Who why when and how beginning powered mobility for young children with cerebral palsy
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Who, why, when and how? Beginning powered mobility for young children with Cerebral Palsy. Outline. Who? - which children with CP benefit most from early use of power Why? - benefits of powered mobility for children with CP When should it be introduced?

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Who, why, when and how? Beginning powered mobility for young children with Cerebral Palsy

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Who, why, when and how?Beginning powered mobility for young children with Cerebral Palsy


Outline

  • Who? - which children with CP benefit most from early use of power

  • Why? - benefits of powered mobility for children with CP

  • When should it be introduced?

  • How? – introduction to powered mobility training


Literature Review

  • May 2007

  • CINAHL and MEDLINE

  • Hand searching

  • Inclusion

    • Children with CP

    • Powered mobility intervention


Power mobility toys


Scooterboard


Gross Motor Function Classification System (GMFCS)

1Walks without Restrictions: limitations are present in more advanced motor skills

2Walks without Assistive Devices: limitations are present in walking outdoors and in the community

3Walks with Assistive Mobility Devices: limitations are present in walking outdoors and in the community

4Self Mobility With Limitations: children are transported or use power mobility outdoors and in the community (are usually joystick drivers)

5Self Mobility is Severely Limited: even with use of assistive technology (may be joystick or alternate access drivers)

Palisano,R. et al. Developmental Medicine and Child Neurology 1997; 39: 214-223


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At what age do you think children in level IV achieve most (90%) of their motor development?

  • 2.5 years

  • 3.5 years

  • 4.5 years

  • 5.5 years

Cross-Tab Label


Level IV

  • Children in Level IV achieve 90% of their motor development by age 3.5 years

    (Rosenbaum et al., 2002)


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At what age do you think children in level V achieve most (90%) of their motor development?

  • 2.7 years

  • 3.7 years

  • 4.7 years

  • 5.7 years

Cross-Tab Label


Level V

  • Children in Level V achieve 90% of their motor development by 2.7 years

    (Rosenbaum et al., 2002)


Importance of independent mobility

  • Self-produced locomotion plays a crucial role in cognitive and psychosocial development


Limited mobility has a negative impact on development

  • Able bodied children in orphanages deprived of normal opportunities to move (Dennis, 1973)

  • Tatlow (1980) found children with disabilities who could not move independently were passive and had vague body awareness


Independent mobility makes kids smarter

  • Campos and Bertenthal (1987) believe that independent locomotion facilitates psychological change

  • Locomotor experience is linked to self-awareness, emotional attachment, spatial orientation, fear of heights and visual/vestibular integration (Kermoian, 1997)


Butler C., Okamoto G.A., & McKay T.M. (1983). Powered mobility for very young disabled children. Developmental Medicine and Child Neurology. 25, 472-474.

  • 9 motor disabled children aged 20 – 39 months

  • Motorized chair at home over a 7 week period

  • 8 children were able to drive safely and independently

  • Stimulated social emotional and intellectual behaviour


Butler C., Okamoto G.A. & McKay T.M. (1984). Motorized wheelchair driving by disabled children. Archives of Physical Medicine and Rehabilitation. 65, 95-97.

  • 13 children with physical disabilities aged 20 to 37 months.

  • 12 children learned to drive the chair competently in an average of 16 days.

  • Able to drive without bumping doorways or corridors and stop without hitting obstacles in less than five days

  • Conclusion:

    • Children as young as 24 months can learn to drive a power chair


Butler C. (1986). Effects of powered mobility on self-initiated behaviors of very young children with locomotor disability. Developmental Medicine and Child Neurology, 28, 325-332.

  • Multiple baseline design

  • 6 children with physical disabilities aged 23-38 months

  • Used chair for less than three weeks

  • Conclusion:

    • Most increased frequency of interaction with objects

    • Increased spatial exploration

    • Affected communication with caregiver


Paulsson K. and Christoffersen M (1984). Psychosocial aspects on technical aids – How does independent mobility affect the psychosocial and intellectual development of children with physical disabilities? Proceedings of the 2nd International conference on Rehabilitation Engineering, 282-285.

