child’s functioning and participation in relation to what was desirable to achieve with Innowalk during the trial period.

All the measurements, tests and analyses were undertaken by a rehabilitation physiotherapist (local hospital) and physiotherapist from the local government agency.

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Participants:

ResultsCase - id. 1:

The records show 18 training sessions in 4 weeks. The average training time was 38.6 minutes. The heart rate records show that the child maintained a level of 58% - 65% of her maximum heart rate, which means that Innowalk has a positive effect in relation to improving conditioning.

Before and after joint measurements show improved movement deflection in the right and left ankle, 10 degrees and 5 degrees respectively. Before the trial period, Botox injection in the right calf were planed. After the trial period, the ankle movement had improved and there was no requirement for Botox as at the time of publishing. Based on observations of the child in Innowalk, it was obvious that she was able to bring the heel of each foot right down. One can think therefore that her calf muscles have been lengthened during training. This in combination with active use of ankle-foot orthotics.

The angle of the Popliteal before and after training was -15 and -25 degrees respectively, indicating that the hamstring muscles are a little tighter. Based on experience, one knows that that muscle has a tendency to become a little tighter in accordance with increased strength and practice standing. It is difficult to get an active stretch in that muscle group over a long time in the same way that one achieves using splints for the ankle joint. There are continued good levels of joint deflection.

Broadly speaking, the spasticity is unchanged. The child has increased muscle tone in her legs in particular and this is the same, 2 before and after. The hamstring muscles were slightly changed, from 1+ to 1, indicating slightly less spasticity here.

Muscle density/mass increased by 0.5cm around the left thigh.

Evaluation of functioning and video analysis of the child before and after the trial period shows improved posture control in the torso. The child sits up straighter with her back against a standard child’s chair. This is also visible when she walks with her rollator. At the same time as the Innowalk trial, she began to practice with a forward-facing rollator. She has made progress using this. Regarding her ability to stand, before the trial it was difficult to get the child to try to stand on her own without help in the kindergarten. She was not confident and supported herself using a table or an adult. It was only at home that they could get her to try and then she managed to stand only for a few seconds. After the trial, although she must continue to secure herself with an adult behind her, the child can now stand alone in the kindergarten for approximately 10 seconds.

The recommendation is for further use of Innowalk for the child.

User id Gender Age Diagnose

Id. 1Id. 2Id. 3Id. 4Id. 5

GirlBoyBoyGirlBoy

4 years4 years10 years12 years3 years

CP - Spastic diplegicCP - Spastic quadraplegicAcquired braindamageCP - Dyskinetic quadrapligicCP - Spastic bilateral

GMFCS level

IIIV

VIV-V

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ResultsCase - id. 2:

The records show 30 training sessions in 4 weeks. The average training time was 37.7 minutes. The heart rate records show that the child maintained a level of 52% - 60% of his maximum heart rate. This indicates that Innowalk has had a positive effect on conditioning.In relation to stomach/bowel functioning and sleep, there has been little change in the trial period compared with earlier patterns.After the training sessions, the child has usually had warmer feet.

Joint measurements show a slight reduction in joint deflection. The spasticity has generally reduced or not changed except for in the plantar flexion, that have become more toned.

The child has increased thigh circumference, 1cm in the right thigh and 0.5cm in the left. This is also confirmed subjectively by the parents and the kindergarten assistant .The videos that were taken after the trial period show improved functioning in relation to all the goals that were set before the start. Level of uprightness and control when sitting and in a forward lying position are improved. This has led to freer arm movements in such a way that he supports himself better and handles toys, etc more easily. One can also see that he lifts his legs higher and with greater ease when he walks both in and out of the NF-Walker.

Most importantly, the child is now more flexible and looser in the body in such a way that it can relax more easily and participate more in different activities. All in all, one can see that the child has got a better quality of everyday life.

The child has been motivated to use Innowalk. The recommendation is for further daily use of Innowalk.

ResultsCase - id.3:

The records show 18 training sessions in 4 weeks. The average training time was 38.6 minutes. The child maintained a heart rate level of 52% of his maximum heart rate. This indicates that Innowalk has had a positive effect on conditioning.

Joint measurements and muscle mass indicates marginal changes except for abduction in the hips. The measurements changed from 30 to 50 degrees. This is positive. The videos that were taken after the trial period indicate some improved functioning in relation to the measurements that were taken before the start.

He sits somewhat sturdier on the mat and has freer hand functioning. This has led to his ability to play with toys without needing to support himself in order to avoid falling. There has been some improvement in stability and balance whilst kneeling beside a latter leaning against the wall. He is now able to take weight on his knees without his legs sliding out from under him.

Despite some improved functioning, the aid is currently considered to be time-consuming and difficult to organise for the staff at the school. The child’s motivation to use Innowalk has been low. Altogether, this has brought about a great deal of strain on the child and the professionals who work with him.

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The recommendation is to discontinue the use of Innowalk.

ResultsCase - id. 4:

The records show 29 training sessions in 4 weeks. The average training time was 36.6 minutes. The child maintained a heart rate level of 52% - 66% of her maximum heart rate. This indicates that Innowalk has had a positive effect on conditioning.

It has been difficult to evaluate movement deflection and spasticity due to pronounced dystonia. It looks like the angle of the hamstring on the left side is better. Significantly, with an extended knee the left ankle now comes to 90 degrees.

A discreet increase in muscle mass is registered (0.4cm in the thighs and 0.3cm in the calves).

It does not look like the number of bowel movements has changed, but they have become easier to expel. The child usually has difficulty with stomach wind and therefore some pain. In the trial period, the guardians noted and the child experienced a significant change in this area. The pain reduced in weeks 2 and 3 and by week 4, it had completely disappeared.

The child began training in Innowalk in high sitting position because the spasticity was triggered when the knees were stretched. By the end of the trial period, the child was able to achieve a full stretch in parts of the training sessions without being dominated by the spasticity. The child also got a better active stretch in the knees whilst walking with help.

The child has improved torso stability and head control. Whilst walking in NF-Walker, there is no swerving towards the right and the head is more upright. Immediately after the training session, whilst sitting cross legged on the floor, the child’s body is a lot more settled and consequently, she has better head control.Whilst walking in NF-Walker, one can see significant, positive changes. The speed is considerably faster, the length of step is even, there is good flow in the movements and the standing leg lands with the whole foot on the floor (not tiptoed like before).

The recommendation is for further use of Innowalk for the child.

ResultsCase - id. 5:

The records show 27 training sessions in 4 weeks. The average training time was 31.6 minutes. The child maintained a heart rate level of 72% - 79% of his maximum heart rate. This indicates that Innowalk has had a positive effect on conditioning.

4 weeks is a short time period, but we believe it can be said that daily training with Innowalk has given the child increased strength in the extensor muscles in the legs. He stands better and has improved control. Torso stability has also improved. The circumferences of the child’s right thigh and calf have increased by 0.5cm and his left calf by 0.8cm. There has been a measureable decrease in the spasticity of adductors, flexors and extensors of the knee. Reduced toning in the hip adductors is important for

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preventing the wrong position and possibly hip dislocation. It is also important for improving walking ability in and out of NF-Walker.

After the trial period, the child walks in the NF-Walker for longer distances and with multiple steps after one another. Directly after training in Innowalk, when he walks with the support of an adult, we also see that he does not cross legs even though he does not have the S.W.A.S.H ortosis (Hip ortosis) on.

