Overview and Description
Background
Wheelchair and Power Mobility for the pediatric population is of overwhelming importance and an often overlooked area of research. The impairment that motor disability places upon a child goes far beyond physical impairment.
A common misconception is that children who operate a wheelchair to achieve independent mobility are isolated by their differences. However, the freedom of independent mobility generates opportunities to participate in familial and societal activities. Patients and their families may not prioritize the use of mobility devices because they prioritize independent ambulation. The act of independent movement, with or without mobility devices, can encourage patients to become accustomed to moving around on their own. Any form of independent movement could help these patients avoid developing learned helplessness and impairments secondary to limited movement.1
The United States pediatric population with impaired motor function need a specialized wheelchair and power mobility evaluation to support and encourage independent development with a management plan tailored to their unique needs. This requires recognition of the individual life circumstances of each patient that contributes to their lived experience as it relates to their particular needs in development and mobility. Wheelchair and power mobility assessment, along with implementation, is a highly specialized medical service with numerous ways to achieve a functional ambulatory outcome.
It is important to highlight that the number of children and adolescents in the United States who utilize a wheelchair to achieve independent mobility are not accounted for in the data available. Currently, the US Census Bureau population data only reports this for adults. However, the process of wheelchair evaluation for adults and children is not the same as one must take into account the growth and development needs of a child to ensure their wheelchair is equipped to support these over the same duration of time.
Evaluation
Pre-wheelchair evaluation
Ascertaining a child’s developmental history initiates the pre-wheelchair assessment with a holistic approach to understanding patients’ needs in all aspects of childhood development: social, emotional, language, communication, cognitive, and motor function.
The US pediatric population begins regular growth and development screening at 2 months of age with their primary care provider. It is important to gather documentation from primary care providers as they may have historically documented a developmental delay, or disorder, that needs to be included in the pre-wheelchair evaluation in order to ensure complete assessment. Through early identification the primary care team provides valuable knowledge on patient history and prior attempted medical therapies. Teasing out what has or has not worked for the patient before can guide proper wheelchair selection.
A child with delayed development in motor function may have limited independence and self-care which can potentially reduce social, academic, and environmental opportunities. Interdisciplinary team collaboration, to acknowledge and achieve patient specific goals of care, is initiated with proper wheelchair fitting and evaluation to improve position.
Fitting the wheelchair to the patient not only increases independence and improves quality of life, but also helps minimize the progression of postural deformities, pressure ulcers, and pain. In addition to considering the patient’s height, weight, and results of a comprehensive pelvic posture exam; it is imperative to consider the patient’s comorbid conditions that may interfere with their ability to operate a wheelchair. Comorbid conditions which result in obesity, malnutrition, sensory deficits, cognitive impairment, or movement disorders such as spasticity can potentially interfere with patient wheelchair utility.2
Wheelchair evaluation
Physician assessment prioritizes determining each child’s baseline abilities along with the tasks in which a wheelchair is intended to aid. The child’s current living environment should be considered since a wheelchair may demand residential and transportation adaptations to accommodate mobility and access. Patient history of prior wheelchair or mobility equipment should also be obtained for understanding of any previous devices or features that worked well or failed to meet patient needs. These assessment pieces are primarily fulfilled by a physician, physical therapist, and occupational therapist. Evaluation that indicates utilization of a wheelchair or power mobility will then receive appraisal from the full multidisciplinary rehabilitation team to effectively coordinate and craft a suitable prescription exclusive to each child.2
Professional Members of a Multidisciplinary Team3
| Team Member | Associated Role |
| Patient & Family | Provide patient history regarding mobility function, prior mobility equipment experiences, and requirements of mobility equipment that prescription documentation must mirror |
| Physician | Foresee known future care needs related to patient condition to ensure prescribed wheelchair functions to accommodate predictable necessities in patient position thereby maintaining patient utility throughout its expected duration |
| Occupational Therapist | Provide focused assessment of child’s performance ability with activities of daily living, any limitations of a patient’s environment, and desired activities mobility equipment is intended to confer patient independence |