  • 12 physically disabled preschoolers aged 2.5 – 5 years

  • Electrical go-kart for 1 year

  • Caregivers and Therapists reported positive effects on emotional, intellectual and motor development


And yet…

  • Ontario study (Palisano et al, 2003) of 636 children with CP

    • only 24% of children at GMFCS level IV and 3% of children in Level V used powered mobility

  • UK report (Staincliffe, 2003)

    • 10% of services exclude under 5’s

    • 46% of services are never referred under 5’s

    • 46% more services offered indoor/outdoor chairs to over 5’s than under 5’s


Opportunities for mobility

  • Children with disabilities should be provided with the same opportunities as other children (and at the same age) to move independently and to explore their environment

  • Options:

    • Supportive walkers/gait trainers

    • Adapted tricycles

    • Powered mobility


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Do you think children with CP under 2 years are able to use powered mobility?

  • Yes

  • No

Cross-Tab Label


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Have you ever used powered mobility with young children with CP?

  • Yes- under age 3

  • Yes – under age 5

  • Yes – but only older children

  • No

Cross-Tab Label


Myth

Young children with CP are not ready to use this expensive type of equipment

X


Jones M.A. (2004). Effects of power mobility on the development of young children with severe motor impairments. Doctoral dissertation: University of Oklahoma Health Sciences Center.

  • 12 children with severe motor impairments -14.8 to 30 months

  • 7 children diagnosed with CP and one with hydrocephalus – all Level IV or V

  • Youngest child with CP - 17 months

  • Randomized control trial

  • Power chair use for one year

  • 4-34 weeks to learn basic wheelchair skills


Results

  • Intervention group had significantly greater improvement :

    • receptive language (Batelle Developmental Inventory)

    • social function functional skills (PEDI)

    • self-care caregiver assistance (PEDI)


Bottos M et al. (2001). Powered wheelchairs and independence in young children with tetraplegia. Developmental Medicine and Child Neurology. 43, 469-477.

  • single subject AB design

  • 25 children aged 3-8 years

  • Tetraplegic CP

  • 6-8 months baseline with before and after measures

  • 6-8 months powered mobility use


Results

  • No significant change in IQ, motor deficit or quality of life

  • Highly significant increase in independence

  • Cognitive level and motor deficit not statistically related to driving performance

  • Most children 21/27 were able to drive

  • Time spent in the chair did correlate with driving performance


Furumasu J, Tefft D, Guerette P (2007). The impact of early powered mobility on young children’s play and psychosocial skills. Proceedings of the 2007 RESNA Annual Conference. Phoenix, AZ: RESNA Press.

  • 23 children, 18-42 months with orthopaedic disabilities, 18-72 months with CP

  • 4-6 month baseline with before and after measures

  • 4 months intervention phase

  • Language, play, social skills


Results

  • Significant improvement in social skills

  • Increased amount of physical play and significantly improved quality of play

  • No change in language or cognitive development


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Would you prescribe a power wheelchair for a child with CP who can propel a manual wheelchair indoors?

  • Yes

  • No

Cross-Tab Label


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Would you prescribe a power wheelchair for a child with CP who can walk with a walker?

  • Yes

  • No

Cross-Tab Label


Myths

Using a power chair will prevent a child from walking

A child who has any potential to propel a manual chair or to walk should be encouraged to do so as much as possible

X

X


Jones M.A. (2004). Effects of power mobility on the development of young children with severe motor impairments. Doctoral dissertation: University of Oklahoma Health Sciences Center.

  • Motor skills did not decline in either the experimental or control group


Bottos M. and Gericke C. (2003). Ambulatory capacity in cerebral palsy: prognostic criteria and consequences for intervention. Developmental Medicine & Child Neurology. 45, 786-790.

  • Children who cannot sit independently and crawl or bunny hop by age 3 are unlikely to walk

  • Those who have achieved these milestones by age 3 will likely walk by age 7 but many will lose the ability to walk in the future

  • Those who walk by age 3 will maintain walking longest, but may still lose ability to walk due to physiological burnout


Gross Motor Function Classification System (GMFCS)

1Walks without Restrictions: limitations are present in more advanced motor skills

2Walks without Assistive Devices: limitations are present in walking outdoors and in the community

3Walks with Assistive Mobility Devices: limitations are present in walking outdoors and in the community

4Self Mobility With Limitations: children are transported or use power mobility outdoors and in the community (are usually joystick drivers)

5Self Mobility is Severely Limited: even with use of assistive technology (may be joystick or alternate access drivers)

Palisano,R. et al. Developmental Medicine and Child Neurology 1997; 39: 214-223


Changing Perspectives?


