Slide 1 ___________________________________ Thinking About Pediatric Wheelchairs
and Seating
___________________________________ David Kemp, OTR/L, ATP
Daniel M. Carney Rehabilitation
Engineering Center
CPRF
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 ___________________________________ Ten Commandments
of Wheelchairs and Seating
i.
Thou shall have questions first, answers second
ii.
Thou shall listen and observe
iii.
Thou shall remember who uses the wheelchair
iv.
Thou shall remember where the wheelchair will go
v.
Thou shall realize that a wheelchair is not an exercise device
vi.
Thou shall not imprison
vii.
Thou shall honor the hamstrings and pelvis
___________________________________ ___________________________________ viii. Thou shall correct when flexible – compensate when fixed
ix.
Thou shall not be limited by the constraints of commercially available equipment
x.
Thou shall know when thee is over thy head
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 4 ___________________________________ Clinical Conditions
___________________________________ Common Non-Degenerative Diagnoses
 Cerebral Palsy
 Spinal Cord Injury
 Spina Bifida
___________________________________  TBI
 Genetic Syndromes
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 5 Clinical Conditions
___________________________________ Common Degenerative Diagnoses
 Rheumatoid Arthritis
 Muscular Dystrophy
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 7 ___________________________________ Clinical Conditions
___________________________________ Other Factors
 Expected growth
 Aging process
___________________________________  Over-use syndromes the wheelchair may
cause
 Cognitive status of the client and secondary
users
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 Orthopedic and Neurological Conditions
___________________________________  Low Tone
 High Tone
 Kyphosis
___________________________________  Scoliosis
 Lordosis
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9 Orthopedic and Neurological Conditions
Low Tone
___________________________________ Common in paralysis, MS, MD and others.
Usually means that more complex postural
supports are needed. Deformities or joint
contractures may occur.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 10 ___________________________________ Orthopedic and Neurological Conditions
High Tone
___________________________________ Common in persons with CP, TBI and others.
Those with high tone often exhibit pelvic
thrusting. A seating system that incorporates
an ischial ledge (anti-thrust) is often indicated
to keep the pelvis in adequate position.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 11 Orthopedic and Neurological Conditions
Kyphosis
___________________________________ Often seen in persons with CP, elderly, and
women over 50. Many people have a natural
kyphosis. Often the leading reason for
slumping and holding the head down.
Cannot be corrected easily. Often painful.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 Orthopedic and Neurological Conditions
Scoliosis
___________________________________ Seen in all conditions. Can happen at any age
and is the biggest reason for lateral falling,
and often mistaken for poor head control.
Three point support often indicated when
possible to correct. Can be compensated for
in contour but watch out for pressure.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 13 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 14 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 15 Orthopedic and Neurological Conditions
Lordosis
___________________________________ Often seen in persons with MD and Spina
Bifida. Most difficult to support. Used by
clients who lack upper trunk strength. Often
used for balance during function.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 16 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 17 Orthopedic and Neurological Conditions
Dislocated / Subluxed Hips
___________________________________ Often seen in those with high tone and those
who never walked. Often confused with leg
length discrepancies. Can be painful and
cause unusual pressure problems on the
pelvis. Often associated with windswept hips.
Can be reduced with surgery but often does
not last.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 18 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 19 ___________________________________ Orthopedic and Neurological Conditions
Posterior Pelvic Tilt
___________________________________ Seen in all types of conditions. Many of us sit
in a posterior pelvic tilt. Related to tight
hamstrings and poor trunk stability. Hips
past 90 degrees of flexion = posterior pelvic
tilt.
Often not correctible. Causes pressure on
sacrum. Can compensate for by opening the
hip / back angle.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 20 Orthopedic and Neurological Conditions
Windswept Hips
___________________________________ Refers to a condition where hips swing to one
direction laterally. A windswept hip condition
may be difficult to spot. If fixed, you can
compensate for it with both hip and trunk
position. If flexible, provide both medial and
lateral hip supports.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 21 Orthopedic and Neurological Conditions
Scissoring
___________________________________ Related to high tone. Can be supported with
medial hip supports.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 22 ___________________________________ Orthopedic and Neurological Conditions
Contractures
___________________________________ Can happen anywhere. Those clients who lack
movement are often at risk. A seating system
is not a stretching device. Hamstring
limitation is often a culprit for clients who
slide out of their systems.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 23 Orthopedic and Neurological Conditions
Deformities
___________________________________ Comes in many different varieties. Very often
seen in Spina Bifida. Prematurity with COPD
common. One side of the rib cage is humped
while the other is flat. Makes scapulas ride in
unusual angles. Can be a source of intense
pressure and pain. Often has to be
compensated for with contoured seating.
