Powered mobility and preschoolers with complex developmental delays

A study on the effectiveness of training in the operation of an electric mobility aid in severely mentally and physically handicapped children

Hideshima Y, Asami T, Ichiba M, Matsuo K, Murata T. A study on the effectiveness of training in the operation of an electric mobility aid in severely mentally and physically handicapped children. Jpn J Compr Rehabil Sci 2024; 15: 8-16.

Purpose

We examined whether operation training for children with severe mental and physical disabilities using recently developed electric mobility aids improves their skills in operating such aids and their daily activities. By doing so, we aimed to clarify the effectiveness of electric mobility aid operation training for children with severe mental and physical disabilities.

Method

Operation training and normal training using an electric mobility aid were conducted for 42 school-aged children with severe mental and physical disabilities, aged 8-18 years old. The trainee children were randomly assigned to two groups: 21 to the intervention group to receive operation training and 21 to the control group to receive general training. The intervention lasted 20 minutes/training session, with three sessions/week over a period of eight weeks. The Powered Mobility Program (PMP) and Pediatric Evaluation of Disability Inventory (PEDI) were used for pre- and post-intervention assessments, and SPSS was used for two-way analysis of variance (ANOVA).

Results

PMP scaled scores significantly increased (p = 0.001) in both groups, but there was no interaction effect. The PEDI scaled scores did not significantly increase in either of the two groups.

Discussion

The effects of the intervention and use of the electric mobility aid on the operating skills of children with severe mental and physical disabilities were explicitly demonstrated. Future long-term studies are required to clarify the effects of training in the operation of electric mobility aids on the subsequent development of severely physically and mentally handicapped children.

Movement as a Gateway to Participation for Individuals With Neuromotor Conditions: A Scoping Review

PURPOSE

The purpose of this scoping review was to examine and analyze the developmental and rehabilitation literature related to movement and participation at key points of transition for individuals with neuromotor conditions.

METHODS

Arksey and O'Malley's scoping review protocol was applied, and 37 articles were included. Extracted data included population, developmental transition points, movement opportunity, type of participation, and outcome measures.

RESULTS

Most studies covered developmental transition points; none examined transitions as a variable for participation outcomes. Physical activity/exercise was the most common movement opportunity. Most publications used formal outcome measures of participation; others used observation or interviews.

CONCLUSION

No publications adequately addressed the effect of movement opportunities on participation during developmental transition points.

Active mobility, active participation: a systematic review of modified ride-on car use by children with disabilities

BACKGROUND

Modified ride-on cars (MROC) are a low-cost option to provide self-directed mobility to children with mobility limitations, in lieu of or as a precursor to other powered mobility devices.

OBJECTIVES

We appraised evidence to (1) describe and categorize MROC study characteristics, (2) synthesize existing knowledge of children's use of MROCs and (3) frame outcomes within the International Classification of Functioning, Disability and Health (ICF) framework.

METHODS

Articles were identified through four electronic databases: Medline, CINAHL, PsycNET, and Web of Science. We included all published, peer-reviewed studies involving MROC use. Relevant data were extracted, and articles were appraised using the American Academy of Cerebral Palsy and Developmental Medicine criteria for group and single-subject designs.

RESULTS

23 studies met inclusion criteria of 204 titles identified from 1980 to 2021. Study designs included case studies, case series, group designs, and qualitative research, but only three studies were rated evidence level III or higher. Children with a range of disabilities used MROCs across multiple settings, including the home, hospital, and community, though use and adherence varied widely. Positive impacts were reported on a range of outcomes related to the ICF framework, with an emphasis on activity and participation.

CONCLUSIONS

MROC studies have primarily addressed activity and participation, with most studies suggesting increased functional mobility and social interactions due to MROC use. More robust research designs with larger samples are needed in order to develop evidence-based strategies for MROC use.IMPLICATIONS FOR REHABILITATIONPhysical and occupational therapists may consider using MROCs as a therapeutic tool or accessible play opportunity as part of a multi-modal approach to increase children's mobility, family engagement, and participation in community life.Personal (e.g., child's enjoyment) and environmental factors (e.g., caregiver attitudes and stress) must be considered when developing plans of MROC 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.

