Cerebral Palsy and ScoliosisHow to fit a child’s wheelchair

Richard C Rooney, MD, FACSrrooney@seattlespinegroup.com

Fitting a wheelchair in pediatric cerebral palsy

Overview

• The positioning team• Anatomical terms• Pelvic positioning• Lower body positioning• Upper body positioning• Questions

The Builders

• Manufacturer – Bodypoint DesignsManufacturer – Bodypoint Designs• Architect – TherapistArchitect – Therapist• Supplier – DistributorSupplier – Distributor• Builder – DealerBuilder – Dealer• Materials – ProductsMaterials – Products• Tools – Educational MaterialsTools – Educational Materials

Anatomical Terms: Planes

Transverse Coronal Sagittal Median or horizontal or frontal or paramedian

Anatomical Terms: Positions1. Cranial toward the head 1. Cranial toward the head 2. Caudal - toward the feet2. Caudal - toward the feet3. Medial - toward the middle3. Medial - toward the middle4. Lateral - toward/from the side4. Lateral - toward/from the side5. Proximal - toward the attachment of a limb5. Proximal - toward the attachment of a limb6. Distal - toward the finger/toes6. Distal - toward the finger/toes7. Superior - above7. Superior - above8. Inferior - below8. Inferior - below9. Anterior - toward/from the front (next slide)9. Anterior - toward/from the front (next slide)10. Posterior - toward/from the back (next slide)10. Posterior - toward/from the back (next slide)11. Peripheral - toward the surface (next slide)11. Peripheral - toward the surface (next slide)12. Palmer - toward/on the palm of the hand12. Palmer - toward/on the palm of the hand13. Plantar - toward/on the sole of the foot13. Plantar - toward/on the sole of the foot

Anatomical Terms: Positions cont.

Anatomical Terms:Movement

• Lateral Rotation (1)Lateral Rotation (1)• Medial Rotation(2)Medial Rotation(2)• Supination (3)Supination (3)• Pronation (4)Pronation (4)• Eversion (5)Eversion (5)• Inversion (6)Inversion (6)• Adduction (7)Adduction (7)• Abduction (8)Abduction (8)  

Anatomical Terms: Movement

Flexion ExtensionFlexion Extension

Ideal Pelvic Posture• Neutral alignment: head balanced over Neutral alignment: head balanced over

spine, spine balanced over pelvisspine, spine balanced over pelvis• Neutral pelvis: ASIS and PSIS are levelNeutral pelvis: ASIS and PSIS are level• Natural spinal curvesNatural spinal curves• Shoulders slightly posterior to pelvisShoulders slightly posterior to pelvis• Head in neutral position with eyes (gaze) Head in neutral position with eyes (gaze)

forwardforward• Equal weight bearing through ischial Equal weight bearing through ischial

tuberositiestuberosities

Asymmetrical Postures

• Posterior Pelvic TiltPosterior Pelvic Tilt• Anterior Pelvic TiltAnterior Pelvic Tilt• Pelvic ObliquityPelvic Obliquity• Pelvic RotationPelvic Rotation

Posterior Pelvic Tilt

• Most common pelvic tendencyMost common pelvic tendency• ASIS in higher than the PSISASIS in higher than the PSIS• Flexed lumbar spineFlexed lumbar spine• Thoracic kyphosisThoracic kyphosis• Shoulder protractionShoulder protraction• Increased cervical extensionIncreased cervical extension• C-type postureC-type posture

What Causes a Posterior Pelvic Tendency?

• Wheelchair considerations:Wheelchair considerations: Seat depth too longSeat depth too long Back support too shortBack support too short Sling back upholsterySling back upholstery Elevating leg restsElevating leg restsLower extremities are not supported wellLower extremities are not supported well

• Physical conditions:Physical conditions:Tight hamstringsTight hamstringsReposition themselves by slidingReposition themselves by slidingCan not maintain 90º of hip flexionCan not maintain 90º of hip flexion

Anterior Pelvic Tilt

• ASIS in lower than the PSISASIS in lower than the PSIS• Increased lumbar lordosisIncreased lumbar lordosis• Thoracic kyphosis is Thoracic kyphosis is

reversed or reducedreversed or reduced• Shoulder retractionShoulder retraction

What Causes an Anterior Pelvic Tilt?

• Weak muscles/Low toneWeak muscles/Low tone• Weak hamstringsWeak hamstrings• Weak abdominalsWeak abdominals• Tight hip flexors Tight hip flexors (ilipsoas and rectus femorus)(ilipsoas and rectus femorus)

Pelvic Obliquity

• One ASIS is higher than the otherOne ASIS is higher than the other• Compensatory C-shaped curve in the lumbar and Compensatory C-shaped curve in the lumbar and

thoracic spinethoracic spine• The shoulder on the side of obliquity tends to be The shoulder on the side of obliquity tends to be

elevatedelevated• The obliquity is named for the side that is lowerThe obliquity is named for the side that is lower

What Causes a Pelvic Obliquity?• Wheelchair considerations:Wheelchair considerations:

Sling back upholsterySling back upholsteryWheelchair too wideWheelchair too wide

• Physical conditions:Physical conditions:Muscle ImbalanceMuscle ImbalanceIrregular muscle tone Irregular muscle tone

(high or low tone on one side of the trunk)(high or low tone on one side of the trunk)

Pelvic Rotation

• One side of the pelvis is more One side of the pelvis is more forward than the other sideforward than the other side

• Keep in mind that some level of Keep in mind that some level of pelvic rotation is usually found pelvic rotation is usually found in an individual who has a in an individual who has a pelvic obliquitypelvic obliquity

What Causes a Pelvic Rotation?