He has normal and good joint deflection before and after the trial period. Sleep patterns have not changed.

For long periods, the child has had problems with stomach/bowel functioning. He takes, among other things, Movicol, a laxative to make the stools softer. During the trial period, the consistency of the stools has become normal and he strains a lot less to pass them. In addition, the child has got a better appetite.

The recommendation is for further use of Innowalk.

Results and discussion:The objective of the trial period was to show that it is possible, in a defensible way, to give assisted movement to children who have little or no possibility of moving on their own. At the same time, it was desirable to record changes in the child related to increased movement/activity.

The children have trained at a heart rate that can have a positive effect on conditioning. The average training heart rate was between 52% and 79% of the maximum heart rate.

4 of 5 children have increased muscle mass in the course of 4 weeks. The increase has been between 0.3cm and 1cm. The measurements are conducted with a measuring strap by the same therapist before and after the trial period. The measurements’ margins of error are available.

One child improved joint deflection in the ankle joint by 10 degrees, which resulted in no longer requiring a Botox treatment that was planned before the trial period. Two other children also improved their joint deflection, one in the hips and the other in the ankle.

Several of the children look like they have achieved some reduction in spasticity due to increased movement. It is uncertain whether it is a transitory improvement or not. The measurements of spasticity are conducted manually using the Ashworth scale and therefore contains margins of error.

Before the trial period, 3 of the children had problems with stomach functioning. For 2 of these children, the problems were associated with expelling the bowel movement. This improved significantly during the trial, and for one child, the consistency of the stools became normal. For one child, the problems with stomach functioning was associated with considerable wind in the stomach, which resulted in constant stomach pains. These were diminishing during the first weeks and had totally disappeared by week 4.

All 5 children improved their posture control during the 4 weeks. Posture control is not measured, but subjectively evaluated from videos and observations before and after the trial period. The children attained better posture control sitting, standing and walking.

Those children who had NF-Walker from before the Innowalk trial period, all improved their walking in NF-Walker afterwards.

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4 of the 5 children were motivated to use Innowalk.

For 4 out of 5, the recommendation was for further use of Innowalk. In spite of positive results for user id. 3, Innowalk was not recommended because the user became difficult and time-consuming for the people around him.

The trial project lasted 4 weeks. We have seen that it is defensible to give assisted movement with the help of Innowalk. In addition, it was recorded that all 5 children had positive results from increased movement. Nevertheless, it is necessary to try out Innowalk on more users over a longer period in order to know more about the effects of this aid on children with movement limitations. Among other things, it could be interesting to make use of objective methods to measure the changes in the strength of the children’s muscles.

Britt Tornes Physiotherapist, Rehabilitation Services Vestfold, NorwayKari Borgen Physiotherapist, Rehabilitation Services Vestfold, NorwayKari Bugge Physiotherapist, Rehabilitation Services Telemark, NorwayTone Mari Steinmoen Physiotherapist, Rehabilitation Services Telemark, NorwayCharlotte Marie Schanke Physiotherapist, Rehabilitation Services Telemark, NorwayRikke Damkjær Moen, Physiotherapist/Specialist, EO Funktion, Norway

This article was published in «Barnestafetten» in Norway in 2009/Issue 56. This is a translated version of the published article in Norwegian.

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ASSISTED MOVEMENT

Project carried out by: Habilitation Service, Hospital in Vestfold and NAV technical aid center in Vestfold Presented by: Medical Manager at Made for Movement in Norway, Rikke Damkjær Moen

Project in Vestfold county in Norway

Introduction/Purpose The Public Health Department in Norway recommends a minimum of 60 minutes of daily physical activity for all children and youngsters. It is well

known that most people with physical disabilities are less physically active than their able-bodied counterparts. The possibility for physical activity

is limited for people with disabilities, but still as important. Based on this knowledge, physiotherapists at a habilitation center and the NAV technical

Aid Center in Vestfold County in Norway decided to evaluate the effect assisted movement in a standing position has on children with former

disabilities for over a period of one year. To provide assisted movement, the helping aid Innowalk was used. The project began in January 2010

and is still ongoing. Plan to finish testing in February 2012.

Case 1 Girl 12 years old.

Diagnose: Spastic bilateral CP, GMFCS IV.

Before start up of the project: Typical asymmetric, with windswept turning

towards the right side. Corresponding curvature in the spine. Left hip was operated

in 2007 because of hip dislocation. There is a high risk for dislocation of the right

hip, with a Reimer’s index on 48%

in June 2010. She has a contraction in both knees, respectively 15 and 19 degrees.

She is highly distressed with obstipation and has problems with consuming enough

fluid. She does not have any walking ability after operation in 2007. Before, she

used to walk in the NF-Walker. Now she is just standing.

Goal: The goal with more movement for this patient was to increase range of

motion in knees and hips, reduce spasticity, improve digestion and prevent obstipation.

End of project period: In the project period the patient has used the Innowalk up

to one hour every day, excluding every fourth weekend and one day each week

where she is at an auxiliary house. When using the Innowalk she always has a

bottle of water with her. She exclaims, “I’m training and the I need to bring water

with me”. It’s normally a challenge to have her drink enough water, but when she

is “training” she drinks a lot. Digestion is stabilized, and she does not need daily

medical treatment. Medical treatment is just needed in the periods in which she is

at the auxiliary house and does not have the Innowalk available. Range of motion

in hips and knees have shown small changes, but Reimer’s index on the right hip in

April 2011 changes to 39% from 48%. She is now walking short distances in the

NF-Walker.

Case 2 Boy 4,5 years.

Diagnose: Spastic bilateral CP, GMFCS V

Before start up of the project: No head control and no voluntary movements. Very spastic. Especially seen in sitting and laying.

Subluxation of the hips, respect-ively 50% and 45% of Reimer’s index. Operation was recommended and carried out in the project period.

Is relying on daily medical treatment due to problems with digestion.

Goal: Improve digestion. Improve range of motion in legs and maintain or improve position of the hips.

End of project period: Uses Innowalk on average 4 times per week, up to 45-60 min each session. He shows positive expectation when he is

transferred into the Innowalk, and is very satisfied when he is walking in the aid. While walking in the Innowalk, he is less spastic. Digestion has

improved and he often has spontaneous evacuation immediately after training. Bilateral hip surgery was carried out in the project period and

Innowalk was a huge advantage in the recovery period after the bandage was removed. Head control has improved. This is seen in video taken

before and after the project period. Parents also report that he is easier to handle now because of improved head control. The child is

very demanding regarding continuous attention from the parents and is often dissatisfied. In the Innowalk he is very pleased and satisfied.

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Method The helping aid Innowalk is used in the project.

Innowalk is an aid that provides assisted move-

ment in a corrected standing position with weight

bearing. The product is individually adjusted to

each users size, movement pattern and function.

A protocol for each child is completed by parents

and responsible physiotherapists at the

habilitation center. Registrations in the protocol

are done before beginning the helping aid

Innowalk , and after 4 weeks, 4 months and 12

months of use.

Following is recommended in the protocol:

Range of movement in hips,

knees and ankles

Muscle mass in thigh and calf

Spasticity (Modified Ashwort)

X-Ray hips

Pain

Bowel function

Sleep pattern

Movement pattern is filmed

In the project period, the Innowalk should be used

3-5 times per week and a minimum of 30 minutes

each session. Project is not completed yet, and a

result summary will be ready March 2012. Three

cases are presented here.

