How do fit a wheelchair for a child with cerebral palsy and scoliosis

1. Cerebral Palsy and Scoliosis
How to fit a child’s wheelchair
Richard C Rooney, MD, FACS
rrooney@seattlespinegroup.com

2. Fitting a wheelchair in pediatric cerebral palsy

3. Overview
• The positioning team
• Anatomical terms
• Pelvic positioning
• Lower body positioning
• Upper body positioning
• Questions

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

5. Anatomical Terms: Planes
Transverse Coronal Sagittal Median
or horizontal or frontal or paramedian

6. Anatomical Terms: Positions
1. Cranial toward the head1. Cranial toward the head
2. Caudal - toward the feet2. Caudal - toward the feet
3. Medial - toward the middle3. Medial - toward the middle
4. Lateral - toward/from the side4. Lateral - toward/from the side
5. Proximal - toward the attachment of a limb5. Proximal - toward the attachment of a limb
6. Distal - toward the finger/toes6. Distal - toward the finger/toes
7. Superior - above7. Superior - above
8. Inferior - below8. Inferior - below
9. 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 hand
13. Plantar - toward/on the sole of the foot13. Plantar - toward/on the sole of the foot

7. Anatomical Terms: Positions cont.

8. 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)

9. Anatomical Terms: Movement
Flexion ExtensionFlexion Extension

10. Ideal Pelvic Posture
• Neutral alignment: head balanced overNeutral 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 ischialEqual weight bearing through ischial
tuberositiestuberosities

11. Asymmetrical Postures
• Posterior Pelvic TiltPosterior Pelvic Tilt
• Anterior Pelvic TiltAnterior Pelvic Tilt
• Pelvic ObliquityPelvic Obliquity
• Pelvic RotationPelvic Rotation

12. 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

13. 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 rests
Lower extremities are not supported wellLower extremities are not supported well
• Physical conditions:Physical conditions:
Tight hamstringsTight hamstrings
Reposition themselves by slidingReposition themselves by sliding
Can not maintain 90º of hip flexionCan not maintain 90º of hip flexion

14. Anterior Pelvic Tilt
• ASIS in lower than the PSISASIS in lower than the PSIS
• Increased lumbar lordosisIncreased lumbar lordosis
• Thoracic kyphosis isThoracic kyphosis is
reversed or reducedreversed or reduced
• Shoulder retractionShoulder retraction

15. What Causes an Anterior Pelvic
Tilt?
• Weak muscles/Low toneWeak muscles/Low tone
• Weak hamstringsWeak hamstrings
• Weak abdominalsWeak abdominals
• Tight hip flexorsTight hip flexors
(ilipsoas and rectus femorus)(ilipsoas and rectus femorus)

16. Pelvic Obliquity
• One ASIS is higher than the otherOne ASIS is higher than the other
• Compensatory C-shaped curve in the lumbar andCompensatory C-shaped curve in the lumbar and
thoracic spinethoracic spine
• The shoulder on the side of obliquity tends to beThe 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

17. What Causes a Pelvic Obliquity?
• Wheelchair considerations:Wheelchair considerations:
Sling back upholsterySling back upholstery
Wheelchair too wideWheelchair too wide
• Physical conditions:Physical conditions:
Muscle ImbalanceMuscle Imbalance
Irregular muscle toneIrregular muscle tone
(high or low tone on one side of the trunk)(high or low tone on one side of the trunk)

18. Pelvic Rotation
• One side of the pelvis is moreOne side of the pelvis is more
forward than the other sideforward than the other side
• Keep in mind that some level ofKeep in mind that some level of
pelvic rotation is usually foundpelvic rotation is usually found
in an individual who has ain an individual who has a
pelvic obliquitypelvic obliquity

19. What Causes a Pelvic Rotation?
• Muscle imbalance causes an irregular pull onMuscle imbalance causes an irregular pull on
the pelvisthe pelvis
• Muscle contracture on one side causes anMuscle contracture on one side causes an
asymmetrical pelvisasymmetrical pelvis

20. 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 independenceOptimize independence
• Enhance functionEnhance function
• Promote comfort/Relieve painPromote comfort/Relieve pain
• Distribute pressureDistribute pressure

21. Pelvic Positioning Considerations
Cont.,
• Correct flexible deformitiesCorrect flexible deformities
• Accommodate fixed deformitiesAccommodate fixed deformities
• Minimize postural supportsMinimize postural supports
• Do not over position: Sitting is a dynamicDo 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

22. Seating Considerations Cont.,
• Consider the seating system and the chairConsider the seating system and the chair
• Determine the objectives of the belt for theDetermine 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 careConsider the needs of the client or care
giver operating the beltgiver operating the belt

23. Seating Considerations Cont.,
• Consider the seating system and the chairConsider the seating system and the chair
• Determine the objectives of the belt for theDetermine 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 careConsider the needs of the client or care
giver operating the beltgiver operating the belt

24. 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

25. 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 sliding’s design and angle prevents the individual from sliding