• Muscle imbalance causes an irregular pull on Muscle imbalance causes an irregular pull on the pelvisthe pelvis

• Muscle contracture on one side causes an Muscle contracture on one side causes an asymmetrical pelvisasymmetrical pelvis

Pelvic Positioning Considerations• 3 points for pelvic stabilization:3 points for pelvic stabilization: seat, back & anterior supportseat, back & anterior support• The pelvis is the keystone of positioningThe pelvis is the keystone of positioning• Optimize independence Optimize independence • Enhance functionEnhance function• Promote comfort/Relieve painPromote comfort/Relieve pain• Distribute pressureDistribute pressure

Pelvic Positioning Considerations Cont.,

• Correct flexible deformitiesCorrect flexible deformities• Accommodate fixed deformitiesAccommodate fixed deformities• Minimize postural supports Minimize postural supports • Do not over position: Sitting is a dynamic Do not over position: Sitting is a dynamic

activityactivity• Understand the clientUnderstand the client’’s needs and then s needs and then

choose the productchoose the product

Seating Considerations Cont.,

• Consider the seating system and the chairConsider the seating system and the chair• Determine the objectives of the belt for the Determine the objectives of the belt for the

seating system and the clientseating system and the client• Consider the clientConsider the client’’s level of compliance.s level of compliance.• Consider the needs of the client or care Consider the needs of the client or care

giver operating the beltgiver operating the belt

Seating Considerations Cont.,

• Consider the seating system and the chairConsider the seating system and the chair• Determine the objectives of the belt for the Determine the objectives of the belt for the

seating system and the clientseating system and the client• Consider the clientConsider the client’’s level of compliance.s level of compliance.• Consider the needs of the client or care Consider the needs of the client or care

giver operating the beltgiver operating the belt

Correction of Common Asymmetrical Postures

• Posterior Pelvic Tilt: C-type PosturePosterior Pelvic Tilt: C-type Posture• Anterior Pelvic Tilt: Spinal ExtensionAnterior Pelvic Tilt: Spinal Extension• Pelvic Obliquity: Lateral TendencyPelvic Obliquity: Lateral Tendency• Pelvic Rotation: Asymmetrical PelvisPelvic Rotation: Asymmetrical Pelvis

Options For Posterior Pelvic Tendency• Center-pull or Dual-pullCenter-pull or Dual-pull• Position belt anywhere between 45° and 90°Position belt anywhere between 45° and 90°• Belt is inferior and anterior to ASISBelt is inferior and anterior to ASIS• The higher the belt is from the ASIS,The higher the belt is from the ASIS, the more the posterior tendency is encouragedthe more the posterior tendency is encouraged• BeltBelt’’s design and angle prevents the individual from slidings design and angle prevents the individual from sliding

Options for Anterior Pelvic Tendency• Four-point hip beltFour-point hip belt• Position the primary padded belt over the ASIS,Position the primary padded belt over the ASIS, and attach to the back of the chairand attach to the back of the chair• Position secondary straps between 45° and 90° to the seat Position secondary straps between 45° and 90° to the seat • Secondary straps prevent the belt riding up Secondary straps prevent the belt riding up into the abdomen and from twistinginto the abdomen and from twisting

Options for a Pelvic Obliquity

• Rear-pull hip beltRear-pull hip belt• Pull from the rear of the padPull from the rear of the pad• Position one side of the pelvis, lock it in place Position one side of the pelvis, lock it in place and then position the other sideand then position the other side• Four-point hip belt is recommended for Four-point hip belt is recommended for an individual with excessive movementan individual with excessive movement

Options for a Pelvic Rotation

• Rear-pull hip beltRear-pull hip belt• Two-point or Four-point hip belt Two-point or Four-point hip belt depending on the individualdepending on the individual

Options for ThrustingLeg harness- Prevents hip extension by holding the femurs into the seatTop strap attaches to back post at 90º, slightly below ASISBottom strap passes under the thigh and attaches to seat railContra-indications: Pelvic fractures, open wounds in the groin area/upper thigh, unstable hip joint

Lower Body Ideal Posture

Feet flat on footplate in Feet flat on footplate in neutral positionneutral position Ankles 90 º Ankles 90 º Knees 105 º & neutral Knees 105 º & neutral abductionabduction Femurs parallel to seatFemurs parallel to seat Footplate position allows 2Footplate position allows 2”” clearance from floorclearance from floor 11”” space from back of knee space from back of knee to front of seatto front of seat

