Short-term, early intensive power mobility training: case report of an infant at risk for cerebral palsy

Joystick-Operated Ride-On Toy Navigation Training for Children With Hemiplegic Cerebral Palsy: A Pilot Study

IMPORTANCE

Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

OBJECTIVE

To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

OUTCOMES AND MEASURES

We assessed children's acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children's affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

RESULTS

Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

CONCLUSIONS AND RELEVANCE

Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP. Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick-operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children's motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

Family-Professional Collaboration on Modified Ride-on Car Intervention for Young Children: Two Case Reports

AIMS

The study aimed to describe the implementation of a collaborative ride-on car (ROC) intervention by applying a practice model of family-professional collaboration. The model involves specific strategies for collaboration, "visualizing a preferred future" and "scaling questions."

METHODS

The participants were two young children with mobility limitations and their mothers. The 12-week of ROC intervention involved training sessions with a therapist and home sessions. The outcomes included the Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS).

RESULTS

The collaborative strategies facilitated parent engagement in goal setting, planning, and evaluation. After the intervention, the mothers' ratings of their children's performance and parent satisfaction on the COPM increased by 6 and 3 points, respectively, and the level of goal attainment exceeded expectations (+1 on GAS) in both families. Prior to the ROC intervention, both families were hesitant to use powered mobility. However, the experience of participating in the ROC intervention process broadened parents' perspectives on self-directed mobility and led them to explore options for their children to move independently.

CONCLUSIONS

The collaborative ROC intervention can be used as an intervention for early mobility and a bridging step for families reluctant to use a powered wheelchair.

Powered Mobility Device Use and Developmental Change of Young Children with Cerebral Palsy

Mobility is a fundamental human right and is supported by the United Nations and the ON Time Mobility framework. The purpose of this study was to understand the effect of a powered mobility intervention on developmental changes of children with cerebral palsy (CP). This study was a randomized, crossover clinical trial involving 24 children (12-36 months) diagnosed with CP or with high probability of future CP diagnosis based on birth history and current developmental status. Children received the Explorer Mini and a modified ride-on car in randomized order, each for 8 weeks. The Bayley Scales of Infant and Toddler Development-4th Edition was administered at baseline, mid-study, and end-of-study. Raw change scores were used for analysis. Total minutes of use per device was categorized as low or high use for analysis based on caregiver-reported driving diaries. Explorer Mini: The high use group exhibited significantly greater positive change scores compared to the low use group on receptive communication, expressive communication, and gross motor subscales (p < 0.05). Modified ride-on car: No significant differences between low and high use groups. Regardless of device, low use was associated with no significant developmental change and high use was associated with positive developmental changes. Mobility access is critical to maximize the development of children with CP and may be augmented by using powered mobility devices. Results may have implications for the development of evidence-based guidelines on dosage for powered mobility use.

RESNA position on the application of power mobility devices for pediatric users

This paper serves as an update to the previous RESNA Position on the Application of Power Wheelchairs for Pediatric Users with more current and additional scientific literature. This document contains typical clinical applications and best evidence from the literature supporting the application of power mobility (PM) for young children and to assist practitioners in decision-making and justification. It is RESNA' s position that age, limited vision or cognition, behavioral issues, and the ability to walk or propel a manual wheelchair short distances should not, in and of themselves, be used as discriminatory factors against providing PM for children. RESNA recommends early utilization of PM for children with mobility limitations as medically necessary, to promote integration and psycho-social development, reduce passive dependency, and to enhance participation, function, and independence.

Feasibility of Using Joystick-Operated Ride-on-Toys to Promote Upper Extremity Function in Children With Cerebral Palsy: A Pilot Study

PURPOSE

To evaluate the feasibility of implementation, acceptance, and perceived efficacy of a joystick-operated ride-on-toy intervention to promote upper extremity (UE) function in 3- to 14-year-old children with hemiplegic cerebral palsy.

