What are the importance, goals, and disadvantages of alternative positions for pediatric wheelchair users?
Most kids, especially those with complex needs, have more than one seating system and mobility base. They might have a lot of positioning equipment, filling up their home and garage. It is very important to look at a child's positioning 24 hours a day when evaluating him or her. I might work hard to develop the best seating system I can, along with a team for an individual child, but they might only be in it two or three hours a day. There are a lot of other hours that they could be in a very destructive posture. We don't want that to happen. So I need to go through all the equipment they have to make sure it's appropriate and that they're in a good position for most of their day and night.
So when working with young students, children may spend time outside of the wheelchair in other positions. This could be at home but also in the classroom. The classroom might have some of this equipment, but it's most likely generic because it's used with multiple children.
The goals of taking a child out of their primary seating system are to
- Provide an alternative position to the wheelchair seating system to prevent range of motion losses from those sustained seated positions
- Provide a position that perhaps places a child at a height for peer activities (with our younger kids, that's a lower height than their stroller or than their manual or power wheelchair)
- Provide a "more comfortable" position. This is important because some alternative positions aren't that different than the wheelchair seating system. So if somebody's in an alternative seat, it might be an alternative to the wheelchair seat, but if the hips and knees are still flexed, it's not an alternative position, and that's not going to prevent range losses that are so common in the hips and knees. Unfortunately, many wheelchair users begin to look more and more and more like their wheelchair, like a seated position, and lose hip mobility into extension.
Disadvantages of alternative positioning systems include
- No generic positioning system will provide as much support as a custom-made seating system to meet an individual's specific needs.
- An alternative seating system will not prevent range losses seen from prolonged seating in the wheelchair seating system.
- Less support can mean less function for a client, and less support may mean less postural support to keep someone aligned, which can lead to someone assuming and maintaining more destructive postures.
It is important to analyze if the alternative position is doing more harm than good. Remember, the student may not be able to function / access as well in the alternative system. It may be best to use this during more passive activities. Optimal position is key to limiting loss of range of motion, orthopedic changes, facilitating function, and access to assistive tech optimizing vision, breathing, and swallowing.
This Ask the Expert is an edited excerpt from the course 4670 Wheelchair Seating For The Pediatric Population by Michelle Lange, OTR/L, ABDA, ATP/SMS