Article

Great Strides with the Rifton TRAM

A TBI Success Story

Cathy Ripmaster, MSPT | March 2015

A few years ago we welcomed a non-traditional student – we’ll call him Jay – at Lincoln Developmental Center (LDC) where we work. Most of our students have had a development disorder since birth; most are undersized and fit well into traditional equipment, but Jay sustained a traumatic brain injury at the age of 14 and arrived at LDC at the age of 17, fully grown, with limited positioning options. It took two or three staff to transfer him out of his wheelchair and into a Pacer or Advancement Chair. He used the XL Pacer, but it was not tall enough for him to encourage an effective gait pattern. From the MOVE program we know that it may take up to 2,000 trials to learn a new skill, but Jay was not given the opportunities for the needed trials because of the time and effort it took to transfer him. We were also concerned about his safety and ours while lifting him.

A TBI patient sits slumped down in a wheelchair with limited mobility and control.

January 2012
Jay uses a feeder seat for sitting.

He has limited right UE and LE movement and poor head and trunk control.

Prior to getting the TRAM, staff transferred using a Hoyer Lift or with 2-3 people manually lifting him.

A traumatic injury case study showing the patient practicing gait training.

June 2012
Jay uses the XL Pacer, but this is even too small for him preventing an effective gait pattern.

Jay's gait is slow and he needs prompting to move his legs. He uses a skate under his right foot to prevent it from dragging.

His goal was to walk 40 feet in the Pacer, but he was only completing this goal at 30%. Changed goal to 20 feet.

Everything changed when we purchased a Rifton TRAM for Jay’s classroom. It took us a while to find the correct adjustments with the walking saddle, but with the help of training materials from Rifton we were able to find the best set up for Jay. He now uses the TRAM for most of the morning and into the afternoon.

A TBI patient goes from sitting to raise his flag and pledge allegiance.

September 2014

The Pledge of Allegiance is a great reason to stand during morning opening.

The iPad is a great visual prompt to hold his head upright.

A TBI patient surrounded by his teacher and classmates goes from sit to stand to walking in his TRAM.

September 2014

Jay is given multiple trials to get up from his chair and walk to the board during opening.

In this case study, the patient works on playing an instrument while getting the head support he needs.

February 2014

Jay using the TRAM for sitting activity to work on trunk and head control and reaching. It is a highly motivating activity, but he still needs posterior head support.

A TBI patient gets assistance from a therapist to find the proper positioning in the walking saddle on the TRAM.

May 2014

It took staff a while to figure out the best configuration for the walking saddle, but eventually they found what worked for Jay.

He is currently able to transition out of his wheelchair with assist of only one person using a stand pivot transfer to his strong side to a mat table. Standing, he is able to bear his weight when he reaches a certain degree of knee extension (a new skill that has developed only this year). The walking saddle is placed on the mat table so when he sits down it is right where it needs to be. While he is supported by another person on the edge of a mat table, the TRAM is positioned around his trunk and the walking saddle that is positioned under his body is attached to the frame. He typically sits on the edge of the mat table while being supported by the TRAM while other students are getting up and ready for the day. He likes to be able to watch people coming and going from the classroom. Typically then he walks to the office for attendance or to deliver a message, or he stands up and walks over to another part of the classroom for morning opening. Once he gets there, he sits down in a standard chair while the TRAM supports him at the trunk and forearms.

A therapist uses the SoloLift and then a TRAM to transfer a TBI patient.

October 2014

Back in October the staff preferred to use the SoloLift to transfer him from his wheelchair to the mat table. They felt they needed more space to use the TRAM than what was available in his wheelchair.

A TBI patient being transferred using the SoloLift and TRAM devices.

October 2014

The staff used the SoloLift to position his hips over the walking saddle and then moved the SoloLift away and positioned the TRAM body support around his trunk.

A TBI patient, with the assistance from a therapist, uses his improved stabilized trunk to work on step by step switches.