METHODS

Exit questionnaires were collected from children, caregivers, and clinicians/camp staff following a 3-week ride-on-toy training program incorporated within a summer camp for children with hemiplegic cerebral palsy. Training encouraged children to use their affected UE to maneuver the ride-on-toy. Questionnaires included Likert scale and open-ended questions to assess enjoyment, acceptance, feasibility, and perceived efficacy of the training.

RESULTS

All stakeholder groups indicated that the training was enjoyable. Clinicians/staff and caregivers indicated that the training increased children's motivation to use their affected UE and reported perceived improvements in UE movement control and function following training.

CONCLUSIONS

Our promising preliminary findings call for future research to systematically assess the efficacy of ride-on-toys to promote UE control and function in children with hemiplegic cerebral palsy.Supplemental Digital Content 1 video abstract, available at: http://links.lww.com/PPT/A404.

Powered mobility interventions for very young children with mobility limitations to aid participation and positive development: the EMPoWER evidence synthesis

BACKGROUND

One-fifth of all disabled children have mobility limitations. Early provision of powered mobility for very young children (aged < 5 years) is hypothesised to trigger positive developmental changes. However, the optimum age at which to introduce powered mobility is unknown.

OBJECTIVE

The aim of this project was to synthesise existing evidence regarding the effectiveness and cost-effectiveness of powered mobility for very young children, compared with the more common practice of powered mobility provision from the age of 5 years.

REVIEW METHODS

The study was planned as a mixed-methods evidence synthesis and economic modelling study. First, evidence relating to the effectiveness, cost-effectiveness, acceptability, feasibility and anticipated outcomes of paediatric powered mobility interventions was reviewed. A convergent mixed-methods evidence synthesis was undertaken using framework synthesis, and a separate qualitative evidence synthesis was undertaken using thematic synthesis. The two syntheses were subsequently compared and contrasted to develop a logic model for evaluating the outcomes of powered mobility interventions for children. Because there were insufficient published data, it was not possible to develop a robust economic model. Instead, a budget impact analysis was conducted to estimate the cost of increased powered mobility provision for very young children, using cost data from publicly available sources.

DATA SOURCES

A range of bibliographic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence (OTseeker), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO, Science Citation Index (SCI; Clarivate Analytics, Philadelphia, PA, USA), Social Sciences Citation Index™ (SSCI; Clarivate Analytics), Conference Proceedings Citation Index - Science (CPCI-S; Clarivate Analytics), Conference Proceedings Citation Index - Social Science & Humanities (CPCI-SSH; Clarivate Analytics), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database and OpenGrey] was systematically searched and the included studies were quality appraised. Searches were carried out in June 2018 and updated in October 2019. The date ranges searched covered from 1946 to September 2019.

RESULTS

In total, 89 studies were included in the review. Only two randomised controlled trials were identified. The overall quality of the evidence was low. No conclusive evidence was found about the effectiveness or cost-effectiveness of powered mobility in children aged either < 5 or ≥ 5 years. However, strong support was found that powered mobility interventions have a positive impact on children's movement and mobility, and moderate support was found for the impact on children's participation, play and social interactions and on the safety outcome of accidents and pain. 'Fit' between the child, the equipment and the environment was found to be important, as were the outcomes related to a child's independence, freedom and self-expression. The evidence supported two distinct conceptualisations of the primary powered mobility outcome, movement and mobility: the former is 'movement for movement's sake' and the latter destination-focused mobility. Powered mobility should be focused on 'movement for movement's sake' in the first instance. From the budget impact analysis, it was estimated that, annually, the NHS spends £1.89M on the provision of powered mobility for very young children, which is < 2% of total wheelchair service expenditure.

LIMITATIONS

The original research question could not be answered because there was a lack of appropriately powered published research.

CONCLUSIONS

Early powered mobility is likely to have multiple benefits for very young children, despite the lack of robust evidence to demonstrate this. Age is not the key factor; instead, the focus should be on providing developmentally appropriate interventions and focusing on 'movement for movement's sake'.