Wiart L. and Darrah J (2002). Changing philosophical perspectives on the management of children with physical disabilities – their effect on the use of powered mobility. Disability and Rehabilitation. 24 (9), 492-498.

  • ICF

  • Dynamic systems theory

  • Family centred care

  • Efficiency

  • Environmental considerations

  • Variety of mobility options


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How do you decide whether a child is ready for powered mobility?

  • Cognitive readiness tests

  • Formal driving tests

  • Provide practise opportunities and evaluate in natural setting

  • Practise with switches and joystick on computer

Cross-Tab Label


Myth

Children need certain cognitive and prerequisite skills before being ready to try powered mobility

X


Furumasu J., Guerette P. and Tefft D. (2004). Relevance of the pediatric powered wheelchair screening test for children with Cerebral Palsy. Developmental Medicine & Child Neurology. 46, 468-474.

  • 26 children with CP (aged 2-6 years)

  • Assessments:

    • Pediatric Powered Wheelchair Screening Test (PPWST)

    • Symbolic Representational Scale (SRS)

    • Coping Inventory

  • 6 wheelchair training sessions – final session assessed using Power Mobility Program (wheelchair driving test)


Results

  • PPWST predictive for children with CP who were able to use joysticks

  • SRS marginally increased predictive power for this group only.

  • Children should be beyond the object level in order to drive functionally

  • PPWST was not predictive for children with CP who used switch controls


Bottos M et al. (2001). Powered wheelchairs and independence in young children with tetraplegia. Developmental Medicine and Child Neurology. 43, 469-477.

  • Cognitive level not statistically related to driving performance

  • Majority able to drive, including 7/13 with moderate to severe intellectual impairment.


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Would you use powered mobility with a child who doesn’t have established cause & effect?

  • Yes

  • No

Cross-Tab Label


Myth

Children need to demonstrate understanding of cause-effect with toys and computers before being introduced to powered mobility

X


Nilsson L. and Nyberg P.J. (1999). Single-switch control versus powered wheelchair for training cause-effect relationships: case studies. Technology and Disability. 11, 35-38.

  • Case study - 1yr old girl

    • Drove with intent at 2 ½ years and understood use of switch toys.

    • Drove functionally at 3 ½ years but did not understand use of computer mouse until age 4 ½.


Nilsson and Nyberg (1999) cont.

  • 40 individuals aged 1-50 functioning at an early developmental level

    • 9 could drive a powered chair but only 2 could use a computer mouse.

    • 14 enjoyed switch toys but only 5 could wait for response from toy before hitting switch again.


Nilsson and Nyberg (1999) cont.

  • 17 infants (typically developing) followed from 3-12 months

    • At 3-4 months infants understood cause-effect with joystick.

    • At 7-8 months they understood direction in chair and used switch toys.

    • At 12 months they still had no interest in computer mouse.


Nilsson’s suggested Developmental Progression

  • Early cause-effect in powered chair

  • Beginning directional control and cause-effect with separate switch and toy

  • Functional Driving

  • Computer mouse use


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Would you ever recommend a power wheelchair for a child who requires 1:1 supervision?

  • Yes

  • No

Cross-Tab Label


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Would you ever use powered mobility with a child who has a marked visual impairment?

  • Yes

  • No

Cross-Tab Label


Myths

X

Children with multiple and complex disabilities are not able to use power wheelchairs

Children with sensory disabilities can’t use power mobility

X


Odor P. and Watson M. (1994). Learning through Smart Wheelchairs: A Formative Evaluation of the effective use of the CALL Centre’s Smart Wheelchairs as past of children’s emerging mobility, communication, education and personal development. http://callcentre.education.ed.ac.uk

  • Qualitative study

  • 13 children with a wide spectrum of physical, cognitive and sensory issues.

  • 3 educational settings.

  • Smart Wheelchair for one school year

  • Progress was measured using IEP goals

  • Computer analysis of interaction


Smart Wheelchair


Results

  • Safe learning environment

  • Promoted broad developmental changes e.g. cause-effect, motivation, initiation, assertiveness and persistence

  • Some children transitioned to standard powered chair


Deitz J., Swinth Y. and White O. (2002). Powered mobility and preschoolers with complex developmental delays. American Journal of Occupational Therapy. 56 (1), 86-96.