Effect of adapted motorized ride-on toy use on developmental skills, quality of life, and driving competency in nonambulatory children age 9-60 months

Adapted motorized ride-on toys (AMTs) provide a feasible option for independent mobility in children with physical limitations. This study explores implications of AMT use on developmental domains and participation in daily activities. It also pilots the Power Mobility Skills Checklist (PMSC) for assessment of AMT operation competency. Nine nonambulatory children, ages 10-35 months, completed a 16-week AMT intervention. The Battelle Developmental Inventory-2 (BDI-2) and Assessment for Life Habits for Children (Life-H) were completed pre- and poststudy to evaluate developmental skills and participation in daily activities. The PMSC was completed at 2-week intervals to assess AMT driving ability. PMSC scores improved significantly for all participants across the intervention. BDI-2 developmental quotients demonstrated clinically significant gains in motor, cognitive, adaptive, communication, and personal-social domains, which varied between participants. Life-H changes were not significant. Improvements in PMSC change scores were associated with more total AMT sessions and increased BDI-2 gains. The PMSC may be effective for obtaining quantitative data on AMT operation and sensitive for assessing change in driving competency.

In the Driver's Seat: A Randomized, Crossover Clinical Trial Protocol Comparing Home and Community Use of the Permobil Explorer Mini and a Modified Ride-On Car by Children With Cerebral Palsy

OBJECTIVE

The aims of this study are 2-fold: (1) to evaluate a powered mobility intervention to promote developmental, activity, and participation outcomes of young children aged 12 to 36 months who have cerebral palsy; and (2) to compare the use patterns (frequency, duration, environment) of 2 different powered mobility options.

METHODS

This study is a multisite, mixed-methods, doubly counterbalanced, randomized, crossover clinical trial, where intervention A is the Permobil Explorer Mini and intervention B is a modified ride-on toy car. The study will take place in rural and urban home and community settings surrounding 3 sites (Washington, Oregon, and Michigan). There will be 24 child-caregiver dyads in the study (8 dyads per site). Primary outcome measures include the Bayley Scale of Infant and Toddler Development, the Youth and Children's Participation and Environment Measure, the Assessment for Learning Power mobility use, automated device use tracking logs, caregiver semistructured interviews, and the Acceptability, Feasibility, and Intervention Appropriateness Measures. Secondary measures include the Child Engagement in Daily Life and caregiver diaries.

IMPACT

The use of powered mobility devices for young children with cerebral palsy has gained traction, with evidence that the use of powered mobility at young ages complements (rather than detracts from) other interventions focused on more traditional mobility skills such as crawling and walking. However, research is limited, and often comprised of low-level evidence. Given the clearance of the first powered mobility device for infants, the Permobil Explorer Mini, and the recent popularity of modified ride-on toy cars as an alternative for powered mobility for young children with disabilities, this study will contribute to rigorous examination of the developmental outcomes, use patterns, and caregiver perceptions of these novel devices.

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.

Perceived Barriers of Modified Ride-On Car Use of Young Children With Disabilities: A Content Analysis

PURPOSE

Modified ride-on cars have emerged as an early powered mobility option for young children with disabilities. The purpose of this study was to identify, extract, and synthesize perceived barriers of modified ride-on car use reported in previous studies.

METHODS

This study was descriptive using a qualitative content analysis of previously published studies identified from a systematic literature search.

RESULTS

Categories of perceived barriers were identified: device, environmental, child-related perceived barriers regarding health, tolerance, and abilities, and caregiver-related perceived barriers regarding physical requirements, time, and motivation. Device and environmental perceived barriers were the most reported.

CONCLUSIONS

Pediatric physical therapists play a critical role in working with families to promote their self-efficacy for using the modified ride-on car and their capacity for overcoming the inherent difficulties associated with use. Most of the reported perceived barriers are modifiable, at least to some degree, with likely effects on modified ride-on car use.

Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy

PURPOSE

To investigate the short-term effectiveness of the first adaptive seating system received by children with non-ambulatory cerebral palsy (CP) who are classified as level IV or V according to the Gross Motor Function Classification System.

MATERIALS AND METHODS

A trained clinical assessor examined 20 children with non-ambulatory CP (mean age: 4.5 years) for their trunk control ability in static, active, and reactive tasks using the Segmental Assessment of Trunk Control. Their primary caregivers were also interviewed about their child's activity and participation using the Paediatric Evaluation of Disability Inventory Computer - Adaptive Test in daily activity and social/cognitive domains and Family Impact of Assistive Technology Scale for Adaptive Seating in child and family functioning domains. Data for each measure were collected 3 times: at baseline (pre-intervention) and then 6 weeks and 3 months after children received their first adaptive seating system.

