Rehabilitation Therapist Role Updated 6/13/2018 Explain that this section was developed by occupational therapists to illustrate the evaluation process and solutions to common positioning challenges related to transportation. Therapists play an integral role in the CPS process when recommending restraints for children with special health care needs. Depending on the facilities, physical therapists might be responsible for evaluations instead of occupational therapists. To give participants a better idea of the role of the rehab therapist in terms of transportation evaluations, instructors were mailed a DVD showing three OT case studies in the summer of 2014. Instructors may show one or all of these videos to supplement this section, or in place of family visits if families are not available to visit the class.

Rehabilitation Therapist Role Includes physical and occupational therapists Assess a child’s physical capabilities and determine ways to improve a child’s interaction with their environment Essential members of a child’s medical team Often work with children who have involved positioning needs 4/6/2019

Rehabilitation Therapist Role Can offer individualized positioning guidelines if questions arise regarding how to position a child in a child safety seat Most are not CPSTs but important to involve them when working with children with complex positioning needs Encourage participants to build relationships with rehabilitation therapists in their local hospitals/communities. A rehab therapist trained to evaluate positioning needs is usually a physical or occupational therapist. In some facilities, recreational therapists or child life specialists may be responsible for conducting the evaluations. 4/6/2019

Rehabilitation Therapist Role Primary goal of CPST rehab therapist is to provide family centered care to enhance participation in every day activities by providing safe transportation options Can be achieved through the use of conventional or specialized restraints A rehabilitation (Rehab) therapist can be a physical therapist (PT), occupational therapist (OT), and possibly a recreational therapist. Rehab therapists who are trained as CPST’s can play an important role in facilitating appropriate transportation options for children with disabilities. Because they can play an integral role in special needs car seat programs, a brief overview of their role in addressing positioning challenges is included in this course. 4/6/2019

Rehabilitation Therapist Role Client and family interview Positioning assessment and intervention Recommendations Order equipment Deliver equipment These are the steps involved in the transportation evaluation process. 4/6/2019

Client / Family Interview Occupational therapist interviewing family 4/6/2019

Client/Family Interview The interview documents: Diagnosis Weight, height and age Positioning assessment Number and position of passengers in vehicle Current child restraint system Type and year of vehicle Installation information Equipment recommended The occupational therapy evaluation form is an example of how to document the evaluation for a child restraint. The form organizes the information gathering process for parent interview and positioning the child in the appropriate restraint. Review the details of the form, “Occupational Therapy Child Safety Seat Evaluation and Delivery Checklist” (included in participant binder for class). Explain that this form is used to conduct occupational therapy car seat evaluations at Riley Hospital for Children at Indiana University Health. Highlight areas for participants to take special note of since this is a form they have never used before. Interview form developed by occupational therapists at Riley Hospital for Children 4/6/2019

Positioning Assessment High muscle tone Muscles are contracting more than normal and muscles are very tight Low muscle tone Muscles are contracting less than normal and may feel very loose There are positioning techniques that can be used in both conventional and adaptive car seats. If a child demonstrates significant positioning needs, an adaptive car seat may be beneficial, as these offer positioning accessories to help inhibit or facilitate tone, depending on the child’s specific needs. 4/6/2019

Positioning Assessment: Head Control Decreased head control Head can fall forward, to the side, or back In these pictures the Occupational Therapist is assessing the child’s head control. The first picture demonstrates a technique used to assess whether the child can maintain their head in alignment with their trunk when pulled to sit against gravity. The second picture demonstrates a child with severe neck extension who postures in this position. 4/6/2019

Intervention: Decreased Head Control Head pads Soft cervical collar or towel rolls Choose a seat that offers head support system This is the same child that we saw in the previous slide who was posturing into neck extension. With the added support of the Traveller plus head rest or a soft cervical neck collar he can be positioned in a functional manner. 4/6/2019

Positioning Assessment: Trunk Control Decreased trunk control Rounded back Falls side to side In this slide the Occupational Therapist is assessing the child’s sitting balance and trunk control by positioning him at the edge of the mat to determine how much/little support he requires. 4/6/2019

Intervention: Decreased Trunk Control Towel rolls on both sides or one side of trunk Consider adaptive car seat with positioning pads Seven and a half year old who weighs 45 pounds with spastic quadriplegia cerebral palsy positioned in the Britax Traveller Plus with additional towel rolls for added trunk support. 4/6/2019 Source: Automotive Safety Program

Positioning Assessment / Intervention Muscle tone in lower extremities Legs can scissor, or cross Foam abductor or towel roll between legs This slide demonstrates the benefits of a pommel for children with adductor tone, and tend to ‘scissor’ their legs. The pommel also helps keep the child’s pelvis properly positioned. Can use a towel roll if abductor not available (for example, on conventional seat). 4/6/2019

Positioning Assessment / Intervention Muscle tone in lower extremities Legs can abduct (far apart) Towel rolls on side of hips This slide demonstrates extremely abducted lower extremities. If necessary you may use rolled towels to maintain the child’s legs within the shell of the car seat. 4/6/2019

Positioning Assessment/Intervention Scoliosis Harness may be looser on one side May be an empty space behind child More padding on one side compared to the other for optimal support Choose a seat that offers options e.g. Roosevelt scoliosis harness Scoliosis harness discussed in Previous chapter on Specialized Restraints and their features. Adjusts at hips to accommodate for asymmetry 4/6/2019

Positioning Assessment/Intervention Anterior/posterior pelvic tilt Towel rolls under knees to help keep pelvis positioned back in seat Place child in seat in an already flexed position to inhibit tone Hip flexion helps to inhibit flexor tone, so placing a child in this position before placing into a CSS will increase one’s ability to buckle/position the child well. 4/6/2019

Recommendations Trial various medical seats Meets child’s needs Meets family’s needs Occupational therapist trying 6 year old child with Leschnyhan syndrome in adaptive booster seats (Monza and Carrot 3). 4/6/2019

Recommendations Take measurements Head circumference Chest circumference Seated waist circumference Shoulder to hip height (seated torso height) Leg length (seat depth) Shoulder width For programs that do not have access to a variety of trial seats accurate measurements of the child should be taken to ensure proper fit in adaptive seat before ordering. 4/6/2019

Ordering Equipment Determine is child restraint will fit in car with other passengers Order equipment Obtain prescription form (prior to appointment) Write letter of medical necessity Agree upon vendor/supplier with family input Vendor receives funding approval and orders child restraint system Example of a family that transports three children, all in car seats, on one vehicle bench seat. Key point-determine if the restraint will fit/install into the vehicle before ordering. When ordering equipment, it is important to know which accessories come standard with the CSS, and which require to be added on to order form. Most vendors and suppliers and not CPSTs. Ask participants about Medicaid restrictions in their state; know how it works in your state in terms of approval for large medical CSS (some states will only approve one or a few types of CSS; others won’t approve any). 4/6/2019

Delivering Equipment Fit and deliver restraint system Install child restraint in family vehicle May need to arrange for heavy duty tether installation Family return demonstrate installation Mechanics trained in vehicle modifications installing the heavy duty tether anchors of the Columbia 2500 into the vehicle floor board. Encourage participants to research and build relationships with local mobility companies specializing in vehicle modification in their area. The mobility company should be contacted to determine their experience with installing heavy duty tether anchors before clients are sent to them. If a mobility company does not have experience, education and resources such as The LATCH Manual can facilitate the process. Mobility specialists installing heavy duty tether anchors 4/6/2019