Not Your Parent's Wheelchair

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August 2004

By Deborah I. Cox, MPT

A wheelchair is simply a seating system mounted over a mobility base that helps an individual to achieve an optimal level of functional independence.¹ A pediatric wheelchair, then, must just have a really small seat and help the child get from point A to point B in performance of their daily activities, right? This is partially true, but there are several more things to consider. Children are, relatively speaking, miniature versions of adults musculoskeletally, and wheelchair assessment for a child is done very similarly to that for an adult in terms of the physical examination. However, children are distinct from adults in two very important ways: 1) children are still in the process of growing and developing; and 2) children function in highly dynamic and variable environments.²

THEY GROW UP SO FAST
The typical wheelchair assessment involves a thorough physical examination. Measurements should be taken in supine as well as in sitting positions to account for effects of gravity. These measurements include hip and knee range of motion; body width at the hips, trunk, and shoulders; trunk height from seat to scapula, shoulders, and head; and lower leg and femoral lengths. Close attention should be paid to pelvic-spinal alignment including pelvic tilt, scoliosis, spinal lordosis and kyphosis, and pelvic obliquity. Consideration should be given to muscle tone and reflexes that may cause variations in body position. And finally, skin integrity and pressure point management must be taken into account to prevent breakdown. If the physical assessment is done properly, the wheelchair ordered for the child should "fit" him or her, at least for now.

One of the important qualities that distinguishes pediatrics from adults is growth. Children, even children with disabilities, are growing and changing physically. A wheelchair that fits them well today may not necessarily fit them in 6 months. For most children, funding will not allow for a new wheelchair to be provided every time he or she grows. However, wheelchairs can be designed so that they are capable of growing with the child. Depending on the chair, this may be accomplished through minor changes to the frame and/or seating system. Opportunity for physical growth in the chair must be taken into consideration when the frame and style of chair are determined.

But growth is much more than a physical change. Children are also growing and developing cognitively, emotionally, and socially. In this case, allowing for growth is not enough. The pediatric wheelchair must actually promote development in order to truly minimize disability and maximize function.

Children grow cognitively by interacting with their environments. The wheelchair seating system should adequately support the child to facilitate optimal attention to cognitive tasks by decreasing effort expenditure for basic activities like maintaining upright posture, breathing, and swallowing. With these "basic" tasks supported, the child can then perform age-appropriate object manipulation and exploration, also known as play. For many adults, play may be considered to be a luxury, but for young, developing children it is crucial. It is how they learn.

Emotional growth and development of self-image are also part of the normal growth process. The wheelchair should promote positive body image and awareness by allowing the child to see his or her body and to have the opportunity for tactile input. In addition, the wheelchair is often seen as part of the child's identity. It should, therefore, be aesthetically pleasing and reflect personality through color choice and decorative options. Finally, the wheelchair should, when possible, give the child some level of control over his or her mobility or participation with the environment. Sense of control is important in preventing learned helplessness.

Finally, children are growing socially. Social growth occurs through peer interaction and communication. Children need to be able to see their friends and peers. This is accomplished through adequate head support to achieve typical line of sight, as well as adjustment of seat height, so that line of sight is at eye level with typical peers. The chair should also allow the child to be present with peers in different social settings. This may be accomplished by using all-terrain wheels that will function over grass or playground surfaces, or by facilitating transfers to the floor for participation in circle-time.

Communication method should definitely be considered in the wheelchair selection and design process, both for promoting social interaction and for communicating basic needs. If a child uses an augmentative communication device, the wheelchair should be able to support the device via a tray table or other mounted system. Alternatively, if the child uses sign language, his or her arms and hands need to be free for movement through adequate proximal support and avoiding restrictive positioners. Finally, if the child is verbal, his or her head and trunk should be adequately supported to help with voice production.

