March 2001

Keeping Kids on the Move

By Andrew Johnston, MPT, and Amy Brashear Kirkner, MPT

Keeping Kids on the Move

The importance of developing the right seating system for pediatric clients whose socialization, learning, and development depend on it.

The selection of seating and mobility devices for the pediatric population presents many challenges. With an age variance ranging from infant up to 18 years old, recommended equipment includes strollers, manual wheelchairs, and power wheelchairs. These mobility devices each require an appropriate seating system designed to meet the child’s individual needs. The selection of seating systems available today is greater than ever. However, each clinician still needs to consider the child’s comfort, function, posture, and activity level when attempting to piece together the total mobility package.

A thorough evaluation of the client must be completed. This should include an assessment of active and passive range of motion, strength, coordination, balance, transfers, and ambulation status. Also, the client’s ability to propel a manual wheelchair or operate a power wheelchair needs to be considered. Postural issues must be identified. During this evaluation, a complete medical history, plans for future surgery, client safety awareness, and visual and cognitive status should also be obtained from caregivers.

Pediatric clients frequently interact with a number of health care providers including but not limited to speech, occupational, and physical therapists; nurses; and physicians. These interventions may occur through programs such as early intervention, school-based therapies, and outpatient-based therapies. It is imperative that these professionals are a part of the decision-making process in selecting an appropriate system. The chosen seating and mobility device needs to facilitate development, socialization, and mobility, rather than act as a barrier.

Extrinsic Considerations

Transportation must be considered, which includes considering all the environments the mobility device needs to be compatible with.

Pediatric wheelchairs frequently need accessibility to cars, minivans, and school buses. The home environment also needs to receive consideration as well as the child’s school. Clinicians at this stage need to identify the limiting factors that exist and must develop strategies to include an assessment of the child’s current abilities, provide an environment that allows the child to grow, and also maximize the child’s ability to interact in a variety of settings.

An often overlooked but critical component in selecting an appropriate mobility system is the role of socialization in a child’s development. For example, while a child may be able to propel a manual wheelchair, she may not be able to keep up with her peers. This may create barriers in a child’s ability to fully participate in school activities, thereby making the mobility device more of a limitation than a means to socialization, learning, and development. Another critical factor in providing wheelchairs for pediatric clients is the integration of communication devices and computer access, which provide children with the ability to interact in their home environment through environmental control units, enhance their independence with communication skills, assist with development of social skills, and provide greater opportunities for performing activities of daily living. The following case study illustrates these factors.

Illustration

Phillip is a 14-year-old male with Duchenne’s muscular dystrophy and asthma. He currently lives at home, which is equipped with a lift to a deck and a ramp to the back entrance. His living space is on the first floor. His parents own a bus with a lift, and his school is accessible. He travels there on the school bus daily. Presently, he has no active movement in his lower extremities and very little movement in his upper extremities. Functionally, he has the ability to drive a power wheelchair, but he must have forearm support to do so. He is unable to propel a manual wheelchair. He presents with plantar flexion contractures and is beginning to develop a pelvic obliquity with abduction and external rotation of both lower extremities. His trunk is becoming flaccid and his sitting balance is fair at best. He is dependent for transfers and is nonambulatory.

Phillip’s mother, grandmother, school therapist, and physiatrist were consulted when the seating system was being decided on. Their comments were all encompassed into the following seating system.

Phillip was evaluated in several power wheelchairs. It was determined that a power base with power tilt seating system and high-end electronics were absolutely essential because they would enable Phillip to interface different drive controls and maximize his independence with functional mobility. He would also have an independent means of weight shifting. The tilt, in combination with other parts of the seating system, allows for more effective breath control and assists in promoting an erect sitting posture. Currently, he can propel the wheelchair using a joystick and forearm support. However, the wheelchair needs to be able to incorporate high-end drive controls as his disability is progressive and the wheelchair must be able to change with his progressive needs. He was fitted with a gel seat cushion with foam base that has Velcro seating components; it allowed us to place his pelvis and lower extremities in a neutral symmetrical positioning. Also, the gel component of the cushion provides him with pressure relief, thereby assisting with maximization of skin integrity. In order to maximize his trunk support and positioning, he was provided with a padded chest strap, swing-away lateral, and the tilt component of the wheelchair. We also had to provide Phillip with a power base as his seat width needed to be 22 in. so a regular power wheelchair would not be accessible in his home. But the 22-in. seat width in combination with a power base allows his wheelchair to be accessible in his home environment, school, school bus, and his parents’ bus. He was provided with angle-adjustable footplates to accommodate his plantar flexion contractures. A head rest was provided for optimal head and neck support when in the tilted position. He was provided with a swing-away joystick mount to allow him to independently access computers and work surfaces at home and at school. This will assist with more effective breathing and help to minimize complications secondary to asthma.

Future Considerations

Phillip needed a system that could be modified as his disease progresses. Currently, Phillip does have functional speech and swallowing and, therefore, a speech device does not need to be incorporated into his power mobility system. However, if this changes in the future, he was provided with optimal electronics whereby a speech device as well as environmental control units can be programmed through his wheelchair to allow him to independently operate these features.

Upon delivery and fitting of the power wheelchair, Phillip was able to operate it independently. His posture was much more symmetrical with his pelvis and lower extremities in neutral alignment. He was able to sit upright in a slightly tilted position in combination with the lateral and the chest strap. He reported that he could take deeper breaths when in a tilted position, and his skin has been in optimal condition since receiving the wheelchair.

A team effort and realistic planning are integral to providing clients with an optimal piece of equipment that will empower them to interface with both their home and school environments.

Andrew Johnston, MPT, and Amy Brashear Kirkner, MPT, are both senior physical therapists at Good Shepherd Rehabilitation Hospital, Allentown, Pa. Kirkner is also the coordinator of the hospital’s wheelchair clinic.

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