Sometimes not if it hurts function.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 24 Orthopedic and Neurological Conditions
Pain
___________________________________ Can take many different forms. Often related
to pressure and positioning. SCI clients have
“pain syndromes” that are often blamed on
the wheelchair. Therapists must investigate
the times pain occurs and what has helped to
relieve it. Let your client be your guide. May
need to make referrals to pain specialists for
treatment. A radical position change can
sometimes help .
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 25 ___________________________________ Orthopedic and Neurological Conditions
Decubitis Ulcers (pressure sores)
___________________________________ Most often seen in those clients who have limited sensation.
First seen as a blister then opens up to expose the wound.
Classified by wound specialists in four stages. Difficult to
heal and are usually chronic. Related to many factors such
as genetics and nutrition. Therapists must account for
those clients who are at most risk and recommend a
seating system despite the lack of history of decubes. A
therapist must evaluate for and teach good weight shifting
habits with those clients that can do it. If not, a therapist
needs to recommend a system that can maximize the
ability to weight shift mechanically.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 26 Self Pressure Management
___________________________________ Therapists must be aware that they need to evaluate the
client’s ability to do self pressure management. The
therapist must evaluate the potential for pressure
problems. Teach strategies that are simple and practical.
A therapist must consider the following:
 Motor abilities
 Sensation
 Desire (or lack thereof)
 Cognition (i.e. memory)
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 27 Evaluation Process
The evaluation form should include:
___________________________________ Personal Information
 Height
 Weight
 Third-party payers
 Diagnosis
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 28 ___________________________________ Evaluation Process
The evaluation form should include:
___________________________________  Problem / reason for referral
 Living environment / transportation
 Medical information / history
___________________________________  Medical equipment needed during use
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 29 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 30 Evaluation Process
The evaluation form should include:
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___________________________________ Physical
Observations
Client/caregiver interview
Tone
Gross motor / transfers / walking abilities
Strength
PROM / AROM
Circulation / skin conditions
Balance
Ability to shift weight
Sensation
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 31 ___________________________________ Evaluation Process
The evaluation form should include:
___________________________________  Recommendations
 Wheelchair reasons
___________________________________  Seating reasons
 Rule out lesser equipment
 Functional goals
 Signatures and dates
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 32 Mat Evaluation
___________________________________ A thorough evaluation done by the therapist is
needed to gain knowledge of what type of
seating will be needed to best fit the client. The
therapist should place the client in multiple
positions. Check for deformities, which joints are
flexible or fixed, and any other conditions that
may hinder good seating.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 33 Measurement
___________________________________ It is crucial to measure in an upright position
and to use a yardstick or other inflexible
device. Best done during a simulation, if
possible.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 34 ___________________________________ Simulation
___________________________________ If possible, try to get the closest possible seating
system and wheelchair together (see DME) and
try the client in it. If possible, let the client leave
with it and go home to test accessibility. You will
gain invaluable info on what works and what does
not. It will also give you an idea of any seating
hypothesis that you may want to further
investigate .
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 35 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 36 ___________________________________ When Can I Get a New Wheelchair?
