The Use of Complex Rehab Equipment in the School Setting Part 3

2020-07-23

Lynda Reagan, PT Newton County, GA School District Step in Time Therapy, LLC 770-823-7301 [email protected]

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Julie Kobak, MA, CCC-SLP Marketing and Education Program Manager Etac –USA 330-397-1157 [email protected]

Part 1

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Role of Equipment

Promoting Helping to Achieve Improving Access to Independence and Education Goals Environment Mobility

Increasing Facilitating Position Participation in Changes Activities 5

Part 2

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Evaluation IEP Goals Equipment Process

Process

Physical Determination Referral Interview Assessment of Equipment

Prescription Follow-Up Measurement Simulation LMN

Delivery Ordering and Checkout Assembly Training

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Part 3

Etac School Room

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Sebastian

“Wh” Questions

8 year old student with cerebral palsy; Sebastian in regular education; needs stander and gait trainer for standing and walking at school

Trials soon to find out what will work for Independent mobility school; order new or use equipment we have? Benefits of standing Do parents want/need equipment for Achieving IEP goals home?

Gather information from teacher, IEP or reports, and parent interview/phone call

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Evaluation Results

• DP-3 • Standard Score: 85 • Age equivalent: 2 y 2 m • MACS • Level 2- He handles most objects but with somewhat reduced quality and/or speed of achievement. May avoid some tasks or use alternative ways of performance • GMFCS • Level 3 –He can walk independently with walker, although gait pattern is poor. He can self propel wheelchair.

Evaluation Results

• Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V) • Sebastian demonstrates strength in basic verbal comprehension when compared to his overall ability. Sebastian's weaknesses are in visual spatial, fluid reasoning, working memory, and processing speed. • Individual Achievement Test, Third Edition (WIAT-3) • Sebastian demonstrates strength in basic reading. Weaknesses were demonstrated in reading comprehension, reading fluency, math calculation, and math reasoning • Sebastian qualifies for Special Education with “Orthopedically Handicapped” designation.

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IEP Goals

1. Sebastian will improve his independence by getting into his wheelchair 1 time a day for at least 3 consecutive days in a 9-week collection period 2. With supervision only, Sebastian will improve his independence by using an assistive device to walk 60-100’ within the school setting for 3 out of 5 days in a 9-week period 3. Sebastian will roll in mobile stander independently from classroom to PE so he is able to participate in activities 3/5 days

Process

Physical Determination Referral Interview Assessment of Equipment

Prescription Follow-Up Measurement Simulation LMN

Delivery Ordering and Checkout Assembly Training

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Determination of Equipment

Team Approach

OT ATP

Peers PT

Family

Student SLP

Teachers Etac

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PT Student • Typically is the lead person • Provides input regarding comfort, position, function of equipment and accessories • Recognizes the student’s physical and functional capabilities Parents/Carers • Coordinates the evaluation, including demos • Provides important information about family’s needs • Identifies equipment and accessories that maximize and goals for equipment use in the school, home and the student’s positioning, function, and community independence • Typically writes LMN Teachers/Staff • Provides input regarding student’s daily life and OT schedule at school (e.g. transfers, assistance needed) • Capable of being lead team member (depending on • Has knowledge about equipment that has been the relationship with the other members) successful in past • Recognizes the value of engagement in meaningful occupations, including ADLs, which can be facilitated ATP by appropriately selected DME and CRT mobility • Analyzes the needs, assists in the selection, and trains systems to achieve health, well-being and the consumer on proper use. participation in school, but ultimately in life as child • Stays up to date on current equipment so family knows tried to achieve goals in life. their options

SLP Manufacturer • Provides information about AAC access, cognition, • Make high quality, safe equipment that meets the preferences and receptive language skills. needs of children and adults, whether they are going to be used at school, home and/or in the community. • Provide means for client to participate in evaluation and decision making (e.g. color of chair) • Can assist with demonstration and education of products 19

My Team

Hi! I’m David Hello! I’m Malachi

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Benefits Of Standing

• Improve hip integrity and “hip health” • Improve cardiopulmonary function • Decrease potential for contractures; promote • Improve psychological well being elongation of muscles • Aid bowel/bladder function • Increase bone mineral density • Improve functional capabilities • Tone reduction • Increase physical activity • Pressure relief from change of position

https://www.gotostage.com/channel/etacus 21

Considerations for Selection of Stander

Standing program goals

Ease of use for teacher/staff member/caregiver

Adjustment for growth

Environment and storage

Child’s tolerance

Incorporation into routines

Physical activity & engagement in stander

Physical support needed

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Goals of Standing

PROMOTE NORMAL SKELETAL PROMOTE FUNCTIONAL FACILITATE BALANCE IN PROMOTE HEALTHY SKIN ALIGNMENT & ACCOMMODATE POSTURE & MOVEMENT MUSCLE TONE STRUCTURAL ISSUES

CONSIDER COMFORT & FUTURE PROMOTE HEALTHY PRE-GAIT ACTIVITIES PROMOTE INDEPENDENCE, GROWTH/CHANGES OF CLIENT PHYSIOLOGICAL FUNCTIONING 23 ACTIVITY, MOBILITY

