November 2005

Strolling Along

By Patti A. Dworak, MSOT, OTR/L, ATP, and Adrienne Levey, MPT, ATP

When evaluating patients for pediatric-dependent mobility devices, the child's lifestyle must be taken into account

Normal development of a child relies greatly on the type of mobility they use to interact with family members and peers, whether it is crawling, walking, or propulsion of a mobility device. Mobility, no matter what the form, impacts the socialization and education of children by allowing them to interact with individuals of similar ages. Without the ability to move around easily, a child may become isolated and/or distanced from their peers. Introduction of mobility aids to a physically challenged child at an early age appears to facilitate psychological, emotional, physical, and cognitive development.¹

The correct pediatric mobility system will facilitate play and interaction between the child and their family, environment, and peers. For a child with a mobility impairment, there are various types of pediatric devices tailored to meet the child's needs including manual wheelchairs, power wheelchairs, strollers, and walkers. Below is an overview of the various types and features of pediatric strollers. They range from very basic to those with custom seating systems.

EVALUATION
When a child is being evaluated for a stroller, the following issues should be considered: the child's diagnosis with regard to its impact on functional mobility; the child's vital statistics such as their age, weight, and height; any other mobility systems currently utilized by the child; and the child/caregiver rationale for the use of the stroller. The first consideration is commonly the child's diagnosis and the condition's prognosis with regard to progression of physical impairment. Other important issues to be considered are the determination of the least involved type of mobility/positioning required by the user and the consideration of any caregiver concerns with regard to the psychological implications of their child utilizing a mobility system. The above issues need to be carefully considered individually and collectively, when prescribing a stroller. A child's diagnosis with regard to functional mobility is important to ensure the most appropriate mobility device is chosen.

A child may be able to ambulate for short distances; however, their gait is unsafe or the child easily fatigues when attempting to ambulate for longer distances. A stroller would greatly assist in improving this child's functional mobility. If a child is able to propel their mobility device independently, the stroller is not the best option because it does not provide optimum positioning for propulsion. For a child that has a chronically progressive diagnosis in regard to physical/functional mobility, a stroller may not be the device of choice. Although a stroller is lightweight and easy to transport, it does not allow for aggressive postural positioning and alignment to promote function. The child's vital statistics also help in choosing the mobility device. On average, a stroller is recommended for children approximately 3 months to 7 years of age. Due to the influence of social norms, it may not be considered socially appropriate for a 13-year-old to utilize a stroller. The height and weight of a child are equally important because of the structural limitations of a stroller. Frequently, the stroller is acquired as a secondary mobility device because of its light weight and its ease of transportation. It is important to keep in mind that if a stroller is going to be used as the primary means of mobility, it does not allow for aggressive seating and positioning, nor does it allow for optimum independent propulsion.

Federal guidelines allow for the purchase of a new mobility device approximately every 3 to 5 years, therefore the parent needs to be aware that the device they agree upon for the child will need to meet the mobility needs of the child over the next several years. The parent's goal for the use of the mobility device also must be known. The child and caregiver's acceptance of a mobility system greatly influences the frequency of use. If a parent is not ready to put their 3-year-old in a wheelchair, but requires assistance with functional mobility, the stroller is an optimal choice.

A child’s diagnosis with regard to functional mobility is important to ensure the most appropriate mobility device is chosen.

ANATOMY OF A STROLLER
The basic pediatric stroller for an individual with a functional mobility impairment is commonly prescribed for a child who demonstrates inefficient mobility. These children are able to ambulate but do so at a decreased rate of speed, with a dysfunctional gait, and/or with increased fatigue/decreased endurance. Basic stroller users are primarily children who have diagnoses that do not require positioning and/or pressure-relieving seating components. This group includes children diagnosed with mild cerebral palsy and those with myelomeningocele, a type of spina bifida with upper extremity involvement.¹

Basic pediatric strollers designed specifically for someone who has a functional mobility impairment resemble a typical child's stroller by consisting of a frame-style or sling-style seat; they are also lightweight and easy to fold and transport. Most of the strollers have swiveling front casters and durable rear tires for outdoor use, and both types have a seat-positioning belt. The strollers differ in that those designed for mobility-impaired children also include flip-up armrests; flexible folding frames that act as a suspension; and adjustable seat depth and footplates so the stroller can grow with the child. Transit system options are available to allow the stroller to be secured in a motor vehicle via tie-down anchors, and more durable seating material is commonly used to accommodate increased muscle tone. With regard to accessories available for a basic stroller, there are many options. They include padded and nonpadded lateral inserts; chest pads; harnesses—pelvic, vest style, H-style, X-style—for additional chest and trunk support; lumbar cushions; and hip abductors and adductors all designed to provide proper seat posture, positioning, support, and comfort for the stroller user. These strollers typically are available with a maximum 28-inch back height for optimal physical support and a weight capacity maximum of 170 pounds. In addition, other accessories, such as trays, covers, and canopies, are available.