RESULTS AND CONCLUSION

The static and active trunk control scores between baseline and 6 weeks, and baseline and 3 months significantly improved. Daily activity scaled scores significantly improved between baseline and 3 months, and 6 weeks and 3 months. Significant, large gains in child and family functioning overall were detected between baseline and 6 weeks, and baseline and 3 months. These findings provide emerging evidence of multidimensional effects associated with the introduction of a first adaptive seating system into the lives of young children with non-ambulatory CPIMPLICATIONS FOR REHABILITATIONThe introduction of an adaptive seating system into the wheelchair of children with non-ambulatory cerebral palsy may be associated with short-term gains in body function, activities, participation and aspects of the child's environment.

Enhanced Steering and Drive Adaptations of Modified Ride-On Toy Cars for Improved Directional Control in Very Young Children With Severe Multiple Developmental Impairments

Background and Purpose: One emerging power mobility device (PMD) option that has gained recognition as a means for a cost-effective introduction to power mobility for young children is the battery powered modified ride-on toy car. Many groups, nationally and internationally, have been modifying battery powered ride-on toy cars by adding seating support and a large center placed push button switch for motor activation. The purpose of this technical report is to introduce an enhanced steering and drive system based on proportional control through a joystick. Key Points: This report offers (1) a technical description of these modifications that allow directional steering and programmable starting and driving velocity, (2) an example of a modified ride on toy, including common seating modifications, and (3) a short summary of results from a group of 7 children under the age of six with complex, severe disabilities. Clinical Impact: Although proportional joystick modifications are more complex than the common single switch activation, they allow children greater control to achieve self-initiated, self-directed movement that allow play, peer interaction, and exploration in their natural environments, even in the most highly complex cases. All seven children were able to intentionally self-initiate activation of the modified ride-on car and experience the subsequent movement.

Comparing children's driving abilities in physical and virtual environments

PURPOSE

To compare children's driving abilities in a physical and virtual environment and to validate the McGill Immersive Wheelchair Simulator (MiWe-C) for the use of children with disabilities.

MATERIALS AND METHODS

Participants included 30 children (17 males, 13 females; mean age 14 y 1 mo, [SD 3 y 6 mo]; range: 5-18 y) with cerebral palsy, neuromuscular disease and spinal cord injury. All children were proficient drivers with more than 3 months' experience, who had their own powered wheelchairs. Participants drove a 15-minute physical route and high-fidelity simulation of that route in a counterbalanced order. Performance of the two routes was compared using the 32 item Powered Mobility Programme (PMP). Differences between the driving modes were analyzed with the non-parametric Wilcoxon signed-rank test. Significance was set at α = 0.05.

RESULTS

The scores for the total PMP score as rated during both simulator wheelchair driving and during physical driving were very high (M = 4.90, SD = 0.20; M = 4.96, SD = 0.12, respectively) with no significant difference between them (z= -1.69, p = .09). Five out of the 32 PMP tasks showed significant differences between driving modes (narrow corridors, crowded corridors, doorway, sidewalks), with higher scores for the physical driving mode.

CONCLUSIONS

Having a validated powered mobility simulator for children provides a viable option for an additional practice mode. The MiWe-C simulator is affordable and a user-friendly simulator that can be used anywhere including at home and in school. Children can be independent when practicing even if they are not yet proficient drivers since continual adult assistance is not needed.Implications for rehabilitationHaving a validated powered mobility simulator for children provides a viable option for an additional practice mode.The MiWe-C is now validated to be used with children 5-18 years with physical disabilities.The MiWe-C is one of the few options for children to practice outside of a research environment.

Use of single-subject research designs in seating and wheeled mobility research: a scoping review

Background: Evidence-based practice (EBP) in seating and wheeled mobility practice is often hindered by a dearth of published research.Purpose: The purpose of this review was to explore and critically appraise the use of single-subject research designs (SSRDs) in seating and wheeled mobility studies published between January 1995 and May 2018.Study Selection: Primary source, peer-reviewed SSRDs focused on exploring the impact of a seating and wheeled mobility intervention were included in the review.Data Extraction: Relevant data extraction, determination of level of evidence, evaluation of methodological rigor, and assessment of the risk of bias were each independently performed.Data Synthesis: The review yielded 19 studies (2 Level III, 15 Level IV, and 2 Level V). A majority of these studies incorporated a withdrawal-type of SSRD and involved subjects representing patient populations with seating and wheeled mobility needs. Methodological rigor/quality features most commonly absent in the included studies included: blinding/masking, inter-rater or intra-rater reliability, >5 data points in each phase, planned replication (≥3 subjects), procedural fidelity methods, randomization, stability of the data during baseline, statistical analyses and use of subject selection criteria. The limited number of published SSRDs, combined with the lower levels of evidence (Levels III-V) provided by these studies, indicates that the use of SSRDs in seating and wheeled mobility research is in the early stages of development.Conclusions: Increasing the methodological quality and rigor as well as reporting methods in future SSRDs involving seating and wheeled mobility interventions may help to support EBP in this area.Implications for RehabilitationSingle-subject research designs (SSRDs) offer both researchers and clinicians the opportunity to contribute to the existing knowledge base in ways that reflect actual clinical practice.SSRDs provide flexibility in adapting and modifying seating and wheeled mobility-related assistive technology devices to meet the individual needs of specific subjects.SSRDs preserve individual responses to seating and wheeled mobility-related assistive technology devices.SSRDs may help to enhance evidence-based practice (EBP) in seating and wheeled mobility practice by spanning the divide between research and practice.Increasing the methodological quality and rigor as well as reporting methods in future SSRDs may help to support EBP in seating and wheeled mobility practice.

