Transportation It is important to consider folding frame wheelchairs if the family vehicle is not accessible. Even if the frame does not fold side to side, many pediatric rigid frames have removable rear wheels and a back that folds down for transport. Many pediatric mobility bases are crash-tested and offer tie-down attachment points on the frame. This is important for transportation. However, the safest place for a child who weighs less than 40 pounds is a car seat. For a child who weighs more than 40 pounds, many adaptive car seats are available, or the child may ride in the mobility base within a vehicle. Even if the family does not have an accessible vehicle at this point, the child may be riding an accessible school bus. The wheelchair seating system is not designed to adequately protect the child during transport. Approved transit systems not only secure the mobility base to the vehicle but also include a strap that crosses in front of the child (Figure 68; Buning, 2018). Ideally, a posterior head support should be used if a client is seated in the wheelchair during transport. Bariatric seating Our society has seen an increase in obesity in the general population. This trend has led to an increased need for wheelchair seating, referred to as bariatric seating, for persons who are obese. Certain considerations, such as size and comfort, must be taken into account for bariatric seating. Goals of bariatric seating The goals of bariatric seating are much different from those of other populations. Many clients who are morbidly obese require wheelchair seating because ambulation has become limited. The client may not require postural support or stability but rather a seating surface in the mobility device. The goal is no longer to position the pelvis in neutral because excessive soft tissue limits the ability to control the position of the pelvis and spine. The goals are to provide adequate pressure distribution and relief, heat and moisture control, and comfort (Tanguay, 2018). Pressure, heat, and moisture It might seem that excessive soft tissue would limit pressure risk, as bony prominences are well protected. However, when the adipose layer increases significantly, skin and tissue integrity decrease, increasing pressure injury risk (Tanguay, 2018). Hygiene becomes more difficult, particularly in skin folds. Heat and moisture are also a problem with excessive weight and skin folds. If skin breakdown occurs, healing is affected by this change in tissue integrity (Tanguay, 2018). The seating surfaces must distribute pressure well and dissipate heat and moisture. Pressure relief is critical, either through power seating or changing position (e.g., standing, if possible). Adequate hygiene is essential. Comfort Because clients who are morbidly obese are often quite uncomfortable, provision of seating that improves comfort is important. Comfort is not always considered medically necessary by funding sources; however, discomfort leads to poor sitting tolerance. If the client cannot sit in the seating system for a reasonable amount of time – for example, 4 to 6 hours – then sitting tolerance is decreased, and the seating system may need to be modified or replaced. Seating interventions Bariatric seating interventions must address the clinical considerations of this population. Issues other than simple weight capacity must be addressed, such as durability, flexibility for change, and the client’s ability for self-propulsion. Weight and durability requirements Seating interventions must meet weight limit and durability requirements. The seating system itself will have a weight limit. The mobility base and any power seating may also each have
Figure 68: Transit System, Including a Lap and Chest Strap
Note . From “Securing Your Convaid,” by Convaid, n.d.b, retrieved from http://www.convaid.com/securing-lightweight-folding- wheelchairs-i-22-l-en.html. © Convaid. Reprinted with permission.
Specific seating challenges The bariatric population presents specific seating challenges. Body dimensions seen among these patients can pose special problems in the measure and design of a seating system. For example, if much of the client’s weight is at the buttocks area, the distance between the posterior buttocks and posterior trunk may be considerable. A back may need to be mounted above the buttocks with hardware that allows contact with the posterior trunk. A privacy flap may then be added to the base of the back to cover the buttock area. If the client carries much of his or her weight at the stomach area, a pannus may be present. A pannus is excessive tissue that may hang below the groin and between the legs, originating from the abdominal area (Tanguay, 2018). This pannus may need to be supported so that the legs are not forced into hip abduction or to support the weight of this tissue. Obesity can lead to lymphedema, cellulitis, or lipoma, particularly in the lower extremities. The shape of this tissue makes it difficult to measure seat depth, seat width, back support, and lower leg position (Figure 69). Figure 69: Lower Extremity Lymphedema Reduces Available Seat Depth
Note . From Broda, n.d., retrieved from http://www.brodaseating.com. Reprinted with permission.
a weight limit. All of this must be considered as a whole. If the client is very close to a weight limit, it may be prudent to move to the next category of equipment so that the client does not exceed those limits if further weight is gained. Seating and mobility equipment designed for higher weight limits tends to be very durable and heavy. This equipment may be more difficult to transport and, with the client in the mobility base, difficult for a caregiver to push.
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