Physical Support Needed

Head Control Hips •Good • Tightness in hip flexors but can achieve full range in stander Trunk Control Knees •Fair • Tightness and mild ROM loss but can achieve full range in standing

Arms & Hands Ankles • Uses both upper extremities • Pronates & internal rotation

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R82 Family of Standing Products

Trials

Mobile (R82 Rabbit) Sit to Stand (EasyStand Prone (Rifton) Bantam)

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R82 Rabbit Up

• Stander and Mobile stander • Angle adjustable center bar • Quick release wheels • Camber angling

Stander Measurements

Prone Supine Measurements to choose the correct product Measurements to choose the correct product size: size: B: Armpit height A: Shoulder height F: Chest width E: Shoulder width Measurements to adjust the product correctly: Measurements to adjust the product correctly: C: Top of pelvis (crista) B: Armpit height D: Lower leg length C Top of pelvis (crista) D: Lower leg length

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Measurements

Armpit HeightChest Width Top of Pelvis Lower Leg Length

Supporting at 3 Points

• Point 1: Stabilize the trunk • Trunk support height determined by child’s postural control capability • Point 2: Stabilize the pelvis • Front Support (cushion) for stabilization • Back Support at sacrum • Point 3: Stabilize the knees • Support can be placed right under the knee or above the knee but never right on top of knee

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Accessories

Back support Chest Support Hip Support Knee Support

Accessories

Flip-up foot plate Hinged Sandal Play box

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LMN: Sebastian

Recommended equipment: R82 Rabbit Goals: Stander, Size 2 with these components: 1. Improve postural alignment-the recommended Back support: to position back an pelvis in standing system will provide the support neutral alignment needed to stand in good postural alignment Chest support: to position trunk upright and stability during the day. Hip support: to position hips in neutral 2. Maximize pressure relief – the recommended stander will provide good shock absorption, alignment and maintain hips and pelvis in pressure relief and skin protection. correct position 3. Accommodate range of motion limitations Flip up footplate: to position feet optimally; (tight hamstrings) also to enable footplates to be moved out of 4. Increase comfort and standing tolerance – the the way and allow him to place feet on ground recommended standing system will improve to transfer into wheelchair comfort therefore tolerance for standing. Knee Support: to position knees in alignment 5. Meet caregivers’ goals – the recommended due to tightness system will achieve family’s goal of having a Foot support straps: to position his feet as he standing system to use for functional activities tends to have spasms and pull feet out of at home. proper position 6. Promote/improve independent mobility- the Play box: for surface/compartment to hold recommended stander, with its lightweight and educational materials; also to provide surface physical properties, will allow proper wheel placement and independence in self for his arms to push against for erect posture propulsion of the stander to get around the (to decrease kyphoscoliosis posture). house 35

Delivery and Checkout

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Dosage

• Systematic review and evidence-based clinical recommendations (Paleg, 2013) • 687 studies -> 84 studies for review -> 30 studies included • Standing program 5 days/week positively affect:

Benefit Dosage

BMD 60-90 min/day

Hip stability 60 min/dayin 30-60o ABD

ROM hip, knee, ankle 45-40 min/day

Spasticity 30-45 min/day

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Standing Program

• Incorporating into everyday routine to meet goals • Be creative • Work with team

IEP Goals

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Determination of Equipment

Equipment Trials- Walkers

Anterior Anterior/Posterior Posterior Posterior

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Walker

Nimbo Kaye walker walker

Sebastian’s Program

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Sebastian’s Program

Tracking Progress- GOALed App

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Trenton

“Wh” Questions

5 year old with spastic quadriplegia Trenton cerebral palsy; needs a stander and gait trainer at home and school

The whole process of getting a Physical benefits (increased activity, stander and gait trainer will take 3-5 control, strengthening, etc.) months, so we need to start process Physiological benefits ASAP. Achieving IEP goals

Gather information from parents and teacher to make best decision possible for his circumstances Schedule ATP to come out for trials and measurements 48 24 48 2020-07-23

Evaluation Results

• DP-3 • Standard Score: 50 • Age equivalent: 2 months • BDI-2 • Total: 45 • low range for each domain assessed • MACS • Level V –Does not handle objects and has severely limited ability to perform even simple actions. Requires total assistance. • GMFCS • Level V -Children are transported in a manual wheelchair in all settings. Children are limited in their ability to maintain

antigravity head and trunk postures and control leg and arm 49 movements. 49

Gross Motor Function

• Between 6th and 12th birthday: Descriptors and illustrations

GMFCS I-II GMFCS III GMFCS IV-V

www.canchild.ca 50 25 50 2020-07-23

IEP Goals

1. Trenton will initiate and take 10-20 steps in a gait trainer when walking in his classroom from one center/activity to another to participate with classmates 2. Trenton will be positioned in 3-4 positions throughout the day 5 days/week as he participates in classroom activities (stander, adapted chair, wheelchair, mat on floor, bean bag, sitting with support) 3. Trenton will stand in stander for 60 min/day for 3-5 days a week to participate in learning activities and active board lessons.