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.

Mobility in pictures: a participatory photovoice narrative study exploring powered mobility provision for children and families

AIM

Rehabilitation professionals are increasingly recognizing mobility as a basic human right and endorsing the efficacy of early powered mobility for children with mobility impairments to foster independence, promote socialization with peers and facilitate participation in family and community life. However, the relationship between mobility and technology provision, when considered in the context of lived experiences of children with mobility impairments and their families, is complex and understudied. Perceptions of these experiences from children's own points of view are especially limited, as is the use of participatory research methods in describing these experiences. The purpose of this study was to empower children and families as co-researchers, investigating their experiences and perspectives of powered mobility provision processes and early use of their mobility technology in their own words and images.  Methods: Two families in a major Midwest metropolitan area- one who was receiving a powered wheelchair and one who was receiving a modified powered ride-on toy car- participated as co-researchers from 2015-2016, documenting their experiences with a research camera and narrating their photos to describe meaningful or important aspects of their respective powered mobility provision processes and early use of their devices.

RESULTS

Four themes emerged: (1) Dys/Function of Mobility Technology; (2) Daily Life, Play and Participation; (3) Emerging Self/Advocacy and (4) Complex Family/Industry Interplay.  Conclusions: These themes and experiences may inform further innovation in powered mobility practices, generate new hypotheses about the role of technology in shaping disability identity and demonstrate the feasibility and impact of using participatory methods more broadly in rehabilitation research. Implications for Rehabilitation Participatory methods may be a useful and underutilized research tool in describing the impact of powered mobility provision processes on child and family experiences of technology and disability. Empowering children and families as co-researchers is important to move the field of powered mobility technology forward in creating innovative, accessible and socially welcoming devices and processes. It is important to capture the similarities and differences in child and family perceptions and experiences within different models of powered mobility provision, such as traditional powered wheelchair prescription and crowdsourced ride-on toy car modification. Powered mobility provision processes and the perceptions and experiences of children and families move beyond business or medical transactions and may help shape disability identity and pride. A disability studies framework may be useful in analyzing the complexities of technology provision and the nuanced interplay between bodies and technology.

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.

Feasibility of a Modified Ride-on Car Intervention on Play Behaviors during an Inclusive Playgroup

AIMS

Children with mobility related disabilities often experience limited participation and access to social interactions. An emerging pediatric powered mobility device are modified ride-on cars that provide self-directed mobility experiences to children with disabilities. This study aimed to determine: (1) the feasibility of a modified ride-on car intervention during an inclusive playgroup, (2) the effect of a modified ride-on car intervention on the play behaviors of children with and without mobility related disabilities.

METHOD

A single-subject research design was implemented. Thirteen children participated in a weekly inclusive playgroup. The five children with mobility related disabilities were provided modified ride-on cars during the intervention. Children's play behaviors were classified with Howes' Peer Play Scale. Intervention effects were examined using nonoverlap of all pairs (NAP).

RESULTS

The intervention was feasible based on participants' good attendance, retention rates, and successful use of modified ride-on cars. Overall children did not experience significant changes in play behaviors, with a few exceptions for decreased solitary, and increased parallel play, and/or direct peer interaction, among children with mobility related disabilities. Future research could examine modified ride-on car use by children with mobility related disabilities focusing on changes in unique play interactions between children with and without disabilities.

Ride-On Car Training for Behavioral Changes in Mobility and Socialization Among Young Children With Disabilities

PURPOSE

To characterize behavioral changes in mobility and socialization in children with disabilities aged 1 to 3 years while they are receiving ride-on car training in the hospital environment.