| Physical Therapist | Conducts comprehensive physical exam of patient supine then sitting. Supine positioning aids in identification of problematic posture and tone with potential of gravity induced deviation enhancement when sitting |
| Rehabilitation Nurse | Invests the most time assisting patient well-being throughout rehabilitation care. Specific focus is given to educating patients and family in self-care, complication prevention, and promoting independence |
| Manufacturing Representative | Serves as a great reference in product utilization capabilities. Expert knowledge aids mobility equipment customization requiring high degree of specialization and mechanical modification to meet complexities of patient needs |
| Supplier | Identifies available fabrications suitable to the patient and processes product orders through documentation submission to funding source |
| Funding Source | Reviews documentation to approve or deny financial coverage of medical equipment. Decision on coverage considers medical justification with respect to diagnosis, the mobility impairment, statement of medical necessity, and if patient coverage plan includes benefit guarantee for equipment |
| Social Worker | Assists in care coordination with insurance companies, discharge planning, and referrals |
| Respiratory Therapist | Commonly required to assist pulmonary function in spinal cord injury. Patients with reduced respiratory capacity warrant evaluation to determine safe utility for self-propulsion equipment |
| Speech & Language Pathologist | Provide assessment and therapies related to patient swallowing, level of cognitive function, and ability to communicate. Important to evaluate in children with developmental delay as power mobility is capable of different device interface modalities for communication |
| Audiologist | Evaluation and treatment of any impairment to hearing is crucial for patient safety. The level of sensory loss may render a child unsafe in decision making capacity while driving their mobility device |
| Dietician | Supports appropriate patient nutrition and healthy weight maintenance. Patient weight and ability to distribute weight impacts seating adjustments |
Components of Clinician Focus to Capture
Physical examination should document4
Weight, skin integrity, muscle tone, motor coordination, vision, hearing, sensory loss, range of motion, movement disorders, spasticity, cardiopulmonary function, capacity for independent propulsion, gastrointestinal or genitourinary issues, musculoskeletal or posture deformity, psychosocial dynamics as a reflection of cognitive function, judgment, and decision-making capacity. Clinical assessment of patient capability alone does not definitively establish if a patient can use mobility equipment safely and effectively.
All wheelchair seating assessments require accurate measurements of the patient’s dimensions in a sitting position:
When seated, most patients have 90 degree angles at the elbows, knees and hips, but it is important to keep in mind that this may not be possible for everyone. Other important aspects of accurate seating measurements include height of backrest, seat height, depth and angle, footrest height and length, armrest height and length.5 In pediatric patients, especially in the younger age groups, it is important to select a device that can accommodate patient growth.
Physical assessment should include4
- Presence of scoliosis, kyphosis or lordosis
- Pelvic tilt/rotation/obliquity
- Pelvic posture is arguably the single most important anatomical focus. Avoid posterior pelvic rotation. Other body parts are anatomically restricted for proper pelvic posture. For example, the angle of knee flexion is set to control hamstring concentric contraction at the hip thereby disabling a force that would elicit a posterior pelvic tilt.
- Shoulder symmetry and position
- Head position
- Sitting position
- Document pelvic abnormalities as flexible or fixed. This is key to determine if sitting position could provide passive correction or requires modification to the deformity.
Functional assessment should include2
- Physical capabilities including strength, range of motion, balance, and coordination
- Ability to complete activities of daily living and instrumental activities of daily living
- Postural control of the head, neck and trunk
- Ability to transfer
- Fine motor control including the ability to self-propel or use the control system on a power mobility device
- Patient’s functional goals
Types of Wheelchairs
Manual Wheelchairs
Manual wheelchairs are driven by the user or a caretaker. They are typically lighter to allow for self-propulsion and require minimal maintenance than other types of assistive mobility devices. The determination of the indications and contraindications to manual wheelchair use rely upon an astute functional assessment for conclusive evidence of a child’s specific positioning which safely allocates the most autonomy possible. Manual wheelchairs are therefore contraindicated in patients with physical or cardiorespiratory limitations incapable of self-propulsion.1
- Standard Wheelchairs
- Standard wheelchairs are generally for short-term rentals as they are prefabricated without adjustable axles. These wheelchairs are not well-designed for self-propulsion due to considerable weight. Standard wheelchairs should be utilized as a means of temporary mobility when a child’s personal mobility equipment cannot meet short term requirements for positioning restriction. This type of wheelchair is not ideal for self-propulsion.1