Case 3 Girl 5 years old

Diagnose: Spastic bilateral CP, GMFCS IV (alternating tone)

Before start up of the project: She does not have any walking ability with an

assistive mobility device, but can walk in the NF-Walker. She is not fond of walking in

the NF-Walker and prefers to move around by crawling or moving on her knees.

For longer distances she uses a wheelchair.

Goal: Increase muscle strength, reduce spasticity and succeed with walking by use of

an assistive mobility device.

End of project period: Over a period of one year, she has used Innowalk in average 3-4

times per week, up to 30 min each session. She has gained independent walking using

a walker. She has been moved from a GMFCS level IV to a GMFCS level III. From being

a girl who mainly moved around using a wheelchair, she is now a girl who is walking

around by a assistive mobility device, a walker. Muscle strength and spasticity have

been hard to measure and no changes are therefore seen.

Participants Children involved in the project have all applied

to NAV technical aid center on a normal basis for

the helping aid Innowalk. The participants have

applied in the period January 2010 until March

2011, and parents have consented to participate

in the project. A total of 13 children with the

following diagnoses were involved:

CP GMFCS II (1), CP GMFCS III (1),

CP GMFCS IV (2), CP GMFCS V (3),

Rettsyndrom (2), Unspecified epilepsy (2),

Brain injury Syndrome (1), Acquired

Braininjury (1).

Results The project is still ongoing and the results will be ready after all 12 month tests are finished during February 2012. The completed project will be

presented at The Nordic Seating Symposium, Stockholm 22 - 24th May 2012.

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IMPROVED GAIT AND GASTROINTESTINAL FUNCTION FOLLOWING INNOWALK TRIAL

INTR

OD

UCT

ION

/AIM

RES

ULT

S

Patient: 13 yearsDiagnosis: spastic bilateral cerebral palsy (CP)GMFCS level III: Walks using a handheld Mobility Device, limitations walking outdoors and in the local community (www.canchild.ca)

6 weeks testing logAug.-Oct.2009 shows: A total of 37 sessionsDuration 20 minutes – 1 hour 45 minutes, mainly approximately 1 hour.

The aim of the project was to evaluate the effect of 6 weeks Innowalk trial on gait and gastrointestinal function in a 13 year old child with spastic bilateral cerebral palsy, GMFCS level III.

Due to a small sample size (1), the results can not be generalized.

In our patient, measured by the angle between the base of support and the calf as the pelvis rises.Source: www.oslo-universitetssykehus.no

Source: www.google.no (searchword: rectus femoris dysfunction)

Rectus femoris tightness Duncan Ely* – test for rectus femoris dys-function (PROM, tested by slow knee flexion):

BeforeRight: 50 degree angle Left: 30 degree angle

AfterRight: 50 degree angle Left: 60 degree angle

First time intervention – testing Innowalk

An illustration of standing alignment

1 - Key Walker 2 - Innowalk

Resistance against rapid passive stretch Hip extensors:

Before AfterRight: 2 Right: 1Left: 2 Left: 1 Measured by the Asworth scale

Hip adductors:

Before AfterRight: 2 + Right: 1 +Left: 2 + Left: 1 +Measured by the Asworth scale

Spasticity: ”disordered sensorymotor control, resulting from an upper motor neurone lesion, presenting as intermittent or sustained involuntary activation of muscles” (JH. Burridge et al, 2005).

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Poster holders: Tonje Thon, Physiotherapist, Children’s Department and Family Health Service, Porsgrunn, Norway, Knut Magne Ziegler-Olsen, Physiotherapist/Adviser at NAV Center of Assistive Technology in Telemark, Norway

Gastrointestinal function

Before (registration period of 2 weeks prior to the 6 week Innowalk trial):- 2-3 toilet accidents, 3 days complained of stomach pain, one of these days, the patient had to go home from school because of pain. - Use medicine for Gastrointestinal Function

During Innowalk trial (6 weeks): No complaints of stomach ache, 1 toilet accident. Now: No medicine for Gastrointestinal Function.

Additional effects:

Muscle circurmferenceCalf Before: Left (affected leg): 21 cm circumference After: Left (affected leg): 21.5 cm circumference

Blood flow- Warm feet after each session (usually they are cold)

GAIT PATTERN – BEFORE TRIALThe feet are significantly outwards rotated throughout the gait cycle, so that the left leg consistently nudges into the back of the right foot in the swing phase when walking at normal speed. This is less pronounced when the patient is walking faster. The upper body is clearly stooping forwards and there is flexion in the hips and knees. Walks with “kissing knees”.

GAIT PATTERN – AFTER TRIALThe feet are slightly less outwards rotated so that the toes are pointing more forward throughout the gait cycle. We can also see that the left foot now and then is nudging the right foot in the swing phase when the patient is walking at normal speed, but not consistently. There is longer distance between the feet in the gait cycle. The upper body is more upright and the patient is walking with slightly less flexion in the hips. The patient still walks with “kissing knees”.

Our professional impression is that walking function has improved.

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The goal of this research is to provide evidence as to whether the daily use of a motion device, for example the Innowalk, in a daily multitherapy conductive education routine has a positive effect on the degree of mobility of the hip joints as well as on the spasticity of the subjects’ hip adductor and ischiocrural muscles.

AIM

MET

HO

DR

ESU

LTS

Litterature research and three-month longitudinal study

Intervention group (7children) and control group (4 children): Bilateral spastic cerebral palsy, GMFCS IV and V, 6-10 years old

Motion therapy device: The Innowalk is a motor operated motion therapy device that places children and adoles-cents with severe multiple disabilities in an upright correct position, and which helps supported walking motion in both sitting and standing position.

Timing of measurements: Before starting the study, after two months, after three months (end of study)

Measuring parameters: Range of motion both hips using the Goniometer. Spasticity of the hip flexor, abducu-tors and the ischiocrural muscles using the Modified Tardieu Scale.

Duration: 45 min 5 times per week in motion therapy device

ROM in the hip joint in flexion (right p=0.006, left p= 0.019), abduction (right p= 0.042, Left p= 0.011), adduction (p= 0.011) and internal rotation (right p= 0.044) improved significantly for all the children in the intervention group compared with the control group. A significant reduction in muscle tone was also determined in the adductor muscles (p= 0.008) and in the ischiocrural muscles (p= 0.021).

Functional improvements was also seen on: Torso control - Endurance when walking, using aids - Standing duration in other standing devices - Quality of gait

No anti-constipation medication was required for the children, normally using this medication, while using the motiion therapy device.

Hip abduction rightConclusion

• Motion therapy device (Innow-alk) have direct effect on the hip joint of children with cerebral palsy• Effects on the range of motion and spasticity could be demon-strated• The determining factor was the duration of the intervention (3 months) • It is an expedient supplement for conductive multitherapy edu-cation or other therapy concepts• This approach provides a possib-lity to mobilise children with cere-bral motion disorders GMFCS IV and V adequately and inde-pendently from from their size and weight in an upright correct position as well as to maintain or even improve mobility of the hip joint.