METHODS

Ten young children with motor disabilities received ride-on car training for 9 weeks (2 hours per session, 2 sessions per week). The driving and socialization behaviors were videotaped for 20 minutes per session (1 session per week) within the same period.

RESULTS

Independent mobility, visual attention to the switch, and positive facial expressions during the training period were significantly improved.

CONCLUSIONS

Ride-on car training has positive effects on behavioral changes in mobility and socialization among young children with motor disabilities. This provides clinicians a novel option for implementing early mobility training in a hospital-based environment.

Underappreciated challenges to pediatric powered mobility - Ways to address them as illustrated by a case report

Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) has published a position paper strongly advocating powered mobility (PM) for children with severe physical limitations (Rosen et al., 2009). Many studies have established that there are gains in social skills and functional mobility. While PM can aid independence, there has been more emphasis on the improvements in socialization rather than the positive changes PM can make in a child's daily living. For example, Bottos and colleagues stated the quality of life did not change for the children in their study (2001). This could be an explanation for why insurance companies deny coverage for PM. However, without coverage for PM, these children face major barriers to mobility and accessibility, even if they are able to use PM at physical therapy. If they obtain PM at home through other funding, transportation still remains an issue. These barriers have not been addressed or only briefly mentioned. We present a case of a 2 years 10 months old boy with rachischisis (cervical level spina bifida) who had impressive gains in both functional communication and social skills through achieving PM.

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.

Wheelchair Needs for Children and Young People: A Review

This work was commissioned by a charity, the Physical Disability and Sensory Impairment Forum, owing to local parental concerns relating to the assessment for and provision of mobility equipment. The project was set up as a preliminary investigation to consider those concerns. A literature review was carried out in order to establish current practice in the National Health Service wheelchair service in England, the role of the wheelchair in children's mobility, the wheelchair and seating needs of children and the met and unmet need. A questionnaire was distributed to children and their parents to gain their views. The response rate was disappointingly poor and, therefore, the results are not presented. However, the full report is available from the author.

The Effect of a Non-Powered, Self-Initiated Mobility Program on the Engagement of Young Children with Severe Mobility Limitations in the South African Context

AIM

To determine the effect of a non-powered, self-initiated mobility program on the engagement of young children with severe mobility limitations, in the South African context.

METHODS

A multiple-probe-across-participant design was used. Four children (aged 2-6 years) with severe mobility limitations underwent an intervention that targeted non-powered, self-initiated mobility. The intervention comprised eight sessions over a 2-week period. Engagement was measured during each baseline, intervention and postintervention session using the Individual Child Engagement Record-Revised (ICER-R). The data were presented graphically and analyzed using statistical procedures appropriate for single-subject designs.

RESULTS

Participants demonstrated an improvement in engagement during the time in which non-powered, self-initiated mobility program was introduced. A reciprocal deterioration in nonengagement was also demonstrated. The results of the study are discussed in terms of various intrinsic and extrinsic factors.

CONCLUSIONS

The use of a non-powered, self-initiated mobility program may be effective in improving engagement in some young children with severe mobility limitations.

'Participation': a systematic review of language, definitions, and constructs used in intervention research with children with disabilities

AIM

Improving participation of children with disabilities is a priority; however, the participation construct lacks clarity. This systematic review investigated how researchers defined 'participation' and the language used in participation intervention research.

METHOD

Nine health and education databases were searched for intervention studies of children with disabilities that included a participation outcome. Quantitative data were extracted using a customized form, and participation text data were extracted verbatim. Themes were derived using a thematic coding approach. These participation themes were applied to the outcome measures used in the included studies to compare participation language with the methods used to quantify participation changes.

RESULTS

Of the 2257 articles retrieved, 25 were included in this review. Five participation themes and nine subthemes were developed. Two themes, attendance and involvement, were directly related to the participation construct. Three additional themes described related concepts: preferences, activity competence, and sense of self.

INTERPRETATION

Attendance and involvement seem to describe the essence of the participation concept. The related themes may provide important avenues to enhance participation outcomes. This review highlighted the need for researchers to define the construct under investigation clearly and select measures carefully, as measurement choice is the mechanism through which the concept is operationalized in research.

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 self-exploration and function through an individualized power mobility training program

PURPOSE

This case report describes the development and implementation of an intervention program that used a Power Wheelchair Trainer (Trainer) to enable an individual with severe impairments to participate in power mobility training.

CASE DESCRIPTION

The participant was an 18 year-old female with spastic quadriplegic cerebral palsy, Gross Motor Function Classification Level V. The examination included the Power Mobility Screen and the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD). Switches on the participant's headrest provided control of the Trainer. Intervention consisted of power mobility training in an engaging environment that was set-up to focus on specific power mobility skills.