  • Single subject ABAB

  • 2 preschoolers with quadriplegic CP

  • Powered mobility riding toy during free play - 3-4 hours total for each child

  • Results:

    • Increase in self-initiated movement during intervention phase with immediate returns to baseline when intervention was withdrawn

    • Some effect on interaction

    • Effect on affect variable


Nilsson L. and Nyberg P. (2003). Driving to Learn: A new concept for training children with profound cognitive disabilities in a powered wheelchair. American Journal of Occupational Therapy. 57 (2). 229-233.

  • Qualitative design

  • 2 preschoolers with profound cognitive, visual and motor disabilities

  • 12 months powered chair use

  • Increased alertness and response to stimuli

  • Increased use of upper limbs

  • Increased understanding of cause-effect


Concern

Families of young children aren’t ready


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What do you think are the greatest barriers for families when beginning to talk about powered mobility?

  • Emotions (i.e. giving up on walking or fear of losing strength)

  • Attitudes (i.e. viewing the child as looking more disabled)

  • Barriers with environment or transportation

  • Funding

Cross-Tab Label


Wiart L, Darrah J, Hollis V, Cook A and May L (2004). Mothers’ perceptions of their children’s use of powered mobility. Physiotherapy & Occupational Therapy in Pediatrics. 24 (4), 3-21.

  • Qualitative study - interviewed5 mothers of children who were using power mobility

  • Negative feelings towards first wheelchair

  • Power mobility seen as a last resort

  • Positive feelings as child experiences increased independence and control

  • Environmental barriers

  • Enables meaningful engagement

  • Positive effect on others attitudes


How?

  • What is the best way for young children with CP to learn to use powered mobility?


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What is your approach to powered mobility training?

  • Informal – let child use chair in daily life

  • Formal training - following directions, obstacle courses etc

  • Safe environment – play based learning

Cross-Tab Label


Durkin J (2005). Developing powered mobility with children who have multiple and complex disabilities: Moving forward. Doctoral dissertation. University of Brighton.

  • Qualitative study – grounded theory

  • Aim – to identify components and development of how children learn to use powered mobility

  • Observation of 11 typical children – 6 months -5 years

  • Observation of 11 children with disabilities

  • Focus group with 7 children who used powered mobility

  • Focus groups with 22 peer professionals


Recommendations

  • Safe learning environment

  • Child-led approach

  • Adult as a ‘responsive partner’

  • Beginning learners are distracted by and cannot attend to adult verbal instruction


Jones M.A. (2004). Effects of power mobility on the development of young children with severe motor impairments. Doctoral dissertation: University of Oklahoma Health Sciences Center.

  • Children with complex difficulties take longer to learn to use the power chair

  • More intense training may be helpful in a structured controlled environment for initial skill acquisition.

  • Blocked trials are better for initial learning but random practise is better for skill retention


Odor P. and Watson M. (1994). Learning through Smart Wheelchairs: A Formative Evaluation of the effective use of the CALL Centre’s Smart Wheelchairs as past of children’s emerging mobility, communication, education and personal development. http://callcentre.education.ed.ac.uk

  • Most successful when child had opportunity for structured and unstructured use throughout the day

  • Less successful outcomes related more to lack of opportunity due to poor environmental support and integration than a difference in the child’s abilities


Nilsson LM and Eklund M (2006). Driving to learn: Powered wheelchair training for those with cognitive disabilities. International Journal of Therapy and Rehabilitation. 13, 517-527.

  • 45 people with profound multiple and cognitive disabilities

  • Age 12 months – 52 years

  • Video recordings

  • Aim – to identify indicators of factors that facilitated or hindered learning joystick use in the powered chair


Recommendations

  • Chair needs to have immediate response when the joystick is moved

  • Midline joystick position

  • Chair needs to have low speed, low power and respond the same way in all directions

  • Use of safety stop switches, bumpers and line followers can interfere with learning


Expectations

  • Exploratory drivers

  • Supervised drivers

  • Independent drivers


Implications for practice

  • Use of a powered mobility device can enhance psychosocial development and independence in young children with CP


Implications for practice

  • Using powered mobility at a young age will not impede development of independent ambulation or other motor skills


Implications for practice

  • Children with CP who have a poor prognosis for independent ambulation (GMFCS Levels IV and V) require assisted mobility opportunities at the same age as their typical peers in order to promote overall development.


