Adaptive Seating in Pediatrics
Robert S. Lin, C.P.O. *
Susan S. Lin, O.T.R. *
Adaptive seating represents one of the most complex areas of orthotic management. No other area of clinical practice requires the degree of knowledge and application of biomechanics, design engineering, tissue physiology, wheelchair design and the clinical manifestation of the many neuromuscular disorders involved. No other area of management effects as many aspects of the patient's life and treatment programs initiated by other professionals. Therefore, it is imperative to solicit input from all members of the multidisciplinary team (Fig. 1). The orthotist, physician, physical therapist, occupational therapist, educator, speech pathologist, social worker, psychologist, and wheelchair vendor must all take part in the prescription formulation (Fig. 2). Unfortunately, formal training for the aforementioned professionals provides very little, if any, information for the evaluation, assessment, and design of adaptive seating systems.
To compound the difficulty of equipment provision, pediatrics offers additional complications that aren't as prevalent in management of the adult population. Because the child is still undergoing physical development and maturation, the clinical picture he/she presents is expected to change. Some of the changes are due to growth (longitudinal and/or circumferential) yet some are due to disease progression, developmental abnormalities, and psycho-social problems that result from an increasing awareness of the physically handicapping condition.
The adaptive seating system must be able to accommodate growth, environmental, and clinical changes in the child. This is particularly important in view of the funding restrictions on equipment replacement set by state or private payment sources.
Another very important consideration in positioning a child is the child's educational goals and limitations. Aside from the physical barriers that a school may present, safe transportation to and from the school in a bus or van must be achieved. Few wheelchair bases are compatible with the lock down mechanism used by local transportation systems. This basic mechanical problem can hamper the educational process even before it begins.
Once the child is in the school environment, many subtle factors can influence the success and acceptance of the adaptive seating system. These factors include whether or not the child is mainstreamed or in a special education program; the physical design of the school such as elevators for multilevel institutions and overall wheelchair accessibility; whether the communication needs of the child are met in a group setting; desk height, which can profoundly effect actual integration; whether medical/nursing facilities are available; and the kinds of recreational provisions offered for physical education.
Because the breadth of information concerning the patient can be extensive, there must be a mechanism to facilitate the collection of this critical data. It is imperative that the primary treating professionals provide this input, because of familiarity with the patient and pre-established goals.
The following In-take form was developed by author Susan Lin, O.T.R. in an effort to provide a concise patient data collection sheet. While the completion of this form can be time consuming, we have found that access to this information is essential (Fig. 3, Fig. 4, Fig. 5, and Fig. 6).
One Approach To Adaptive Equipment Provision
In 1981, Newington Children's Hospital initiated its first formal Adaptive Equipment Clinic. The clinic is covered by seven members of the core team with three others forming the ancillary team. The core consists of a physician, orthotist, seating specialist, physical therapist, occupational therapist (who serves a dual function as the Adaptive Equipment Coordinator), speech pathologist, and social worker. The ancillary team is comprised of an educator, psychologist, and durable medical equipment vendor.
The clinic is held one morning per week, divided into four one-hour appointments. Every third week of each month is reserved for a re-check clinic and follow-up care is provided every six months. The follow-up appointments are one half hour long, with eight patients checked in a morning.
Prior to the first patient evaluation, the In-take forms for all new patients scheduled that day are reviewed and discussed. This enables us to establish a preliminary game plan as well as discuss certain confidential factors that may influence management. Formulation of the actual prescription occurs during the hour appointment, with various tasks assigned to appropriate team members to ensure follow-up of our recommendations.
Over the past five years, the NCH Adaptive Equipment Clinic has provided an ideal forum for patient and equipment evaluation and prescription. The aforementioned protocol evolved slowly and has worked very well considering our resources, patient population, time and cost constraints.
Those factors that have universal application are the need for a multidisciplinary approach, the need for follow-up appointments, and a sound understanding of seating principles.
The recent emphasis on adaptive seating has finally enabled the orthotist to assist in management of the entire spectrum of patients, not just those who are candidates for ambulation. The appropriate seating system can be a therapeutic tool which enhances the quality of life and serves as an adjunct to other rehabilitation efforts.