RESULTS

Scores on the Power Mobility Screen and the CPCHILD were higher after intervention.

DISCUSSION

The outcomes of this case report appear to support the use of the Trainer, which allowed the participant to practice power mobility skills and participate in self-exploration of her environment.

Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework

Background

Wheelchairs for disabled children (≤18 years) can provide health, developmental and social benefits. World Health Organisation and United Kingdom Government reports demonstrate the need for improved access to wheelchairs both locally and internationally. The use of health economics within this field is lacking. Provision of wheelchairs based on cost-effectiveness evidence is not currently possible. We conducted the first systematic review in this field to incorporate evidence of effectiveness, service user perspectives, policy intentions and cost-effectiveness in order to develop a conceptual framework to inform future research and service development.

Methods

We used an adapted EPPI-Centre mixed-method systematic review design with narrative summary, thematic and narrative synthesis. 11 databases were searched. Studies were appraised for quality using one of seven appropriate tools. A conceptual framework was developed from synthesised evidence.

Results

22 studies and 14 policies/guidelines were included. Powered wheelchairs appear to offer benefits in reduced need for caregiver assistance; improved communicative, personal-social and cognitive development; and improved mobility function and independent movement. From 14 months of age children can learn some degree of powered wheelchair driving competence. However, effectiveness evidence was limited and low quality. Children and parents placed emphasis on improving social skill and independence. Participation in wider society and development of meaningful relationships were key desired outcomes. Policy intentions and aspirations are in line with the perspectives of children and parents, although translation of policy recommendations into practice is lacking.

Conclusions

There is a distinct lack of high quality effectiveness and economic evidence in this field. Social and health needs should be seen as equally important when assessing the mobility needs of disabled children. Disabled children and parents placed highest priority on independence and psychosocial outcomes of wheelchair interventions. Translation of policy and guidelines into practice is lacking and more effective implementation strategies are required to improve services and outcomes. Future research should focus on outcome measure development, developing economic evaluation tools and incorporating these into high quality studies to address known research gaps. The novel conceptual framework maps current gaps in evidence and outlines areas for development.

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.

Practice considerations for the introduction and use of power mobility for children

AIM

The aim of the study was to support clinicians in recommending and justifying power mobility for children of different ages and abilities, and with different needs. The study comprised three distinct parts: a literature review; a Delphi consensus; and clinical practice considerations.

METHOD

A scoping review of eight electronic databases and manual searches carried out in February 2011 identified 15 themes or transferable messages among 27 articles meeting initial inclusion criteria and these formed the basis of a draft paper. Informal consensus at two international conference presentations refined and modified the paper to include 10 messages supported by 24 articles. The literature review was updated in May 2012 and a modified Delphi process sought to formalize the consensus process with an international panel of 16 expert clinicians and researchers using a priori criteria of 80% agreement.

RESULTS

Evidence from studies was classified using the American Academy of Cerebral Palsy and Developmental Medicine guidelines, with evidence from most studies being classified as either level IV or level V, apart from one study each with evidence classified as level II and level III. Expert consensus on the content and wording of nine transferable messages may raise evidence overall to level III.

INTERPRETATION

This paper suggests that power mobility may reasonably be considered as an effective and appropriate intervention for children lacking efficient, independent mobility from around 12 months of age including children who may never become competent drivers and children lacking independent mobility only in early childhood.

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.

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.

Effects of power wheelchairs on the development and function of young children with severe motor impairments

PURPOSE

The purpose of this pilot randomized controlled study was to identify any effects of power wheelchairs on the development and function of young children with severe motor impairments.

METHODS

Participants were 28 children with various diagnoses, aged 14 to 30 months when they entered the study. The Battelle Developmental Inventory (BDI), Pediatric Evaluation of Disability Inventory, and Early Coping Inventory were administered at entry and after 12 months.

RESULTS

The on-protocol analysis comparing median change scores showed the experimental groups' BDI receptive communication scores, and their Pediatric Evaluation of Disability Inventory mobility functional skills, mobility caregiver assistance, and self-care caregiver scores improved significantly more than the control group's scores. An intention-to-treat analysis upheld the findings and revealed an additional difference between the groups' BDI total score.

CONCLUSION

The results support use of power wheelchairs with children as young as age 14 months to enhance development and function, although additional research is needed.