FUTURE WORK

Future research should focus on developing, implementing, evaluating and comparing different approaches to early powered mobility.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018096449.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 50. See the NIHR Journals Library website for further project information.

Exploring the Unmet Need for Technology to Promote Motor Ability in Children Younger Than 5 Years of Age: A Systematic Review

Objective

To (1) identify types of technology that promote motor ability in children younger than 5 years of age, (2) report on the type of support these devices provide, and (3) evaluate their potential for use in the community (outside of the laboratory or clinic).

Data Sources

A literature search of PubMed was conducted in February 2019 using specific terms, including child, rehabilitation, movement, and instrumentation.

Study Selection

The search yielded 451 peer-reviewed articles, which were screened by multiple reviewers. Articles that described the use of devices for the purpose of motor rehabilitation and/or assistance (regardless of device type or body part targeted) in the age range of 0-5 years were eligible for inclusion.

Data Extraction

In conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, final stage data extraction consisted of full text readings where each article was reviewed twice by 3 independent reviewers.

Data Synthesis

About half of the devices available (46%) for children younger than 5 years of age are orthotics and corrective casting devices. There are more facilitative (ie, power mobility devices) than inhibitive (ie, casting) technologies being used. Approximately 60% of the devices are designed for use by a single body part. Walking is the most common motor skill addressed. Although most of the devices were used to some degree outside of the laboratory or clinic, most of the devices available are considered investigative and are not available for commercial purchase.

Conclusions

Many types of pediatric devices to assist movement exist, but the current scope of employed devices is limited. There is a need for developing technology that allows for, if not supports, high-dosage, early, and variable motor practice that can take place in community settings.

Modified Ride-on Cars as Early Mobility for Children with Mobility Limitations: A Scoping Review

Aim: This study aims to systematically examine and map current available evidence describing the benefits of modified ride-on car use for young children with mobility limitations and identify potential applications to occupational and physical therapy practice while illuminating gaps in knowledge to be explored in future research. Methods: An electronic database search, manual search of bibliographies, contact with existing networks and organizations were used to identify all relevant literature. Studies addressing modified ride-on toy use by children ≤6 years old with identified mobility delays were included. Data were extracted and analyzed independently by the investigators using a standardized process. Results: Thirteen case studies and one case controlled study involving children ≤6 years old with a variety of diagnoses were included in the review. Studies were at the activities and participation levels and focused on mobility, interpersonal interactions and relationships, communication, and Community, Social, and Civic Life. Conclusion: Findings support the use of modified ride-on cars as a form of early mobility to encourage the development of social-emotional and mobility skills in young children with mobility limitations. Future research with valid, reliable outcome measures that address changes in developmental levels across domains is indicated.

Standing Tall: Feasibility of a Modified Ride-On Car That Encourages Standing

PURPOSE

The purpose of this study was to determine the feasibility of infants with Down syndrome to use a modified ride-on car with seated and standing modes.

METHODS

Participants included 4 infants with Down syndrome. Families were asked to provide at least 8 minutes of modified ride-on car driving per day, at least 5 times per week throughout the 9-month intervention.

RESULTS AND CONCLUSIONS

Families demonstrated a variety of adherence rates to the intervention. Infants demonstrated independent activation of the modified ride-on car in seated and standing modes and enjoyed driving. The modified ride-on car intervention was feasible and warrants further testing to address barriers that influence adherence to the intervention.

Power mobility for children: a survey study of American and Canadian therapists' perspectives and practices

AIM

To explore the views and practices of paediatric occupational therapists and physical therapists in Canada and the USA regarding the implementation of power mobility for children with mobility limitations.

METHOD

This descriptive study utilized a web-based survey that included questions pertaining to therapists' decisions to trial and use power mobility, agreement or disagreement with statements developed from published practice considerations regarding power mobility, and the frequency of performing tasks related to power mobility prescription and training.