Determination of Equipment

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Goals of Standing

PROMOTE NORMAL SKELETAL PROMOTE FUNCTIONAL FACILITATE BALANCE IN PROMOTE HEALTHY SKIN ALIGNMENT & ACCOMMODATE POSTURE & MOVEMENT MUSCLE TONE STRUCTURAL ISSUES

CONSIDER COMFORT & FUTURE PROMOTE HEALTHY PRE-GAIT ACTIVITIES PROMOTE INDEPENDENCE, GROWTH/CHANGES OF CLIENT PHYSIOLOGICAL FUNCTIONING 53 ACTIVITY, MOBILITY

Medical Benefits

• Positioning for Hip Health: A Clinical Resource, Sunny Hill Health Centre for Children BC, Canada • Positions: supine, sitting, standing & walking

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Trials in Classroom

Tri-standerSit to Stand Supine Prone

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Trials

Supine (R82 Caribou)

Trials

Supine (R82 Gazelle)

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Trials

Prone (R82 Gazelle with headrest)

Accessories

Head support system Head support with Trunk support Side supports, interior facial aperture For correct positioning and For correct position and For extension of the trunk For positioning of trunk upright support in the vertical or support in prone support. Helps support the and decrease lateral flexion prone position child’s trunk position

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Accessories

Strap for side supports Tray with bowl and Knee Supports Foot Support cover, plastic For safety and trunk To serve as support surface alignment for upper extremties. To hold educational materials and facilitate functional use of upper extremities.

LMN: Trenton

 Mounting hardware, 36-9475– to be able to Goals: mount headrest 1. Improve postural alignment. The  Turtle Bar System, short, 98619-25 – for mounting headrest to main frame recommended standing system will  Anatomic head support, small, 5099001 – to hold provide the support needed to stand the head posteriorly; poor head control in good postural alignment and  Head support with facial aperture, 88117-1-to support head as he does not have head control stability throughout the day. (head flexes forward, shoulder protract 2. Maximize pressure relief. The  Trunk Support extension, size 1, 88106-1 – to recommended stander will provide allow for trunk length and to attach supports  Side/Trunk support pads,88075-1- to position pressure relief and skin protection. trunk upright due to child flexing laterally 3. Accommodate range of motion  Strap for Side supports, 88250-1-to keep trunk limitations (tight hamstrings) aligned  Trunk Strap, 88200-1 – to hold trunk back and 4. Increase comfort and therefore keep from laterally flexing standing tolerance.  Knee support pads/straps, 88161-1– to position 5. Meet caregivers’ goals. The knees in place and decrease flexing  Foot support/88145-1- to secure positioning of recommended system will achieve feet in stander family’s goal of having a comfortable  Tray, 88108-0: for educational materials and to standing system to use for functional help allow child to be upright as child can push up on tray to stand more erect and counter kyphotic activities at home. posture that often develops. 62 31 62 2020-07-23

Delivery & Checkout

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One year later

Versatility

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IEP Goals

1. Trenton will initiate and take 10-20 steps in a gait trainer when walking in his classroom from one center/activity to another to participate with classmates 2. Trenton will be positioned in 3-4 positions throughout the day 5 days/week (stander, adapted chair, wheelchair, mat on floor, bean bag, sitting with support) 3. Trenton will stand in stander for 60 min/day for 3-5 days a week to participate in learning activities and active board lessons.

Determination of Equipment

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Considerations for Selection of Walker/Gait Trainer

Walking goals

Stage of recovery: acute vs later rehab stage

Endurance, cardiopulmonary status, balance

Space, size of walker or gait trainer base of support

Storage: collapsible or not

Environment/setting: home, school, work, indoor or outdoor use

Ease of use

Adjustments for growth

Level of physical support required

Posterior Walker

Head Control Patient has head control

Patient has upper trunk control Trunk Control Support around pelvis may be needed (back, side support)

Patient able to bear weight through legs If good arm strength, some of weight bearing can be Active Weight Bearing through the hands or forearms May need flip down seat for rest or forearm supports

Forearm support may be necessary if no active Upper Extremity Function use of hands

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Anterior/Posterior Gait Trainer

Good to limited Head Control Head support may be needed

Limited Trunk Control Chest support placed in upper thoracic area, possibly UE supports; as improves, lower chest support

Unable to manage full WB independently Active Weight Bearing Seat with sacrum support, a sling seat, or back and hip supports used to stabilize around the pelvis and partially support body weight

Forearm support (troughs) may be necessary if no Upper Extremity Function active use of hands

If scissoring, can be reduced by using a leg LE stance & gait pattern separator or ankle prompts

Trial 1 & 2

R82 Mustang

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Measuring for a Walker or Gait Trainer

Axilla height: • For choosing the correct size of walker • R82Mustang, R82 Pony Chest width: • For choosing the correct size of chest support

Total height: • ½ the total height will be the approximate height for “handle height” • R82 Crocodile

Axilla Height Chest Width

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Accessories

Head support and bar Arm support Abdominal support Circumferential chest extension support As he has poor and Provides forearm support. Provides additional anterior For support of the upper body inconsistent head control Helps the child to stabilize the pelvic control Decrease flexion/extension of shoulder girdle trunk