Not to be forgotten is that social interaction "takes two." Children in wheelchairs need to be approachable by other children. Much has been done to eliminate stereotypes and stigmas that go with disability, but children need to feel as if their friend in the wheelchair is not scary or different. This can be achieved again by making the wheelchair aesthetically pleasing and simplistic in design. Some wheelchairs even have light-up casters that are comparable with children's tennis shoes that light up with impact on the ground. In addition, positioners should not obscure the ability to see the child's trunk and limbs, and lapboards, if needed, should be clear. The child in the wheelchair should continue to look like a child.

TEAMING UP FOR FUNCTION
The second trait that makes children unique is their ever-changing environment. Children function in a variety of settings, and while in those settings a variety of individuals may be assisting with or supervising their mobility. As many individuals as possible should be involved in the decision-making process. Consideration of these different points of view helps to make the chair versatile as well as decreasing the risk of abandonment of the device.

The decision-making team should, at the least, involve the child's family or caregivers, a rehabilitation specialist, and an equipment specialist. On the simplest level, this is a PT, a wheelchair vendor, and the child's parent. And of course, it is important to remember that the child is actually a part of the decision-making team. The team may also expand to include other family members, teachers, transporters or bus drivers, school therapists (occupational, physical, and speech), private practice therapists, medical specialists, psychologists, social workers, and funding specialists. The team will vary depending on the setting and complexity of the child's care network. While it may seem that it would make things less complex by minimizing the people involved, it is crucial to remember that each member of the team has a different perspective to offer regarding the child's function.³

As the child moves throughout the day, there are differences in the functions that he or she performs at school in comparison with those at home or with those in a clinical setting. Likewise, different individuals that interact with the child throughout the day may place different importance on functional tasks. Parents may focus on issues like toileting and transfers. Therapists may place emphasis on the child being able to access a switching device while seated in the chair because this is seen as a means to increase the child's independence.⁴ Both tasks are functional for the child. Similarly, a private practice therapist may feel it is important for the child to self-propel the manual wheelchair during a 30-minute session, whereas a school OT may feel that dependent propulsion down the hallway is more appropriate to reserve upper extremity strength for fine motor tasks. While these goals may seem in conflict with one another, both views of the child's function are equally valid given the different settings.

Lastly, inclusion of multiple team members in the decision-making process increases the likelihood that those team members will actually utilize the wheelchair.⁵ As previously discussed, the ways that different individuals view the wheelchair as being functional for the child may be in conflict with one another. In some instances, an individual may think the child's function is better served without the wheelchair. If this is for a short period of time here or there, it is inconsequential. If it is someone who spends a large amount of time each day with the child, a decision like this could be devastating.

SUMMARY
A pediatric wheelchair is indeed a smaller seating system mounted over a mobility base that helps a child get from point A to point B. The important thing to recognize is that the child is every day learning new things about how he or she fits in with the world. That child is making friends and exploring the playground and going to music or art class. He or she may be starting and ending the day with a parent, but midday is spent interacting with the school's bus driver, teachers, counselor, and therapists.

It is the responsibility of the rehab specialist to make sure that, while using a wheelchair to get from point A to point B in all of these different settings and with all of these different people, that disability does not slow the child down.

Deborah I. Cox, MPT, is a pediatric and adult physical therapist at Kadlec Medical Center in Richland, Wash.

REFERENCES

Bergen AF. The prescriptive wheelchair: an orthotic device. In: O'Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation Assessment and Treatment. 4th ed. Philadelphia: FA Davis Co; 2000:1061-1092.
Ratliffe KT. Clinical Pediatric Physical Therapy: A Guide for the Physical Therapy Team. Philadelphia: Mosby; 1998:275-312.
Carlson SJ, Ramsey C. Assistive technology. In: Campbell SK, ed. Physical Therapy for Children. Philadelphia: WB Saunders Co; 1995:621-659.
McDonald R, Surtees R, Wirz S. A comparison between parents' and therapists' views of their child's individual seating systems. Int J Rehabil Res. 2003;26:235-243.
Zhao H. Predictors of assistive technology abandonment. Assist Technology. 1993;5:36-45.

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August 2004