Author; Physiotherapist Jana Käferle

Deg

rees

Deg

rees

0 0

-2 -2

-4 -4

2

1 12 23 3

2

4 4

6 6

8 8

10 10

12 12

14 14

16 16

Measurements Measurements

Hip abduction left

Interventiongroup Controlgroup

Effect of a motion therapy device on the hip joints of children with bilateral spastic cerebral palsy, GMFCS IV/V aged 6 to 10 years, as a procedure embedded in the conductive multi therapy system.

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An investigation of whether gross motor function, joint mobility and spasticity in the lower limbs of children with CP can be affected by using the “Innowalk” motorised training and stimulation aid.Author: Hege M. Hansen, Manual therapistThe text is a summary of a Master’s thesis in Manual Therapy at the University of Bergen, 2014

Background to the project: Physiotherapy treatment for children with cerebral palsy who have impaired or no walking function is increasingly being combined with motorised training and stimulation aids. The aim of these is to stimulate and improve the child’s activity level, body structure and body functions. An increasing number of children with cerebral palsy in Norway have been given the Innowalk training and stimulation aid, which, among other things, is supposed to affect joint mobility and prevent painful spasticity.

Purpose and approach: To investigate whether gross motor function, joint mobility and spasticity in the lower limbs of children with cerebral palsy can be affected by using the Innowalk motorised training and stimulation aid.

Material and method: The study uses quantitative approximation and a single-subject design. The sample is strategic and comprises two children with cerebral palsy (GMFCS levels 3 and 5). Observation and testing were carried out before and after the intervention in collaboration with the children’s local municipal physiotherapists in familiar surroundings. During the intervention period, the children used Innowalk daily for 9 and 12 weeks respectively. Gross motor function was assessed using the GMFM-66 test, spasticity was measured using a modified Ashworth scale and joint mobility in the lower limbs was measured with a goniometer.

Results: “Child 1” showed an improvement on one dimension of GMFM-66. Joint mobility showed a clinically significant change measured at 2 SD on three joint measurements: dorsal flexion of the right ankle with knee extended, outward rotation of the right hip and inward rotation of the left hip.“Child 2” showed an improvement on two dimensions of GMFM-66 and had three joint measurements that showed a clinically significant change measured at 2 SD: popliteal angle of the right knee, dorsal flexion of the right ankle with knee extended and inward rotation of the right hip. The study did not demonstrate any clinically significant change in spasticity in either child.

Conclusion: The approach of the study was to investigate how gross motor function, joint mobility and spasticity in the lower limbs of a child with CP can be affected by using a motorised training and stimulation aid. As the study involved only a small number of participants (N=2), it is not possible to generalise the results. However, the study does tell us something about a potential effect and trend after intervention for the two children who took part, and may serve as a pilot for a subsequent larger study involving more participants. The results from GMFM-66 and measurement of joint mobility show

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that it is possible to achieve a positive change in both gross motor function and joint mobility using the aid in question. Where spasticity is concerned, the present study has not demonstrated any change, although it has been shown that 30 minutes of standing activity daily could affect spasticity (Stevenson, 2010; Kheder & Nair, 2012). A child with GMFCS level 5 is at risk of developing contractures and pain, and the effect of the aid could be of great significance in terms of contracture prophylaxis. Good range of movement can also reduce the risk of dislocation of joints and surgical procedures as a result of the aforementioned contractures. It is likely that a child with GMFCS level 3 could achieve a certain walking function using aids. In order to optimise walking function, it is important to have good range of movement in the joints in the lower limbs, as well as muscle strength and trunk control, which will affect the child’s balance and opportunity of independent movement.

Keywords: Cerebral palsy, child, joint mobility, ROM, gross motor function, spasticity, “Innowalk” motorised training and stimulation aid

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Evaluation of the use of Innowalk by two patients, 4–6 times a week respectively

Patient 1Man born 1984. 31 years of age.Bilateral cerebral palsy GMFCS IIIActivity level 1 (based on the Saltin–Grimby Physical Activity Level Scale)

TargetsNo explicit targets under the heading “Goals” in the notes but patient has following aim: - to raise the activity level.Trained 36–45 minutes, 5–6 times a week.

Results relative to targetsThe baseline measurements taken are shown in brackets. Measurements are reported where they differ from the baseline.

The patient has clearly achieved his target in that he has trained on so many occasions. Patients says himself that for once he finds being active enjoyable and positive.

Measurements3 metres 41 steps (39 steps)Outward rotation of hip: left 55 (50)Knee extension: right -20 (-30); left -35 (-40)Hamstring angle: left 120 (110)

Results, miscellaneous – side effectsHe thinks his gastrointestinal function has probably improved.

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Patient 2Man born 1957. 58 years of age.Bilateral cerebral palsy GMFCS IIIActivity level 2 (based on the Saltin–Grimby Physical Activity Level Scale)Plays table tennis once a week.

TargetsNo explicit targets under the heading “Goals” in the notes but patient has following aims:- to improve stamina- to achieve “up and go” more easily/quickly- to be able to climb on to low stool more easily (get in and out of electric wheelchair and ordinary car)Trained 45–60 minutes, 4 times a week

Results relative to targetsThe baseline measurements taken are shown in brackets. Measurements are reported where they differ from the baseline.

The targets the patient set have been achieved: he is walking with improved balance and strength according to what he says, and finds it easier to climb into and out of an electric wheelchair and car. “Up and go” is both quicker and easier.

MeasurementsTUG (Timed Up and Go) 26 secs (31 secs)Walking with self-selected stride length – no change.Walking with as long a stride length as possible – 23 secs for 12 steps (32 secs for 12 steps)Standing hip flexion – raising the foot: right 11 cm (6 cm); left unchanged at 15 cm.Outward rotation of hip: right 54 (40); left 42 (33)Hip flexion: right 103 (97)Knee flexion: left 150 (140)Hamstring angle: 135 (118)

Results, miscellaneous – side effectsEasier to walk.Better balance (doesn’t hold on to the walls so often)Tonus generally reduced during activity.Always manages to get foot up on the footplate of electric wheelchair and to climb in and out of car at the first attempt. (2–4 attempts)Table tennis is going better; patient is standing more upright and not getting pain in the curve of the back. (Pain in curve of back after each training session)

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SummaryOur two test subjects were people with cerebral palsy GMFCS III, activity levels 1 and 2 (according to the Saltin-Grimby Physical Activity Level Scale). The most important thing for us (two registered physiotherapists) to say in summary is that this training method suited our test subjects very well. Many of our patients, particularly those with GMFCS III, have difficulty finding forms of training where they feel comfortable, which they can do independently and where the training in itself produces tangible results for them. The Innowalk achieved this.In a short time, we were able to record measureable results and could see that our motivational talks were no longer required to get the patients to do their training. The patients found the training pleasurable and were more likely to do more than fewer sessions than had been agreed.

Britt-Marie Rydh Berner Lotta Ahlborgleg Sjukgymnast leg SjukgymnastTonusmottagningen R 61 Vuxenhabiliteringen R 61britt-marie.rydh-berner@ds.se lotta.ahlborg@ds.se

Rehabiliteringsmedicinska Universitetskliniken StockholmDanderyds sjukhus AB141 86 Stockholm

Made for Movement have permission to quote the results from the two cases made by Britt-Marie Rydh Berner og Lotta Ahlborg Physiotherapists at Danderyds hospital Stockholm

INNOWALK

Ulrik has had the Innowalk since 2012 and uses it regularly at home for 30–60 minutes a day. After just a short time, Ulrik experienced a positive change in his gastric and bowel function. The movement in the Innowalk has also resulted in increased appetite and sleeping better at night. Ulrik has become stronger and has better posture, which has led to increased stability and control in the upper body.

