Pediatric Thoughts, & Ideas - Sunrise Medicalmarketing.sunrisemedical.com/.../Presentations/Pediatric_Thoughts_Ideas_Half.pdfPediatric Thoughts, & Ideas Considerations when choosing

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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Pediatric Thoughts, & IdeasConsiderations when choosing seating and mobility options.

Presented by:

Steve Boucher, OTR/L, ATP & Angie Kiger, M.Ed., CTRS, ATP/SMS

Clinical Education Specialists, Sunrise Medical LLC

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CONFIDENTIAL AND PROPRIETARY

Duplication or Distribution Prohibited

6-2014

Seminar Content Disclosure

• The authors and presenters of the Sunrise Training &

Education Programs (STEPS) are full-time employees of Sunrise Medical.

• We do not intend to endorse any particular model, brand

of product or manufacturer.



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Upon completion of this course, participants will be able to:

• Identify three (3) reasons as to why mobility is important for

human development.

• Provide three (3) reasons why early intervention for seating

and positioning is so critical for the pediatric client.

• Identify three (3) different types of mobility base options.

Course Objectives

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AGENDA

30 Minutes Introduction to development as related to positioning and mobility

45 Minutes Evaluation

30 Minutes Positioning and Seating

30 Minutes Dependent Mobility Systems

15 Minutes Break

30 Minutes Independent Mobility Systems

45 Minutes Justification and funding

15 Minutes Questions and Wrap-up

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Housekeeping

Restrooms

Handouts

Breaks

CEUs

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• IACET CEU CREDIT

• Must be paid in full

• Must sign in at the registration table

• Must provide last 4 of your SSN

– If you didn’t provide it when you pre-registered, there will not be a certificate onsite

– You can still provide the last 4 of your SSN now on your evaluation, certificate will be provided within 45 days

• Must complete the evaluation form and turn it in at the close of the seminar

• It is a requirement that to receive CEU credit, you must attend the full course

CEU Requirements

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What’s The Big Deal?

• “Providing clients with proper seating and positioning is

vital for feeding, communication, and socialization! I evaluated a little girl with spastic quadriplegia cerebral

palsy who was previously told that she did not have the

motor control to use an AAC device; however, after I

worked with our ATP and OT to obtain a loaner seating

system she was using a dynamic screen AAC device with her eyes in just a few sessions.”

– Becky, Speech Therapist from Florida

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• Benefits to proper seating

and mobility

– Improve respiratory and

gastrointestinal status

– Access to the environment

– Improve developmental

milestones

– Reduction or prevention of risk

for injuries in the future

• Why is mobility so

important?

– Neuronal pathway

development

– Somatosensory system

development

– Spatial awareness / depth

perception

– Body control in gravity

– Cognition

– Decision making

– Social interaction / Inclusion

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Building Blocks for Pediatric Seating & Mobility

Development

Evaluation

Seating

Mobility Base

Growth, Accessories, & Aesthetics

Funding & Documentation

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Skill Development Review

• 1-3 months– Begins to develop a social smile – Imitates some movements and facial

expressions – Grasps and shakes hand toys – Lifts head while in prone

• 4-6 months– Reach for and grasp objects – Smiles at self in a mirror – Move toys from one hand to another

• 7-9 months– Struggles to get objects that are out of

reach – Enjoys social play – Control of trunk and sits without

support

• 9-12 months– Object Permanence– Means-end behavior (crawls to get

what they want; pulls string toy)– Standing, creeping and walking

• 13-18 months– Purposeful exploration of toys– Trial and error learning– Responds to simple commands– Walks

• 19-24 months– Build a 6 cube block tower– Runs– Kicks a ball

• 2-3 years old– Stars to use short sentences– Scribbles with crayon– Jumps off a step

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Spinal Development

• In the womb and at birth an infant’s spine will have a

convex curve and is shaped like a “C”.

• This spinal alignment is called the primary curve and is

kyphotic.

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Spinal Development

• The curve in the cervical spine

develops as the child begins to lift his head and the neck

muscles are strengthened.

• The curve in the lumbar spine

results as the child starts to crawl.

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Spinal Development

• A healthy adult spine has four curves when

viewed from the side, located in the cervical, thoracic, lumbar and sacral areas.