October 2014

Jay is using arm prompts to stabilize his trunk and hold his head up. He is able to maintain trunk stability and head control as he moves his left arm across midline to activate a communication switch.

A TBI patient walks up to the secretary at the front office in the TRAM to greet her and his teacher.

October 2014

Jay does attendance every morning. He has decreased the amount of time it takes to walk down to the office and greet the secretary.

Jay has been evaluated for new IEP goals as his walking was well beyond 20 feet. His new goal is to walk 150 feet in less than 10 minutes.

During morning opening, the teacher has the students listen to Alicia Key’s “New Day” on the iPad. Students walk from peer to peer passing the MINI JAMBOX (which is a hand held Bluetooth speaker) to encourage interaction, grasping, holding and reaching out. Jay is able to transition from sit to stand using the TRAM, walk over with assistance to another student, hand them the speaker, and then walk back to his chair to sit down. With the assistance of the TRAM, he is also able to stand up and hold a flag for the pledge of allegiance and return to his seat. Jay has an opportunity during this time to identify which students are in attendance that day, stand up and walk over to greet them or place his picture on the board to show that he is present. He may also walk up to the board to assist with the calendar or to make a choice of which classroom job he may do during the day. All of this occurs within the first 30-45 minutes of the morning activity in the classroom. Within this time, Jay has had the opportunity to transition from sitting to standing 4 or 5 times, pivot transfer 3 or 4 times, walk a short distance of 5 to10 feet 4 or 5 times, and step backward 2 or 3 times.

A TBI patient positioned properly using the chest support in the TRAM walks down the hallway as his teacher looks on.

November 2014

Staff found that positioning the TRAM body support lower on Jay's torso and moving the arm prompts further back, made it easier for him to stay forward and use his arms to realign his trunk.

He continues to get multiple opportunities during the day to work on different skills.

A therapist assists a TBI patient transferring him from a chair to a mat table.

January 2015

Jay can bear enough weight to assist in transitioning from sit to stand from his chair to the mat table eliminating the need for equipment to get out of his wheelchair in the morning.

A TBI patient, with the help from his therapist works on properly positioning his head and trunk.

January/February 2015

In January Jay began sitting on the mat table with one hand support and prompts at his trunk for balance.

By February he was working on actively maintaining an upright head and trunk position in sitting and realigning his trunk for balance.

A TBI patient is successfully able to step consistently in a TRAM device with assistance from his therapist.

February 2015

Now Jay can walk to the secretary's office (150 feet) in the TRAM in 5-7 minutes.

He now steps consistently with his left leg

Jay is also working on side-stepping to get close enough to the board and on stepping backwards to sit down in his chair.

Prior to using the TRAM, he may have been sitting in his wheelchair, feederseat or a large Advancement Chair during the entire activity. And half the time he wouldn’t have even attended because he was less active and engaged.

Without a doubt the TRAM has improved Jay’s quality of life. He is now an active participant in his class. He is closing in on the 2,000 trials in multiple areas of motor skills. He engages with peers and staff by lifting up his head and reaching out. He is more consistent in activating a switch for choice making. He is now stepping more consistently and he is assisting during transitions from sitting to standing with and without the support of the TRAM. The TRAM has eliminated the need to lift him into equipment, which has increased his opportunities to move, resulting in an increase in functional skills. Every time Jay figures out a new skill the look of accomplishment and pride on his face is priceless.

A TBI patient, with help from his therapist works on standing and stepping.

February 4, 2015

Jay now bears most of his own weight in standing with support under one arm and with the other hand held.

As it is a new skill, he is not always consistent, but he sure is proud of his accomplishment.

A TBI patient sits on a mat working on a variety of motor skills.

February 19, 2015

Jay now sits independently at the edge of a mat table for 45 seconds.

He continues to surprise us day by day and his personality has been coming out more and more every day.

A TBI patient, with the help from his therapist is successfully standing.