Adapted Seating Interventions for Children with Medical Complexity

As school-based therapists, we are often asked to provide information about opportunities for sitting, standing, and moving (including walking and gross motor engagement). School is a naturally supportive environment for children of all abilities to become more involved. Furthermore, positioning plays an important role in learning. This article focuses on improving the success of children with medical complexity (CMC) in the classroom and beyond. Children with medical complexity are defined as having high health care needs, one or more chronic conditions, and often require medical technology and significant environmental modifications (Cohen, 2011). Typically, children in this category function at Gross motor functioning classification system (GMFCS) level IV or V (CanChild).

Adaptive seating for CMC: a review of the research

While it is difficult to find strong evidence supporting adaptive seating interventions in this population, there are some smaller studies that can help guide our selection of interventions. O’Grady and Dusing (2016) shared a case study of a 22-month-old girl with significant motor impairments and compared her problem-solving behaviors in prone, sitting, and supine positions. They found that when the girl was seated with manual supports, her problem-solving behaviors improved in both frequency and quality relative to other positions. In a small study conducted by da Costa, et al. (2017), trunk support and head control were studied in children with GMFCS levels IV and V. Children with GMFCS level V were found to have better head control with a higher level of trunk support (i.e., in the armpits or mid-ribs). . However, children in GMFCS level IV were found to have better control with a lower level of support (i.e., at the waist or hips). To optimize the child’s motor skills, the authors suggest that the level of support be determined based on the child’s level of trunk segmental control.

Children with medical complexity have different diagnoses, along with different physical and cognitive abilities, making standardized research difficult. Inamdar, et al. (2021) conducted a systematic review examining seating interventions for young children (aged five years or younger) with or at risk for cerebral palsy. Their findings suggest that strong evidence on sitting interventions is lacking and that more research is needed in this area. However, they did find that physical therapy interventions that included adjuncts (such as kinesiotaping) may be beneficial in improving the sitting ability of young children with cerebral palsy. They also suggested that adaptive seating with intensive, child-directed, task-specific interventions could be beneficial. Similarly, Acharya, et al. (2023) conducted a systematic review of adaptive seating and found limited evidence that adaptive seating improved postural control and sitting ability. Although adaptive seating is necessary for children with medical complexity, this finding adds some confusion to our decision-making process and leaves us with challenging decisions in terms of seating strategies for these children. Until we have more studies, we will have to rely on the information currently available, student responses, information from families and educational staff, and, of course, our own clinical judgment.

Positioning ideas for optimal seating results

Adaptive seating kits can be used both in intervention plans and to achieve measurable functional goals to help children and adults with complex medical needs more easily participate in classroom and community activities. Let’s look at various pieces of Rifton equipment and explore how they would be used in the classroom and beyond.

The Rifton Compass chair looks like a standard classroom chair but with curved edges and a defined seat boundary. It is height adjustable and has support arms. This chair allows you to practice sitting and control your head with practical support. For the child with a little more control (i.e. GMFCS level IV), some foam wedges and a seat belt and/or pelvic supports can be added for seated activities with the help of a caregiver as needed. This can be a good way to initiate more movement opportunities for short periods of time. As suggested by daCosta et al., therapists should try to provide a lower level of support to improve head control in children with GMFCS level IV or higher.

If the child needs more support, the Rifton activity chair may be a better option, especially if they spend a lot of time sitting, as many of these children tire easily. This activity chair offers a variety of options to support the positioning of children with increased tone, poor postural control, and reduced endurance. Measure small (and slow) gains in sitting time, sitting balance, degree of upright sitting, and/or decline in postural support to show objective progress over time. Again, considering daCosta’s article, this chair could be a good option for children who are at GMFCS level V. The headrest is removable and you can tilt the chair with the child seated, allowing you to practice controlling the head at various angles. These chairs can be used in a variety of settings, such as in school classrooms or bedrooms in a home. Incorporate functional activities for participation while sitting, such as academics, communication, eating, grooming, art, music, and recreational activities.

Although the Rifton Wave is a bath chair, here are some ideas on how it can be used for children with sitting difficulties. The Wave is more supportive and is best for those students who need to be in a semi-reclined position due to orthopedic, medical, or physical restrictions. When sitting in Rifton Wave, interventions to increase participation may include active movements of the arms, legs, head or trunk and active assisted hygiene tasks. Sometimes, when space or funds are limited, or equipment needs to serve multiple children or multiple purposes, a child can use the Rifton Wave on the floor for morning circle time, classroom assignments on the floor or leisure activities to be at the same level as their peers or siblings. Fabric covers can be added to the chair to improve aesthetics in the classroom. A child in this position could also use a elevated play center/toy bar.

The Rifton Hygiene and Grooming System (HTS) is another great addition to the classroom. In addition to toileting, it can also be used to assist in the practice of functional tasks associated with toileting. Like the Rifton activity chair, this chair offers many accommodations that provide postural support and enhance active participation. When seated in the HTS, an intervention could include participating in a transfer, participating in the toileting process, or participating in self-care/hygiene tasks. Therapists can adjust the tilt of the HTS and supports for the hips, arms and trunk, with interventions to support active movements while providing the optimal support needed for toileting.

With all of these adaptive seating options, it can be helpful to include add-ons like kinesiotaping. Additionally, consideration of both the user’s height and the height of peers is crucial when evaluating participation in classroom and community activities. Can other people interact with the child and does the chair adapt to the activity? Some of the chairs, like the activity chair, can be raised or lowered depending on the height of your companions and the activity you want to focus on.

Another important consideration is the use of adaptive equipment, such as switches, to improve participation. Sometimes the best level of engagement will occur through the incorporation of technology. For example, while some children cannot actively roll a ball, they may be able to use a switch to move a ball or use a switch to signal others to roll it. Including children in these activities is a significant way to improve active movement.

Measure sitting tolerance and create appropriate sitting goals

To measure activity tolerance and provide the best recommendations for sitting time, a variety of pain scales should be used, including the Individualized Numerical Rating Scale (INRS) (Solodiuk and Curley, 2003) and the Face, Legs, Activity, Cry and Consolation (FLACC) scale (Merkel et al., 1997). A copy of these scales should be kept in areas where children/young adults are served, to help staff identify painful behaviors and know when to stop or modify an activity based on these responses. Some children can also use a switch to alert staff and help them change positions.

Children and adolescents with medical complexity can make very small, but highly functional changes, measured with SMART (Specific, Measurable, Attainable, Relevant, Time-bound) or GAS (Goal Achievement Scale) style goals using adaptive equipment. Some of the gains will be at the caregiver’s level of assistance (i.e., the caregiver may be providing less support or assistance). Some ideas for targets using Rifton adaptive seats include:

Examples of SMART goals:

• To participate in their academic program, with maximum transfer and positioning assistance, the student will sit in the Compass chair for five minutes in order to access their communication device.
• To enhance engagement in self-care and receive postural support using the HTS chair, the student will hold their head upright for 15 seconds when brushing their hair, with maximum assistance with the brush.
• To participate in an academic program with classmates, with full postural support from an activity chair with 15° posterior tilt, the student will sit for 60 minutes in music class with peers, without pain behavior as measured by the FLACC.

GAS target example:

We hope this information has been helpful. Our next post will focus on standing activities for children and adults with medical complexity.

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