Toileting in Schools with the TRAM

Using the Rifton TRAM for toileting can make a huge difference for both students and staff, providing both safety during transfers to the toilet and dignity and privacy for the student. Because students with disabilities have a wide range of needs, there are many ways to use the TRAM for this purpose.

Here are some methods we’ve found here at Socorro,  presented as three case studies. (I’ve changed the names for the sake of the students’ privacy.)

Case Story 1: Student with High Tone

Amanda is 17 years old with spastic quadriplegic cerebral palsy, minimally low trunk tone and good head control. She weighs 90 pounds, has a G-tube and is on a continuous feeding pump. She is able to communicate verbally. 

Amanda is ambulatory using the Pacer gait trainer with the arm prompts, chest prompt, and hip positioner. She requires maximum assist from one care provider for all her transfers and does not demonstrate safe independent sitting balance.

Amanda uses the Rifton TRAM for all bathroom transfers at school with a standard toilet.

Toileting Procedure

Here is the process we’ve found works best for Amanda:

• We ask that she not wear tight fitting pants. 
• From her wheelchair we place the body support snugly around her and secure the thigh straps. The straps are positioned more distally (toward the knee joint) to allow for clothing adjustment without removal of the straps. 
• Amanda is raised up slightly and her clothing is adjusted (pants down). We readjust the straps as necessary.
• We move her over the toilet and lower her.  We loosen the body support system but keep it in place for safety. We pull the TRAM slightly forward and lock the wheels. 
• We step out to give Amanda her privacy.
• After toileting we reposition and secure the body support system and thigh straps.
• For cleaning (hygiene care) we lift Amanda above the toilet and adjust her clothing.
• Amanda is then lowered back into her wheelchair directly from the TRAM.

The TRAM has made an amazing difference for Amanda. She now has regular and dignified toileting opportunities, and because of this she does not use pampers at school anymore.

Case Story 2:  Non-Ambulatory Student with Contractures

Brianne is 16 years old with cerebral palsy and arthrogryposis. She weights 175 pounds and has multiple joint contractures including severe hip and knee flexion contractures, upper trunk rotation and other deformities. Her medical history is significant for spinal fusion secondary to scoliosis. 

Brianne is non-ambulatory and requires maximum assist of two adults for transfers.

We have used the TRAM successfully with Brianne for transfers to a change table and from the change table to the toilet.

Toileting Procedure

This is the process that works best for Brianne:

• From her wheelchair, we place the body support system snugly around her and attach the thigh straps. The straps are positioned more proximally to the hip joint, for increased security.
• Brianne is raised from her wheelchair and lowered onto a high-low table. (Our table is open on the floor so it works well with the TRAM, as the TRAM wheels fit under the table.)
• The TRAM straps and body support are then removed. We assist her into a supine position and help with clothing adjustment. Then after a supine-to-sit transition, we lift Brianne with the TRAM from the high-low table to the toilet.  
• We leave the body support system in place but loosen it for comfort during toileting.
• After toileting we reposition and secure the body support system and thigh straps as needed.
• We then lift Brianne off the toilet with the TRAM, perform hygiene care and then lift her back onto the high-low table for clothing adjustment. 
• We then transfer her back to the wheelchair.

Due to Brianne’s significant contractures and deformities it is too difficult to complete the clothing adjustment while in the TRAM. However, using the TRAM avoids physical lifting during the procedure. Most importantly, Brianne can void in the toilet rather than suffer the humiliating diaper change.

Case Story 3: Non-Ambulatory Student with Low Tone

Emilio is 14 years old with Duchene’s Muscular Dystrophy. He demonstrates poor trunk control and very low trunk tone. Emilio is non-ambulatory and he weighs more than 220 pounds. 

Emilio ordinarily uses a urinal and rarely has to use the toilet at school; however, when he needs the toilet we use the TRAM. 

We first use the TRAM for transfers to a change table and then from the change table to the toilet. (With Emilio, clothing adjustment is difficult even on the table.)

Because Emilio is significantly involved, this process is time consuming, but we have determined it is the safest procedure for this particular student and for the staff.

For Emilio’s transfer, we use a third thigh strap from side to side, placed under the ischial tuberosities. This is required for safety due to his poor trunk tone. Because of direct skin contact, this is a personal strap that is maintained and sanitized regularly, for Emilio’s use only.

Toileting Procedure

This is the process that has worked best for Emilio:

• We place the body support system snugly around him and attach the thigh straps while Emilio is still seated in his wheelchair. The straps are positioned more proximally to the hip joint, for increased security.
• When we raise Emilio off the wheelchair surface, we add the third strap.
• Emilio is then lowered onto a high-low table. (Our table is open on the floor so it works well with the TRAM, as the TRAM wheels fit under the table.)
• We remove the TRAM straps and body support. Then we assist him into a supine position and help with clothing adjustment. After a supine-to-sit transition Emilio is lifted again with the TRAM from the high-low table to the toilet.  
• Important note: when we are lowering Emilio onto the toilet we have to remove the third thigh strap which can be difficult. We do this  when he is in contact with the toilet and he leans forward, allowing us to slide it out.
• We leave the body support system in place but loosened for comfort during toileting.
• After toileting, the body support system is secured as needed.
• We then raise Emilio up for hygiene, place the third strap and move him to the high-low table to complete the clothing adjustment. 
• Emilio is then transferred back to his wheelchair.

Using the TRAM, Emilio receives quality care for his hygiene needs and is provided the dignity of using a toilet. Additionally, both staff and student stay safe during the transfers.

David Zoller is a physical therapist working for the Socorro Independent School District in El Paso, Texas.