by Michelle Crouse, MPT, ATP
Making decisions about mobility equipment and technologies to be used by children who are affected by developmental and acquired injuries requires a systematic approach that takes many factors into consideration. The child’s current physical function—as well as the predicted physical function—needs to be taken into account. Cognitive function, too, is crucial, and sound decisions about mobility equipment must closely consider the patient’s current and expected cognitive function. Additionally, patient and family goals for the equipment must be considered, as well as the family’s acceptance and willingness to use the equipment in the home.
The range of equipment that could be presented to a family is quite varied and can become confusing for parents and caregivers. As physical and occupational therapists, it is our job to know the equipment and present families and patients with options that will help to meet the patient’s motor goals. Following are several key considerations, questions, and general criteria to keep in mind when deciding on the appropriate piece of equipment for a patient.
Medically Based Strollers
Multiple reasons support the use of a medically based stroller, which has utility for a wide range of physical abilities and disabilities. For example, the physical function of the child that will use the stroller can vary considerably, from being dependent on caregivers for all mobility to being able to ambulate independently but unable to walk community distances or for long periods of time. Furthermore, the child’s cognitive function can vary from severe disability to typically developing cognitive abilities. Children can use the stroller only for transport and long distances or for full-time seating to facilitate upright posture for play and feeding. Understanding the patient’s family and the patient’s goals for the device will help the therapist in the decision to choose this piece of equipment.
The benefits of the stroller include: dependent mobility, easy setup and tear down for loading in a non-modified vehicle, storage for medical equipment, recline function for rest periods, and increased social acceptability of the device compared to a wheelchair. The downsides of the stroller from a therapist’s perspective can be: dependent mobility when the child may be able to propel themselves in a different device, the child generally sits back in the device and is not as front forward to participate in activities from the stroller, and strollers lack precise positioning that the child may need to maintain an appropriate seated posture to prevent musculoskeletal issues from developing.
Another mobility technology that offers versatility for pediatric users are manual wheelchairs. The functional variation these devices offer ranges from providing dependent mobility with aggressive seating to independent community distance propulsion. So, too, can the child’s physical and cognitive function vary depending on the type of manual wheelchair that is being considered. A manual tilt-in-space wheelchair with rehab seating that fully supports the child is usually used with a child that has both severe physical and severe cognitive delays. This device provides dependent positioning and dependent pressure relieving that is provided by the parents or caregivers. Additionally, this device can be fit with accessories for communication devices, UE support trays, and ventilator trays. The child generally does not self-propel this type of device.
A manual wheelchair can also be lightweight with rehab seating that is supportive, but not confining. This type of chair is generally propelled by the child as a means of mobility in the home and school. The child’s physical function can vary from non-ambulatory to household ambulation but uses the wheelchair for longer distances or during times of fatigue. The child must possess the strength in at least two extremities to move the device while seated in it. A manual wheelchair can be propelled with both arms, both legs, or one arm/one leg in combination. The child’s cognitive function needs to support the motor planning required for self-propulsion. The child needs to understand the cause and effect of his or her hands on the wheels to propel the device. He or she must also possess the visual and perceptual skills to move themselves safely through space and around obstacles.
Children who use these chairs often are learning to walk, but require assistance of the wheelchair to be mobile for long distances and for lengthy times. Usually, the chair is both self-propelled for shorter distances and used for dependent mobility for longer distances. Cognitive abilities range from low average to above average intelligence in the user. This device can also be adapted to support oxygen tanks, communication devices, and UE support trays, but these accessories add weight which may limit the amount and distance of self-propulsion that the child can accomplish.
The last type of manual wheelchairs are the ultra-lightweight chairs that are configured to fit each child personally and are designed for full-time propulsion in the community as well as the home and school. These devices are optimally configured to take into account the child’s center of gravity and propulsion stroke to make propulsion both effective and efficient for full-day mobility. These types of wheelchairs may be used by a spinal cord patient following an injury, or by an older child affected by cerebral palsy who requires the wheelchair for community mobility. The child must have strong UEs, as these chairs generally are not propelled using the feet. The child must also have the endurance to traverse long distances in the chair. Likewise, the child must understand and be able to complete independent pressure relieving in this type of chair to be a candidate. Insurance payors will want to know that the child is independent with wheelchair propulsions, transfers, and pressure relieving to approve this type of chair.
