Anterior or posterior walkers for children with cerebral palsy? A systematic review

Abstract

Objective: To review the literature comparing use of anterior and posterior walkers (PW’s) by children with cerebral palsy (CP) to determine which walker type is preferable.

Methods: Electronic databases were searched using pre-defined terms by two independent reviewers. Reference lists of included studies were hand searched. Studies published between 1985 and 2016 comparing use of anterior and PW’s by children with CP were included. All study designs and outcomes were accepted. Risk of bias was assessed using the “Quality assessment standard for a cross-over study”. Quality of evidence was evaluated using GRADE.

Results: Six studies were analysed. All studies had small sample sizes. A total of 4/6 studies were randomized. A total of 4/6 had high risk of bias. Outcomes included velocity, pelvic tilt, hip flexion, knee flexion, step length, stride length, cadence, double stance time, oxygen cost and participant/parental preference. Velocity, trunk flexion/pelvic tilt, and stability may be improved by using a PW, however, GRADE quality was very low for all outcomes and there was heterogeneity between studies. The majority of participants and parents preferred the PW.

Conclusions: Heterogeneity and low quality of existing evidence prevented recommendation of one walker type. Well-designed studies with adequate power are needed to inform clinical recommendations.

Implications for rehabilitation

• Clinical recommendations cannot be made for whether anterior or posterior walkers are preferable for children with cerebral palsy based on the existing evidence.

• Velocity, trunk flexion/pelvic tilt, and stability may be improved by using a posterior walker.

• The majority of walking aid users and their parents preferred posterior walkers.

• Adequately powered studies designed to minimize bias are needed.

Keywords:

• Cerebral palsy
• child
• gait
• mobility
• physical disability
• walkers
• walking aids

Acknowledgements

Dr. Alison Rushton – for her assistance with the study protocol, the NIHR – for funding backfill of the authors’ clinical post. Thank you to the West Midlands Clinical Academic Internship Programme and in particular Dr David Punt for his help and support with preparation of the manuscript. Dale Bradbury – for the illustrations used in Figure 1.

Disclosure statement

The authors report no conflicts of interest.

Additional information

Funding

This article presents independent research funded by the National Institute for Health Research (NIHR) and Research Trainees Coordinating Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Miss. Poole was a National Institute of Health Research (NIHR) faculty member, and received funding from them to backfill her clinical post to support her research whilst this review was written.