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 37 ___________________________________ Selecting a Manual Wheelchair
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Factors for consideration in choosing a manual
wheelchair:
Wheelchair weight
Durability
Adjustability
Seat-to-floor height
Depth
Caster problems
Ability to fold / break down
Cost
Grow ability
Smallest possible is usually the best
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 38 Possible Issues
___________________________________  Cross brace / tube change out
 Frame rail changes
 Depth adjustable push handles
 Adjustments in attaching hardware
___________________________________  Often needs wider longer seating
 Legrest length  Caster wheel size
___________________________________  Drive wheel size
___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 39 Depth Adjustable Back
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 40 ___________________________________ Umbrella Strollers
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 41 Tilt in Space Strollers
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 42 Types of Manual Wheelchairs
___________________________________ Standard Folding Hospital Wheelchairs (capacity
under 250 pounds)
 Steel frames
 Heavy
___________________________________  Little adjustment
 Not durable
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 43 ___________________________________ Types of Manual Wheelchairs
___________________________________ Heavy Duty Folding Wheelchairs (Bariatric)
(capacity > 250 pounds)
 Large
 Steel or aluminum frames
___________________________________  Double cross braces
 Little adjustment
 More durable
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 44 Types of Manual Wheelchairs
___________________________________ Lightweight Folding Wheelchairs
(capacity under 250 pounds)
 Light weight
 Aluminum frames
___________________________________  More adjustment
ore options
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 45 Types of Manual Wheelchairs
___________________________________ Ultra Lightweight Folding Wheelchairs
(capacity under 250 pounds)
 Lightest weight
 Aluminum frames
___________________________________  Most adjustment
 Most options
Most durable of the folders
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Manual Wheelchairs
Lightweight Rigid Frame Wheelchairs < 250 pounds
___________________________________ Non-folding (back can fold down)
Aluminum or Titanium frames
More adjustability (maybe)
More options
More durable
Reduces frame flex / best for self propulsion
Bad for weight bearing transfers
Good for seat to floor height
Backs have limited strength
Bad for growth
ad for lower leg room
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___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Tilt-in-Space Wheelchair
Aluminum
___________________________________  Adjustable and grow able
 Can shift a client’s weight
 Reduces effects of gravity on posture
 Reduces shear during weight shifts
___________________________________  Only choice if lateral support is needed
 Heavy
 Bad for self-propulsion
 Increased seat-to-floor height
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Recliners
___________________________________  Steel or aluminum frames
 Better for self-propulsion over tilt
 Heavy
___________________________________  Poor choice if lateral support is needed
 Encourages sliding out
 Provides best weight shift
___________________________________  More shear in weight shift than tilt
___________________________________ ___________________________________ ___________________________________ ___________________________________ One Arm Drive Wheelchairs
___________________________________  Wheel mounted with axle or hand crank
 Requires excellent strength and coordination
 Limited speed and distance
___________________________________  Inefficient for long distances
 Mainly used in home
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Pressure Equalization vs. Pressure Elimination
Equalization
 ROHO
 Gel / Jay
 Contour
 Foam
___________________________________ Elimination
 Ride Designs
 Doughnut
 Tie off
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Pressure Equalization
___________________________________  The more surface area supported, the greater
the pressure equalization, and the greater the
pressure relief
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Pressure Elimination
___________________________________  Pressure elimination refers to removing pressure directly
off of a vulnerable area. These cushions remove
pressure by moving it around a sharp spot. The surface
area rarely changes, which is a problem for those who
move about in their chairs. Sometimes can be the only
solution for bony protrusions
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Correction vs. Accommodation
___________________________________  One of the most misunderstood problems with advanced
seating. If a client has a fixed deformity, or if a condition
is difficult to correct, then accommodation of the position
is the only choice. If a client’s position is correctible with
little effort then this should be done. Many long-term
wheelchair users cannot (or will not) tolerate much
correction. Let that be a lesson to you pediatric
therapists.
___________________________________ ___________________________________  Let function and comfort be your guides.
___________________________________ ___________________________________ ___________________________________ ___________________________________ Planar vs. Contour Seating
___________________________________ There has always been a raging debate which is
best. The planar system is easier to build and
better for transfers. It can be adjusted easier for
changes in growth or support. A lower seat-tofloor height is obtainable. The planar systems
are not as comfortable and provide little pressure
relief.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Planar vs. Contour Seating
___________________________________ Contoured systems are more comfortable and
can accommodate/correct posture. They are
hotter to sit on and eat up a lot of depth.
They tend to be heavy, and often place the
client in a difficult position for self-mobility.