• These four curves are extremely important in

the spine (both adult and child), for this is how the body handles the stress of gravity.

• If these curves do not exist, the body's center of

balance is shifted, causing undue stress on the spinal column and spinal cord.

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Motor Control Hierarchy

• Pelvic stability

• Thoracic extension

• Lumbar extension

• Scapular mobility

• Separation of pelvic and shoulder girdle

• Weight shift through pelvis

• Dissociation of movement

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Items To Keep In Mind

• Children should be allowed to meet

recognized milestones, even if his/her positioning is modified

• Should be encouraged to develop stable sitting at an appropriate age

• Children normally achieve

momentary, unstable sitting when placed in position between 3 and 7

months, thus we should provide our

children with effective support in sitting at equivalent age.

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Items To Keep In Mind

• With controlled movement, body experiences

– Response to gravity

– Activation of vestibular system

– Weight bearing

• Immobile child

– Minimum experience with gravity

– Difficult to integrate sensory-motor skills

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Importance of Positioning and Play

• Play is described as the “work” of children.

• Through play, children learn to solve problems, make decisions, persevere, and interact with people and objects in the environment.

• Through play, children develop language symbolic thinking, social skills, and motor skills

• Without proper seating and positioning, a child may not be able access toys or equipment for play.

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• Motor limitations

• Physical tolerance

• Environmental Barriers

• Inaccessible toys

• Caregivers

• Equipment

Potential Roadblocks

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Development

Evaluation

Seating

Mobility Base



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Clinical Best Practices

• Are there any related to seating and mobility?

• What would they be?

• RESNA Wheelchair Provision Guide

http://resna.org/dotAsset/22485.pdf

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Prior to the evaluation

• Completion of an intake form by the client or

parent/caregiver. Information should include:– Goals of the evaluation

– Brief background of the client including experience with Assistive Technology and specifically power

mobility.– Current level of function

• If contact information is provided, contact

should be made to the clients school team

and/or outpatient therapists.

• Review any documents provided by the family

or referring physician.

• Arrange loaner equipment including alternative

controls and demo power wheelchairs.

Where Do We Start?

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What are the Goals?

• Child– Peer interaction– Independence

– Fun

– Play – Explore

– Interact – Learn - feel, touch, do

– Looks “cool”

• Family– Aesthetics (low profile)

– Acceptability– Accessibility

– Ease of use

– Comfort

• Clinician– Good positioning

– Complimenting therapy goals

– Easy to use

– Promote independence

– Safety

• Funding Source

– Thorough documentation

– Meeting the criteria

– More later……

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Clinician

Funding

SourceSchool

Family Child

Supplier

Slicing Up The “Pie”

Who is fighting for a piece of the pie when it comes to choosing equipment?

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The Pediatric Evaluation

• Medical history

– Diagnoses and associated conditions

– Secondary diagnoses

– Prognosis and potential for change

– Complications/contraindications

– Surgeries (past, present, and future)

– Medications (past, present, and future)

• Physical Status

– Orthopedic

– Neuromotor – strength, ROM, tone

– Primitive postural reflexes

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• Skin Integrity/sensation

• Cognition/behavior

– Integrate, sequence, retain information

– Judgment

• Perceptual/visual limitations

• Endurance– Effects of current mobility system?

• Functional skills

– Present and desired skills in seating/mobility system

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• Transportation

– School bus

– Family vehicle

• Integration with other assistive technology

– Communication device

– Computer

– Environmental control

• Simulation

– Beneficial to all to try before final decision is made

• Funding


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General Flow Of The Evaluation

• Explain the purpose and process of the evaluation with the client and caregivers.

• Review goals of the evaluation and case history with the client and caregivers.

• Evaluate the client’s positioning in his/her current seating system and make adjustments/modifications as needed.

• Complete a mat evaluation.

• Equipment trials with the client.

• Review of recommendations with the client and caregivers.

• Review follow-up plan (i.e.

funding process, dealer contact information, potential

delivery time, etc.)