Ulrik is a six-year-old boy with cerebral palsy (GMFCS

IV), spastic quadriplegia. The basis for applying for the

Innowalk was that Ulrik showed an interest in using

his body. The aim was to increase his activity level, and

achieve more movement and increased muscle strength.

CEREBRAL PALSYGMFCS IV

• Improved gastric and bowel function

• Increased appetite• Better sleep• Strengthened

musculature• Improved posture• Improved trunk

stability and general body control

• Reduced spasms• Sense of

accomplishment• Energy and

increased quality of life

Made for MovementMovement for those who are unable to do so on their own

ULRIK’S EXPERIENCES WITH THE INNOWALK

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CASE REPORT

CEREBRAL PALSY

• Cerebral Palsy (CP) is a group of disorders• CP is the commonest cause of physical disability in

early childhood• Overall, the CP rate is between 2 and 3 per 1000

live births• CP involves a disorder of movement and posture

and of motor function• It is due to a non-progressive interference/lesion/

abnormality. This interference/lesion/abnormality is in the developing/immature brain

”Ulrik is a happy and inquisitive boy who likes to be active. When he is standing in the Innowalk, he is proud and has a sense of accomplishment. The Innowalk gives him positive energy and increased quality of life. He likes to be at the same height as others and to have a normal perspective on things. Ulrik smiles and laughs. Innowalk lets him enjoy life.”

- Ulrik’s parents

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INNOWALK

From the age of 18 months, Ada used a standing frame for 1 year. She had Innowalk when she was 2½ years old and, during the trial period, was involved in a project to test and measure various functions before and after having the aid. Changes in terms of transition from standing to sitting on a bench were measured, and unaided sitting increased from a few minutes to half an hour. Measurements were also made of clinically important changes in joint mobility, which may be significant in the long term for Ada’s ability to walk in other walking aids.

Eighteen months after Ada started using Innowalk, she still uses it every day at the day nursery, for 30 minutes twice a day. She stands in Innowalk and joins the other children in activities such as reading, drawing and group time.

Ada is 4 years old. She was born 3 months premature and

has cerebral palsy with a functional level of GMFCS IV.

For her parents, it has been important to stimulate her

in an active standing position with weight bearing and

in a walking pattern. The aim has been for Ada to build

up her body’s strength and stability, something that will

give her the opportunity for increased activity and social

interaction.

CEREBRAL PALSYGMFCS IV

• Increased stability and strength

• Better gastro- intestinal function

Made for MovementMovement for those who are unable to do so on their own

• Better joint mobility in ankles and knee tendons

• Improvements in gross motor skills

ADA’S EXPERIENCES WITH INNOWALK

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CASE REPORT

“The staff at the day nursery are good at integrating her training in Innowalk with activities with other children. Ada likes standing in Innowalk.”- Ada’s mum

Thanks to Innowalk, Ada has gained more strength and stability in her body, and the increased activity stimulates and improves her gastrointestinal function, which is now better than before.

CEREBRALPARESE

• Cerebral Palsy (CP) is a group of disorders• CP is the commonest cause of physical

disability in early childhood• Overall, the CP rate is between

2 and 3 per 1000 live births• CP involves a disorder of movement and posture

and of motor function• It is due to a non-progressive interference/lesion/

abnormality. This interference/lesion/abnormality is in the developing/immature brain

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INNOWALK

The Innowalk has been a central element of the rehabilitation. The aim of using the Innowalk was to get Peter into a safe standing position with weight bearing as soon as possible after the plaster was removed. This allowed him passive movement of the legs with corrected gait, and stimulated the muscles and joints. Peter had walked in the NF-Walker until the operation, and the aim was to enable him to resume using it.

Even before the operation, Peter was introduced to the Innowalk so that he would feel confident in using the aid. This enabled him to start using the Innowalk as soon as possible once the plaster was removed.

After just one week out of plaster, Peter was moving in the Innowalk for 40 minutes at a time. He was able to decide for himself the speed and traction on his hip and knee.

“I’ve known of children who have walked using the NF-Walker before a hip operation but unfortunately have lost their walking function after the surgery or have taken a long time to regain it. They have often experienced severe pain in connection with mobilisation and handling. We therefore wanted to find out whether Peter could get moving more quickly after the operation if training was supplemented by movement in the Innowalk.”

- Peter’s physiotherapist

Peter has cerebral palsy (GMFCS IV). A dislocated hip

resulted in surgery on the left hip, with simultaneous

lengthening of the hip flexors, Achilles tendons and

adductors on both sides. After six weeks in plaster, Peter

was able to start rehabilitation.

CEREBRAL PARESEGMFCS IV “AFTER HIP SURGERY”

• Central part of his rehabilitation

• Secure position with weight bearing

• Stimulation of muscles and joints

Made for MovementMovement for those who are unable to do so on their own

PETER’S EXPERIENCES WITH INNOWALK

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CASE REPORT

DISLOCATED HIP

• Children with cerebral palsy have increased risk of dislocating a hip

• Children with cerebral palsy, GMFCS level V, have a higher risk of dislocating a hip than those with GMFCS levels II to IV

• Withouth screening and interventions, 10-20% of children with cerebral palsy experience a dislocated hip

Peter used the Innowalk at nursery – between 30 and 50 minutes every day. He enjoys moving in the Innowalk. It was often used in combination with other activities at the table, such as playing with an iPad.

“As a physiotherapist, I find that Peter is immediately more mobile and better tolerates movement and traction in the muscles and joints after he has been moving in Innowalk.”

- Peter’s physiotherapist

• Increased mobility• Better tolerates

movement and extension of muscles and joints

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INNOWALK

«The Innowalk provides us with relief and is easy to use every day, allowing Marla to experience independent movement.

The Innowalk makes everyday life easier for Marla. It enables her to move her legs while weight bearing – which approximates the normal movement of a healthy person. She really enjoys using the Innowalk.

Without the Innowalk, Marla’s opportunity for movement would be severely limited. She would miss out on important mental stimulation.

We find that the Innowalk meets a fundamental need for movement in our daughter”

- Marla’s parents

Marla is a 13-year-old girl with Rett syndrome. Her doctor

recommended Innowalk after a hip operation. Today, the

Innowalk is an important training aid that she uses at

home.

RETT SYNDROME

• Increased flexibility in the joints

• More stable gait• Increased trunk

stability• Improved ability to

stand upright• Increased heart and

lung capacity• Better concentration

at school• Positive effect on

respiration• Improved digestion• Reduced number of

epileptic seizures

Made for MovementMovement for those who are unable to do so on their own

• Postive effect on sleeping rhythm

• Reduces pain

MARLA’S EXPERIENCES WITH INNOWALK

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CASE REPORT

RETT SYNDROME

• A postnatal neurological disorder that is first recognized in infancy and seen almost always in girls, but can be rarely seen in boys

• Causes serious disturbances in brain development, leading to mental disability, difficulties in social interaction and problems with purposeful movements

• Worldwide, it affects 1 in 10 000 girls. In Norway, an average of three children are born with Rett syndrome every year

• The symptoms occur in connection with a gradual stagnation of the child’s development after 6-18 months www.rettsyndrome.org.