They are very costly, time consuming, and are
not very adjustable or growable.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Types of Seat Cushions-Air Flotation
(ex. ROHO, Star)
___________________________________ Pros
 Great for pressure relief
 Can be customized
 Very light in weight
 Pressure relief all over cushion (except for Nexus)
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Seat Cushions-Air Floatation
(ex. ROHO, Star)
Cons
 Not as durable
 Requires maintenance
 Poor choice for the incontinent
 Expensive
 Raises seat-to-floor height a lot
 Poor for positioning
 Clients often don’t feel stable
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Seat Cushions-Gels / Fluid
___________________________________ Pros
 Durable
 Customizable
 Moderate pressure relief
___________________________________  Easy to clean
 Stable
 Can grow
 Modest ability to correct
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Types of Seat Cushions-Gels / Fluid
___________________________________ Cons
 Better for thin or long legged clients
 Some have poor pressure relief
 Gel can go everywhere
___________________________________  Heavy
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Seat Cushions-Planar
___________________________________ Pros
 Easy to customize
 Good for transfers / movement in chair
 Good for seat to floor height
___________________________________  Washable
 Can grow
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Seat Cushions-Planar
___________________________________ Cons
 Poor pressure relief
 Foam breaks down over time
 Poor comfort
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Types of Seat Cushions-Contour
(ex. Signature 2000, Foam-in-Place, Contour U, Silhouette,
Ottobock, Ride Designs, Aspen)
___________________________________ Pros
 More able to correct / accommodate
 Good pressure relief
 Looks good
___________________________________  Great comfort
 Sometimes the only choice for deformity
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Seat Cushions-Contour
(ex. Signature 2000, Foam-in-Place, Contour U, Silhouette,
Ottobock, Ride Designs, Aspen)
___________________________________ Cons
 High seat-to-floor height
 Eats up depth
 Hot
___________________________________  Very time consuming to make
 Very expensive
 Little growth available
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Types of Seat Cushions-Slings
(Material)
___________________________________ Pros
 Easy to breakdown chair for transport
 Low seat-to-floor height
 Washable
 Cheapest
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Types of Seat Cushions-Slings
(Material)
___________________________________ Cons
 Poor pressure relief
 Little support
 Fabric stretches over time
 Painful
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Backrests / Back Cushions
Hard support / General Contour
(ex. J2 Back, Otto Pro series, etc.)
___________________________________ Pros
 More support than sling
 Can go between canes / more depth
___________________________________  Easy to clean / remove
 Looks good
 Some pressure relief
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Backrests / Back Cushions
Hard support / General Contour
(ex. J2 Back, Otto Pro series, etc.)
___________________________________ Cons
 Have to remove to fold frame
 Limited options with lateral supports
___________________________________  Often too short to fully support back / tilt, recline
 Bad for headrest mounts
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Backrests / Back Cushions
Slings
___________________________________ Pros
 Easy to breakdown chair for transport
 Can be placed low (paras / super quads)
 Good for maximum depth (increases over time)
___________________________________  Sometimes best choice fro bariatric
 Good for those that use chair for long distance
transport
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Backrests / Back Cushions
Planar
___________________________________ Cons
 Stretches
 Limited support
___________________________________  Encourages poor posture
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Backrests / Back Cushions
Planar
___________________________________ Pros
 Can handle heavy lateral supports
 Easy to clean
 Can mount headrest / harness
___________________________________  Can be customized easily
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Lumbar Supports
___________________________________  Usually soft
 Good for very low tone
 Often requested
___________________________________  Seldom helps posture
 Used as fillers
 Can be uncomfortable
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Shoulder Blocks
___________________________________  Seldom work
 Uncomfortable
 Difficult for transfers
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Pelvic Belt
___________________________________  Used for positioning pelvis
 Over-used for restraint
 Not a car restraint
 Difficult for clients with limited coordination
___________________________________  Flexes too much
 Limits movement
 Needed for safety
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Upper Body Positioners / Tray
 Can act as a lateral
 Clear material is best to view lower body
 Often not covered by third-party payers
 Therapist must clarify that they are needed
___________________________________ for positioning
___________________________________  Can limit slumping
 Padding is needed if it is your cornerstone
 Tough with recline
 Never to be used during transport
 Difficult to secure well
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Elbow Blocks
___________________________________  UBP mounted
 Needed for low tone and tilt-in-space
 Makes putting on an UBP difficult
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Hip Abductors
___________________________________  Wide and varied
 Good for wind sweeps / scissoring
 Should not be used to prevent sliding (Pommel)
 Makes transfers difficult
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Hip Guides
___________________________________  Limits sloshing around in chair
 Part of the three-point correction system
 Placed in towards pelvis
 Makes pelvic belt difficult to place properly
___________________________________  Limits in-chair mobility
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Hip Adductors
___________________________________  Limits frogging
 Placed along thighs / knees
 Protects lower legs from rigging
___________________________________  Limits transfers
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Foot Supports
___________________________________  Often needed to hold pelvis in position
 Often disliked by clients
 Come in many forms (toe straps, ankle
huggers, shoe holders, toe pegs)
___________________________________  Difficult for client to manipulate independently
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Case Study #1
___________________________________ Taylor
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________  Name: Taylor
 Age / Weight: 12 years old / 42 lbs.
