Provision of wheelchair and seating to client with Downs Syndrome with challenging behaviour

Abstract:

This case study details the difficulties faced by patient who requires a standard wheelchair but due to challenging behaviour requires alterations for his own safety,

The case:

The client has Downs Syndrome* and challenging behaviour. I first met the patient in the Wheelchair Services at the Freeman Hospital when the problems were brought to our attention.The parents, school and other were noticing that the client was unintentionally physically hurting himself on the framework of the chair as he threw his arms and legs about whilst sat in the chair. Safeguarding concerns were being raised by both school staff and his parents, asking questions why the patient was bruised when he came into school or when he came home from school. Fingers were being pointed and suspicion raised, when it fact the bruising was caused by the patient trashing about whilst in the wheelchair. Although the patient couldn't walk he was very mobile within the chair and was causing damage to himself. Mum wanted him safe but not restrained, that led to challenges.

Trying to fully pad a wheelchair and make it look presentable is very difficult. Issues that we had to consider included;

• Padding must be easy to remove from the chair.

• Patient must be able to get in and out of the chair safely with help.

• The wheelchair must be transportable.

• Adding the padding to the chair increase the width of the chair as both inside and outside of chair had to be padded,

• Patient doesn't like to be restrained.

The seating team which consists of an Occupational Therapist, a Regional engineer, myself (Seating Specialist), parents and patient met at the Freeman Hospital in the Wheelchair Services and discussed the issues. The following ideas/solutions were examined;

• To harness patient into the chair. This would consist of a padded lap-belt, (to keep him within position in the chair) a dynamic chest harness, (to prevent forward movement our of the chair) ankle huggers (to fasten his feet down) and padded wrist cuffs ( which would allow a controlled level of movement). None of this was acceptable to mum, other that the padded lap-belt and chest harness.

• To fully pad the inside and outside of every metal component of the wheelchair. This was acceptable with mum however, making something like this is very difficult to make it look presentable.

• Moulded systems but this wouldn't work because he doesn't have postural seating problems.

• Modular systems also wouldn't work because he doesn't have postural seating problems.

Much discussion continued and although there was no obvious answer, there had to be compromise. It was agreed that the most suitable option that would give the patient some movement within the system whilst still protecting him was to fully pad the wheelchair.

With everyone's agreement this was the best way forward. We organised a tilt in space wheelchair which comes as standard with comfort seating and we padded the inside of the armrests and extended the padding over the outside of the metal framework and covered it all in one piece. We fully padded the elevating leg rests on the inside and outside so that when the client kick his legs out over the front of the chair he doesn't hurt himself. We fitted a padded lap-belt and dynamic harness. We extended the back cushion higher up to include a once-piece head rest which was fully padded with no gaps apart from a small gap for easy use of harness. Once again with the help of a very experienced fabric department , the finished product was not just practical but aesthetically pleasing.

Most materials that we chose were for shock absorption rather than pressure relieving properties So, we could cover these in standard foam which is CB50 with a covering of Dartex which is a wipe-able and breathable material and marched in with the standard cushions of the wheelchair.

Conclusion:

Patient can now use his wheelchair safely without the risk of causing himself harm. Although the parents had to compromise they are happy with the outcome, they feel that his safety is being met whilst the adaptations to the wheelchair look like they are part of the original chair. 

*"Down Syndrome (DS or DNS), also known as trisomy 21, is a generic disorder caused by the presence of all or part of a third copy of chromosome 21. It is typically associated with physical growth delays, characteristic facial features and mild to moderate intellectual disability. The average IQ of a young adult with Down syndrome is 50, equivalent to the metal ability of an 8 or 9 year old child, but this can vary widely".

Author: Ron Seager