Looking Down the Road
If you attend a seating seminar, review literature, or listen to therapists converse at a conference, much of the discussion focuses on applications of seating and positioning with the pediatric client. Although this is not the largest population of wheelchair users, (geriatric wheelchair users are by far the largest population), pediatric clients present clinicians with unique challenges that differ significantly from the adult user.
It is important to remember, however, that children to grow up to be adults with adult problems and considerations. The definition of pediatrics itself can present a challenge. When positioning an infant, we may have different issues than we do when working with school age children or teenagers.
Seating and positioning components must be versatile and able to provide varying levels of support and sizing.
Of course, there are some general concerns that must be addressed; the primary one being growth. Children grow and change quickly. Seating and positioning components must be versatile and able to provide varying levels of support and sizing. However, growth components should also be low profile, as not to interfere with functional activities. In a recent conversation with pediatric therapists, on OTR/L, ATP pointed out that components made to fit pediatric clients are adequate, but the hardware attaching them to the base is often bulky in comparison. The components may be "shrink-to-fit," but the hardware needs to match as well.
Aside from the actual size of components, you also must take anatomical development into consideration. Beyond simple growth in height and weight, there are at least two areas you need to pay special attention to and the first is the spine. When a child is born, the spine is C-shaped. The development of the cervical and lumbar lordoses occurs only as a child goes through specific developmental changes. At six to eight months, as a child starts to lie prone and lift and turn the head, the cervical muscles and ligaments change the orientation of the joint of the spine allowing for head righting and upright head control. If the active movement is not facilitated at an early age, head control and position will be limited later in life based on permanent changes in anatomical structure. The lumbar spine also forms a lordotic curve only when weight bearing through the lower extremities occurs. If a child is always seated and does not experience a significant amount of weight bearing, we will see a flatter lumbar spine. Also of note, even if a child has developed a normal lumbar curve, biomechanics dictate that the curve naturally lessens in the seated posture. Both of these examples provide strong justification for early intervention and positioning that includes a variety of positions including prone and assisted standing.
Furthermore, the pelvis, the foundation for seated function, is not completely developed at birth. While the relative shape of the pelvis does not change significantly, the pediatric pelvis is more pliable as the three bony structures that comprise the pelvis do not fuse into a solid structure until teenage years. You need to be careful about providing proper pelvis support and not changing or hindering fusion of the bony areas. Growth, in general, must be facilitated as normally as possible while minimizing the impact of tone (high or low), developmental delays and health.
With all that in mind, you can take a more educated approach to pediatric equipment selection. First, you have to recognize the impact of growth and development and try to facilitate both with positioning systems. Next, you need to recognize the limitations to seating and positioning. The best seating and positioning system will not prevent bony deformities such as scoliosis, cannot impact the affects of medications and other medical interventions, and will not always facilitate normal development (acquisition of head control, for example). By intervening early and appropriately you can minimize the effects of secondary complications but not eliminate them. Lastly, you may need to change the way you think about pediatric seating long-term. While postural control and stability are immediate concerns, you must remember that function, mobility and skin may be issues in the future. Skin, in particular, is often ignored because "pressure isn't a problem." However, many children may experience skin integrity issues due to external braces and fixations devices, medications as well as friction and shear. As the child grows into a teenager and adulthood, we need to consider lifestyle, functional potential and independent mobility. You need consider switching from planar to more contour systems and consider cosmetics, mobility and comfort with all your pediatric clients.
While seating and positioning with children presents many unique challenges, the impact we can have on a child's quality of life and functional potential greatly outweighs any difficulties encountered. By assessing the anatomical, developmental and environmental needs of the child, you can foster better success down the road. While it is true that children are not just small copies of adults, they deserve the same considerations and opportunities to interact with their environment and their peers, function at the highest level possible, be independently mobile, achieve comfort and enjoy a high quality of life. Through seating and positioning interventions you can help facilitate all of these things. The importance is to intervene early and appropriately to minimize secondary complications and provide support and stability for independent function.
This article originally appeared in the September 2002 issue of HME Business.