Implications for practice

  • IQ and cognitive readiness tests do not predict which children with CP will become functional power chair users


Implications for practice

  • Children with CP may need more time and training than other children learning to use powered mobility. Potential cannot be determined based on a short term trial


Implications for practice

  • Young children may learn to use switches and joysticks in a powered mobility device more easily than with toys and computers.


Implications for practice

  • Initial training for powered mobility in therapy sessions is helpful before the child is ready to use a power chair in daily life

  • Children need time to play and explore on their own and may be distracted by adult direction

  • Mixture of structured and unstructured training


Implications for practice

  • Time and environmental support are very important


Equipment options

  • Child Development Centres

  • Wheelchair vendors

  • Red Cross Loan Bank

  • Sunny Hill


Review


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Would you try powered mobility with a child with CP under the age of 2 if equipment was available?

  • Yes

  • No

Cross-Tab Label


0 / 20

Would you prescribe a power wheelchair for a child with CP who can propel a manual wheelchair indoors?

  • Yes

  • No

Cross-Tab Label


0 / 20

Would you prescribe a power wheelchair for a child with CP who can walk with a walker?

  • Yes

  • No

Cross-Tab Label


0 / 20

Would you ever use powered mobility with a child who doesn’t have established cause & effect?

  • Yes

  • No

Cross-Tab Label


0 / 20

Would you ever recommend a power wheelchair for a child who requires 1:1 supervision?

  • Yes

  • No

Cross-Tab Label


0 / 20

Would you ever use powered mobility with a child who has a marked visual impairment?

  • Yes

  • No

Cross-Tab Label


0 / 20

What do you think is the best way to assess readiness for powered mobility?

  • Cognitive readiness tests

  • Formal driving tests

  • Provide practise opportunities and evaluate in natural setting

  • Practise with switches and joystick on computer

Cross-Tab Label


0 / 20

What do you think is the best way to train powered mobility skills?

  • Informal – let child use in daily life

  • Formal training - following directions, obstacle courses etc

  • Safe environment – play based learning

Cross-Tab Label


0 / 20

What are the greatest barriers to use of powered mobility in your area?

  • Therapist attitudes

  • Parental attitudes

  • Time

  • Equipment

  • Funding

Cross-Tab Label


0 / 20

What solutions would be most helpful?

  • Information for parents

  • Information for therapists

  • Easy access to loan equipment

  • Information for managers

Cross-Tab Label


0 / 20

Will your practice change as a result of this information?

  • No- I knew all this already

  • I’ll begin providing information to parents sooner

  • I’ll look into options for loaning or using powered mobility equipment

Cross-Tab Label


Questions or Comments?


References

  • Campos, J.J. & Bertenthal, B.K. (1987). Locomotion and psychological development in infancy. In K.M. Jaffe (Ed). Childhood powered mobility: Developmental, technical and clinical perspectives (11-42), Washington (DC): RESNA.

  • Kermoian, R. (1997). Locomotion experience and psychological development in infancy. In: J.Furumasu (Ed). Pediatric powered mobility: developmental perspectives, technical issues, clinical approaches (pp7-21), Arlington (VA): RESNA.

  • Palisano, R.J., Rosenbaum, P.L., Walter, S.D., Russell, D.J., Wood, E.P., & Galuppi, B.E. (1997). Development and reliability of a system to classify gross motor function in children with cerebral palsy. Developmental Medicine and Child Neurology, 39, 214-223.

  • Palisano RJ, Tieman BL, Walter SD, Bartlett DJ, Rosenbaum, PL, Russell D and Hanna SE (2003). Effects of environmental setting on mobility methods of children with cerebral palsy. Developmental Medicine and Child Neurology. 45, 113-120.

  • Rosenbaum, P.L., Walter, S.D., Hanna S.E., Palisano R.J., Russell, D.J., Raina, P., et al. (2002). Prognosis for gross motor function in cerebral palsy: Creation of motor development curves. Journal of the American Medical Association, 288 (11), 1357-1363.

  • Staincliffe S (2003). Wheelchair services and providers: discriminating against disabled children? International journal of Therapy and Rehabilitation, 10 (4), 151-158.


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