26. 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 seatPosition secondary straps between 45° and 90° to the seat
• Secondary straps prevent the belt riding upSecondary straps prevent the belt riding up
into the abdomen and from twistinginto the abdomen and from twisting

27. 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 placePosition 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 forFour-point hip belt is recommended for
an individual with excessive movementan individual with excessive movement

28. Options for a Pelvic Rotation
• Rear-pull hip beltRear-pull hip belt
• Two-point or Four-point hip beltTwo-point or Four-point hip belt
depending on the individualdepending on the individual

29. Options for Thrusting
Leg harness- Prevents hip
extension by holding the
femurs into the seat
Top strap attaches to back
post at 90º, slightly below
ASIS
Bottom strap passes under
the thigh and attaches to
seat rail
Contra-indications: Pelvic
fractures, open wounds in
the groin area/upper thigh,
unstable hip joint

30. Lower Body Ideal Posture
 Feet flat on footplate inFeet flat on footplate in
neutral positionneutral position
 Ankles 90 ºAnkles 90 º
 Knees 105 º & neutralKnees 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

31. Lower Extremity Conditions
• Extension/Flexion PatternsExtension/Flexion Patterns
• Leg Length DiscrepanciesLeg Length Discrepancies
• AmputeesAmputees
• Contractures/DeformitiesContractures/Deformities

32. Extension Pattern/Reflex
• Hips extend & adduct
• Knees extend
• Ankles plantar flex
• Anterior foot positioning required

33. Flexion Pattern/Movement
• Hips flex
• Knees flex
• Ankles dorsiflex
• Posterior foot
positioning required

34. 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

35. Lower Body Positioning
Considerations Cont.,
• Always use a hip belt in conjunction with foot
supports.

36. 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

37. Secondary Support Options:
Adjustable-Angle Footplates
• AccommodatesAccommodates
contractures,contractures,
deformities,deformities,
amputations & legamputations & leg
length discrepancieslength discrepancies
• Individually adjustableIndividually adjustable
in height, depth, widthin height, depth, width
& plantar/dorsiflexion& plantar/dorsiflexion

38. Secondary Support Options:
Fulcrum Series Footplate
• Accommodate fixed
deformities of the foot or
ankle
• Capable of
inversion/eversion,
plantar/dorsiflexion &
depth adjustments

39. Upper Body Ideal Posture
Same spinal curves as erect standing:
lumbar lordosis
minimal thoracic kyphosis
minimal cervical lordosis
Trunk symmetry
Neutral alignment: head balanced overNeutral alignment: head balanced over
spine, spine balanced over pelvisspine, spine balanced over pelvis
Shoulders slightly posterior to pelvisShoulders slightly posterior to pelvis
Head in neutral position with eyes (gaze)Head in neutral position with eyes (gaze)
forwardforward

40. Causes of an Asymmetrical Trunk
• Wheelchair considerations:Wheelchair considerations:
Back support too lowBack support too low
Wheelchair too wideWheelchair too wide
• Physical conditions:Physical conditions:
Postural weakness/Low TonePostural weakness/Low Tone
Hypertonicity of certain muscle groupsHypertonicity of certain muscle groups
Extensor patternExtensor pattern
Fixed postural deformities- Kyphosis/ScoliosisFixed postural deformities- Kyphosis/Scoliosis

41. 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

42. Secondary Support Options:
Standard ‘H’ Style Harness
• Provides shoulder retraction
Rear-Pull:
• Caregiver operated
Front pull:
• User operated
• Dynamic kit available- 3 strengths,
promotes respiration & limited
movement

43. Secondary Support Options:
Trimline Harness
• Provides shoulder retraction
• Crossover & backpack styles
• Comfortable choice for women
Front-Pull:
• User operated
• Dynamic kit available- 3 strengths,
promotes respiration & limited
movement
Rear-Pull:
• Caregiver operated

44. Dynamic Straps
• Allow the user to lean forward 3Allow the user to lean forward 3” to” to
4”4”
• Allows for easier breathingAllows for easier breathing
• Increased arm movementIncreased arm movement
• Acts as aActs as a “shock absorber” to“shock absorber” to
enhance comfortenhance comfort
• Available in 3 strengthsAvailable in 3 strengths

45. Secondary Support Options:
Chest Strap
• Allows more upper torso movement andAllows more upper torso movement and
provides little shoulder supportprovides little shoulder support
• Velcro™ fastening & D- ring design for limited
hand functioning

46. BP Proprietary Features
• Webbing
• Foam and Pad Shape
• Durability and Maintenance
• Comfort

47. Summary
• The positioning team
• Anatomical terms
• Pelvic positioning
• Lower body positioning
• Upper body positioning
• Questions

48. References
Albert 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 Symposium
Sheila Buck. Back to Basics and Beyond #3. Therapy Now, 2001.
Seventeenth International Seating Symposium. Seating & Mobility for
People with Disabilities, 2001.