Accessories

Seat Leg separator Ankle prompts Guide bar Guidance for correct walking Provides a resting position Helps to prevent feet crossing Allows caregiver to direct and pattern that a child can use when midline and so maintains a assist the child’s movements. fatigued. neutral walking pattern. To keep the legs in more To help decrease muscle tone neutral For Mustang size 1 and 2 and allow increased To help advance the legs as step/stride length the straps will also help to pull forward as he steps

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LMN: Trenton

Recommended equipment: R82 Mustang Gait Trainer, Size 2, with these components: Goals: Head support – he has poor head control and extends his head 1. Improve postural alignment - the recommended most of time; he did well during the equipment trail with the gait trainer will provide the support and stability Mustang with the head support on needed to stand in good postural alignment Turtle Bar System – a bar system to attach head support during walking. Chest Support – circumferential support to keep trunk upright 2. Maximize pressure relief – the recommended gait as child laterally flexes or extends trunk; has no trunk control trainer will provide pressure relief and skin and needs full support to stabilize protection as the child will have opportunity to be Arm Support – he cannot hold onto any handgrips so he needs positioned outside of his wheelchair an arm support where his forearms rest and can be strapped in, 3. Accommodate range of motion limitations –the then he can push up on the arm support to stand up more recommended gait trainer will allow the child to straight Hip support on curved bar – helps keep hips and pelvis in stand and move even though the child has position so that he can stand up and take independent steps decreased range Pelvic support- he needs circumferential pelvic support to keep 4. Increase comfort and standing tolerance – the his pelvis from shifting side to side as he does not have control recommended system will help the child obtain an of pelvis, trunk or hips. optimal position for gait, decrease energy Seat – to support for his pelvis and buttocks, separate the hips, expenditure and pain to maximize time in and provide resting surface standing position for walking. Leg Separator – Trenton has hip adductor spasticity which leads 5. Meet caregivers’ goals – the recommended gait to extreme difficulty dissociating/separating legs, so when he trainer will achieve family’s goal of having a piece takes steps he scissors. The leg separator keeps him from of equipment that their child can use in the home scissoring and allows him to take independent steps for learning how to take steps thereby increasing Ankle Prompts – to provide guidance for correct walking pattern Attendant guide bar – for safety; to be used to make sure that his mobility, independence and participation in he does not crash into anything by attendant being able to help activities of daily living. steer it. He could propel the demo by himself but was not able to steer or guide it. 77

Delivery & Checkout

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Use of Gait trainer at home

Versatility

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Versatility

Other Equipment to Consider

Seating

Transportation Commercial Car Seat Car Seat for Special Needs

Bath/Hygiene

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Option for Seating

R82 Scallop

Floor seat 83

Transportation Options

R82 Convaid Wallaroo Carrot 3 84 42 84 2020-07-23

Trenton’s Equipment Program

Trenton’s Program

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Tracking Progress- GOALed App

Gross Motor Function

• Between 6th and 12th birthday: Descriptors and illustrations

GMFCS I-II GMFCS III GMFCS IV-V

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State of the Evidence

• State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Don’t do it Palsy (Novak et al 2020) • Reviewed 398 intervention outcome indicators • Motor interventions Probably • In high-income countries, severity is lessening, and the rate of co-occurring epilepsy and intellectual disability is falling • Three in four will now walk Do it • Children with cerebral palsy may be more likely than ever to be treatment responsive to motor interventions

Motor Interventions

• Training-based interventions, including action observation training • Bimanual training • Constraint induced movement therapy • Goal-directed training • Home programs using goal-directed training • Mobility training • Treadmill training • Partial body weight support treadmill training • Environmental enrichment to promote task performance is effective • Adapting the environment and task to enable task performance via context-focused therapy 90 45 90 2020-07-23

Task-oriented training Motor Interventions

• Real-life task and activities • Self-generated active movements • High intensity • Directly targets the achievement of a goal set by a child (or a parent proxy)

Child’s Goals

• Children’s self-identified goals are achievable to the same extent as parent identified goals and remain stable over time. • Children can be trusted to identify their own goals for intervention, thereby influencing their involvement in their intervention programs. (Vroland-Nordstrand et al 2015)

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Gait Trainer Outcomes

Level I RCT Distance & Speed

Level 2 Cohort Steps

Level 3 Case Control Studies Mobility level, bowel function, BMD

Level 4 Case Reports and Case Series

Level 5 Expert Opinion, Anecdotal Activities, participation, affect, motivation

Paleg & Livingstone 2015 93 Moreau et al. 2016

Gait Trainer Outcomes

• The primary population of children using gait trainers includes children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels IV and V • Lack of valid, sensitive and reliable tools for measuring change in body structure and function, activity and participation outcomes • Twelve different clinical tools were identified in the systematic review • Spatiotemporal measures appear to be less useful than functional measures

PEDI COPM GAS Quebec User Pediatric Canadian Goal Evaluation of Evaluation of Occupational Attainment Satisfaction Disability Performance Scale with Assistive Inventory Measure Technology

Livingstone & Paleg 2016 94 47 94 2020-07-23

Jaylen

R82 Wombat

Living95

“Wh” Questions

10 year old child with cerebral palsy and anophthalmia (no eyes/ Jaylen blindness) who needs a way of standing and walking at school & home

