Locomotion, or the ability to move from one place to the next, is a very important stage in infant development. For a typically developing child, locomotion begins with crawling at approximately 9 months of age and progresses to walking. This ability to move allows infants to explore their environment while promoting psychological, social, and cognitive development.1 Through movement, children learn more about their world and gradually gain independence as they grow. For children with decreased abilities to move on their own, it is of utmost importance to provide them with the equipment they need to achieve mobility. The nature of working with pediatric patients, more than any other patient population, creates the challenge of continually meeting their evolving needs as they grow and develop. CAUSE FOR CHANGE A pediatric mobility device is an adaptive piece of equipment that provides a child with locomotion. When transitioning into a new mobility device, it is important to determine the type of mobility that can be achieved by the child and the reason why the current device is no longer appropriate. Typical reasons for transition to a new device include the child outgrowing the current device, the device is not providing adequate postural support, the child has a change in functional ability or a change in environmental demands, and different positions—such as standing—are recommended for various health benefits. Changes in height and weight can significantly affect the ability of a child to use the device. Inappropriate postural support can lead to the development of musculoskeletal deformities such as spinal scoliosis or can lead to the development of pain. Furthermore, a change in functional abilities may require the child to transition from a dependent device to an independent mobility device. While using a dependent device such as an adaptive stroller, the child relies on caregivers to provide the movement from one place to another. With an independent device such as a manual or power wheelchair, the child can perform the movement by himself. When a child begins school or an occupation, they may require more energy efficient mobility options, such as a power wheelchair, instead of their current manual wheelchair or walker. The role of the clinician, in collaboration with patients and families, is to assess the goals of a new mobility device and to decide which device can best meet each child’s individual needs and optimize their functional abilities. Whether helping a child experience mobility for the first time or assisting with the transition to a new mobility device, many other factors need to be considered by the clinician: What are the needs of the child and the family? What are the goals that can be achieved with the use of the piece of equipment? What equipment should be considered for this child? With a thorough mobility assessment, these and other questions will be answered. EVALUATION PROCESS A pediatric mobility evaluation differs from an adult evaluation because a child’s functional abilities are affected by their constant growth and development. There are also specific considerations for a child to be able to interact with peers including the determination of the height from the floor to the seat of a wheelchair. The type of foot plate, footrests, armrests, and seat cushion can affect the child’s ability to perform independent or assisted transfers from the floor into the device. Most importantly, it is essential to determine the child’s ability to accomplish independent adaptive mobility. The evaluation process for pediatric mobility devices is driven by the child’s mobility needs and the needs of the family, as well as the following factors. The clinician must perform a physical assessment addressing impairments such as strength, range of motion, pain, posture, and skin integrity and sensation. Identification of impairments in any of these areas will determine the amount of additional support the device must provide. For instance, if a child consistently leans to one side, trunk support will be necessary to achieve appropriate posture for efficient movement. Additional technology, such as a pressure mapping system, can provide helpful insight to determine the best options for seating components. Furthermore, a child’s vision and cognition levels are important for determining safety during mobility and for completing activities of daily living while using their device. Understanding a child’s home environment and lifestyle is essential to determine accessibility of the mobility device into the child’s life. This includes access to the home, the layout of the living space, the terrain inside and around the home, and where and how the child will use the device to optimize their function or social interaction. Many solutions are available to address potential access issues, including ramps and automated door opening systems for entry and exit, as well as stair lifts and elevators for movement inside the home. Ceiling-mounted or portable patient lifts can be used where transfers are required, and nosing ramps are available to aid smooth movement for mobility devices. Optimally, a home evaluation with the recommended piece of equipment is performed to ensure it meets the child’s needs in the environment where it will be used. Frequently, mobility devices also need to serve the purpose of stationary positioning devices to meet the needs of the child for activities of daily living. For instance, a gait trainer may need to be used as a static standing device or a wheelchair may need to be used as a supportive seat for feeding. These additional equipment goals need to be considered during the evaluation and addressed during equipment recommendations. Furthermore, clinicians need to determine how the child will be transported in or with the recommended equipment to ensure its functional use. PEDIATRIC MOBILITY OPTIONS Recommendations for pediatric mobility can be challenging for rehabilitation professionals when making clinical decisions based on the evaluation process. For those children unable to perform independent locomotion, adaptive mobility