The Right Fit

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March 2003

By Ginny Paleg, MPT

A dependent push system is defined as a seating system mounted on a mobility base that a child cannot propel by him or herself. These systems were formerly called “strollers,” but for reimbursement reasons are now referred to as transport chairs or dependent push systems.

Which child needs a dependent push system?

An infant who needs postural supports
A mildly involved child who wants to access the outdoors and rugged environments (hiking trails, baseball fields, horseback-riding stables, etc)
A moderately involved child who walks independently but needs to be transported for long distances
A severely involved child who needs a lightweight system for short trips when a heavy, bulky system is too burdensome
A child who needs one seating system to work in a variety of settings and multiple bases (power, manual, transport, high/low base, etc)

A physical therapist should consider recommending a dependent push system in the following typical scenarios. A child who has severe gross motor or cognitive dysfunction will most likely never be able to propel him or herself in a traditional manual wheelchair. In this situation, the rehab team may choose a dependent push system because it is easier to fit into a car trunk and a narrow hallway (often found in apartments and mobile homes). An infant is not expected to self-propel and the rehab team may identify that a dependent push system may be more cosmetically appealing (visually, it may resemble a typical stroller). Sometimes parents are in a hurry and do not want to manage a 60-pound wheelchair for a trip to the store, so the team will recommend a transport system in addition to a traditional wheelchair (Table 1).

Here is a quick guide to choose which dependent push system is best for your patient.

Table 1. Gross Motor Function Classification System (GMFCS)

TRANSPORT SYSTEMS

Transport systems are made for the child with poor postural control, and who weighs too much to use a typical stroller (more than 40 pounds). These systems can also be used as the primary mobility system for a child who can ambulate independently for moderate or short distances but may feel fatigue at the mall or Disney World. If a child typically sits in a mobility device for longer than an hour at a time, this is probably not the best choice. By nature of its portability, it cannot offer the support and comfort that a child who does not ambulate for most of the day requires. Use the following list to evaluate the features of a dependent push system to make sure it fits with the child’s needs. If the child does not already own a wheelchair, the letter of medical necessity should be a breeze and the system should be covered by their insurance company (if they have coverage for a wheelchair). If not, see the sample letter information at the end of this article.

Here are some things to look for: it is foldable in all four directions (like an umbrella stroller); firm insert so child is supported adequately; easy-to-use seat belt; and shoulder harness, should the child need to stay upright on a bus. See that footrests are height adjustable, and determine if they need to flip out of the way for transfers. Also look for ease of steering (direction locks on front wheels for gravel, wood chips, etc); upright vs tilt (a child who can walk independently may not like seeing the world at a fixed 15-20 degree angle); adjustable tilt, if needed; and ability to go flat if diaper change is needed. Look for a tray, tie-downs, that it is crash-tested, heel locks for directional control, locking brakes, shock absorbers, material that can be replaced and cleaned easily, supports that can be added and stay in place, and handles that are at a comfortable height for the caregivers.

INFANT SYSTEMS

If a child cannot sit independently by 9 months of age, the early intervention team may recommend an adaptive positioning system to introduce the child to the upright position. This is essential for the development of vision, vestibular function, and cognition. There are many seating systems available that are meant to be stationary on the floor. This may work well in a center-based program, but may not be the best option in the home. Since most surfaces in the home are elevated, and the caregivers and siblings may be on the move, a mobile base may be optimal. There are even some systems that can go up and down from floor level to counter height for maximal accessibility.

In these systems, look for many of the same things listed above for transport systems, but also a foldable base and pull-out seating system; lots of room for growth in the seat depth and width; a ventilation tray or oxygen tank holder if needed; a sun shield; shock absorbers; and easy to clean material. Look for the option to be rear or forward facing; ability to go flat for diaper changes; optional highchair or high/low base for home and school use; and ease of mounting into a manual wheelchair base when the child is ready for self-initiated mobility. Also look for compatibility with a power mobility base for early training.

When looking for systems for children with severe gross motor and/or cognitive issues, and the dependent push system will be the child’s only system, make sure it has room for growth and several functional options. Many companies are now making systems that can transform themselves into highchairs, chairs that go up and down (to the floor), and chairs that pop into manual or power bases.

THE REIMBURSEMENT LETTER

If a child is small (under 40 pounds) and can be positioned well in a commercially available stroller, then buy one. If a child instead needs a piece of medical equipment, be prepared to write a letter of medical necessity and justification.

When writing such a letter, first you would state the child’s medical history. For example, Peter is a 3-year-old boy with spastic diplegic cerebral palsy as a consequence of prematurity. He is functioning at the 12-month level for gross motor function and the 2-year level for cognitive function. He has tightness of hamstrings and hip flexors as well as his heelcords, bilaterally. He uses bilateral hinged ankle foot orthotics for ambulation in a supportive walker.

Then describe the child’s current level of function: Peter is unable to sit independently for long periods of time. He can ring sit for 1-3 minutes with a posterior pelvic tilt. Given enough time and when motivated, he can transition from supine to sitting and from sitting to prone. He cannot yet pull to stand independently. Peter can cruise along furniture when placed upright. He occasionally falls backward if he gets excited. His backward protective responses are delayed, and he is unable to fall safely. Peter can take steps when his mother fully supports him and in his gait trainer. He lives at home with his parents and three siblings. The home is on one level, with three steps into the home.

Next, explain that the child needs a positioning system to allow him to be successful in the home and educational environment. In a regular classroom chair, his back and hips are not supported enough so that when he gets excited, he falls backward. When Peter attempts to reach or weight shift, his feet come off the floor (increased quadriceps tone) and he loses his postural stability and cannot perform the educational task. After 1 to 3 minutes, his hamstring tightness causes his pelvis to slide forward and he begins to slide out from his chair. Then, you would recommend the specific dependent push system. For Peter, this would be a modular seating system for both indoor and outdoor use that should continue to be appropriate for him through age 12. This chair is the ideal solution for Peter because his needs change throughout a typical day. The back of the seat adjusts in proportion to the seat bottom so the pivotal point of recline remains anatomically correct. This system can be combined with five different mobility bases—transport, indoor high/low, and outdoor high/low—and can pop into a manual wheelchair or crash-tested power base.

You would explain that this system is best for Peter because it is the only system on the market that can go all the way to the floor or is high enough for him to access his dining room table or computer cart. This system offers all the support Peter needs to accomplish his activities of daily living and educational tasks. As he improves and grows, the supports can be adjusted, added, or removed. By providing Peter with this dependent push system, he will be able to sit independently at a table (fully supported) as well as be transported to and from various locations. As Peter gains more skills and continues to interact with his peers and family, this system will adapt and continue to offer Peter an appropriate sized seating platform.

Include with the letter a full assessment of the child, as well as a video of the child successfully functioning in the classroom in the system.

In conclusion, dependent push systems make sense for many children with gross motor, cognitive, pulmonary, and cardiac issues, just to name a few. With a good letter of justification, many third-party payors are reimbursing for this essentia equipment, which can help the child access the environment and decrease their handicap.

Ginny Paleg, MPT, is an NDT-certified pediatric physical therapist in Washington, DC. She is an adjunct faculty member and doctoral candidate at the University of Maryland’s School of Physical Therapy in Baltimore. She can be reached at www.ginnypaleg.com or ginny@paleg.com

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