RESULTS

Most respondents reported that child characteristics (e.g. cognition, safety awareness) were important factors in decision-making about power mobility, whereas other child characteristics (e.g. communication abilities, age) were not as important. Family resources and home accessibility were also not considered important. The average age at which respondents considered power mobility for children was 2 years 3 months. The majority of respondents agreed with statements developed from published practice considerations and most frequently performed various power mobility tasks twice a year or less.

INTERPRETATION

Although most respondents appeared to have positive views regarding power mobility, few appeared to actively perform power mobility tasks in their practice. Resources to support therapists in the early introduction of power mobility may be beneficial.

WHAT THIS PAPER ADDS

Occupational and physical therapists positively view early introduction of power mobility for children with mobility limitations. Few therapists actively provide early power mobility experiences. Power mobility training and monitoring power mobility devices are important therapist roles.

Perspectives on Early Power Mobility Training, Motivation, and Social Participation in Young Children with Motor Disabilities

The efficacy of traditional training programs (e.g., neurodevelopmental therapy) in promoting independent mobility and early child development across all three International Classification of Functioning, Disability, and Health levels lacks rigorous research support. Therefore, early power mobility training needs to be considered as a feasible intervention for very young children who are unlikely to achieve independent mobility. This perspective article has three aims: (1) to provide empirical evidence of differences in early independent mobility, motivation, daily life activities, and social participation between young children with typical development and motor disabilities; (2) to discuss the contemporary concepts of and approaches to early power mobility training for young children with motor disabilities and the current need for changes to such training; and (3) to provide recommendations for early power mobility training in pediatric rehabilitation. Independent mobility is critical for social participation; therefore, power mobility can be accessible and implemented as early as possible, specifically for infants who are at risk for mobility or developmental delay. To maximize the positive effects of independent mobility on children's social participation, early power mobility training must consider their levels of functioning, the amount of exploration and contextual factors, including individual and environmental factors.

Power Mobility Training Methods for Children: A Systematic Review

PURPOSE

To summarize and critically appraise the existing evidence related to power mobility training methods used in research studies conducted with children 21 years or younger.

METHODS

A systematic review was conducted using 16 electronic databases to identify primary source quantitative studies published in peer-reviewed journals. Data extraction, determination of level of evidence, evaluation of methodological rigor, and assessment of the risk of bias were completed. The Evidence Alert Traffic Light Grading System (EATLS) was used.

RESULTS

Twenty-seven studies were included in the review. Levels of evidence were II to V; scientific rigor scores were 2 to 7.

CONCLUSIONS

An overall Yellow EATLS level of evidence was found indicating that therapists should use caution when providing power mobility training interventions and measure outcomes related to established goals in areas such as development, functional skills, or use of a power mobility device.

Current Status of the Utilization of Powered Wheelchair in Preschool Children with Locomotive Disability in Japan

[Purpose] This study aimed to elucidate the actual state of powered wheelchair (PWC) prescription for preschool children with disabilities in Japan, and also to determine the approximate number of preschool children with disabilities who would potentially benefit from PWC use. [Subjects and Methods] A total of 318 facilities providing rehabilitation for disabled children in Japan were enrolled in the study. A questionnaire about PWC use for preschoolers was mailed to the facilities. Each study items were analyzed employing the Fisher's exact test. [Results] Of the 318 facilities, consent to participate in this study was obtained from 108 (return rate: 34.0%). After PWC provision, many facilities reported improvement in quality of life indices for preschool children with disabilities. It was revealed that there were 6 preschool children from 2 to 6 years of age with disabilities who might acquire a means of independent locomotion through PWC provision and thereby experience improved quality of life. [Conclusion] There was no negative comment from the facilities studied about the prescription and provision of PWC for preschool children with disabilities.

