EL MANEJO DE CONFLICTO EN LA PAREJA

Collapsible and lightweight manual wheelchairs can be used outdoors for mobility.

Wheelchairs

Encourage wheeled mobility in all children who have poor potential for walking. Strollers and wheelchairs are options for wheeled mobility. Use strollers, wheelchairs which tilt backwards, or wheelchairs with reclining backs in children who are totally dependent and do have any potential for independent mobility. They provide caregiver relief in transport and ease of care.

A wheelchair is a mobility as well as a seating device (positioning device) in children with severe motor dysfunction, poor sitting balance and no functional ambulation [B]. Independent mobility can be achieved with manual or power wheelchairs in children who have adequate cognitive and motor function. Independent wheeled mobility allows the child to explore his surroundings, contributes to his mental improvement, socialization and self esteem.

Prefer motorized wheelchairs in severely involved children who have upper extremity dysfunction [C]. Motorized wheelchairs have a great positive impact on the life of the severely impaired child and his family. Consider prescribing them as early as four-five years of age and enable the child to move around independently to explore his surroundings and to take part in family life without spending too much energy.

Some severely involved spastic and athetoid children spend excessive energy while trying to walk with walkers and crutches. Motorized wheelchairs preserve energy and improve the level of social and educational function. Even though there is an argument that early use of the motorized wheelchair causes laziness and decreases cardiovascular capacity it is obvious that the beneficial effects of early independent mobilization with less energy expenditure far outweigh the risks.

Choose an age-appropriate mobilization device and teach the child how to use it [D].

Wheelchair use in terms of function

Independent Independent in sitting and rising from a wheelchair.

Manual or power wheelchair

Needs help in transfers

Somebody is necessary to help to sit in and rise from a wheelchair.

Manual or power wheelchair

Dependent The child is carried when sitting in and standing up from a wheelchair.

Strollers, wheelchairs which tilt backwards, or wheelchairs with reclining backs Children with spastic diplegia have problems with posterior balance and tend to fall back- wards. In this case, prescribe a walker. The child who walks very slowly in high guard posi- tion and falls backwards after a few steps ben- efi ts from a reverse walker as an aid to improve his balance.

Most total body involved children prefer to use power wheelchairs because involve- ment of the upper extremities makes them unable to use manual wheelchairs.

A

A

C

C

D

D

B

B

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Mobility Aids & Assistive Devices

Hip and spine alignment depend upon the pelvis which should be horizontal in the wheelchair. Seating systems aim to keep the pelvis this way. Add neck and arm rests, knee pads, foot sup- ports and adductor pillows if necessary.

If the wheelchair is too deep, the spastic hamstrings pull and the patient slides out of the chair. This will create the false impres- sion that the chair is too small for the patient. Always check to see whether the pelvis is properly aligned in the chair.

Factors in wheelchair prescription Foot rests Long enough for the shoe to fit inside

Hold the feet in neutral position Able to swing out of the way

Velcro bands for restraint if feet control is poor Seating Height: feet placed firmly against the foot rests

ankle in neutral, hips & knees in 90o flexion Depth: support both thighs

not compress the poplitea

Width: wide enough to relieve the trochanter prevent the pelvis from slipping sideways

Firmness: to limit of tolerability for maximum stability prevent pressure sores over the bony prominences Back Height: the middle of the scapula

Width: accommodate the trunk Supportive peds inside Semirigid to prevent kyphosis

Custom molded body braces for scoliosis Reclining

Portability Light to fit inside an automobile

Propulsion Sufficient upper extremity function: self propelled dysfunctional upper extremity: caregiver propelled

The wheelchair must be very comfortable. The back of the chair should have a slight inclination of 110o to the ground in children with poor trunk control. This position also prevents excessive stress on the spastic hamstring muscles.

There are many factors to consider when prescribing a wheelchair [A]. Always make sure that the chair is comfortable for the child. Do not use the wheelchair to stretch the spastic muscles, because this will be too uncomfortable for the child [B,C].

Seating systems

Seating systems provide support and stability, prevent postural deformity and enable the use of upper extremity in the severely impaired child without trunk control. Seating devices have various components. They can be made both for the back and for the seat. They are either linear, contoured or custom-molded [D].

Linear systems

Basic material for linear systems consists of wood for the base, foam for comfort and pressure relief and a cover. They can also have abductor or adductor supports at the sides. Linear systems compensate for the child’s growth and accommodate to the size. They are not comfortable and insufficient to relieve pressure over the bony prominences.

Contoured systems

Contoured systems are better aligned to the body. They do not accommodate to growth so one must renew the system frequently if the child is growing fast. This increases the cost of treatment [E].

Custom-molded systems

Custom-molded seating systems provide the most trunk support. They enable sitting in children who have complex deformities. They are expensive, need to be replaced as the child grows, and limit the child’s movements in the seating device.

Seating systems

Linear Contoured Custom-molded

Trunk support Good Better Best Comfort Good Better Best Accommodate

to size

Yes No No

Expense Less More Most

A

A

E

E

C

C

D

D

B

B