- Tilt-in-Space Wheelchairs
- Tilt-in-Space wheelchairs are a type of manual wheelchair that allows the user to relieve pressure from the pelvis and sacral areas while also reducing the amount of trunk and head control required while in the chair. These types of wheelchairs are designed with a lever that allows the user to adjust their position from upright to horizontal without adjusting the seat-to-back angle. As a result of their design, they are typically heavier than a standard manual wheelchair and are typically used as a dependent assistive device rather than for self-propulsion.1
- Folding wheelchair
- Folding wheelchairs are a type of manual wheelchair that may be well suited for children who are able to self-propel. These chairs have a removable seat that allows the sides to be pushed together so the chair becomes compact for transport. Folding wheelchairs are further classified into lightweight or ultra-lightweight, but they are still heavier than rigid-frame wheelchairs. The weight of the folding wheelchair increases the risk of stress injury to the user or caretaker who pushes the wheelchair and lifts it into or out of cars for transport. Furthermore, while the frame-folding design is beneficial for transportation with limited storage capacity, propulsion of folding wheelchairs requires a lot of energy input that may not be favorable to all users.1
- Rigid-frame wheelchair
- Rigid-frame wheelchairs are utilized for their design advantages. These wheelchairs are the lightest weight wheeled mobility aids and have the greatest capacity for axle adjustability. Unlike folding wheelchairs, rigid-frame wheelchairs may not fit into smaller vehicles.1
Power Wheelchairs
Power wheelchairs or exoskeletons are used in the pediatric population for patients with various levels of mobility impairment but are particularly well suited for users with poor limb strength and coordination. Research advocates for the utilization of power mobility in children as young as 12 months of age evidenced by improvement in many metrics of child development. Power wheelchairs are controlled through a variety of mechanisms such as joystick, touchpad, head array and sip-and-puff switch. Exoskeletons are more commonly seen in individuals with spinal cord injury, and unlike wheelchairs can help with maintaining a patient’s level of physical activity and cardiovascular fitness. While these power mobility devices can provide an opportunity for independent function, they lack suitable utility for patients with severe cognitive impairment or patients without wheelchair accessibility for home entry and vehicle transportation due to a weight of 200+ pounds. Additionally, power wheelchairs are contraindicated for visually impaired patients and those limited by judgment and motor coordination required to drive a power wheelchair.1
Relevance to Clinical Practice
Goals for seating and mobility
The goals for seating and mobility aim to increase a child’s independent function in a manner that also prevents potential complications from developing due to wheelchair use. The prescribed seating system will create the most ideal patient position to support and stabilize posture in relation to safety. A large consideration should go towards the seating systems ability for pressure relief. The goal for pressure relief capabilities is to maintain skin integrity to protect against pressure injuries and ulcerations. Decisions regarding the seating base should focus on promotion of proper pelvic posture and a slight anterior pelvic tilt. Pelvic posture abnormalities should be distinguished as a fixed deformity or flexible deformity due to the respective trunk and head alignments. When a pelvic deformity is fixed, the seating system must accommodate trunk and head alignment. If a pelvic deformity is flexible, then it is possible the sitting position could provide some passive correction.2
Seating can be contoured, planar, or custom-molded depending on patient need. Contoured seating is for patients with only mild deformities and support requirements. These are extremely conducive to accommodating the growth of a child. Planar seating is not made for full-time wheelchair users as the seating system is flat with minimal support and pressure relief capabilities. Custom-molded seating is for patients with significant deformities in posture requiring maximal support to compensate for substantial tone abnormality. These are individualized seating systems for a patient however, they lack the ability for modification as the child grows. The seating cushion material is also a worthy consideration as material changes provide varied levels of pressure relief and stability. Foam or plastic cushions have the highest stability yet have the least pressure relief ability. Air cushions are essentially the opposite of this with the largest pressure relief ability, but the least stability. Then there are hybrids which are somewhere in the middle of both features as the name would indicate. Additionally, the seat to back angle is paramount for hip positioning and managing dystonia and spasticity. Focused assessments and measurements warrant options for customization to fit each patient depending on the type of mobility device, which serves a wide array of patient needs.2
Factors to consider when writing a wheelchair prescription5
