Reflection on the ‘Paediatric developmental and adult neurological seating assessments’ breakout session by Marion May MSc BA (Hons) at the 2022 PMG Conference.

Written by Rhys Campbell-Smith, Senior Wheelchair Therapist for St Georges University Hospitals NHS Foundation Trust.

At the start of this breakout session, Marion May asked the question “why have I put paediatric developmental and adult neurological assessments together?”. It’s a valid question, and most therapists would tell you to complete a baby’s developmental assessment differently from the way you would assess, say, the seating assessment for a recently discharged adult patient with a brain injury.

Most of the time I would assess a child with one eye on supporting growth and one eye on supporting independent mobility and function. While assessing an adult, I might do the same minus the potential for growth or postural change. Well, Marion disagrees with this. She proposed that in paediatric developmental assessment you are looking for the windows of opportunity when neuroplastic change begins to affect the postural and motor development of a baby, child or adolescent, arguing that adult neurological assessments are exactly the same.

We know infants and children have masses of potential for neuroplastic change, and that this is mostly down to their motivation for exploration in the environment, both social and physical. A baby will receive an extrinsic and intrinsic reward for their inquisitiveness. Extrinsically, the reward comes from immediate sensory stimulation, i.e., food or a toy. Intrinsically, the baby’s brain and central nervous system learns to develop extension and rotational posture and motor movements to obtain this reward. This encourages further exploration and practice, and inevitably the child will develop stable and functional posture to achieve more rewards as they grow. They will isolate that individual limb to grab a toy or a piece of food and break that mass movement pattern down into bite size pieces, a process that Marion calls “fractionation”.

Marion stated that this doesn’t stop as we get older; adults too are motivated by stimulus in their environment and have the capacity to re-learn and re-develop independent and functional posture through similar windows of opportunity. I was intrigued about what the connecting factor was, for, as far as I knew, we therapists in wheelchair services refer to physiotherapy and occupational therapy services to complete rehabilitation, or maybe refer to spasticity clinics for a review of Botox release. How could assessing for seating systems or mobility equipment in exactly the same way improve outcomes for both paediatric and adult populations?

It all comes down to neuroplasticity, a term used for describing the brain’s potential for the nervous system to learn and change by using Growth Associated Proteins (GAPs). This is not something limited to our time as a baby, a child or in puberty -  it’s something we use all the time, even as adults. GAPs are used for committing information to memory, including the development of pathways responsible for motor skills. You are more neuroplastic during certain times in your life than others, during times of “hormonal flush”. This is when the brain dumps a large number of GAPs onto the central nervous system and peripheral nervous system. This is a prime window of opportunity for the body to change its posture or improve its independent function, provided the seating system is supportive enough. These times include the following:

• A baby after birth
• Puberty
• Menstruation
• Menopause
• While the brain is recovering from trauma.

“So, where do you start a seating assessment?” Marion asked quite bluntly. I thought this was an obvious answer. After the basics of introduction, you start at the pelvis, you find the anterior superior iliac spine and posterior superior iliac spine, and observe for pelvic tilt, obliquity and rotation. You then observe and feel the spine’s position using the spinous process as guidelines, and check the range of motion in all four limbs. This way you secure a base of support around which you can build a posturally supportive seating system as much as required.

Well, it turns out I missed a step according to Marion (pictured above right). The first thing you do is….nothing. You watch, calmly and without any unnecessary external stimulus. This is because the minute you do anything at all, you alter their tone. Any one of the sensory systems can be stimulated easily and affect tonal change.

Thinking back on it now, this information is something I have come across many times throughout my life as an occupational therapist, especially while working for several years in community paediatric therapy services. But I always used it as a tool for intervention, i.e. sensory integration therapy. I’ve rarely considered that reducing the stimulus to a bare minimum during both adult and paediatric seating assessments can significantly improve the accuracy of my assessment data. For example, the somatosensory system is a complex system of sensory neurons and pathways that responds to changes at the surface or inside the body. It is also involved in maintaining postural balance by relaying information about body position to the brain, allowing it to activate the appropriate motor response or movement. Someone with an impairment in this system may struggle to regulate this response, and so the slightest activation of the somatosensory system can alter the presenting posture before I’ve had a chance to observe anything.

What did I take from this breakout session and how will it influence my clinical practice? I suppose the first thing will be to ‘look before you touch’ when undertaking an assessment, reduce stimulus and take your time if you can. Secondly, not all people should be assessed in the same way, but all people regardless of age or condition have the capacity for neuroplastic change at certain times in their life. It’s up to us as wheelchair therapists to look for the windows of opportunity and find the right times to intervene. Maybe we might improve posture and mobility more than we think we can.

Photograph courtesy of Clinton Davin