There are two tilt options available on strollers—fixed tilt and tilt-in-space. The fixed tilt stroller targets a user with little upper body control and no potential for self-propulsion. The tilt-in-space stroller targets a user who requires adjustable tilt, whether for pressure relief or for respiratory requirements. The tilt-in-space stroller offers the same advantages the tilt-in-space wheelchair provides. When tilting a child, her orientation in space changes while maintaining her hip angle. This allows for pressure relief and assistance with head/neck control, respiratory function, feeding, and adjusting the line of vision. When determining which tilt stroller is appropriate for a child, you must know what goal you are trying to accomplish. Most tilt-in-space strollers offer a 5° to 45° tilt range. The recline option is also available on the tilt-in-space stroller. Recline opens the seat to back angle from 90° to 135°. Recline assists with range of motion, hygiene, comfort, and respiration. All of the options and accessories available on the basic stroller are also available on the tilt strollers.

Another type of stroller that provides seating and positioning is an adaptive stroller. With the adaptive stroller, an alternative seating system attaches onto the stroller base. This is usually indicated when a child requires aggressive seating and positioning for postural control, tone/spasticity, and safety. Adaptive seating may include a solid seat, solid back, laterals, adductor pad/pommel, abductor pads/hip guides, headrests, and foot supports. Contoured seating systems as well as foam in place can also be used with the adaptive seating stroller for the more involved child. This type of stroller has the ability to transport ventilators, intravenous poles for feeding tubes, and oxygen. Similar to the tilt strollers, all the accessories and options available on the basic stroller are also available on the adaptive stroller. Parents that have very young children with special mobility needs are usually more accepting to the adaptive stroller than a wheelchair because aesthetically it resembles a standard stroller.

Lightweight and easily transportable, a stroller can be the ideal mobility choice for children who are unable to propel themselves in a wheelchair or ambulate long distances.

LIFESTYLE OPTIONS
With the emergence of a more active lifestyle being adopted by many of today's families, jogger-type pediatric strollers designed for children with special needs are becoming increasingly popular. This type of stroller is designed with convenience and maneuverability in mind. Jogger strollers are available equipped with bicycle-style wheels that allow them to roll easily over gravel, sand, rugged trails, and other surfaces normally inaccessible to conventional strollers and wheelchairs. They are equipped with shock absorbency systems for the rider's comfort. They are easily foldable and transportable. The jogger utilizes either a single bicycle wheel in front for traversing rough terrain or two front swivel wheels that allow it to easily roll through crowds and tight places. The jogger-style strollers include features such as hand brakes, wrist straps, safety harnesses, and footplates. They typically can accommodate up to 150 pounds with regard to weight capacity. Many manufacturers offer modifications and adaptive positioning systems to be mounted on the stroller base.

Due to the fact that there are many options available with regard to pediatric strollers for functionally impaired children, most strollers can be accommodated with one of the dependent mobility devices at some point during their early years. These specialized strollers are more often than not the precursor of a more sophisticated, customized functional mobility. One must always keep in mind the ultimate goal in seating and mobility is to help a child achieve their greatest potential for mobility to promote a healthy lifestyle.

Patti A. Dworak, MSOT, OTR/L, ATP, is an occupational therapist at the Good Shepherd Rehabilitation Hospital Wheelchair Clinic, Bethlehem, Pa. Adrienne A. Levey, MPT, ATP, is a physical therapist at Good Shepherd Rehabilitation Hospital Wheelchair Clinic, Bethlehem, Pa.

REFERENCE
1. Wright-Ott C, Egilson S. Mobility. In: Case-Smith J, Allen AS, Nuse Pratt P, eds. Occupational Therapy for Children. 3rd ed. St Louis: Mosby-Year Book Inc; 1996:564-566.

RESOURCE
Carlson SJ, Ramsey C. Assistive technology. In: Campbell SK, ed. Physical Therapy for Children. Philadelphia: WB Saunders Company; 1995:621-656.

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