is pursued. Mobility options for this population include forearm crutches, walkers, gait trainers, dynamic standing systems, manual wheelchairs, power wheelchairs, and adaptive strollers. The child’s ability and/or need for lower extremity weight-bearing and ambulation versus seated positioning in a wheelchair is considered when exploring pediatric mobility options. For a child who is nonambulatory, dynamic standing systems offer the option of independent mobility with self-propulsion of a wheeled base while maintaining the benefits of lower extremity weight-bearing with the user in a standing position. A child with limited opportunity for lower extremity weight-bearing is at risk for compromised skin integrity, pain, as well as developmental and musculoskeletal concerns. An assistive technology that can be helpful for meeting the locomotion needs of children who have low function and low cognition is a tilt-in-space manual wheelchair. These devices are designed to be pushed by a caregiver for an individual who is totally dependent for mobility. The tilt feature can be helpful for pressure relief as well as tone management and comfort. Models built with removable armrests can aid in bilateral transfers. Standing and gait training programs are necessary for gaining gross motor skills, for participating in activities of daily living, and for overall improved health. Research shows that weight-bearing during standing promotes bone mass maintenance,2 hip joint integrity, pressure relief, increased range of motion, spasticity and contracture management, and overall psychological well-being.3-4 In addition, improved circulation and skin integrity, as well as efficient respiration, bowel, bladder, and kidney functions, occur whether the child is participating in static standing or ambulation.4-5 When pursuing standing mobility, the child’s lower extremity functional range of motion and endurance must be considered. Unlike static standing systems, use of forearm-crutches, walkers, and gait trainers allow the child to participate in adaptive ambulation. These devices offer a varying degree of external support. The amount of external support a child requires is based on the child’s overall strength, endurance, balance, and safety while using the device. In some cases, the child may utilize a gait trainer or walker for portions of the day, but rely on a wheelchair or adaptive stroller for community distances. When adaptive ambulation is not appropriate, clinicians must consider the option of seated wheeled mobility such as manual or power-assist wheelchairs. Dependent on the child’s functional abilities, clinicians must consider the child’s capacity to safely propel a wheelchair (manual or power-assist) for functional distances in all environments. If a child is unable to perform self-propulsion, they may require a manual wheelchair to meet their positioning needs, but a caregiver will provide locomotion. Because this type of dependent device limits a child’s independence, alternative options such as power mobility are strongly considered and pursued before final recommendations. Power wheelchairs promote independent mobility for those children who have varying functional limitations. The technology available for power mobility allows children to use a gross motor movement of any extremity or even a puff of air for locomotion, and for managing their daily needs with environmental control units. Power mobility also may be pursued instead of manual propulsion for purposes of energy conservation. This will allow the child to participate in other physically and cognitively demanding daily activities while maintaining independent mobility. Other considerations for both power and manual options include custom seating to meet needs related to pressure relief, tone management, and safety with transfers. Examples of custom seating options would include, but are not limited to, a tilt-in-space feature, armrests, and leg rest options. Power and manual tilt-in-space options provide redistribution of pressure and positioning necessary to meet these needs. In addition, removable armrests allow for increased safety with lateral transfers. Lastly, elevating leg rests can aid in improved circulation, accommodation for abnormal tone and limited range of motion, improved comfort, and pain management. Collaboration with patients and families allows us, as therapists, to identify equipment that provides the greatest level of independence, ideal positioning, accessibility, and daily equipment utilization to facilitate our patients’ evolving developmental needs. Adaptive pediatric mobility is a fundamental stepping-stone toward physical, psychological, social, and cognitive developmental gains. Through these gains, children and their families can live fulfilling and meaningful lives. Bobbi Ann Jurena, MOT, OTR/L, is an occupational therapist senior at Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC). She earned her Master of Occupational Therapy in 2009 from the University of Pittsburgh. Briana D. McClintock, MS, OTR/L, is an occupational therapist at Children’s Hospital of Pittsburgh of UPMC. She graduated from Duquesne University in 2012 with a Master of Science in Occupational Therapy. Shannon E. Spady, PT, MPT, is a physical therapist senior at Children’s Hospital of Pittsburgh of UPMC. She earned her Master of Physical Therapy degree in 2003 from Ohio University. For more information, contact RehabEditor@allied360.com. References 1. Rosen L, Arva J, Furumasu J, et al. RESNA position on the application of power wheelchairs for pediatric users. Assist Technol. 2009;21:218-226. 2. Damcott M, Blochlinger S, Foulds R. Effects of passive versus dynamic loading interventions on bone health in children who are nonambulatory. Pediatr Phys Ther. 2013;25:248-255. 3. Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther. 2013;25:232-247. 4. Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther. 2001;81(8):1392-1399. 5. Stuberg WA. Considerations related to weight-bearing programs in children with developmental disabilities. Phys Ther. 1992;72:35-40.
May 11, 2020
August 11, 2020