Modified ride-on toy cars for early power mobility: a technical report

BACKGROUND AND PURPOSE

Children with significantly decreased mobility have limited opportunities to explore their physical and social environment. A variety of assistive technologies are available to increase mobility; however, no single device provides the level of functional mobility that children developing typically enjoy. The purpose of this technical report is to formally introduce a new power mobility option--the modified ride-on toy car.

KEY POINTS

This report will provide (a) an overview of toy car features, (b) examples of basic electrical and mechanical modifications, and (c) a brief clinical case.

CLINICAL IMPLICATIONS

With creative use and customized modifications, toy cars can function as a "general learning environment" for use in the clinic, home, and school. As such, we anticipate that these cars will become a multiuse clinical tool to address not only mobility goals but also goals involving body function and structure such as posture and movement impairments.

The impact of early powered mobility on parental stress, negative emotions, and family social interactions

Powered mobility has been found to have positive effects on young children with severe physical disabilities, but the impact on the family has been less well documented. We evaluated the impact of early powered mobility on parental stress, negative emotions, perceived social interactions, and parental satisfaction with wheelchair characteristics such as size and durability. The participants were parents of 23 children with disabilities-10 with orthopedic disabilities (average age 30.1 months) and 13 with cerebral palsy (average age 47.0 months). Pretest assessments were completed two times: at initial wheelchair evaluation and at wheelchair delivery. A posttest assessment was completed after each child had used the wheelchair for 4-6 months. Parents reported a lower perceived level of stress at the time of wheelchair delivery, although the magnitude of this effect was fairly small, standardized mean difference (δ) = .27. They also reported an increased satisfaction with their child's social and play skills (δ = .38), ability to go where desired (δ = .86), sleep/wake pattern (δ = .61), and belief that the general public accepts their child (δ = .39) after several months using the wheelchair. Parents reported an increase in interactions within the family at the time of wheelchair delivery (δ = .66). There was no decrease in negative emotions. Parents were satisfied with most factors relating to the wheelchair itself, with areas of concern being wheelchair size and difficulty adjusting the wheelchair. The findings suggest that self-initiated powered mobility for a young child had a positive impact on the family.

Power mobility and socialization in preschool: follow-up case study of a child with cerebral palsy

PURPOSE

Our previous study found it feasible for a preschooler with cerebral palsy (CP) to use a power mobility device in his classroom but noted a lack of typical socialization. The purpose of this follow-up study was to determine the feasibility of providing mobility and socialization training for this child.

METHODS

Will, a 3-year-old with CP, 1 comparison peer, 2 preschool teachers, and 2 therapists were filmed daily during a training and posttraining phase. Adult-directed training was provided in the classroom by therapists and teachers during the training phase. Mobility and socialization measures were coded from video.

OUTCOMES

During training, Will demonstrated greater socialization but less mobility than the comparison peer. Posttraining, Will socialized less but was more mobile, though less mobile than the comparison peer.

DISCUSSION

Short-term, adult-directed power mobility and socialization training appear feasible for the preschool classroom. Important issues regarding socialization and power mobility are discussed.

A critical review of powered mobility assessment and training for children

PURPOSE

Assessment and training of young children using powered mobility tends to be based on expert opinion although research in this area has recently been completed. This review critiques available research and discusses the studies in relation to theory and expert opinion.

METHOD

A literature review was completed to identify research regarding powered mobility training for children with developmental disabilities. Two recent qualitative studies were identified and their models and assessment tools were compared and discussed with recommendations for clinical practice and research.

RESULTS

The focus of the two studies is on a continuum of learning, the reciprocal relationship of trainer and trainee, and impact of the social and attitudinal environment on powered mobility skill development. The assessment tools and training protocols are backed up by motor learning principles and expert opinion. Further research is required to incorporate the tools into clinical practice and to examine additional psychometric properties.

CONCLUSIONS

Rather than focusing on readiness skills or pass/fail tests, clinicians should explore early mobility options for clients at the beginning of the continuum of learning, reflect on how they relate to and impact on their clients' learning, and set up the environment to facilitate independent learning and exploration.

Power mobility and socialization in preschool: a case study of a child with cerebral palsy

PURPOSE

Power mobility training for young children and infants appears feasible under controlled conditions. Dynamic, natural environments provide the ultimate test of training. The purpose of this case study was to determine whether it was feasible for Will, a 3-year-old boy with cerebral palsy, to use a power mobility device (UD2) in his preschool classroom and to quantify his classroom mobility and socialization.

METHODS

Will, 2 peers (typically developing), and 2 teachers were filmed daily in class during a baseline phase without UD2, followed by a mobility phase with UD2. We coded socialization and mobility measures from video recordings.