- Adjustability to account for future growth of the patient and adapt to changing functional needs, particularly in patients with neurodegenerative diseases
- Caretaker ability to maintain and transport the wheelchair
- Addition of aids for communication and education for a school environment
- Height adjustment to allow pediatric patients to lower the seating surface for interaction with other children or to participate in activities that others perform while seated on the floor
Other factors in the wheelchair prescription process
Complications of wheelchair use
Complications from wheelchair use arise if the wheelchair is not appropriately fitted to the patient or used as intended. Improperly fitted wheelchairs can lead to pressure injuries, skin sores and irritation, muscle tightness or postural deformities, and respiratory difficulties because of poor trunk support. Furthermore, a poorly fitted wheelchair can result in limited participation in daily activities, decrease independence, and ultimately reduce quality of life. In addition to physical complications, limited independence and ability to integrate in a social setting can negatively impact self-esteem and the mental health of a patient.5
Meeting patient needs
Healthcare providers should engage in discussion with patients and their caregivers to determine if a wheelchair prescription was appropriate and the mobility device was able to be well integrated into the patient’s life and routine. The discussion should be ongoing as the patient grows and their motor impairment evolves. Most users consider a mobility device an extension of themselves, especially in the pediatric population it is important to provide options and access for the patient to personalize their wheelchair or power mobility device through the use of color, patterns, custom spoke guards, and materials.5
Cutting Edge/Unique Concepts/Emerging Issues
Examples of recent advances/Recent legislation issues/Future directions
In 2022, the state of Colorado passed a ‘right to repair’ law for power wheelchair users which mandates that much like motor vehicles, owners of power wheelchairs should have access to repair shops with the appropriate tools to maintain and/or repair their power wheelchairs. This law intends to reduce repair times and minimize the amount of time wheelchair users are without a functioning mobility assist device. As of 2024, 30 states have a ‘right to repair’ law, but many of these including the law in Colorado do not extend to manual wheelchairs or scooters.4
Gaps in Knowledge/Evidence Base
Assessment and compilation of research related to need for pediatric wheelchair and power mobility data points would assist healthcare providers and policymakers to effectively allocate resources, conduct research, and advocate for impact policy changes. The Child and Adolescent Health Measurement Initiative has made strides as a statistical database for the US pediatric population that better describes childhood disability in numerous ways, such as those with special health care needs. The 2022 data report does make evident that pediatric care needs are not being effectively met yet highlights a need for continued data collection in relation to outcome.6
There is also limited research on the psychosocial impact of mobility assist devices and how to fit a device to a patient based on the psychosocial effects. This limitation is likely a result of the ethical and logistical challenges involved in obtaining consent from minors and their guardians, the need for a diverse sample of participants, as well as the time and resources needed to conduct longitudinal studies.
Lastly, there are still minimal tools available to assess the success and long-term outcomes of assistive devices. The lack of understanding about the long-term outcomes significantly hinders innovation and development of devices that are better suited to the dynamic needs of patients as they grow and become functioning members of their communities.5
References
- Ward, Marcie, et al. “Orthotics & Assistive Devices.” Pediatric Rehabilitation: Principles and Practice, 6th ed., Demos Medical, New York, NY, 2020, pp. 196–229.
- Digiovine, Carmen P, et al. “Wheelchairs and Seating Systems.” Braddom’s Physical Medicine and Rehabilitation, 6th ed., Elsevier, 2021, pp. 261–290. ClinicalKey, https://www-clinicalkey-com.ezproxy.shsu.edu/#!/content/book/3-s2.0-B978032362539500014X. Accessed 14 Apr. 2024.
- Rinaldi, R. J., & Srinivasan, R. (2022). Handbook of Pediatric Rehabilitation Medicine. Springer Publishing Company. https://doi.org/10.1891/9780826184498
- Lisa I. Iezzoni, M. (2022, July 21). Millions rely on wheelchairs for mobility, but repair delays are hurting users. Harvard Health. https://www.health.harvard.edu/blog/millions-rely-on-wheelchairs-for-mobility-but-repair-delays-are-hurting-users-202207212785
- Roberts, A. J., & 22, O. published: O. (2021, October 13). Wheelchair and power mobility for adults. PM&R KnowledgeNow. https://now.aapmr.org/wheelchair-and-power-mobility/#gaps-in-knowledge/evidence-base
- Child and Adolescent Health Measurement Initiative. 2022 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved [04/13/24] from [www.childhealthdata.org].
Author Disclosures
Cristina Marie Sanders, DO, MS
Nothing to Disclose
Julie Elizabeth Essick, MS IV, MBA
Nothing to Disclose
Lauren O’Keefe, MD
Nothing to Disclose
Sanjana Ayyagari, MS IV
Nothing to Disclose
Rajashree Srinivasan, MBBS
Nothing to Disclose