Pediatric Series

As My Spirit Moves Me!

Dynamic Seating Meets Children Where They Are...Then Goes with Them

News flash: Kids move. They can squirm, stretch, grab, twist, reach, kick, all while seated. They’re supposed to. Child development experts say movement doesn’t just help infants and kids to gain strength; it also helps them to communicate and to learn.

That’s no different for children who use seating & mobility equipment. But due to clinical issues, these children may need specialized technology to support their movement. Perhaps they have low or high muscle tone. Maybe they’re prone to uncontrolled movements or have weaknesses in certain parts of their bodies.

In the past, seating wisdom called for finding a functional posture for these kids and keeping them statically within it — a choice that can cause pain, poor positioning and broken equipment.

Fortunately, clinicians, ATPs and seating & mobility manufacturers are devising new ways to help kids who use wheelchairs to be properly positioned while also having freedom to move. Even better: The different approaches to this matter means kids can be supported in different ways, depending on what works best for them.

Who Can Benefit from Dynamic Seating?

Repetitive, involuntarily movements can be common for children with neurological involvement “where there would be some abnormal tone,” says Vicky Heidler, ATP/SMS, rehab sales evaluator for Miller’s Adaptive Dynamic Seating for ChildrenTechnologies. “Definitely cerebral palsy, and I’ve also used dynamic systems with kids who have Rett Syndrome. It’s not really athetoid, but they tend to be in a constant kind of movement. And you can see a lot of extension there, as well.”

Heidler says that these children can react significantly to stimuli such as their wheelchairs hitting a bump in the pavement.

“It would be a little more prolonged than what would happen typically if you were startled by something,” she says of the movements that can be triggered.

Lee Johnson, sales & education manager of the western U.S. for Quantum Rehab, has experience with the company’s Kids UP dynamic seating & mobility line.

“One of the fascinating parts of dynamic seating is that we have seen beneficial application in both hypertonic and hypotonic presentations,” he says. “In cases where there is the expression of high tone, profound spasticity and repetitive extensor activity, dynamic seating can allow for that movement, without compromising seating & positioning. In hypotonic presentations, a dynamic seating system can provide a safe, controlled framework for the possibility of movement toward the development of core strength and control. Most commonly, cerebral palsy is where we see these ‘symptoms.’”

How Is Dynamic Seating Achieved?

The goals of dynamic seating are often similar for various clients, but successful results can be achieved in different ways.

“Stabilizing seating devices are important,” says Darlene Hawthorne, business development manager for Thomashilfen. “However, seating devices that do not allow freedom of movement can restrict activities to the same degree as too little stability. Children should be able to bend slightly forward. Arms and shoulders should be able to move freely so they can, for example, reach for objects on a table, providing a basis to develop fine motor skills. Children with weak/low tone, too strong or unintentional muscle activity have a great deal of difficulty using their hands purposely. Depending on the child’s challenges, needs and considering their environment and activities, most children would benefit from freedom of movement. Sometimes this is the biggest challenge in selection of a seating system: to create a balance of stability and movement.”

Noting that “no seating device should allow a child to sit for hours without moving,” Hawthorne says Thomashilfen achieves dynamic seating through a Micro-Stimulation (MIS) system, constructed of wing suspensions that move with the child and provide feedback — for every movement the child makes, the MIS system provides counter movement.

She adds, “With Micro-Stimulation systems, children are able to self-correct their posture through the sensory feedback, allowing better awareness of the environment, and [they] can relax more easily.”

Another approach is for the seating system and its parts — such as head positioning and lower-extremity positioning components — to move through space as the child moves, rather than to remain static and resisting when the child pushes on them.

“I’ve used it with kids with a lot of extensor tone for a couple of reasons,” Heidler says of these kinds of dynamic seating systems. “It moves when they extend so when they’re extending, they’re not pushing against something hard. You can see some drop in pain, if that’s an issue.

“The other big reason is people who have that strong extensor tone a lot of times will be very hard on their chairs. You see welds break on frames, and footrests especially will break, so we use dynamic springs or something that when you push on it, it gives a little bit. It releases some of the force that the frame is taking from that pushing.”