RESULTS

Will was more mobile and interactive when driving UD2 than during the baseline phase; however, he remained notably less mobile and interactive than his peers.

CONCLUSIONS

The use and assessment of power mobility in a preschool classroom appear feasible. Issues important to maximizing children's use of power mobility for classroom participation are discussed.

Establishing access to technology: an evaluation and intervention model to increase the participation of children with cerebral palsy

Children with a diagnosis of cerebral palsy often have significant physical limitations that prevent exploration and full participation in the environment. Assistive technology systems can provide opportunities for children with physical limitations to interact with their world, enabling play, communication, and daily living skills. Efficient access to and control of the technology is critical for successful use; however, establishing consistent access is often difficult because of the nature of the movement patterns exhibited by children with cerebral palsy. This article describes a 3-phase model of evaluation and intervention developed and used by Assistive Technology Services at the Aaron W. Perlman Center, Cincinnati Children's Hospital Medical Center, to establish successful access to technology systems in children with cerebral palsy.

Assistive devices for children with functional impairments: impact on child and caregiver function

Functional impairments can limit a child's ability to participate in the experiences of childhood. This'deprivation'can, in turn, have a negative effect on such children's development, academic performance, and quality of life, as well as on the lives of their caregivers and families. Many adults use assistive devices to overcome functional impairments and enable them to participate in daily activities; however, such devices may be underutilized by children. Each of the 54 studies reviewed in this report identified one or more functional impairments towards which an assistive device was targeted: accessing a computer (n=3 [studies]), activity assistance (n=2), behaviour changes (n=3), communication (n=30), independent feeding (n=1), living skills (n=1), mobility (n=9), modifying the environment (n=1), nutrition (n=4), and postural stability (n=2). The aim of this review was to determine the impact of assistive devices on the components of functioning defined by the World Health Organization's International Classification of Functioning, Disability and Health. The impact of these devices was found to be overwhelmingly positive. Study outcomes reported were mainly child-focused and could be classified as influencing activity, participation, and personal contextual factors, with relatively little attention paid to caregiver-focused outcomes. Few studies provided either qualitative evidence or experimentally-based quantitative research evidence using controls.

Quality medical homes: meeting children's needs for therapeutic and supportive services

OBJECTIVE

The objective of this study was to determine whether the quality of a medical home is associated with access to needed therapeutic and supportive services among children with special health care needs.

METHODS

Data from the 2000-2001 National Survey of Children With Special Health Care Needs were used in the analysis. The primary group of interest was children who were 0 to 17 years of age and needed therapeutic (n = 15,793) or supportive (n = 23,376) services. For each characteristic of a quality medical home, the percentage of children who needed and received therapeutic and supportive services was generated. Logistic regression was used to control for covariates while modeling the association between overall quality of a child's medical home and having unmet needs for therapeutic or supportive services.

RESULTS

Of all children identified as needing services, 16.2% had unmet therapeutic and 9.8% unmet supportive service needs. Only 23.9% of the children who needed therapeutic and 32.5% of children who needed supportive services met the criteria of having a quality medical home. High-quality care within medical homes was associated with a decreased likelihood of having unmet needs for therapeutic and supportive services. Each characteristic of a quality medical home was associated with unmet need, as were severity of the child's condition, family income of <200% of the federal poverty level, underinsurance, and maternal education beyond high school.

CONCLUSIONS

Among other factors, having a poor-quality medical home seems to be a barrier to receiving needed therapeutic or supportive services for children with special health care needs. Efforts on the part of pediatricians to establish quality medical homes for all children could have the added benefit of facilitating access to needed therapeutic and supportive services and promoting the health and well-being of children with special health care needs and their families.

Mothers' perceptions of their children's use of powered mobility

Physical therapists and occupational therapists frequently assist parents with the exploration and use of powered wheelchairs for their children with physical disabilities. The purpose of this study was to explore parents' experiences and perceptions of their children's experiences with the receipt and use of powered mobility. Qualitative methods were used to gain insight into the experiences of five mothers of children with physical disabilities who use powered wheelchairs. Information was collected during individual interviews with the mothers. Data analyses revealed five higher-level themes identified across the participants. Results of this study suggest that mothers initially perceive powered mobility as a "last resort" mobility option. The perceived effects of their children's use of powered mobility were significant and included increased personal control, independence, and opportunities to participate in age appropriate, meaningful activities. The mothers perceived that increased independence positively affected others' attitudes toward their children and allowed their children to develop more "legitimate" relationships with their peers.