A pediatric mobility device user affected by a cervical spinal cord injury caused by a motor vehicle accident uses a power wheelchair with a U-handle joystick. Here he is depicted working on driving accuracy and maneuvering around obstacles without making contact with the objects.
by Melanie R. Connel, PT, DPT; Teresa Adkison, PTA; and Kathryn D. Letourneau, PT, DPT
Every day at pediatric rehabilitative hospitals, wheeled mobility technologies are used to help children become more functional and independent. Technology advances provide options for children who need assistance with movement and positioning, but defining which technology is the right technology for a child depends on that child’s level of function, positioning needs, environment, and cognitive level.
Mobility is an interaction between the environment, the patient, and the task the patient wants to achieve. When looking at the child and the best adaptive technology for them, it is important to understand their interests, characteristics, impairment, and current ability, and the task they want to achieve. The environment also helps therapists better understand how to modify the equipment to achieve what’s important for the child and the family.
Along with providing mobility for a child, these technologies strengthen and provide movement and positioning options for improved long-term outcomes and overall function. There is no one-size-fits-all solution, but the high level of customization helps therapists choose the right technology to meet a child’s needs.
Strollers
Strollers provide the opportunity for children to be in an upright position. Strollers can adapt to fit the size of the child and provide a seating option for families wanting something more mainstream than a wheelchair. They provide advantages for families, including ease of folding and transporting, which results in less hassle and enhanced convenience.
Positioning options for strollers help a child stay in an upright position, resulting in increased awareness, alertness, and engagement with their environment. Most strollers are a dependent form of mobility, requiring a caregiver to propel them, which can limit the child’s independence.
Gait Trainers
Gait trainers give children who are unable to walk independently the ability to walk with support. The main advantage of gait trainers is the ability to simulate walking. Active weight-bearing gives the child the ability to actively use their muscles to take steps, which in return works toward strengthening and increasing endurance and motor control.
Gait trainers offer a variety of options based on the child’s needs, including:
• Maximal versus minimal support, depending on the child’s positioning needs;
• Lateral and hip support, which keep the trunk and pelvis aligned or positioned appropriately;
• Static versus dynamic trainers to help simulate a natural gait pattern; and
• Arm supports, which provide stability as well as allow for upper extremity weight-bearing.
Gait trainers are durable technologies that allow children to maneuver through their natural environment and interact with peers. Children can also leave their trainers at school and use them to walk around the classroom.
Standing Systems
Standing frames are manufactured in a variety of styles, ranging from static to dynamic, that help improve circulatory and respiratory health. Standing frames include:
• Sit-to-stand frames, which allow the child to transition from a seated position to standing;
• Prone standers, which provide full support while encouraging upper extremity weight-bearing;
• Supine standers, which provide increased support and are very adaptable to be used with patients of all functional levels; and
• Dynamic standers, which encourage independent propulsion and postural control.
Because standers place children in upright positions, they enhance bone density health, encourage better functioning of internal systems, and minimize risk of joint contractures. They also improve respiratory health through stretched lung capacity and deepening hip and joint sockets to reduce the risk of dislocation.
Many standers have trays that allow for a surface for play, writing, or use of a communication device, providing children the opportunity to participate in activities that may not be accessible from a chair. Standers allow the child to be in an upright position for face-to-face interaction, helping them to interact with peers more easily.
Manual Wheelchairs
Manual wheelchairs provide mobility for children with the ability to propel themselves, as well as options for dependent mobility. Increased supports that put a child in an upright position improve their posture, visual attention, and alertness. Manual wheelchairs are customized for the child’s size and can be easily transported to give a child the opportunity to attend school outings with peers or community events with family.
Lightweight chairs provide the option of having a lower floor-to-seat height, which can make transfers easier and allow children to pull up to various surfaces, such as a desk at school to interact in the same space with friends. The lightweight chair makes it easier to move with little exerted energy for a child with low endurance or stamina. Some lightweight chairs have foldable options for easy transport, which can be beneficial for a child of driving age that can fold the chair to place in the car’s front seat.
Children who require a higher level of support use reclining and tilt-in-space chairs. The tilt allows the caregiver to change the chair’s positioning, which provides better weight distribution and pressure relief. Trays can be added to these chairs for play, schoolwork, or a communication device.
Power Wheelchairs
Once a therapist decides a child is ready for power mobility, there are many features to consider, including:
• Front-wheel drive offers better stability, obstacle climbing, and a smaller turning radius than rear-wheel drive;
• Mid-wheel drive maneuvers well indoors and is most like walking because it places the drive wheels underneath the child’s center of gravity; and
• Rear-wheel drive tracks straighter and drives better at high speeds, as well as over uneven terrain.
Other options include power tilt and recline, which can tilt the seat back to offer pressure relief. Power wheelchairs can include power leg rests to move the legs up and a seat elevator to move the child vertically. This helps children to complete functional tasks and engage with peers and family.
Power wheelchairs can be operated with a variety of control types, depending on the child’s function. Proportional controls, which allow for a multidirectional function, include options such as a joystick, mini-joystick, and a mushroom-type stick. If children don’t have the ability to use proportional controls, they can use non-proportional driving activated by switches or sensors. Some non-proportional driving options include head array, which is built into the headrest; fiber optics; sip and puff; and proximity switches, which can mount underneath a tray.
Power wheelchairs allow a child to move and play with other kids, helping to improve cognitive and social skills.
The adaptive tricycle is a fun way to work on strengthening and endurance, as well as safety awareness. This user, who has a traumatic brain injury, uses the tricycle to steer around obstacles and focus on awareness of the environment.
Adaptive Tricycles
Adaptive tricycles are used to provide lower extremity strengthening and maintain leg flexibility. The reciprocal motion of pedaling helps with motor learning, coordination, and learning bilateral lower extremity movement before gait training.