Lower Extremity Conditions

• Extension/Flexion Patterns Extension/Flexion Patterns • Leg Length DiscrepanciesLeg Length Discrepancies• AmputeesAmputees• Contractures/DeformitiesContractures/Deformities

Extension Pattern/Reflex

• Hips extend & adduct• Knees extend• Ankles plantar flex• Anterior foot positioning required

Flexion Pattern/Movement

• Hips flex• Knees flex• Ankles dorsiflex• Posterior foot

positioning required

Lower Body Positioning Considerations

• Lower extremity positioning directly affects the position of the pelvis

• Lower extremity positioning helps sustain the position of the hips and knees

• Correct positioning assists in the prevention of deformities and distributes pressure

• Footplates positioned too low increase pressure under the thigh

• Footplates too high increase sacral area pressure• Do not over position- Balance function & support

Lower Body Positioning Considerations Cont.,

• Always use a hip belt in conjunction with foot supports.

Secondary Support Options:Ankle Huggers™

• Balances lower extremities in response to head & upper body movements/patterns/ reflexes

• Reduces joint stress• Stabilizes feet without blocking

movement or circulation• Dynamic kit available

Secondary Support Options:Adjustable-Angle Footplates

• Accommodates Accommodates contractures, contractures, deformities, deformities, amputations & leg amputations & leg length discrepancieslength discrepancies

• Individually adjustable Individually adjustable in height, depth, width in height, depth, width & plantar/dorsiflexion& plantar/dorsiflexion

Secondary Support Options:Fulcrum Series Footplate

• Accommodate fixed deformities of the foot or ankle

• Capable of inversion/eversion, plantar/dorsiflexion & depth adjustments

Upper Body Ideal PostureSame spinal curves as erect standing:

lumbar lordosisminimal thoracic kyphosisminimal cervical lordosis

Trunk symmetryNeutral alignment: head balanced over Neutral alignment: head balanced over spine, spine balanced over pelvisspine, spine balanced over pelvisShoulders slightly posterior to pelvisShoulders slightly posterior to pelvisHead in neutral position with eyes (gaze) Head in neutral position with eyes (gaze) forwardforward

Causes of an Asymmetrical Trunk

• Wheelchair considerations:Wheelchair considerations:Back support too lowBack support too lowWheelchair too wideWheelchair too wide

• Physical conditions:Physical conditions:Postural weakness/Low TonePostural weakness/Low ToneHypertonicity of certain muscle groupsHypertonicity of certain muscle groupsExtensor patternExtensor patternFixed postural deformities- Kyphosis/ScoliosisFixed postural deformities- Kyphosis/Scoliosis

Seating Considerations

• Spine posture depends on pelvic positioning & the integrity of lumbar lordosis• Manipulative skills of upper extremities dependent on

trunk stability & symmetry • Do not over position- Balance function & support• Good trunk alignment is essential for head & neck control• Always use a pelvic support with an anterior trunk support

Secondary Support Options:Standard ‘H’ Style Harness

• Provides shoulder retractionRear-Pull:• Caregiver operatedFront pull:• User operated• Dynamic kit available- 3 strengths,

promotes respiration & limited movement

Secondary Support Options:Trimline Harness

• Provides shoulder retraction• Crossover & backpack styles• Comfortable choice for womenFront-Pull:• User operated• Dynamic kit available- 3 strengths,

promotes respiration & limited movement

Rear-Pull:• Caregiver operated

Dynamic Straps

• Allow the user to lean forward 3Allow the user to lean forward 3”” to to 44””

• Allows for easier breathing Allows for easier breathing • Increased arm movement Increased arm movement • Acts as a Acts as a ““shock absorbershock absorber”” to to

enhance comfortenhance comfort• Available in 3 strengthsAvailable in 3 strengths

Secondary Support Options:Chest Strap

• Allows more upper torso movement and Allows more upper torso movement and provides little shoulder supportprovides little shoulder support

• Velcro™ fastening & D- ring design for limited hand functioning

BP Proprietary Features

• Webbing• Foam and Pad Shape• Durability and Maintenance• Comfort

Summary

• The positioning team• Anatomical terms• Pelvic positioning• Lower body positioning• Upper body positioning• Questions

ReferencesAlbert M. Cook, Susan M. Hussey. Assistive Technologies: Principles and

Practice. Mosby-Year Book, Inc., 1995.Diane E. Ward. Prescriptive Seating for Wheeled Mobility. Health Wealth

International, 1994.Thomas Hetzel. Helping Gravity Help You. Bodypoint Designs, Inc., 1998.Jean Anne Zollars and Patty Ruppelt. Beyond the Obvious – Developing

the Inner and Outer Eye. Thirteenth International Seating SymposiumSheila Buck. Back to Basics and Beyond #3. Therapy Now, 2001.Seventeenth International Seating Symposium. Seating & Mobility for

People with Disabilities, 2001.