 Dx: Cerebral Palsy – Spastic Quadriplegia – Hypotonic
 Problems: Taylor in poor position in school. Taylor is
___________________________________ expected to use his communication system in school,
but will not hold his head up. Taylor having pain due
to unknown reasons. Taylor tried a number of seating
systems without success.
 Living Environment: Lives at home with Grandma.
Has aides both at home and school. Is never left
alone
 Communication: Non-verbal, uses communication
device inconsistently
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________  Transport: Family has van with lift. Taylor is
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transported in school bus and family van while sitting
in wheelchair
Likes: Attention from adults, to be rocked and
cuddled by caregivers, some subjects in school
ADLs: Total dependence
Transfers: One man total lift
Health: Has seizures when ill, history of dysphagia
and GE reflux, history of colds, history of severe
constipation. Is incontinent. Has circulation issues,
no history of poor skin integrity /decubiti. Has had
red areas from AFOs
Other: Only sits in current wheelchair for 3-4 hours
per day
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________  Current Wheelchair: 14” X 14” Zippie TS, 90 degree
hangers, kidz angle adjustable footplates, Jay GS seat
cushion, Silhouette back rest, Lateral pads – medium
size, Ottobock large Combi headrest, and UBP
 Physical: Taylor is a slim child who exhibits wind swept
hips to the right side with severely tight hamstrings
bilaterally. He has a slight (but flexible) scoliosis
c-curve to the right. Taylor can bear some weight but
does not assist with transfers. Upper extremity function
is limited. Taylor has no ability to transfer his own
weight himself. Taylor will disengage from all activities if
he is in discomfort. Taylor has experienced more pain in
recent months.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 76 ___________________________________ Backrests / Back Cushions
Planar
___________________________________ Cons
 Heavy
 Not overly comfortable
___________________________________  Limited ability to conform to deformity
 Difficult to remove
 Eats depth
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 77 Backrests / Back cushions
Contour (ex. Signature 2000, Contour U, Silhouette,
Foam-in-Place)
___________________________________ Pros
 Customizable / excellent lateral support
 Good pressure relief
___________________________________  Contours to fixed deformity
 Maximum correction possible
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 78 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 79 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 80 ___________________________________ Backrests / Back cushions
Contour (ex. Signature 2000, Contour U, Silhouette,
Foam-in-Place)
___________________________________ Cons
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Hot
Limits movement
Difficult to remove
Heavy
Difficult to clean
Eats a lot of depth
Laterals too thick (except Silhouette)
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 81 Headrests
___________________________________  Comes in many different forms
 Often over-emphasized
 Lateral support difficult on ears
___________________________________  Most are not very adjustable
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 82 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 83 Neck Collars
___________________________________  Danmar / Hensinger type
 Often overused
 Looks like a life preserver
 Airway concerns
___________________________________  Line of sight rules often apply
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 84 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 85 ___________________________________ Anterior Trunk Supports / Harness / Chest Strap
___________________________________  If everything isn’t right – CAN BE DEADLY!
 Butt Back!! Lower Straps Tight!!