Good rehab potential to ambulate He needs it SOON as he is really with assistance with device showing an interest in standing and (possibly one day without device) walking now; more motivated than -Physiological and physical benefits previously demonstrated -Achieving IEP goals

Interviews with staff and family Therapist schedules evaluation and starts the process for stander and device for walking 96 48 96 2020-07-23

Evaluation Results

• DP-3 • Raw Score:7 • Standard Score: <50 • Age equivalent: 10 months

• MACS • Level III –Handles objects with difficulty. Needs help to prepare and/or modify activities • GMFCS • Level IV - needs assistance for maneuvering and propelling wheelchair; with walking

IEP Goals

1. Jaylen will continue to help those assisting him transition himself with minimal assistance only from one piece of equipment to another 3x/day 2. He will assist with transfer to/from wheelchair or chair to assistive device to walk to restroom 1x/day 3. He will walk from his classroom to other classroom (such as PE, music, art, computer) with assistive device and moderate assistance 100’ 1x/day, 3-5x/week 4. He will be in a stander 60 min/day 3-5 days/week in order to participate in circle time 5. He will get in and out of his wheelchair with moderate assistance 2/3 trials 98 49 98 2020-07-23

Determination of Equipment

Head Control Hips •Good • Decreased strength Trunk Control Knees • Fair, flexes forward, lack of stability, fearful • Decreased strength Arms & Hands Ankles • Uses both upper extremities • Pronate

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Goals of Standing

PROMOTE NORMAL SKELETAL PROMOTE FUNCTIONAL FACILITATE BALANCE IN PROMOTE HEALTHY SKIN ALIGNMENT & ACCOMMODATE POSTURE & MOVEMENT MUSCLE TONE STRUCTURAL ISSUES

CONSIDER COMFORT & FUTURE PROMOTE HEALTHY PRE GAIT ACTIVITIES PROMOTE INDEPENDENCE, GROWTH/CHANGES OF CLIENT PHYSIOLOGICAL FUNCTIONING 101 ACTIVITY, MOBILITY

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Trials of Equipment

Prone

Sit to Stand

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Trials

• R82 Meerkat • Who can benefit: • Client with limitations in trunk control (e.g. DD, CP) • Advantages: • Allows dynamic movement with individualized segmental support

Upright/ Dynamic

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SATCo – Segmental Assessment of Trunk Control

Trunk segment (control) Anatomical landmark Between segments

• Head • Shoulders • Upper Thoracic • Axillae • Mid Thoracic • Inferior scapula • Lower Thoracic • Lower ribs • Upper Lumbar control • Below ribs • Lower Lumbar • Brim of pelvis • Full spinal control Three scores: Static, Active, Reactive

Saavedra & Woollacott 2015,Curtis 2018 104 52 104 2020-07-23

LMN: Jaylen

Goals: He would benefit from having an R82 Meerkat dynamic stander as standing would keep legs elongated and give him proprioception to help show him what it is like to be fully weight bearing through legs in extension, instead of as in flexion as he tends to do at all lower extremity joints.

When he stands in the Meerkat, especially with dynamic rocker on base, he can work on segmental trunk control and strengthening by moving the trunk support down as he gains control.

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Accessories

Chest Support Pelvic Support Knee Support Foot Sandals

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LMN: Jaylen R82 Size 3 Meerkat stander with these components: trunk support: to help hold trunk erect and in line with the vertical support; as he improves, the trunk support can be lowered to help him gain segmental control pelvic support: to hold hips and pelvis in alignment and vertical with the support and prevent lateral shifting knee supports: to have a surface to push against knees to help them stay in extension as we need full extension of legs for full weight bearing and for training and leg strengthening large foot sandals: to keep feet from sliding; to keep feet in alignment with legs

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Delivery & Checkout

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R82 Meerkat

• Active Standing • Rocker Off • Chest Support at Mid Thoracic (Between inferior scapula and lower ribs)

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Tracking Progress

• Lower level of support

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R82 Meekat

• Active Standing • Rocker Off • Challenge: • Chest Support off • Support and pelvis and below

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R82 Meerkat

• Challenge: • Dynamic Standing • Rocker On • Chest Support on

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Walking

• After Meerkat stander activities and hippotherapy • Progress observed with trunk control during stepping

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Tracking Progress- GOALed App

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Determination of Equipment

Kaye R82 Suspension Crocodile 115

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Jaylen’s Program

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Jaylen’s Program

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Thank You Sebastian, Trenton, Amari, and Jaylen!