For children with decreased trunk control, adaptive tricycles work the trunk and help with balance training. Other features of adaptive tricycles include:
• Conventional handlebars, or loop grips if additional stability is needed;
• Pedal straps to secure feet in place;
• Seat options and a seat belt to provide pelvic stability;
• Harness systems for children with a weaker trunk;
• Flat or contoured headrests that offer more stability with head control;
• Caregiver assist is available for children needing more assistance with steering;
• Trays for communication devices;
• Hand pedals that allow patients to drive the tricycles with their arms instead of legs.
Exercise is another benefit of these tricycles, helping with endurance training, cardiorespiratory training, and social interaction. These tricycles incorporate play into therapy to help children experience mobility, and can be used in the community, at school, at home, and in therapy clinics.
Technologies’ Role in Cognitive and Behavioral Health
All of the sensory-perceptual and motor functions work together, so impairing mobility affects the other domains. A major purpose of adaptive mobility equipment is to allow children to gain independence and explore their environment. The environment affords opportunities for children, including peer participation and the development of social skills. Adapting and using the equipment allows the child to discover ways they can achieve functional tasks.
Adaptive mobility equipment helps to eliminate learned helplessness, or the mental state of being powerless to control your environment. This equipment helps to negate those negative psychosocial effects by helping children realize they can perform day-to-day tasks.
Giving children the opportunity to become initiators in their environment promotes self-assurance and social skills. A child with a disability or a new injury resulting in a loss of function changes how a family functions. Providing opportunities to get out of the house has a huge effect on positive family life and self-confidence.
Multi-Disciplinary Approach
A coordinated, team approach is essential when working to meet the patient’s goals. This requires working with occupational therapists, speech therapists, physicians, the child’s family, and the child in order to set goals that help the child become as functional and independent as possible.
Occupational therapists and physical therapists collaborate to determine what controls and positioning a child needs to be more functional depending on their level of upper extremity function. Occupational therapists and speech therapists are also familiar with environmental controls and use adaptive toys that help the patient learn cause and effect needed with power mobility.
PTs can also work with speech therapists to find ways to mount communication devices on the mobility equipment for a child that is non-verbal. This mounted device allows the patient to communicate with peers, family, and therapists.
By taking the child’s function and needs into account, therapists can work to choose the best adaptive mobility technology for their interests. The additional supports and options for each technology also help kids stay engaged with their peers, family, and environment throughout rehabilitative therapy.
Although there is no universal solution for adaptive mobility technology, the customization of each of these technologies to meet the child’s needs and preferences provides better long-term outcomes for a child’s overall functionality and independence. RM
Melanie R. Connel, PT, DPT, received her Doctoral degree in Physical Therapy from the University of Oklahoma Health Sciences Center in May of 2011. She has been employed at The Children’s Center Rehabilitation Hospital in Bethany, Oklahoma, since June 2011, where she is currently a physical therapist in the Pediatric Medical Rehabilitation Unit.
Teresa Adkison, PTA, received an Associates in Applied Science degree in the Physical Therapist Assistant program at Oklahoma City Community College in 1998. She has been employed at The Children’s Center Rehabilitation Hospital in Bethany, Oklahoma, for 18 years, where she is currently a physical therapist assistant in the Pediatric Medical Rehabilitation Unit.
Kathryn D. Letourneau, PT, DPT, received her Doctoral degree in Physical Therapy from the University of Oklahoma Health Sciences Center in May of 2016. She has been employed at The Children’s Center Rehabilitation Hospital in Bethany, Oklahoma, since June 2016, where she currently is a physical therapist in the Pediatric Medical Rehabilitation Unit. For more information, contact [email protected].
Successful Letters of Medical Necessity
RM Editorial Staff
Letters of medical necessity (LMN) are seemingly at two ends of the spectrum depending on the perspective of the therapist who creates them: either the LMN is a breeze or the bane of one’s existence—and not just in general, but the feeling can change based on the type of product. The emotions, whether positive or negative, are likely a direct correlation with past approval rates. Compounding the issue for clinicians, changing or breaking the cycle requires (in most cases, certainly not all) accepting that the letters being written could be better. This is not meant to imply the prose or grammar is poor, but the LMN could be missing key structural components that could change the outcome. A few things to consider when crafting an LMN (some are basic, but often these are sources for additional information requests):
1. Ensure every piece of information is included that the payor source requires. This may include: writer’s expert credentials, basic consumer information, history and physical exam- diagnosis/onset, prognosis, co-morbid conditions, functional and physical assessment
2. Justify the selected device. This includes: addressing devices considered but not selected, providing evidence the patient can use the selected device, make the case for patient compliance, and justify each component by listing them and connecting each directly to the patient’s need
3. Outline of the prescribed standing program
recommendations
4. Any applicable research to support intended outcomes
5. Structure/format the letter so that elements are clearly defined and information can be found quickly. Avoid writing a pen pal-type letter that forces the reviewer to read each and every line to find the key pieces of information
Part of the equation when attempting to improve LMNs and subsequent approvals is keeping in mind that the letter should make it hard for a reviewer to find a reason for denial. There are payors that consider certain equipment “experimental” or systematically cite phrases or pieces of published research to support that position, when the conclusion of such research would actually support the therapeutic intervention. To combat this, LMNs must be clear, concise, but comprehensive – and while it is simple in theory, translating guidelines and recommendations to practice is not always simple. The good news: there are tools available that help simplify the justification process. Product-specific tools that don’t limit clinical judgment and guide users through the letter-writing process rather than attempt to write the letter for a clinician, will likely lead to a better letter that is connected directly to a patient’s medical need.
