Disclaimer: For the purposes of this case study, the child will be referred to as Hazel, to protect her identity. The child featured in the image above is not the individual referenced in this case study and is used for illustrative purposes only.

Case Study

A Therapist’s Approach to Selecting a Child’s First Wheelchair

Nearly every child uses a buggy, but not every child then moves in to a wheelchair. As a therapist working in Child Development, I have the pleasure of being a part of children and families’ journeys and going through the many stages of grief, acceptance, development, excitement and change.

Collaborating on their first wheelchair is a milestone moment for many families and children, and to me, feels like such a special moment of connection between a therapist and family as you work to identify what this will look like and the changes that will come along with this.

Deciding what wheelchair or equipment solution will suit the child and family requires multifactorial considerations. In my experience, this is very different in every case, both from the assessment process, to the final equipment outcome. This case study shows the breakdown of the final mobility solution for this bubbly, curious 5-year-old.

Initial requirements identified (using Te Whare Tapa Wha Model – Mason Durie), summarised:

The capacity for physical growth and development

• Hazel’s recent hip x-rays showed bilateral progressive hip dysplasia.
• Due to low tone in her core, Hazel was often sitting in posterior pelvic tilt in a kyphotic posture (correctable).
• Hazel is able to sit independently unsupported but requires a large base of support for optimal hand function and ability to reach, dance and play.
• Hazel is using a walker for around 1-2 hours during the day.
• Seizures can cause changes to physical ability.
• Hazel is working on grasp strength and precision with fine and gross motor skills.
• She has a hypermobile and hypotonic profile.
• Hazel is an active mover and seeks sensory input through vestibular and proprioceptive system.

This determines us as individuals and as a collective, who and what we are, where we have come from and where we are going.

• Hazel communicates through touch, facial expressions and eye contact. Being able to come close to others and her environment is very important for communication and connection.
• Important roles include being a learner, a play partner, a friend, a daughter, an explorer.
• Spending time outdoors in the garden and connecting with nature is important to Hazel.
• Hazel enjoys being independent and having opportunities for independent mobility.
• Transiting from a buggy and relying on others for mobility and access to objects.
• Allowing time and ability to move at her own pace.

The capacity to belong, to care and to share where individuals are part of wider social systems.

• Hazel is affectionate and loves cuddles, kisses and being close.
• Family make-up was considered – she has 2 parents as day-to-day carers.
• Community connections involve walking, accessing public transport, visiting exhibitions, horse riding, swimming and going to the park.
• Connection and relationship to the therapist and team working on equipment provision. Importance of a solid rapport for trust, acceptance and understanding.

The capacity to communicate, to think and to feel mind and body are inseparable. This is about how we see ourselves in this universe, and the perception that others have of us.

• Hazel feeling safe and secure in her equipment.
• Positive emotional reaction to new equipment and allowing a transition process for acceptance of new equipment.
• Sense of ownership and pride in the equipment – that it expresses personality, likes and can become an extension of self and a way of expressing and self-identity.
• Hazel can become overwhelmed with new experiences so ensuring the positive experience and introduction of the equipment.

• Places of belonging include in the home, at school, at horse riding, extended family homes.
• Connecting with the family pet.
• Hazel’s school is wheelchair accessible in all areas (indoor and outdoor).
• Hazel’s home environment is accessible – a ramp was built as part of modifications, with a rubber wedge to bridge the step up to the front door.
• The back yard has no ramp access (3 steps) – this is a barrier to accessing the back yard freely.
• Ability to transport the equipment – current family vehicle would require the chair to fold.

Wheelchair Base

Zippie X’Cape Children’s Wheelchair

This wheelchair was selected for a variety of reasons, some of them being:

• Built-in growth. This chair has 2” width growth and 3” depth growth built in. This is important to me as a therapist for many reasons, the obvious being cost effectiveness of the equipment, and time management of not needing to order new equipment when the child outgrows the initial set up. But more importantly, allowing the child to stay with their chair for a good amount of time, reducing the amount of change to deal with and allowing a connection with their chair.
• The X lock cross brace technology. This allows the folding frame to become similar to a ridged frame from a performance perspective. I like the sturdy and durable nature of this, while allowing the chair to fold for different life activities.
• The light weight yet sturdy, durable nature of this chair. Light weight for lifting in and out of the car, pushing the child up and down hills and allowing the option for Hazel to learn to self-propel.
• The chair is completely configurable, which allowed me to adjust the tipping point and centre of gravity of the chair to get a perfect balance for Hazel to be able to self-transfer in safely, start working on some self-propelling, feel stable and secure while adjusting to the wheelchair (vestibular stimulation can be much different between a buggy and wheelchair).
• Foot plates on this chair allow for lots of adjustments. For Hazel, sitting at 90 degrees was not a preferred or comfortable position, and she sat with her legs at approximately 70 degrees, and had a pattern of movement to kick her legs forward and cross her feet at the front. The footplate adjustment allowed for this accommodation, without changing leg hangers to 70 degree hangers. The position achieved could be tailored just right for Hazel to avoid feet slipping behind the foot plates, or hanging off the front unsupported, pulling Hazel into more posterior pelvic tilt.

Cushion

Spex Classic High-Contour adjustable cushion, 15″ wide x 14″ deep, with contouring cell system for pelvis, hip and leg positioning.

Hazel is able to move and reposition herself in her cushion, although needs contouring to prompt her pelvis and hips to sit in a symmetrical position. Due to hip dysplasia, it was important to keep Hazel in some abduction, hence the need for the medial thigh support contouring on the Spex high contour cushion. Although, it was also important to consider that Hazel is doing standing transfers and needs to be able to clear the medial thigh support contouring to get into the seat. The high contour Spex cushion allowed for the right height to meet both these needs.  The customisable Spex inserts also allowed lateral contour to provide pelvic stability and reduce posterior pelvic tilt.

See image below for alignment of hips and lower limbs due to cushion positioning. Hazel was previously sitting in adduction and posterior pelvic tilt with a slight correctable pelvic rotation.

Back Support

Zygo Active Mid Back Support 14” Wide x 16” High

An active, yet supportive back support was chosen. As this is Hazel’s first wheelchair, self-propelling is a new concept and something that is being explored for independent mobility for Hazel. While her chair will mostly be used for attendant propelled, keeping an efficient position for self-propelling was something I wanted to achieve. This back support provided lateral trunk support as a prompt for Hazel to self-correct, without adding the bulk and weight of separate lateral trunk supports.

Head Support and Accessories

• Spex Circle 150 Head Support pad with Stylo 130 Mechanism
• Spex Centrepoint shoulder harness, size small with comfortable, waterproof pads
• Spex 2-Point Padded Hip Belt, Centre Pull with Centre Release buckle, size small
• Tray Top Clear Polycarbonate – size medium, with cutout
• Spoke guards
• Stroller height adjustable handles

Accessories on this chair allowed Hazel to customise the chair to reflect her personality and make this an extension of herself, instead of a stock standard wheelchair. Hazel could pick the colour of the frame and cross bar, as well as the design on the spoke guards. It also comes with light-up castors to make this a real children’s chair.

Overall, the Zippie X’Cape wheelchair met the needs of the child, family and community, while also providing the necessary postural and functional considerations that myself as an occupational therapist holds important. It also is an attractive option for funding bodies due to its large ability to grow and be modified as needs change. I found this chair to be a sturdy, yet flexible option and from a therapist point of view, I love the functionality of this chair, allowing children to access all environments.