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Trenton, Wreck, and Ameria

Questions

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Certificate Instructions

• Deadline: • Go to: www.brainsbuilder.com 1. Select “Take an assessment” 2. Enter Your Assessment ID: 3. Enter Your Login: etac 4. Complete quiz & evaluation 5. Certificate of Completion will be sent to the email you provide in evaluation Contact: Annette Hodges, [email protected]

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References: 1. Anaby D. (2016) Current Rehabilitation Practices for Children with Cerebral Palsy: Focus and Gaps. Physical & Occupational Therapy in Pediatrics 37(1):1-15. 2. Angeli J, et al. (2019) ICF-inspired goal-setting in developmental rehabilitation: an innovative framework for pediatric therapists. Physiotherapy Theory and Practice. DOI: 10.1080/09593985.2019.1692392 3. Angsupaisal M et al (2015) Adaptive seating systems in children with severe cerebral palsy across International Classification of Functioning, Disability and Health for Children and Youth version domains: a systematic review. Dev Med Child Neurol. 57(10):919-30. 4. Barks L & Davenport P (2012) Wheelchair Components and Pulmonary Function in Children with Cerebral Palsy, Assistive Technology, 24:2, 78-86. 5. Benfer et al (2013) Oropharyngeal Dysphagia and Gross Motor Skills in Children with Cerebral Palsy. Pediatrics May 2013, 131 (5) e1553-e1562. 6. Bouck EC, Flanagan SM. (2015) Exploring assistive technology and post-school outcomes for students with severe disabilities. Disability and rehabilitation. Assistive technology 11(8). 7. Costigan and Light (2011) Functional Seating for School-Age Children with Cerebral Palsy: An Evidence-Based Tutorial, Language, Speech, and Hearing Services in Schools, 10.1044/0161-1461(2010/10-0001), 42, 2, (223-236). 8. Couriel JM, Bisset R, Miller R, Thomas A, Clarke M. (1993) Assessment of feeding problems in neurodevelopmental handicap: A team approach. Arch Dis Child 69: 609-613. 9. Curtis, D.J., Woollacott, M., Bencke, J., Lauridsen, H.B., Saavedra, S., Bandholm, T. and Sonne-Holm, S. (2018). The functional effect of segmental trunk and head control training in moderate-to-severe cerebral palsy: A randomized controlled trial. Developmental Neurorehabilitation, 21(2), pp.91-100. 10. Diacianno B et al (2015) RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs: 2015 Current State of the Literature. Retrieved 5/7/20 https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNA%20PP %20on%20Tilt%20Recline_2017.pdf. 11. Effgen S, McEwen I (2008) Review of selected physical therapy inter-ventions for school age children with disabilities. Physl Ther Rev. 13(5):297-312. 12. Effgen SK, Chiarello L, Milbourne SA (2007) Updated competencies for physical therapists working in schools. Pediatric Physical Therapy 19:266-274. 13. Gangil A et al. (2001) Gastroesophageal Reflux Disease in Children with Cerebral Palsy. Indian Pediatrics 2001; 38: 766-770. 14. George, F.K. (2018). The importance of static and dynamic posture: how making static equipment dynamic may improve movement and function of children with neurological impairment - A retrospective service evaluation. Association of Paediatric Chartered Physiotherapists Journal. 9(2), pp.56-63 15. Goodwin J, Lecouturier J, Basu A, Colver A, Crombie S, Smith J, et al. (2018) Standing frames for children with cerebral palsy: a mixed-methods feasibility study. Health Technol Assessment 22(50). THE USE OF COMPLEX REHAB EQUIPMENT IN THE SCHOOL SETTING

16. Hulme et al (1987) Effects of Adaptive Seating Devices on the Eating and Drinking of Children with Multiple Handicaps. The American Journal of Occupational Therapy Volume 41,2:81-89. 17. Inthachom R et al (2020) Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy, Disability and Rehabilitation: Assistive Technology, DOI:10.1080/17483107.2020.1731613. 18. Jeffries L, et al. (2018) Description of the Services, Activities, and Interventions within School-Based Physical Therapist Practices across the United States. Physical Therapy 99(1). 19. Katz et al. (2018) The effect of body position on pulmonary function: a systematic review. BMC Pulmonary Medicine 18:159. 20. Kiger, Angie (2014) Teamwork: Together, Everyone Achieves More. Mobility Management October 2014. 21. Knox V. (2018) Should school-based physical therapists be more targeted in their interventions for children with disabilities? Developmental Medicine & Child Neurology 60: 1068–1075. 22. Livingstone, R.W., & Paleg, G.S. (2016). Measuring Outcomes for Children with Cerebral Palsy Who Use Gait Trainers. Clinical Rehabilitation 1–15. 23. Lyons, E. A., Jones, D. E., Swallow, V. M. and Chandler, C. (2017) An Exploration of Comfort and Discomfort Amongst Children and Young People with Intellectual Disabilities Who Depend on Postural Management Equipment. Journal of Applied Research in Intellectual Disabilities, 30: 727–742. 24. Long T & Perry D. (2008) Pediatric Physical Therapists' Perceptions of Their Training in Assistive Technology. Physical Therapy 88:629-639. 25. Mccoy S, et al. (2018) School-based physical therapy services and student functional performance at school. Developmental Medicine & Child Neurology 60(Suppl. 2). 26. McDonald R, Surtees R. & Wirz S (2004) The International Classification of Functioning, Disability, and Health provides a model for adaptive seating interventions for children with cerebral palsy. British Journal of Occupational Therapy, 67,293–302. 27. McEwen I & Lloyd L (1990) Positioning school-aged children with cerebral palsy to use augmentative and alternative communication. Language, Speech, and Hearing Services in Schools, 21, 15–21. 28. McEwen I (1992) Assistive Positioning as a Control Parameter of Social- Communicative Interactions Between Students with Profound Multiple Disabilities and Classroom Staff Physical Therapy 72(9):634-44. 29. Moreau NG, Bodkin AW, Bjornson K, et al. (2016) Effectiveness of rehabilitation interventions to improve gait speed in children with cerebral palsy: systematic review and meta-analysis. Phys Ther. 96:1938–1954. 30. Morress C (2006) Bottom-up or top-down? An occupation-based approach to seating. OT Practice, 11, 12–16. 31. Novak, I., Morgan, C., Fahey, M. et al. (2020) State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 20, 3. THE USE OF COMPLEX REHAB EQUIPMENT IN THE SCHOOL SETTING

