1. Equipment Prescription for Pediatric Mobility This series will empower you to:

2. Objectives Explain what is the same and what is different about pediatric seating and mobility Set pediatric mobility goals and choose the best equipment to achieve them Overcome "Phony Prerequisites" and otherwise justify use of specialized equipment to families and third party payors  (OK, maybe 70% of the time anyway) Troubleshoot problems with equipment  (As long as it is brought in to clinic or you at least have a photo)

3. So What's the Difference? (What are you going to tell us that Dr. Smelz didn't, big shot pediatric person, huh?)

4. Growth and Development  Adults - Focus on Function  Children Also Grow and Develop Size concerns Orthopedic concerns Developmental milestones  Age appropriate expectations  Equipment helps recreate or simulate usual sequence

5. Growth adjustability and replacement  Orthotics every 6 months  Wheelchair-Equivalent every 3 years  Less well defined for other items

6. Correct Sizing  Seat depth and slump  Seat width and reaching wheels, using trunk supports and/or hip guides  Footrest length, distal thigh support  Back height and chest harness

7. Troubleshooting 101  "Start at the pelvis“  Seat to back angles  Pelvic tilt  Pelvic obliquity  90 recline tilt reverse

8. Orthopedic Issues  Bad seating aggravates  But - “You can’t do orthopedic surgery with a wheelchair!” - - Dr. Richard McCarthy

9. Custom Molded Seating WARNING – WARNING – “HISTORICAL PERSPECTIVE” ALERT!!

10. Limit use appropriately  Asymmetrical fixed deformity AND poor postural control  Possibly in movement disorder for extra stability  Pressure relief vs. stability can be an issue

11. The Roseanne Rosannadanna Syndrome (-or- Welcome to Trade Off City)  some chairs don't fold  some chairs don't fold easily  no tilt chairs good for pushing (will a fixed tilt or more trunk support do?)  power chairs break down more often  adaptive car seats comfy, supportive but take up half the back seat! and weigh a ton!  Sliders and Easy Stand Magician are great but you can't make it up on volume if you're LOSING money (Why "Allowable" is a four-letter word.)

12. More examples LIbre tilt – “yeah sure, it folds!” above Nexus Roho-Jay hybrid cushion right It “counts” as a wheelchair…

13. About powered mobility  Minimum Age = About 18 months Medicaid won’t get any chairs until age 2 anyways  Hooray for parent support groups!  Perfect vision, DL not required  Some need training  Some don’t!

14. DEVELOPMENT – Milestones  Sit 6 months*  Floor mobility shortly thereafter (varies)* *DDS may fund, may need loan closet, school help  Stand 10-12 months  Walk 10-14 months  Drive 15-16 years  Drive parents crazy 2 years and again at 13 years  Get own health insurance 26 years

15. GOALS Functional and Developmental  Independent Sitting  Crawling and Creeping getting into stuff and making the grownups childproof the house  Supported Sitting enable UE function  Independent walking  Assisted walking  Exercise walking  Weightbearing - static vs dynamic  Total lift versus weightbearing transfers  Driving supporting the auto insurance and body shop industries  Being safe while driving or being driven staying off the inpatient unit

16. How to Help - Sitting  Corner Chair  Floor Sitter  Bumbo Seat – less support  http://www.brighthub.com/education/early-childhood/reviews/36686.aspx  Tumbleform feeder seat – more support  Wedge – head/trunk control

17. How to Help – Early Mobility  Crawlabout, Crawligator, Prone scooter  Caster cart, big wheels up front 1 st chairs

18. How to Help - Standing  Prone, upright, supine  Research lacking vs “ballistic” weightbearing  No “bad girl, go stand in the corner!” syndrome

19. More standers

20. Mobile Standers  Parapodium  Swivel Walker Bridge to Parawalker?  Batmobile (“Dynamic Stander”)  Standing chimney with orthotics

21. Walking  Walkers  Forward or reverse  Walker add-ons Weighted Arm supports, troughs, “prompts” Pelvic stabilizer Abductor bar  Gait Trainers  Treadmill/weight relief systems  Crutches, canes, hemiwalkers age/coordination issues

22. Can’t hold on? So what?

24. Baby walker style  Sit-slump-kick syndrome  Delays normal walking ~ 1 mo  Injury risks for typical age use

25. Lite Gait  Not generally suited for home use  Pool therapy alternative

26. Transfer Aids - How To Avoid the Ashley Treatment  Passive or max assist transfers may be necessary (try to avoid if possible) MDA, quadriplegia 2 SCI, low cognitive function

27. Bath options  Full support shower chairs  Roll-in shower  Bath bench with hand held shower Specify back support, padding if needed

28. Access and safety on the road Forward facing essential Secure to frame of chair OUT of chair would be better!

29. What's a Waiver and what can we get on it?  Still medical model, you will be asked for prescriptions  But medical profession less in control  Focus on staying out of institution  Less tainted with the idea that it must be undesirable for use in the absence of disability  Capped amount of funding per year  Regular Medicaid must reject  Aka Katie Beckett – most states under DDS

30. Waiver Haiku (yes, this lecture could have been far,far worse…)  Still no van or lift  Though we're off the waiting list...  Bad case manager?  On waiver whole year  But still giving daily bed baths...  Needed the ramp first!