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The Mat Assessment

Should be done with the client

sitting on a firm surface:

– Thighs should be level relative

to the hip joint

– Two people assist as needed

– Be sure that feet are supported

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The Mat Assessment - Sitting

Use a caliper/firm measure stick or

tape for accurate measurements

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The Mat Assessment - Supine

Measurements can be done in

supine, if sitting is not attainable

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Additional Evaluation Considerations

• Screenings, reports, or formal consultation– Physicians – neurologist, ophthalmologist, orthopedic surgeon, physiatrist, etc.– Speech Therapist

– Teacher - classroom aide– School therapists – IEP

– Audiologist

• Cognition– Ability to following directions (one-step, two-step, multi-step, related, non-related, etc.)– Initiation of exploring the environment independently

– Visual learner vs. auditory learner (supports needed?)

• Vision Status– Acuity vs. processing– Field loss, field neglect, color blind, visual motor, etc.

• Auditory status– Acuity vs. processing

• Communication Status– Verbal vs. non-verbal

– Picture based vs. word based

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Development

Evaluation

Seating

Mobility Base



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Seating & Mobility Is Provided To…

• Support postural alignment:

– Provide balance for function

– Provide base of support for stability

– Slow down or correct flexible deformity

– Accommodate fixed deformity

– Optimize functional tone

– Inhibit non functional tone

• Protect skin integrity:

• Facilitate function:

– Activity related functions

– Physiological functions

• Increase sitting tolerance:

– Consider comfort over time

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Let’s Think About Standing…

• Center of mass of the entire body is located over the feet

• These are our supporting area

• Lets experience the varying muscle reactions that occur

with changing support area..

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The Sitting “Footprint”

• Where are all the loading surfaces?

• How can we maximize the footprint?

• What is the optimal footprint?



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Approx. 2-2.5”

Worthy Considerations

• Consider the height difference

between the ischial tuberosities and the femur

– 2-2.5” in an adult

– Not as much in small children

or infants

Important for

• Lateral, anterior, and posterior stability and /or….

• redirecting load from the ITs

to the trochanters



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When seated, the center of

mass of the trunk is only over the pelvis with the

ischial bones as the

supporting area 4.5”13”


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Remember without

posterior

support….

The cushion will

fail


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Posture

• State of active stability

– Muscles are active

– Allowed to assist with creation and maintenance of posture

• Sensory feedback and reaction is critical

– Motor strategy is facilitated and fostered

• Goal = improved function!

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Position

• Alignment and stability are key

• Muscle quietness

• Limited sensory input and response to input is minimal

• “One” correct position

– Less ability to improve motor strategies

– Function not enhanced

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Positioning For Function

• What posture would our body choose to prepare for

activity?

– Possible variable positions – sitting by itself is hard work!

– Posture of readiness?

– Shoulders and head in front of pelvis

– COG in front of base of support

– Feet on floor / footplate, weight bearing

– Knees < 90 flexion (“under” the body)

– Posture cannot be not maintained all day

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Positioning For Function

• With controlled movement, body experiences:

– Response to gravity

– Activation of vestibular system

– Weight bearing

• Immobile child

– Minimum experience with gravity

– Difficult to integrate sensory-motor skills

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Positioning For Mobility

• Initial independent mobility

• Wheel is visible to child

• If possible, feet should be

visible to the child

• Visualization of cause & effect

• Improved access for short

upper extremities

• Consideration of power

mobility

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Positioning for Tone

• Reduce as many triggers as possible in the

seating mobility system

• Respect that sometimes static solutions are

not ideal for dynamic postures

• High Tone

– What can the seating and mobility system do

in reality to effect the inhibitors?

– What might it be doing to motivate the

triggers?

• Low Tone

– What is the biggest challenge?

– Is it the head?

– The bowling ball on the noodle idea?

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Positioning for Clinical Needs

• Respiratory

• Feeding/GI (reflux management)

• Contractures

• Communication (access to a

device or for vocal quality)

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Analyzing Postures - Stability

• We know that to understand stability – we must

understand balance, posture – relationship with gravity-neuromuscular integrity etc

• We have looked at an optimal position of the spinal

curves as they relate to gravity

• Lets review some of the more common seating postures

and how they relate to stability and ultimately function

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Common Deviated Pelvic Postures

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New pressure points

at sacrum and spine

Accompanied

by increased kyphosis

Ischials travel forwards

Posterior Pelvic Tilt

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Anterior Pelvic Tilt

With an anterior pelvic tilt, the ASIS

(anterior superior iliac spine) are lower than the PSIS (posterior

superior iliac spine).

