Page 12 - Mobility Management, January 2019

Pediatric Series
The GMFCS Level V Child
hours as they are likely to spend in a wheelchair daily. “Contractures and range of motion are also of concern due to
the lack of physical activity in their limbs.”
“Level V,” said Josh Tucker, National Sales Manager at Leggero,
“means that their level of movement is extremely low — if any. Therefore, repositioning oneself is not possible. This could lead to skin breakdown (decubitus ulcers). The lack of muscle use leads to atrophy and in some cases, contractures. This is where tilt is beneficial. We can take pressure off of the ischials and redistribute. So yes, skin break- down is a common concern. If the child is unable to communicate to you that they are not comfortable, it is up the caregiver to make sure they are being positioned properly and alleviating pressure.”
Functional Objectives
Even for a child who is unable to consistently and intentionally move, Tucker added that optimizing function must still be an important goal.
“Function is primary,” he said. “We want the child to be engaged, and life to be easy as possible for Mom/Dad/caregiver. Having a properly functioning chair and seating can have an effect on a number of activities and recreation for the child and family, making it easier for a care worker to feed a youngster, to improve the child’s field of vision, and to increase comfort.”
Proper positioning, Malmberg noted, impacts more than just skin and soft tissue health.
“The goal is always to allow or accommodate for a functional position,” he said. “You focus on core/trunk stability first, and then try to achieve a level visual plane and as upright positioning as possible to allow them to interact with their environment. Communication, eye contact, respiratory function, digestion — all are achieved better in an upright position.”
“I firmly believe sitting and positioning are key,” Tucker said. “Their ability to maintain anti-gravity head and trunk postures and arm/leg control is extremely limited. Having appropriate positioning and seating can have a positive impact on the pulmo- nary function of children with cerebral palsy, with implications for capacity for speech and overall lung health.”
Tucker also wants to optimize opportunities for the child to interact with his or her environment.
“We want the child to feel engaged,” he said, “so maintaining eye contact is always important. At Level V, sensory disorders, cognition, communication are all affected. Upright seat positioning or forward inclined, anterior pelvic positioning shifts the center of gravity forward. That will decrease posterior pelvic rotation for a more upright and stable sitting posture. Meanwhile, a posterior or reclined position may reduce pressure on the ischials, and reduce activity of hyperactive muscles. There have been a few studies that show a straddled or saddle-seat posture (with hips abducted and externally rotated) may improve postural control.”
And there can be other benefits as well.
“When children are level with their peers,” Tucker noted, “social, emotional and psychological development is enhanced.”
The Importance of Positioning Options
As with any wheelchair user, however, optimal positioning must include the opportunity to change position frequently.
Asked about the importance of building in tilt and recline for the Level V child, Malmberg said, “In my opinion and experi- ence, they are essential. When trying to justify these two options, I would always point out that even in our vehicles, office chairs, and chairs at home, we all have these features because our body requires repositioning, weight shifting, etc. No one would ever
The GMFCS in Detail
The Gross Motor Function Classification System (GMFCS) was created in 1997 by Robert Palisano, Peter Rosenbaum, Stephen Walter, Dianne Russell, Ellen Wood and Barbara Galuppi of the CanChild Centre for Childhood Disability Research, McMaster University in Hamilton, Ontario, Canada.
In 2007, Palisano, Rosenbaum, Doreen Bartlett and Michael Livingston released an expanded and revised version that included information on older children ages 12 to 18.
The GMFCS describes mobility-related abilities for children under the age of 2 years; from age 2 to age 4; from age 4
to age 6; from age 6 to age 12; and from age 12 to age 18. Those abilities are grouped into five levels, with Level I in each age category describing the most
complex, functional activities, and Level V describing the most basic activities.
The activities change to remain
age appropriate as the child ages. For example, a child with a Level I score before the age of 2 is capable of sitting on the floor with both hands free to manipulate objects. Expected activities for a child with a Level I score at the age of 8 include getting into and out of a chair without needing hand support, and moving
from the floor to a chair without needing objects for support.
The GMFCS also includes information on how to determine the most accurate score for a child. For example, instructions recommend paying attention to and most heavily weighing a child’s typical abilities —
actions the child most commonly performs — rather than focusing on a more complex “best” physical achievement that the child can only rarely accomplish.
For more information on the GMFCS E&R (expanded and revised), go to https:// tinyurl.com/gmfcspdf. m
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