A comparison of the efficacy of weight-shift vs. joystick control of a robotic mobility device by infants ages 5 to 10 months

The onset of crawling in infants contributes to cognitive, perceptual, social, and emotional development. Conversely, infants with motor impairment that delays or prevents autonomous mobility often have associated developmental delays. Evidence suggests that providing mobility may have positive developmental outcomes, however powered wheelchairs may not be recommended for very young children, due to safety concerns and the child's level of cognitive maturity. The WeeBot is a mobility device controlled by infant weight shifting while seated; infants as young as 5 months have learned to use it. This study compares the efficacy of using the WeeBot vs. using the traditional manual joystick to control a robotic mobility device. Participants were 20 typically developing infants between 5 and 10 months who had not yet achieved independent mobility. A quasi-experimental two-group design was used: The first 10 participants recruited used the WeeBot (weight-shift); the next 10 used the joystick. Results showed that infants learned to use weight-shift control more easily and more skilfully than did infants using the joystick. The ability of infants to use the WeeBot suggests that an intuitive alternative control might allow very early powered mobility for children with disabilities, which might have implications for various aspects of their development.

The use of modified ride-on cars to maximize mobility and improve socialization-a group design

AIM

To examine the effects of ride-on car (ROC) training versus conventional therapy on mobility and social function in young children with disabilities in a hospital-based environment.

METHODS AND PROCEDURES

Twenty young children with disabilities, aged 1-3 years, were recruited. The treatment group (n=10) received ROC training of 2h/session, 2 sessions/week for a total of 9 weeks in the hospital environment. The control group (n=10) received conventional therapy alone. Assessments included the Chinese version of the Pediatric Evaluation of Disability Inventory and the Parenting Stress Index.

OUTCOMES AND RESULTS

After a 9-week intervention, the treatment group showed improvements in mobility and social function, whereas the control group showed improvements in social function alone. Four children in the treatment group had clinically meaningful changes in mobility and 3 in social function, as compared to 2 and 1, respectively, in the control group.

CONCLUSIONS AND IMPLICATIONS

This is the first group study that demonstrated the potential benefits of ROC training on mobility and social function in young children with disabilities in the hospital environment. Future studies should include a larger sample size to detect any differences between ROC training and conventional therapy.

Power Mobility Training for Young Children with Multiple, Severe Impairments: A Case Series

AIMS

Young children with neurodevelopmental conditions are often limited in their ability to explore and learn from their environment. The purposes of this case series were to (1) describe the outcomes of using an alternative power mobility device with young children who had multiple, severe impairments; (2) develop power mobility training methods for use with these children; and (3) determine the feasibility of using various outcome measures.

METHODS

Three children with cerebral palsy (Gross Motor Function Classification System Levels IV, V, and V) ages 17 months to 3.5 years participated in the case series. Examination included the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) and the Dimensions of Mastery Questionnaire (DMQ). An individualized, engaging power mobility training environment was created for each participant. Intervention was provided for 60 minutes per week over 12 weeks.

RESULTS

All participants exhibited improvements in power mobility skills. Post-intervention PEDI-CAT scores increased in various domains for all participants. Post-intervention DMQ scores improved in Participants 1 and 2.

DISCUSSION

The participants appeared to make improvements in their beginning power mobility skills. Additional research is planned to further explore the impact of power mobility training in this unique population.

Electrically powered indoor/outdoor chair performance for children aged 7 to 9 years

Introduction

Northern Ireland wheelchair guidelines state that wheelchair users who wish to drive their National Health Service provided powered wheelchairs outdoors must complete an electrically powered indoor/outdoor chair test. Within the same guidelines, children in Northern Ireland under the age of 10 years are not permitted to complete this assessment. Research was completed to evaluate how children under 10 years would perform in electrically powered indoor/outdoor chair training and testing under adult supervision.

Method

A case-study design was utilised with three children aged 7–9 years to evaluate if: (a) these children can complete electrically powered indoor/outdoor chair training/testing safely with adult supervision; (b) the length of time using an electric powered indoor chair correlates with performance on electrically powered indoor chair training/testing; (c) the current Northern Ireland guidelines on age restriction should be re-evaluated so that each child is assessed on an individual basis rather than age.