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Right Obliquity

Pelvic Obliquity

Compensating

Scoliosis

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Left Side Forward – Rotated To Right = Right Rotation

Pelvic Rotation

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Skin Integrity

• Young children are not so much at risk – why?

• Parents, caregivers and the children need to be

prepared to take care of/pay heed to skin…

– Regular skin checks

– Weight shifts

– Selection of support surfaces/technology to respect shear and

pressure reduction

• Educate children at a young age on the importance of

skin health, make it a part of the ADL routine.

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Consider A Seating Ladder

Basic off the shelf seating – non customizable

Off the shelf seating – customizable

Custom made seating – linear and contoured

Custom made seating – molded

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Standard & Adjustable Cushions

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Custom Seating Surfaces

• Flat Seat

• Wedge Seat

• Anti Thrust Seat

• Contour Seat

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Standard & Modular Backs

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Custom Backrest Shapes

• I Back

• T-back

• Curved Back wood and foam

• Bi angular

• Grid

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Dynamic Backrest Options

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Additional Seating Components

Positioning Belt Lateral

Foot plate/rest

Headrest

Hip GuideTray

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Development

Evaluation

Seating

Mobility Base



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Dependent Wheelchair Frames

Zippie Mighty Lite

Zippie TS

Zippie Iris

Kid Kart Express

Zippie Voyage

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• “When we were told that we should look into getting our

daughter a special stroller, we didn’t see the point because she still fit in a jogging stroller. But the first time

I saw her sitting in her KidKart I was shocked at how

upright she was sitting and how much more engaged

she was in her surroundings. Our daughter is deaf/blind,

so being closer to her world had a tremendous impact on her development. It was also a wake-up call to her dad

and I about how important proper positioning is for

Maryn.”

» Kim – Arlington, VA

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Time For The Stroller Talk

• When is it appropriate to recommend adaptive seating

for a child?

• What is the best way to approach the family?

• What information do you need to have prepared prior to

talking with the family?

• Why might a family tell you “no”?

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Standard vs. Adaptive

Standard Stroller

• Mainstream

• Lower profile

• Standard seating option only

• Limited recline available in some

brands.

• Easily transportable

Adaptive Stroller

• Seating & positioning options.

• Durability

• Storage and accessories for

transporting medical equipment

• Seating system removable

• Tilt, recline, & transit available

• Foldable base

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Stroller To Wheelchair

• Why do some parents hesitate

with transitioning from a stroller to a wheelchair?

– Strollers (even adaptive

strollers) look more

mainstream

– Accessibility

• Home

• Transportation

– Ease of getting from point A to

point B

– Acceptance

– Funding

• Why is it important to move a

child from a stroller to a wheelchair?

– Positioning

– Age appropriateness

– Seating

– Access to the environment

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• Who is appropriate for tilt, recline, or

elevating leg rest?

– Consider the client’s:

• Ability to change position / shift weight

• Postural stability

• Physiological risks

• Problems with homeostatic control

• Mobility Related Activities of Daily

Living (MRADLs) needs

• Environment demands

Dynamic Seating for Dependent Manual Wheelchairs

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Clinical Justifications: Tilt

• Provides for pressure

redistribution

• Accommodates joint

contracture(s)

• Maintains specific seated

angles

• Adds no resulting shear forces

• Minimizes extensor spasticity

• Provides for position change

• Minimizes effects of gravity

• Provides increased trunk

stability and head control

• Improves postural alignment

• Improves visual field (fixed kyphosis)

• Maintains access to specialty devices mounted on chair

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• Poor access to perineal area

• No change in hip or knee

position

• Risk of contracture

• Discomfort with sensate

clients?