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INNOWALK

Jonathan underwent surgery for this at the age of seven. His functional level was further reduced after suffering status epilepticus six years ago, at which stage he lost his walking function.

In May 2014, Jonathan started training in the Innowalk at the foundation Radarveien day centre in Oslo. The aim with the Innowalk was to increase his activity level, and see how activity with weight bearing and repeated movements would affect his motor functional level.

Today, Jonathan takes a greater part in transfers . His trunk stability has improved significantly, and he clearly enjoys the sensation of movement in the Innowalk. His mood improves and those around him find it is easier to motivate Jonathan to take part in other activities.Jonathan uses the Innowalk four times a week for up to 40 minutes.

“At times when Jonathan is on poor form and not so inclined, he’s not so receptive to training and activities. What works well is the training and activity he gets in the Innowalk. Those of us around him find he is in a better mood, smiles and expresses a sense of wellbeing.”

- Physiotherapist at the foundation Radarveien

Jonathan is a young man of 23. He is physically disabled

and has impaired cognitive function as a result of a benign

tumour on the hypothalamus. He has daily epileptic

seizures.

BRAIN TUMOR

• Improved motor functional level

• Increased muscle strength

• Increased independence in transfers

Made for MovementMovement for those who are unable to do so on their own

• Joy of movement – stable mood

• Reduced oedemas• Increased bladder control• Easier to motivate to do other

activities• Sense of accomplishment

JONATHAN’S EXPERIENCESWITH INNOWALK

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CASE REPORT

HYPOTHALAMIC HAMARTOMA

• A benign (non-cancerous) tumor in the brain, close to the hypothalamus, of unknown cause

• Estimated to occur in 1 in 200 000 children and teenagers worldwide

• Treatment options have increased in the last 10 years but surgery is associated with a high level of risk www.hopeforhh.org

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Case report

DiagnoseICP of spastic tetraparesic typeHip dysplasia with decentration of the right hip joint with increasing pain and adduction contracture.

Orthopaedic therapiesAngulation osteotomy with head-neck resection of the right hip joint with angular stability plate implantation and post-operative application of a hip-leg cast on 24/08/2011.

1. Reason for the rehabilitation measureThe above mentioned operation of the right hip joint had become necessary because the patient suffered significant adduction contracture pain and loss of function. The goal of a procedure of this kind is to preserve the patient’s sitting ability and therefore participation in positions without pain and a build-up of tension – he was supposed to achieve sitting ability for a day- to-day relevant period of time and become able actively to assist, to a minor extent, in transitional movements.

On a test basis, the Innowalk was calibrated to the patient’s needs and prepared for further application. Below we describe the related experience and the further prospects (3.) from a therapeutic point of view, which render apparent the necessity of the treatment of the patient with the Innowalk.

2. Therapeutic contents and goals supported by the use of the Innowalk:Individual physiotherapyImprovement of joint mobility - passive movements of the right hip to maintain the surgical outcome, maintenance of the passive abduction ability, improvement of the hip flexion ability, improvement of the tolerance of selective motions around the right hip joint. Because of the underlying neurological disease, the patient has a tonic reaction to changes in body and joint position, and frequently responds to individual joint movements with a paroxysmal increase in tension. Because of the variable positions that can be set in the Innowalk (very precise adjustments between a sitting position with a 90° hip angle and a standing position with extended hip joint), passive movements in the right hip and knee were well tolerated by the patient. At the beginning of the trial, he started in a seated position with approx. 45° hip flexion. At present, he is already tolerating the start with a hip flexion of 65°.

Muscle strength build-up - dystonic-spastic motion disorders primarily involve a lack of control and hypertonia in all relevant muscle groups. Within the scope of an activity level (held sitting position), by means of frequent changes in position, by modifying the sitting position (sitting on moveable surfaces), the patient was able to develop more strength for better torso control and orofacial function, for movements of the left foot (communication) and for negligible coactivity of the right leg with supported rising from the held sitting position (in the therapy situation).The Innowalk provides fundamental support in muscle build-up, as the continuous movements counteract the sudden loss of muscle tone, which is typical for athetosis, thus enabling the patient to develop a basic tension in his torso and maintain it for as long as possible (which is decisive for everyday functions such as eating, communication, care activities, as well as participation in the social environment – eye contact).Sensitivity normalization – after a hip-leg cast and with involuntary changes in the tension build- up,

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the patient finds it difficult to regain control over his reactions (paroxysms). The continuously repeating demands on his motion and perception system should help him reduce and tolerate pain.With its belt system, the Innowalk provides the patient with a degree of safety and support that enabled him to reduce the fear of a loss of position and of experiencing pain. Using a mirror, he was able to monitor his movements and, because of the improved fundamental tone in his torso, unambiguously indicate the desired speed and position by means of gestures and eye movements.

Device supported therapy:NF Walker – Before the operation on his right hip joint, the patient was mobile with a NF Walker. This type of care was helpful in his need for autonomy. Because of his orthostatic dysregulation, it is not possible to place him in a vertical position in a standing aid.In the consultations prior to the extensive hip operation it was pointed out that the active introduction of stepping leg movements in the NF Walker can represent an excessive strain in a status post angulation osteotomy. For this reason, a different mobility aid had to be found for the patient. Innowalk – Training with the Innowalk makes it possible to bring the patient into a safe and acceptable, open hip-angle position. The passive movement of the legs in a reciprocal walking pattern achieves a tolerance of continuous alternation between extension and flexion of the right hip joint, stretching of the muscle structures around the right hip joint by means of the contralateral range of movement, thus improvement and maintenance of the abduction ability and symmetry on the torso. By now, he tolerates the training with the Innowalk for 20 minutes at a time.

3. Future therapeutic goals supported by the use of the Innowalk:As described above, the continuous training with the Innowalk will provide the patient with decisive support in the attainment of the further therapy goals (such as improvement of the joint mobility, muscle strength build-up, sensitivity normalization, improved cardiovascular situation and thus better tolerance of an erect position).To summarize, it is also necessary from a physiotherapeutic point of view that he should, over the long term, achieve high quality muscle tone regulation to continue developing and consolidating the rehabilitation process, thus preventing a relapse or the development of a scoliosis, frequently accompanied by a long-term prognosis of complex and expensive operations.It is therefore important to find a means in addition to physiotherapy that will not only place the patient into a vertical position but also involve him in physiological activity. We consider these sensorimotor requirements to be met by the Innowalk and would therefore, from a physiotherapeutic point of view, recommend prescription of this device.

This case report is written by a physiotherapist. Originally in German. This is a translated version.

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Case report

DiagnoseCentral muscular hypotonia. Combined development disorder / complex malformation syndrome

Therapy according to the prescription Physiotherapy-CNS-children (according to Bobath Vojta)

The patient is an eight year old boy who has been coming to my clinic for therapy since June of 2003. He is being treated with the Bobath and Vojta methods, with input from SI therapy. The patient is also regularly treated with manual therapy, as he presents with recurring blockages over the entire spine. Because of hemiparesis on the right hand side, he presents a distinct tone asymmetry, which constitutes an impairment especially in connection with changes in position. The patient is dominated by hypotonia in his torso, and he finds it very difficult to overcome gravity. His head/neck area is also hypotonic, which also becomes evident in a strongly diminished eye-hand coordination and the dominance of early childhood reactions. Problems are created by his emotional alertness and a reduced drive to maintain and secure erect positions, which is also due to impaired motor attention. Overall, the patient appears distinctly impaired in his understanding of movements and his sensorimotor deficits make it very difficult for him autonomously to regulate himself and his muscle tone. In particular the proprioception option – i.e. the pressure in the joint surfaces, primarily in the vertical direction – leads to qualitatively good regulation of the muscle tone. The patient experiences the best possible muscle tone regulation when, in addition to the therapeutic measures, he either stands on a vibration plate (which is however very difficult to implement) or is “activated” with the INNOWALK by Made for Movement. The continuous leg motion that can be seen in this device enables the patient to produce so much muscle tone for sitting up that he can not only better counteract gravity but can also sufficiently control his dystonic leg muscles.