Findings

Paediatric powered wheelchair users aged seven to nine years can become competent electrically powered indoor/outdoor chair users with adequate training and adult supervision. Length of time (years) driving an electrically powered indoor chair may not correlate with improved electrically powered indoor/outdoor chair performance.

Conclusion

Regional Northern Ireland criteria relating to electrically powered indoor/outdoor chair provision for children should be revised in order to consider an individual needs assessment, rather than imposing an age restriction.

Cerebral palsy

Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.

The child and family experience of power mobility: a qualitative synthesis

AIM

The aim of this study was to critically synthesize qualitative evidence regarding the child and family experience of power mobility, and to examine how this evidence fits with current theoretical concepts.

METHOD

Electronic database/hand searches were undertaken in September 2012 and updated in February 2014. The searches were restricted to qualitative studies published in English before February 2014 that included at least one child under the age of 19 with a disability and described an outcome related to the use of power mobility. Inclusion criteria were set a priori. Two reviewers independently screened titles, abstracts, and full-text articles and extracted data. McMaster qualitative review forms were used for quality appraisal.

RESULTS

Of 259 titles, 21 met inclusion criteria. From 143 codes, 15 second-order themes were developed using constant comparison and analysis. Three overarching themes emerged: power mobility experience promotes developmental change and independent mobility; power mobility enhances social relationships and engagement in meaningful life experiences; and power mobility access and use is influenced by factors in the physical, social, and attitudinal environment.

INTERPRETATION

This qualitative research provides rich and rigorous evidence supporting the benefits of power mobility for children and families. Numerous factors, which warrant careful consideration, influence power mobility access and use.

Promoting leisure participation as part of health and well-being in children and youth with cerebral palsy

Participation in leisure is a human right and is central to the health of children and youth. The World Health Organization's International Classification of Functioning, Disability and Health for Children and Youth supported a change in thinking about what outcomes are most relevant in the context of children's health and places participation as one of the constituent elements of health. Participation is also a fundamental rehabilitation and health promotion outcome for children with cerebral palsy as identified by youth, parents, and health professionals. Several studies have identified individual and environmental factors related to participation in leisure; new studies are now determining the best interventions to promote participation. This article summarizes recent findings and proposes important topics for neurologists to consider in exploring leisure pursuits with children with cerebral palsy and their families and in working with rehabilitation professionals to promote engagement in leisure opportunities as part of integrated care.

Systematic review of power mobility outcomes for infants, children and adolescents with mobility limitations

OBJECTIVE

To summarize and critically appraise the evidence related to power mobility use in children (18 years or younger) with mobility limitations.

DATA SOURCES

Searches were performed in 12 electronic databases along with hand searching for articles published in English to September 2012 and updated February 2014.

REVIEW METHODS

The search was restricted to quantitative studies including at least one child with a mobility limitation and measuring an outcome related to power mobility device use. Articles were appraised using American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) criteria for group and single-subject designs. The PRISMA statement was followed with inclusion criteria set a priori. Two reviewers independently screened titles, abstracts and full-text articles. AACPDM quality ratings were completed for levels I-III studies.

RESULTS

Of 259 titles, 29 articles met inclusion criteria, describing 28 primary research studies. One study, rated as strong level II evidence, supported positive impact of power mobility on overall development as well as independent mobility. Another study, rated as moderate level III evidence, supported positive impact on self-initiated movement. Remaining studies, rated evidence levels IV and V, provided support for a positive impact on a broad range of outcomes from to International Classification of Functioning (ICF) components of body structure and function, activity and participation. Some studies suggest that environmental factors may be influential in successful power mobility use and skill development.

CONCLUSION

The body of evidence supporting outcomes for children using power mobility is primarily descriptive rather than experimental in nature, suggesting research in this area is in its infancy.