“This really comes down to a basic belief that a seating system should partner with the clinical goals of therapists toward addressing the condition, rather than simply being a place where children sit,” Johnson says. “A dynamic seating system brings a substantial advantage to the table because it allows the possibility for that movement, without compromising the vital principles of good seating and positioning. If the child’s condition dictates needing freedom for involuntary movement, dynamic seating can dramatically reduce fatigue and pain, enhancing quality of life.”

In explaining how such systems work, Heidler says, “For those people with extensor tone, when they extend, the [seat] back moves with them and comes back up with them. If you do that in a system where there’s no give, your hips will slowly slide out of the system. You can prove that in your own chair: If you push and come back down, and you push and come back down, your butt scoots out, and you end up rounded at your pelvis. So positioning wise, that’s why we would use [dynamic seating].”

But Heidler adds, “It only helps if the seatbelt is tight enough, too.” Which leads to a third approach to dynamic seating: dynamic postural supports.

“Dynamic systems are important for muscle strength,” says Alexis Basabe Kopca, product manager for Adaptive Engineering Lab. “In the case of pediatrics, muscle growth is critical. Static seating systems, such as molded systems, may fit the client one day, but the client has to sit in it for years. As the client grows, but the seating system remains static, it can restrain movement, possibly causing pressure sores.”

That’s when postural supports can be a helpful intervention.

“Using supports and accessories that help properly position the client, but still allow movement, enhances a dynamic seating system,” Kopca says. “For example, chest supports allow for more movement of the shoulders than a traditional butterfly-style support. Also, belts with a four-way dynamic stretch allow for more movement than rigid non-stretch options. If a four-way dynamic stretch does not provide enough positioning, a belt with a two-way limited stretch is ideal for a controlled flexibility.”

Jill Alm, marketing & education manager for Bodypoint, stresses using postural supports that fit properly and are the right size.

“The challenge is that all manufacturers use different sizing guides and size references,” she says. “So you are challenged with trying to figure out what a small, medium or large really is.”

As an example, she cited a recent case. “We worked with Michelle, an ATP, and her client, Luke, a 9-year-old with spastic quad CP. For Luke, Michelle’s goal was to provide computer access using direct-access switch technology. She was working with his existing positioning system. In particular, she was working with an anterior trunk support that was not providing him the support he needed to control his head movements to access the switch. While it was a dynamic support, the fit was not correct. The support was too large. At his shoulders, Michelle could easily put two or three fingers under the support, and it gapped in front of his body. Due to the mounting system on the support, the fit could not be adjusted tighter. So the support hung on his body, providing inadequate positioning, and was not getting him any closer to reaching his full potential in school.”

Once the seating system was reconfigured and a dynamic shoulder harness was added, “Luke responded well to firm support at his shoulders,” Alm says. “He relaxed, his respiration improved, and he didn’t have to work so hard to hold his head upright.”

As for getting funding for dynamic seating systems and components, Heidler recommends documenting previous equipment that failed, and why.

“If that person is repeatedly breaking things from stress, how is that presenting?” she asks. “What’s the history? I have several individuals who, before we got the dynamic system, were breaking the hangers on their wheelchairs every four to five months.”

She also suggests including information on pain levels, if static systems are causing the child discomfort.

Johnson says seating teams may have to educate funding sources, since dynamic seating is a relatively new intervention.

“Including notes about a trial of a traditional static seating system, and why it is not appropriate for the child, is always a great idea,” he says. “Including information regarding seating tolerance and the severity of tone, including the frequency of extensions, is really important to establishing the justification for dynamic seating. It’s always a good idea to quantify those observations with a number, rather than only adjectives. If during a trial, the child has shown increased ability to engage with one or more activities of daily living while in the dynamic seating system, that is fantastic information to include, as well.

“When dynamic seating operates as a system that takes into account the physics involved in the movement of a child’s body

This article originally appeared in the October 2014 issue of Mobility Management.

In Support of Upper-Extremity Positioning