Tilt vs. Recline - the Pressure Debate

Upright surface area Tilted surface area

Clinical Concerns: Tilt

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Clinical Justification: Recline

• Provides change in position &

body angles

– Provide relief for sensate clients

• Allow for personal care while in

chair

– Bladder management,

dressing

– Avoid additional transfers

• Allow supine transfers

• Shifts and expands weight bearing

surfaces

• Decreases peak pressures

• Provides different body angles

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• Shear Forces During Recline

• Pivot point of equipment does not match client’s pivot

point at hip

• Extensor Spasticity

Low pivot point of recline

Clinical Concerns: Recline

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• Elevates LE to:

– Accommodate knee extension contractures

– Accommodate orthotics, prosthetics,

casts

– Provide position change/support with recline

Clinical Justification: Elevating Leg Rests

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Independent Manual Wheelchairs Frames

Zippie Zone

Zippie GS

Zippie 2

Zippie Kidz

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Independent Manual Mobility Considerations

• Folding vs. Rigid

• Weight and materials

• Standard Configuration vs. Reverse Configuration

• Rear Wheel

– Vertical Position

– Seat to floor height

– Lateral Position

– Camber

• Casters and Caster Housing

• Back support

• Front rigging

• Arm rests

• Foot plates

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Postural Balance and Stability

• Postural Balance: keeping one’s center of mass within

the base of support.

– Being stable in sitting to complete ADLs

• Orientation: the ability to maintain appropriate

relationships between body segments and between the

body and the environment for function(Shumway-Cook, et. al).

• Trunk and pelvic control are key for postural stability!

• Seating system (cushion and back support) impact.

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Postural Balance and Stability

“Squeezing” the Frame:

• To maintain a more erect posture without loss of stability

during propulsion

• Achieved by tilting the seat

and closing the back angle to

less than 90 degrees

• Requires low back rest to allow extension over backrest for

postural stability

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Seat Inclination for Postural Support

• Position client so they are sitting “IN” the chair, not

“ON” the chair!!

YES! TRY AGAIN!!

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• Children develop thru exploration/stimulation

• Children without physical impairments begin mobilityat ~12 mo

• Give children with disabilities the same opportunities – Introduction to power mobility as young as 12-18 months

– Time and practice to learn and make mistakes

– Appropriate supervision

• Marginal ambulation or manual propulsion:– Risk of stress/damage to muscles, joints

– Requires energy and endurance

– Reduces energy available for other activities

Pediatrics & Power

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RWD – footrests

MWD – footrests or rear stabilizers

FWD – rear casters

Power Wheelchair Bases

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Drive Station (Switch-It, Inc.)

Mechanical Switches (ASL, Inc.)

Head Array (ASL, Inc.)

MicroPilot (Switch-It, Inc.

And MANY

MORE!

Specialty Controls

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Power Assist Systems

• Individuals with limited upper extremity strength

• Individuals with compromised respiratory systems

• Individuals not “ready” for a power mobility device

– Environment reasons

– Psychological reasons

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Development

Evaluation

Seating

Mobility Base



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Considerations For Growth-Seating

• What's reasonable?

• What's the expectation?

• When looking at order forms – Do we ever struggle with

what size to order when respecting growth predictions?

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Growth rate at the hips

Femur growth rates

These will dictate both the width and depth of the mobility base and subsequently it's seating system.

Growth: 2 Primary Considerations

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• Research has shown that the Pelvis grows approximately 3/8" to 1/2" per year in width and femurs grow on average 3/4" per year.

• We can conclude that a seating system should then be 2" - 3" wider than the hip width including the thickness of any lateral pads (since these sit on top of the cushion).

• Taken together this should provide 3 to 4 years of growth in normal circumstances.

• Back height growth is less critical as this can be more easily adjusted with less mobility base constraint.

Growth Considerations for Seating

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• What is to much growth?

• Chair frames

– Should have both width, depth and seat to floor height change

capability

• Quick Adjustments

– Moving the back post

– Growing the cross brace, or strut tubes

– Swapping side frames (height)

• More Involved Adjustments

– Adjustment kit

– New frame

Growth Considerations for Mobility Bases

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Growth Examples

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Accessories

CanopyVent Tray

IV Pole

Adjustable Push Handle

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WAIT… Don’t Forget The

Most Important Parts!

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Development

Evaluation

Seating

Mobility Base



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Critical Questions

• Who is the funding source?

• What is the client’s medical history?

– Diagnosis (primary, secondary, etc.)

– Surgeries (previous and upcoming)

– Medications (past, present, future)

• What equipment has the patient had?

– Not just wheelchairs

– When was it received, why does it no longer meet their needs

(medical - primary)? Who funded the equipment?

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The Funding Source

• The reviewers are required to ensure that the coverage

criteria/rules are met.

• The budget must be managed through their decisions.

• How do you learn the coverage criteria for all the funding

sources?