A path model for evaluating dosing parameters for children with cerebral palsy

Dosing of pediatric rehabilitation services for children with cerebral palsy (CP) has been identified as a national priority. Establishing dosing parameters for pediatric physical therapy interventions is critical for informing clinical decision making, health policy, and guidelines for reimbursement. The purpose of this perspective article is to describe a path model for evaluating dosing parameters of interventions for children with CP. The model is intended for dose-related and effectiveness studies of pediatric physical therapy interventions. The premise of the model is: Intervention type (focus on body structures, activity, or the environment) acts on a child first through the family, then through the dose (frequency, intensity, time), to yield structural and behavioral changes. As a result, these changes are linked to improvements in functional independence. Community factors affect dose as well as functional independence (performance and capacity), influencing the relationships between type of intervention and intervention responses. The constructs of family characteristics; child characteristics (eg, age, level of severity, comorbidities, readiness to change, preferences); plastic changes in bone, muscle, and brain; motor skill acquisition; and community access warrant consideration from researchers who are designing intervention studies. Multiple knowledge gaps are identified, and a framework is provided for conceptualizing dosing parameters for children with CP.

Modified toy cars for mobility and socialization: case report of a child with cerebral palsy

PURPOSE

Children with cerebral palsy have limited opportunities to explore their physical and social environment. The purpose of this study was to determine the feasibility of using a "ride-on toy car" as a readily available, low-cost, fun, and functional option for children with special needs.

METHODS

Brenden, a 21-month-old child, was provided a modified ride-on toy car for a 15-week study period divided up into a 1-week baseline, 12-week intervention, and 2-week postintervention. We coded mobility and socialization measures from video recordings.

RESULTS

Brenden was more mobile and had more vocalizations during the 12-week intervention.

CONCLUSIONS

Modified toy cars have serious potential to be a fun and functional power mobility option for children with special needs. The opportunity now exists to quantify several effects, including peer socialization, cognitive measures, and body structure/function goals involving neural, muscular, and skeletal physiology. Group study is required to formally test these findings.

Modified ride-on car for mobility and socialization: single-case study of an infant with Down syndrome

PURPOSE

Before the onset of walking, children with Down syndrome experience limited mobility yet are never considered candidates for traditional powered mobility devices. The purpose of this single-case study is to quantify the feasibility and family perceptions of including modified ride-on car use as an option for increasing daily mobility, socialization, and fun for a child with Down syndrome.

METHODS

A 13-month-old child, Natalie, and her family were video recorded during the 28-week study using her ride-on car in their home and community.

RESULTS

Natalie demonstrated and her family reported increased movement, mobility, and socialization over the study period.

CONCLUSIONS

Ride-on car use appears feasible, fun, and functional to increase daily mobility for pediatric populations working toward independent walking.

Independent mobility after early introduction of a power wheelchair in spinal muscular atrophy

Weakness resulting from spinal muscular atrophy causes severe limitations in functional mobility. The early introduction of power mobility has potential to enhance development and mitigate disability. These outcomes are achieved by simulating normal skill acquisition and by promoting motor learning, visuospatial system development, self-exploration, cognition, and social development. There are few reports on early power mobility in spinal muscular atrophy, and it is typically not prescribed until school age. The authors evaluated 6 children under age 2 years with neuromuscular disease (5 spinal muscular atrophy, 1 congenital muscular dystrophy) for power mobility. Parents recorded the practice hours necessary to achieve independence using the Power Mobility Skills Checklist. Four children achieved independence in all items on the checklist by 7.9 months (range: 73-458 days). Introduction of early power mobility is feasible in spinal muscular atrophy patients under age 2 years and should be introduced in late infancy when children typically acquire locomotor skills.

Facilitating Child Participation through Power Mobility

Wheeled power mobility can fulfil an intrinsic desire to be mobile, to explore one's environment and to be active and participate in occupations regardless of age. This opinion piece briefly presents the potential of power mobility for children with physical impairments, the recent evidence base, an exploration of the readiness and training of children in the use of power mobility, and current United Kingdom prescription practice. This mode of intervention should no longer be considered as the final option but, rather, as a tool to prevent passivity and dependence and to enable children to optimise their participation in childhood occupations.