32. Nwaobi OM, Smith PD (1986) Effect of adaptive seating on pulmonary function of children with cerebral palsy. Dev Med Child Neurol. Jun;28(3):351-4. 33. Paleg G, Livingstone R. (2015) Outcomes of gait trainer use in home and school settings for children with motor impairments: a systematic review. Clin Rehabil. Nov;29(11):1077-91. 34. Picciolini, O, et al. (2008) “Postural Management” to Prevent Hip Dislocation in Children with Cerebral Palsy. Hip international: the journal of clinical and experimental research on hip pathology and therapy 19 Suppl 6(1):S56-62. 35. Public Law 108–446, Individuals with Disabilities Education Improvement Act of 2004, 118 STAT. 2647–2808. Available at: http://www.copyright.gov/legislation/pl108-446.pdf 36. Rigby PJ, Ryan SE, Campbell KA. (2009) Effect of adaptive seating devices on the activity performance of children with cerebral palsy. Arch Phys Med Rehabil 90:1389-95. 37. Ryan SE (2016) Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol. 58 Suppl 4:78-82. 38. Ryan SE (2011) An overview of systematic reviews of adaptive seating interventions for children with cerebral palsy: where do we go from here? Disability and rehabilitation. Assistive technology 7(2):104-11. 39. Saavedra, SL., Woollacott, MH. (2015). Segmental contributions to trunk control in children with moderate-to-severe cerebral palsy. Archives of Physical Medicine and Rehabilitation, 96(6), 1088-1097. 40. Saavedra, SL., Donkelaar, PV., Woollacott, MH. (2012).Learning about gravity: segmental assessment of upright control as infants develop independent sitting. Journal of Neurophysiology, 108 (8), 2215 – 2229 41. Sahinoglu D et al (2017) Effects of different seating equipment on postural control and upper extremity function in children with cerebral palsy. Prosthetics and Orthotics International Vol. 41(1) 85–94. 42. Schiariti V, et al. (2018) Implementation of the International Classification of Functioning, Disability, and Health (ICF) Core Sets for Children and Youth with Cerebral Palsy: Global Initiatives Promoting Optimal Functioning. International Journal of Environmental Research and Public Health 15(9):1899. 43. Schiariti V, Mahdi S, Bölte S. (2018) International Classification of Functioning, Disability and Health Core Sets for cerebral palsy, autism spectrum disorder, and attention-deficit–hyperactivity disorder. Developmental Medicine & Child Neurology 60(9). 44. Shin, H., Byeon, E. & Kim, S.H. (2015) Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy. J Physiol Anthropol 34, 17. 45. Stavness, C. (2006) The effect of positioning for children with cerebral palsy on upper-extremity function: A review of the evidence. Physical and Occupational Therapy in Pediatrics, 26(3), 39–53. 46. Taylor, K. (2009) Factors Affecting Prescription and Implementation of Standing- Frame Programs by School-Based Physical Therapists for Children with Impaired THE USE OF COMPLEX REHAB EQUIPMENT IN THE SCHOOL SETTING

Mobility. Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association 21(3):282-8 47. Vialu C, Doyle M. (2017) Determining Need for School-Based Physical Therapy under IDEA: Commonalities across Practice Guidelines. Pediatric Physical Therapy 29(4):350-355. 48. Vroland‐Nordstrand, K., Eliasson, A.‐C., Jacobsson, H., Johansson, U. and Krumlinde‐Sundholm, L. (2016), Can children identify and achieve goals for intervention? A randomized trial comparing two goal‐setting approaches. Dev Med Child Neurol, 58: 589-596. 49. Wilson RA, Kolobe TH, Arnold SH, McEwen IR (2015) Concurrent validity of the School Outcomes Measure (SOM) and Pediatric Evaluation of Disability Inventory (PEDI) in preschool-age children. Phys Occup Ther Pediatr. Feb:35(1):40-53. 50. World Health Organization International Classification of Functioning, Disability and Health (ICF) (2019) https://www.who.int/classifications/icf/en/ accessed Nov 20, 2019. 51. Wynarczuk K, Chiarello L, Gohrband C. (2017) Goal Development Practices of Physical Therapists Working in Educational Environments. Phys Occup Ther Pediatr. Nov 37(4):425-443. 52. Wynarczuk, K et al. (2019) School-Based Physical Therapists’ Experiences and Perceptions of How Student Goals Influence Services and Outcomes, Physical & Occupational Therapy in Pediatrics. https://doi.org/10.1080/01942638.2018.1546254.