Power wheelchairs can support a wide range of both physical and cognitive abilities. Generally, the child only needs to possess cause and effect for initial training to begin with powered mobility. As long as the child can understand that by accessing the joystick or switch he or she makes the chair move, training can begin. Training on the device will determine whether the child has the visual, perceptual, motor learning, and desire to be independent with powered mobility.
Physically, power wheelchairs can be fully supportive for a child who has no voluntary motor control or only provide seat and back support for a child who has independent sitting balance, but is unable to use his or her legs for mobility. The power chair can be propelled using a joystick (which requires hand function), a head array (which requires head voluntary and controlled head movement), or a sip-and-puff system (which requires mouth and breath control). Powered mobility should also be considered for the child who can walk, but is unable to do so independently for long distances, over uneven ground, or without suffering extreme fatigue which then makes them dependent for other ADLs. An example might be a young teenager who has a stroke or TBI, can walk in a protected environment on level ground, but easily loses his or her balance on uneven ground and when in a crowded area. Ambulation in the school setting will be unsafe and difficult to complete. A power wheelchair is one answer to allow this child to be independent with mobility in the crowded and uneven surfaces found in and around a school.
Though a great range of physical and cognitive abilities and disabilities can be supported by gait trainers/walkers, the ability to tolerate lower-extremity weight bearing and the presence of—at minimum—an automatic stepping response are key. If the child will not or cannot bear weight on his or her legs, a gait trainer is not appropriate. If the child does not possess an automatic or voluntary stepping response when in weight bearing, a gait trainer is not appropriate. Cognitive function must support the desire to move in space and the stepping response.
Gait trainers are available in models designed to fully support the child, or provide partial body weight support. Or the device can be as simple as a reverse or forward walker that is used primarily for balance and to allow UE assist with ambulation. There are plentiful accessories that can be used to physically support the child, from something as simple as forearm prompts and a seat to pelvic guides, adductor prevention straps, and head rests.
The gait trainer decision should take into account both the child’s current skills as well as the predicted level of motor ability. Devices can have many accessories added to them to support ambulation training early in development and then be stripped of the accessories as cognitive level and ambulation abilities develop. Early weight bearing and ambulation training have been proven effective time and again in facilitating not only motor development but also cognitive development. If a client can bear weight and has a stepping response of some kind, a gait trainer should be considered as a key piece of equipment in their physical therapy program.
Standers are medical equipment that are utilized to support the child’s physical functions of developing/maintaining bone density, promoting tolerance of lower-extremity weight bearing, promoting efficient gastrointestinal functioning, strengthening through upright positioning in an against gravity position, development of vision through upright engagement with the environment, and strengthening of the respiratory and swallowing systems through against gravity positioning. Using the stander will help to eliminate medical complications that can develop in children who are unable to independently move themselves or stand on their own. The stander can be used among children who have any level of cognition.
Standers can be dependent, in which the parent or caregiver places the child into the device then stands them up, or they can be used independently by a child who can transfer themselves and use a hydraulic arm to pump themselves up into standing. A stander can be static, where the child is not mobile in the device, or it can be dynamic, where the child can propel the stander through the environment. Standers have very few contraindications, but the child’s orthopedic surgeon should be consulted if hip dislocations are present. In a child with a spinal cord injury, blood pressures should be monitored until standing tolerance is developed following the injury.
Physical and occupational therapists have many options when considering equipment for their patients. Each piece of equipment is as individual as the child, and can serve to facilitate independence and advancement of both motor and cognitive skills in the child. My recommendation is to trial multiple pieces of each type of equipment before reaching a final decision. Over the years, children have surprised me, which has served to underscore the value of the trial and the benefit it provides in demonstrating which piece of equipment is best. RM
Michelle Crouse, MPT, ATP, is a physical therapist at Madonna Rehabilitation Hospital, Lincoln, Neb. For more information, contact [email protected].