 Often overused
 Hot and restrictive
___________________________________  H‐ style
 Butterfly
 Slim Line
___________________________________  Doesn’t work well with coats
 Not designed as a car / bus restraint
___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 86 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 87 Occipital Neck Rings
___________________________________  Limits lateral head movement
 Not to be used as a shoulder block if possible
 Good for those clients who get under their
headrest
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 88 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 89 Forehead Straps
___________________________________  Not many good ones
 Uncomfortable
 Don’t work with small foreheads
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 90 Lateral Supports
___________________________________  Cane mounted are weak
 Needs to adjustable
 Swing-away best for transfers
___________________________________  Can correct or be a block
 Limits ability to move in chair
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Goals:
1. Encourage Taylor to sit-up and be able to use his
communication devices / switches consistently
2. Decrease pain and increase tolerance of wheelchair
during the school day
3. Repair broken components on wheelchair
___________________________________ ___________________________________ Wheelchair: Grew current Zippie TS to 16” wide to
accommodate new seating, set backrest angle to
100 degrees, added rigging extensions for
increased tibia length, and made general repairs
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Seating: Simulated and scanned for a wide, deep
contoured cushion that would accommodate the
windswept hips and prevent Taylor’s forward sliding.
Made a new backrest support and move the backrest
to the left side, mounted a new headrest that has
more lateral support and a headstrap that allows side
to side movement. Re-used the lateral pads but
added more aggressive padding to each. Constructed
a new UBP and added a flexible harness for comfort.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Considerations When Selecting a Powered Wheelchair
___________________________________  Programmable vs. non‐programmable
 Extremely heavy
 Need a van with ramps or lift
 Need tie downs
___________________________________  Always breakdown
 Risk of injury to clients and those around them
 A manual back‐up is always needed but seldom fundable ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Consumer Level Power
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Considerations When Selecting a
Powered Wheelchair
___________________________________  Extremely expensive before and after
 Often have the chair for 7-10 years +
 Consider where they will drive the chair
___________________________________  Can the chair be changed to incorporate a tilt or
recline if the client degenerates
 Speed
 Range
 Durability
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ What Makes It “Pediatric”
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ Considerations When Selecting
a Powered Wheelchair
___________________________________ A joystick is both the accelerator and steering
mechanism. It requires a great deal of
coordination to use. The type and placement is
often crucial to functional use.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Joystick Adaptations
___________________________________  Extensions
 T-handles
 Goal-posts
___________________________________  Knobs
 Center-mounts
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Other Types of Drive Systems
___________________________________  Head array
 Chin control
 Sip-n-Puff
___________________________________  Wafer board
 Scanners
 Individual switches
___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Electric Powered Wheelchairs
___________________________________ Other Systems (more is often NOT better)
Not “if” but “when” they break
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Electric Powered Wheelchairs
___________________________________  Powered Tilt-in-Space
 Powered Recline
 Power Elevation
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 121 ___________________________________ Drive Wheel Configuration
___________________________________ Gone are the days when a powered wheelchair was
just a manual wheelchair with electric motors
connected to the drive wheels with a belt. Today’s
powered chairs are extremely sophisticated, powerful,
and smooth. Most chairs are direct drive to either a
12” / 14” wheel that is placed in the front (frontwheel drive), middle (mid-wheel drive), and end
(rear-wheel drive) of the base of the wheelchair.
Each kind has its pros and cons. Your clients’
satisfaction with his/her chair is often tied to the drive
wheel location.
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 122 Rear Wheel Drive
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 123 Mid Wheel Drive
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 124 ___________________________________ Front Wheel Drive
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 125 Power Tilt in Space
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 126 Power Recline
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 127 ___________________________________ Power Elevating Foot Support
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 128 Power Elevating Seat
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 129 Power Assist Wheels
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP Slide 130 ___________________________________ Transportation
___________________________________  What is the law?
 Thoughts on common practice
 WC 19 compliant
 WC 20 compliant
___________________________________  Your role with home and school transport
www.travelsafer.org
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 131 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 132 David W. Kemp, OTR/L, ATP
___________________________________ Daniel M. Carney Rehab Engineering Center
5130 E. 20th North
Wichita, Kansas 67208
316‐651‐5215
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Use with permission only from David W. Kemp, OTR/L, ATP