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Resources: International Classification of Function (ICF): https://www.cdc.gov/nchs/icd/icf.htm ICF Browser: https://apps.who.int/classifications/icfbrowser/ British Columbia’s Consensus on Hip Surveillance for Children with Cerebral Palsy Information for Health Care Professionals Caring for Children with Cerebral Palsy 2018 https://childhealthbc.ca/sites/default/files/clinical_booket_hip_surveillance march_2018.pdf Gross Motor Function Classification System - Expanded & Revised https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded- revised-gmfcs-e-r# Positioning for Children GMFCS Levels IV-V: Focus on Hip Health Clinical Tool http://www.childdevelopment.ca/Libraries/Hip_Health/sunnyhill_clinical_tool_Hip_Health_F ull_FINAL.sflb.ashx Goal Attainment Scale https://cerebralpalsy.org.au/our-research/about-cerebral-palsy/assessments-and-outcome- measures/goal-attainment-scaling-gas-goals/#1465514451876-288cc4e4-5c04 APTA: Physical Therapy for Educational Benefit https://pediatricapta.org/includes/fact- sheets/pdfs/15%20PT%20for%20Educational%20Benefit.pdf APTA: The Role of School-based Physical Therapy: Successful Participation for All Students https://pediatricapta.org/includes/fact- sheets/pdfs/12%20Role%20of%20SchoolBasedPT.pdf APTA: Dosage Considerations: Recommending School-Based Physical Therapy Intervention Under IDEA Resource Manual https://pediatricapta.org/includes/fact- sheets/pdfs/15%20Dosage%20Consideration%20Resource%20Manual.pdf?v=1 APTA: Resource/Fact Sheet Safe Student Lifting and Transfers in the School Setting: A Decision-Making Guide https://pediatricapta.org/includes/fact- sheets/pdfs/18%20Safe%20Lifting%20and%20Transfers%20in%20Schools.pdf THE USE OF COMPLEX REHAB EQUIPMENT IN THE SCHOOL SETTING

AOTA: Occupational Therapy in School Settings FACT Sheet https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fact- Sheets/School%20Settings%20fact%20sheet.pdf ASHA- School-Based Service Delivery in Speech-Language Pathology https://www.asha.org/SLP/schools/School-Based-Service-Delivery-in-Speech-Language- Pathology/ Seek Freaks- ASSISTIVE TECH: Choosing a Stander for the Classroom and Home https://www.seekfreaks.com/index.php/2018/02/17/resources-choosing-a-stander-for-the- classroom-and-home/

Etac – US Recorded webinars: To access recordings of webinars on the topics of seating, standing, gait, transporting children with spica casts, and tilt-in-space wheelchairs, visit this website. Please note these recorded webinars are not offered for CEUs. https://www.gotostage.com/channel/etacus R82 Education To access product Brochures, Guides and Clinical workbooks for R82 products such as R82 seating systems, gait trainers, standers, hygiene and transportation equipment. http://www.r82.org/education/ Etac - US Sales Team Contact Title Territory Mobile Phone E-mail Address Charles Larose Sales Manager Western United States & Canada (613) 852-1369 [email protected]

Chris Reidmiller Sales Manager Eastern US (913) 461-0032 [email protected]

Scott Gregory Sales Manager US, Safe Patient Handling/Adult Wheelchair (704) 975-6833 [email protected] & Hygeine Matt Abrahams, CPST Territory Manager Carolinas (910) 599-8180 [email protected] (North Carolina, South Carolina) Jason Barrett, ATP. CPST Territory Manager Texas, Oklahoma (980) 288-0180 [email protected] Barry Drumheller Territory Manager North East Atlantic (610) 390-1910 [email protected] (New Jersey, East Pennsylvania, West New York) Don Jones, ATP, CPST Territory Manager Pacific Central, Pacific Northwest (408) 402-2188 [email protected] (North California, Northwest Nevada, Pacific Central) John Liberton, CPST Territory Manager Indiana, Kentucky, Michigan (317) 914-9398 [email protected] Gary Quellet, ATP Territory Manager Florida, Coastal Alabama (470) 822-7282 [email protected] Brendon Reid, CPST Territory Manager Great Lakes West (312) 244-0578 [email protected] (Iowa, Minnesota, Wisconsin, Illinois) Dennis Wulfken, CPST Territory Manager New England, East NY (980) 288-9047 [email protected] (New York, Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont Steve Ricker Territory Manager East North Central (614) 940-1295 [email protected] (Ohio, West Pennsylvania) John Keady Territory Manager West South Central (531) 220-6765 [email protected] (Colorado, Kansas, Missouri, Nebraska) Kari Kujansuu Territory Manager Canada East (Ontario and the Maritimes (647) 302-9876 [email protected] Newfoundland, New Brunswick, Nova Scotia and PEI) Malachi Slice, ATP Territory Manager South Atlantic (404) 291-0936 [email protected] (Georgia, Tennessee, Inland Alabama) Mark Gil, ATP Territory Manager Pacific South (310) 803-6479 [email protected] (South California, South Nevada) Renaud Vantyghem Territory Manager Canada West (British Columbia, Alberta, (250) 580-2971 [email protected] Saskatchewan and Manitoba) Joel Mello, ATP • Territory Manager Safe Patient Handling (352) 425-8420 [email protected]