EQUIPMENT AND ENVIRONMENT

Wheelchairs

Children with SCI are affected in many ways, and equipment and environment can lessen the impact of their disabilities and enable them to participate in age- appropriate activities.

Age and level of injury will dictate the extent of changes needed in the environment and the type of equipment needed (Table 11.7). Infants and toddlers may be well served by usual infant/tod- dler equipment, although those who require mechanical ventilation may be well served by a twin stroller to accommodate all of the necessary equipment. As children approach 2 to 3 years of age, they need to be provided with a mobility device to allow them to explore their environment. This may be a riding toy, such as a hand tricycle or powered riding toy, or an appropriately sized wheelchair. Transportation in a vehicle will still require the use of an appropriate toddler car seat. For those children with tetraplegia or with medical problems that preclude the use of a manually propelled wheelchair, a power wheelchair may be necessary. Prior to prescribing such a device, various control systems should be tried to see if the child can learn to drive a wheelchair and which system best suits their needs. Prerequisites to learning to drive a power wheelchair include:

1. At least one repeatable motor movement to drive the chair (eg, hand, head movement)

2. Understanding of cause and effect (knowing that an action causes something to happen)

3. Understanding of directionality

4. Ability to follow simple commands (42)

Children as young as 18 months have been shown to have the ability to drive power wheelchairs (43). However, if they require complex controllers, such as chin control rather than hand controllers, they may need to be closer to 4 or 5 years of age. But you do not know if a child can use any specific controller until you have tried it.

School-age children and adolescents need increasingly more independence and typically travel greater distances, so they may need power mobility to allow for this independence. All children who will be transported in their wheelchairs in vehicles should have transit-ready wheelchairs that meet WC19 standards (44).

Orthotics

Orthotic management of the child with an SCI must consider the child's age, developmental status, and functional status as well as the physical features of their home and school environments. Orthotic options include orthoses for positioning as well as orthoses to enhance function in standing or ambulation. See Chapter 6 for a detailed discussion of orthotics. A recent study looked at ambulation in 169 children and youth with SCI. After a mean follow-up of 9 years, 56 of these patients were nonambulators, 17 were community ambulators, 42 were household ambulators, and 54 were therapeutic ambulators. Young age at injury and lower neurologic levels were positively associated with greater likelihood of ambulation (45).

11.7

Mobility Equipment Options

AGE	LEVEL	MANUAL OR POWER	CONTROLLER	SPECIAL FEATURES
0-3 years	Paraplegia Tetraplegia	Stroller or riding toy Stroller	Hand
3-10 years	Paraplegia Tetraplegia	Manual Manual and power	Hand, chin	Tilt, recline, vent tray, standing
>10 yrs	Paraplegia Tetraplegia	Manual Manual and power	Hand, chin	Tilt, recline, vent tray, standing

Special Considerations in High Tetraplegia

Children with high tetraplegia (C1-C4 levels) all have some type of partial or complete respiratory dysfunction.

Whether they require full- or part-time mechanical ventilation depends on their level and the completeness of their lesion. Some may be ventilated only at night via face mask, while others require tracheostomies and full-time ventilation. Issues unique to this population include increased risk of pulmonary infection, the developmental impact of being assisted by a machine for life support, and the impact of a tracheostomy on swallowing and communication. This group of patients also has more problems with maintaining blood pressure in the upright position and in accessing their environment. Wheelchairs should be “selfcontained,” with all necessary equipment carried.

Long-Term Follow-up

Children with SCI can expect to live a relatively long time (46) and thus will most likely be affected by complications related to growth that adults do not experience. These complications include contractures, which are most likely to occur during periods of rapid growth, hip subluxation, and scoliosis. A study at Shriners Hospital for Children in Philadelphia found that 93% of their patients who sustained SCI under the age of 10 years had hip subluxation as compared to 9% of those over 10 years old at the time of injury (47). While the sample size was small (only 62 patients total), this echos the impression of clinicians. Researchers at the same institution also looked at prevention of scoliosis in children with SCI. They found that bracing with a thoracolumbosacral orthosis before the scoliotic curve reached 20 degrees delayed the time to surgical correction of the deformity.

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