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Common Funding Sources

• State Medicaid Programs

• Private Insurance

• Medicare

• Worker’s Compensation

• Veterans Affairs

• How does secondary insurance work?

– Will it matter to you?

• Others…?

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Simplify

Your time is limited…

• As you go through your evaluation, keep in mind that at the same time you are also creating your documentation.

• Think about “climbing a ladder” to justify the equipment selected.

• Tie your thought process and selections to what will be

down on paper.

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Documentation

• Is your evaluation completed electronically or hand-written?

• Letter of medical necessity?

• Template or not?

• Important documentation reminders:

– Your clients are individuals

– Proof-read!

– Contradictions

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6-201495CONFIDENTIAL AND PROPRIETARY


###### Rev#

• We have selected the Zippie Zone because it has growth capabilities.

OR…

• Being a 10 yo, Xavier will continue to grow. We have selected the Zippie Zone pediatric mwc, due to the ease of growing the frame. This will also assist in keeping the insurance costs at a minimum as Xavier does grow. This frame offers 3” of built-in depth growth and the growth in width only requires replacements of several parts, not the entire frame. In addition, the center of gravity adjustment will also grow with the chair allowing us to keep him in the most efficient seated position as possible. Other mwc’s tried were… but did not meet his needs due to…

Documentation

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Final Questions to Ask Yourselves

1. Does the client and/or caregiver have a clear understanding of the plan?

2. Have I specified that the recommended equipment is in fact the minimal equipment essential to this client?

3. Have I demonstrated how I ruled out lesser level equipment?

4. Is the equipment that I am recommending in fact the least costly alternative?

5. Do I have all of the information needed for funding?

6. Has my documentation left the reader with a clear picture of the consequences to the client in the absence of having the recommended equipment?

http://www.google.com/url?sa=i&rct=j&q=free+quil+and+ink+paper&source=images&cd=&cad=rja&docid=mm97eMSHCS0tvM&tbnid=ddMP4W9b5bvx0M:&ved=0CAUQjRw&url=http%3A%2F%2Fwebclipart.about.com%2Fod%2Fhobbiespastimes%2Fss%2FQuill-And-Ink.htm&ei=upEQUd7VFuqi2wXPz4D4AQ&bvm=bv.41867550,d.b2I&psig=AFQjCNEtO-70VsFASo_3m2lmdMzf-XTjfw&ust=1360126757378350

http://www.google.com/url?sa=i&rct=j&q=free+quil+and+ink+paper&source=images&cd=&cad=rja&docid=mm97eMSHCS0tvM&tbnid=ddMP4W9b5bvx0M:&ved=0CAUQjRw&url=http%3A%2F%2Fwebclipart.about.com%2Fod%2Fhobbiespastimes%2Fss%2FQuill-And-Ink.htm&ei=upEQUd7VFuqi2wXPz4D4AQ&bvm=bv.41867550,d.b2I&psig=AFQjCNEtO-70VsFASo_3m2lmdMzf-XTjfw&ust=1360126757378350

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Upon completion of this course, participants will be able to:

• Identify three (3) reasons as to why mobility is important for

human development.

• Provide three (3) reasons why early intervention for seating

and positioning is so critical for the pediatric client.

• Identify three (3) different types of mobility base options.

Course Objectives

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Questions???

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Want More Information??

• www.EducationinMotionBlog.com

• www.sunrisemedicaleducation.com

• “To Infinity and Beyond with Custom Seating” .7 CEUS

• “Bet You Can’t Catch Me” .2 CEUS

• “Pediatric, Thoughts, Ideas, and Solutions” .7 CEUS

• “On Your Mark, Get Set, Go!” .2 CEUS

http://www.educationinmotionblog.com/

http://www.sunrisemedicaleducation.com/

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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Thank You For Attending!“Embrace every challenge! Determination and perseverance will significantly impact someone’s life!”

Steve Boucher,

[email protected]

“Always remember that at the end of the day, your client is your number one priority!”

Angie Kiger, Clinical Education [email protected]

Documents

Pediatric Thoughts, & Ideas - Sunrise Medicalmarketing.sunrisemedical.com/.../Presentations/Pediatric_Thoughts_Ideas_Half.pdfPediatric Thoughts, & Ideas Considerations when choosing