The resulting muscle tone regulation can actively be promoted, and he thus also for the first time has the option to participate in everyday life in a standing position – i.e. also at eye level with the people sitting around him – and to make eye contact with his environment.

The long-term effect of this measure is not insignificant, so that the INNOWALK outstandingly supplements the patient’s therapeutic treatment.

To summarise, it is also extremely important from a physiotherapeutic point of view that he should, over the long term, achieve target oriented and high quality muscle tone regulation in order, in particular, to prevent consequential damage such as a severe hip dislocation or a scoliosis, which are frequently accompanied by a long-term prognosis of complex and expensive operations.

It is therefore important to find a means in addition to physiotherapy that will not only place the patient into a vertical position but also involve him in physiological activity. We consider these sensorimotor requirements to be met by the Innowalk and would therefore, from a physiotherapeutic point of view, recommend prescription of this device.

This case report is written by a physiotherapist. Originally in German. This is a translated version.

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INNOWALK – BENEFICIAL EFFECT IN SPINAL MUSCULAR ATROPHY By Ulrika Skjellvik Tollefsen

There are many exciting aids on the market nowadays. One is Innowalk, a motorised aid that provides assisted movement in a standing position for children with impaired mobility. It is so new on the market that there are no studies of its effect. Several case studies have been carried out involving Innowalk, but to date no articles have been published. One study is in the process of publication and several others have been started, mostly concerning users with cerebral palsy (CP).

In this article, I shall present a case in which I have chosen to look at the effect of training in Innowalk for a boy with the muscle disease spinal muscular atrophy (SMA). I have compared the results with results from other studies that focus on training/physical activity for the group of neuromuscular diseases in general and SMA in particular (Carter, 2012, Grimby, 2004, Abresh, 2009, El van der Kooi, 2013). Presentation of the case Martin is seven years old and has a diagnosis of spinal muscular atrophy, type 3. He has reduced muscle tone, strength and balance, affecting his walking function, which is unsteady and rolling. He easily loses his balance and falls over, and it is difficult and requires a lot of energy for him to get himself up. Martin often has to sit down, and needs help to get up and to get dressed. Over the last two years, his carers and other people around him have noticed a decline in his functional level. Martin confirms that he quickly tires when playing and doing activities at school and at home. The diagnosis is progressive in nature, and will in time lead to further loss of function (Campbell, 2012).

His physiotherapy treatment focuses on measures to establish good routines for contracture prophylaxis, increase stamina and independence, and maintain walking function for as long as possible.

The Norwegian Labour and Welfare Administration (NAV) provides assistance to obtain technical aids. Martin is still able to walk, but two summers ago I procured a manual wheelchair for him. He uses this to go longer distances and to get around quickly. Prior to Innowalk, Martin was having weekly physiotherapy, trained three times a week with an assistant, and did daily mobility and stretching exercises with his carers.In autumn 2013, I applied for a trial with Innowalk for Martin. The aim was to improve the effect of daily

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FACT BOXSpinal muscular atrophy (SMA) is a hereditary neurological disease, the most important symptom of which is weakness in striated muscle tissue. The disease is one of the most common muscle diseases (neuromuscular diseases). Onset may be during gestation, in early childhood or in the teenage years, and there are significantly different degrees of severity (Frambu 2013).

SMA is defined in three groups: Type 1: can only lie, starts before the age of 6 months Type 2: can sit, starts before the age of 18 months Type 3: can walk, or has been able to

My name is Ulrika Skjellvik Tollefsen and I’m a specialist community physiotherapist. This summer I also qualified in specialist physiotherapy for children and adolescents. In the spring of 2014, I completed postgraduate training in children’s physiotherapy at Oslo and Akershus University College. As part of my degree, I wrote a case study, and that is what I want to present here. The article concerns spinal muscular atrophy and training in Innowalk as a supplement to traditional physiotherapy.

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movement and stretching in the home, and to provide an alternative/supplement to traditional stretches. At times, it was difficult for Martin’s parents to motivate him to do his training because he was tired. The hassle of following up training/physiotherapy every single afternoon was also an extra strain for both Martin and his parents. Innowalk was intended to motivate Martin and make it easier for his parents to follow up on his training at home. A further aim was to prevent contractures, allow weight bearing on the joints in a ‘more correct’ position, maintain muscle strength and, as a result, enable Martin to retain walking function for as long as possible. Another goal was to provide Martin with motivation and joy of movement through physical activity on his own terms.

TheorySpinal muscular atrophy (SMA) is a hereditary neurological disease, the most important symptom of which is weakness in striated muscle tissue. The disease is one of the most common muscle diseases (neuromuscular diseases). It may start during gestation, in early childhood or in the teenage years, and may have significantly different degrees of severity (Frambu, 2013). SMA is defined in three groups:

Type 1: can only lie, starts before the age of 6 months Type 2: can sit, starts before the age of 18 months Type 3: can walk, or has been able to

This classification provides a practical way to group the variations in the disease (Frambu, 2013, UNN, 2013). In type 3, the disability usually manifests before the age of ten, and includes problems getting up from the floor, using stairs and keeping up when playing with peers (Campbell, 2012). This is the case for Martin. According to Campbell (2012), the pathological characteristic of SMA is an abnormality in the large anterior horn cells in the spinal cord. According to Oslo University Hospital (2013), signals from the brain are not transferred to the muscles. The muscles do not function, leading to muscle wastage/atrophy. The number of cells lost and the progressive degeneration of the remaining cells correspond to the loss of function (Campbell, 2012). From a perspective of socio-cultural participation, social participation is a prerequisite for human development, wellbeing and selfhood (Rogoff, 2003). Through social participation in culturally constituted communities, Martin will shape his personal development throughout his childhood and on into his adult life (Gulbrandsen, 2006). Training is defined here as purposeful, systematic and regular activity to maintain and, if possible, increase muscle strength, physical function and stamina in hereditary chronic, progressive muscle diseases (ffm.no, 2013). According to UNN (2010), enjoyment of physical activity leads to a more positive attitude to one’s own body.

ProcedureBefore starting the trial with Innowalk, I gathered information from others with experience of SMA and Innowalk, and discussed my intentions regarding the user with several colleagues. In order to acquire this aid for Martin to try out, I had to carry out detailed preliminary work and obtain approval for the trial from both the Consultant Physiotherapist at the Rehabilitation Centre and the HSE representative. Before, during and after the trial, I recorded videos of Martin walking with and without the walking frame, standing up from a sitting position on the floor, and how long this took. The aim was to document any results/changes and to provide a basis for comparison (baseline). Martin stood in Innowalk for at least 45 minutes, five days a week for four weeks.

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An important element of the trial was logging the training every day, and I made a home visit once a week for follow-up. This ensured good compliance, in the sense that it made sure Martin was using Innowalk as intended, and made us all aware of how he was using it and the effect of the training. There were two days when he did not use Innowalk because he was ill. ResultsSome positive results were seen after just one week. Martin said it was easier to go into his parents at night, and his mother had noted both that the training in the afternoons was going more easily and that Martin had lost weight. Half-way through the trial period, I observed that Martin’s quality of movement when standing up/getting up from the floor had improved. Part of the reason for this was that he was now choosing to get up via a half-kneeling position. The video recorded after the trial period showed that Martin no longer needed breaks to walk the same distance without aids. The assistant said he had more stamina during the school day. His parents summarised the results as follows:

Martin doesn’t complain about pains in his legs. We find he has improved circulation: his legs are nice and warm. He is crawling upstairs again, and has more energy on a daily basis. He has lost weight. The parents also say they can see that it is generally easier for him to move. Martin himself says that he ‘runs’ like other children. Daily training is going well. Martin is motivated and happy in his new aid.

The intention with using the aid in the home has been realised, and many of the other goals also seem to have been achieved. It is interesting that the results were apparent after only a short time. Martin’s muscles seem to be working better. His parents are both positive and optimistic about what Martin is getting out of the training; it does him good in several ways. Martin is happy in Innowalk and says that it is easier to move around. This is probably why the comprehensive training programme is going well. Discussion:Various studies of physical activity in persons with neuromuscular diseases (Grimby, 2004; Abresh, 2009; El van der Kooi, 2013; Wahl, 2009) support several of my findings. Physical activity and training can counter inactivity and secondary effects such as overweight, osteoporosis (brittle bones) and cardiovascular disease, as well as contributing to increased energy (Grimby, 2004). In Martin’s case, we saw weight reduction after just one week, and he quickly gained more energy. According to Campbell (2012), traditional training principles explicitly state that achieving an improvement in fitness requires one to train a minimum of three times a week and maintain this for eight weeks or more to see results. Several small studies have reported improvements in walking, strength and function following treadmill training for children with CP. I assume parallels can be drawn with Innowalk, and therefore believe that improved walking function and increased energy in daily life may be a result of improvement in fitness. The training principles specified above are satisfied (45 mins x 5 days per week), although the duration has not yet passed eight weeks. Martin will continue to be followed up on a weekly basis at school and regularly with regard to Innowalk. I believe this will reduce the risk of over-training, which brings us to the next point.

In the case of diseases of the motor anterior horn cell – here SMA – there is a concern that too much training can increase the loss of the muscle-controlling nerve cells (motor neurons). The healthy nerve cells can become overloaded if they try to compensate for the lost cells (Abresh, 2009). It is important that Martin is not exposed to over-training, which in turn can bring about a form of fatigue syndrome. The training ‘dosage’ must therefore be taken into consideration. Training without pain is the key, according to paediatric endocrinologist Alfred Slonim (Abresh, 2009). His blueprint for training is short and sweet:

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‘No gain with pain’. He recommends light aerobic training such as sessions on the treadmill and cycling, all supervised by a doctor/physiotherapist with the requisite knowledge (Abresh, 2009). Both treadmills and Innowalk are motorised forms of training equipment, which is why I consider training in Innowalk to be ideal if Martin does not experience pain at the time or afterwards. He has not indicated any pain while training. Pains immediately after or a day or two after training are a sign of incorrect training or over-training, and should result in the training being stopped temporarily or reduced in intensity (Abresh, 2009). Martin’s parents were informed of this so that they could provide quick feedback if pain occurred in connection with or subsequent to training. Martin no longer has pains in his legs, and I believe the regular movement he has experienced using Innowalk at home may be the reason for this. Abresh (2009) writes that correct training may reduce some forms of pain. If the pains are an effect of stiff joints and long-term immobility, training in the form of stretching and joint mobility may be useful (Abresh, 2009). I believe that maintaining independent walking function for as long as possible will delay the development of contractures in the joints, as well as the development of scoliosis. This is confirmed by Campbell (2012), who writes that individuals who maintain independent walking function have a lower incidence of scoliosis and less serious curvatures if scoliosis should develop. It is important to emphasise Martin’s own experiences in connection with the training. After a short time, he said – in his own words – ‘I can run like a normal child’ and ‘training in Innowalk is good’. It is important to engage Martin so as to maintain his motivation to continue training, and to provide affirmation. All action and interaction is participation. I consider that maintaining Martin’s walking function for as long as possible may help to ensure his social participation at school and in daily life. It will be easier for him to follow his classmates around. By taking part in organised experiences of everyday life and in opinion-forming processes over time, Martin will develop as an individual (Gulbrandsen, 2006). I believe that continued walking function will strengthen his potential for participation: participation with regard to his disability, in an individual and social perspective (Grue, 1999; Ulvik, 2009).If the results continue in this positive direction, I think this may be very good for Martin. An improved functional level will give him a sense of mastery, which will help to improve his self-image and self-confidence (Grue, 2013). I consider my experiences in this case may be significant for others with the same diagnosis as Martin. Innowalk enables any walking function and general physical fitness to be maintained and possibly even improved. This, in turn, will have positive ripple effects, as described above. Conclusion:The case report has shown that for Martin, who has SMA, training in Innowalk has produced positive results in a short time in the form of better walking function, more energy and a genuine sense of moving more easily. It remains to be seen whether the results are lasting. Eighteen months after starting to use Innowalk, Martin is still very happy in it and continues to have better sitting balance, trunk control, arm strength, etc. The time perspective of the case was limited, but I chose to be positive since several of the results are supported by various studies of training in people with neuromuscular diseases (Grimby, 2004; Abresh, 2009; El van der Kooi, 2013; Wahl, 2009). If the training is adapted to the individual child, takes account of his/her particular needs and requirements, and is closely monitored to avoid over-training, I think that Innowalk can be recommended for this user group. Grimby (2004) found that strength and conditioning can be carried out with a positive effect. The condition for this is that the training programme must be drawn up individually, based on analysis and knowledge of the diagnosis and functional level, and adapted

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on the basis of an understanding of the underlying pathology. Grimby (2004) states that the effect of the training must be monitored carefully. Several health care professionals are seeing the benefit of Innowalk in their practice. It would be interesting and useful if more colleagues were to document their results and confirm any effects of using this aid. Systematising the information in this case report has made me aware of what, how and why I have thought as I do, and given me new ideas for further work with Martin and other children I meet in my practice. The goal of increasing Martin’s motivation for training at home, and improving how this goes, has been achieved – despite the fact that training in Innowalk is a time-consuming activity. However, I believe Martin and his parents will be motivated by seeing the results of the work they are doing, in the form of an improved functional level for Martin.

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Rogoff, B. (2003) The cultural nature of human development. New York: Oxford University Press Ulvik, O. S Barns rett til deltakelse – teoretiske og praktiske utfordringer i profesjonelle hjelperes samarbeid med barn Tidsskrift for Norsk Psykologforening, 2009, Vol 46, nummer 12, side 1148-1154http://www.psykologtidsskriftet.no/index.php?seks_id=98504&a=2

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This article was first published in Barnestafetten (Norwegian Pediatric Physiotherapy Organization) November 2015 - no 76 - 33. This article is published with the authors permission.