Download - Who, why, when and how? Beginning powered mobility for young children with Cerebral Palsy
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)
1 Walks without Restrictions: limitations are present in more advanced motor skills
2 Walks without Assistive Devices: limitations are present in walking outdoors and in the community
3 Walks with Assistive Mobility Devices: limitations are present in walking outdoors and in the community
4 Self Mobility With Limitations: children are transported or use power mobility outdoors and in the community (are usually joystick drivers)
5 Self 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
40%
35%
5%
20%
1 2 3 4
At what age do you think children in level IV achieve most (90%) of their motor development?
1. 2.5 years2. 3.5 years3. 4.5 years4. 5.5 years
Level IV
Children in Level IV achieve 90% of their motor development by age 3.5 years
(Rosenbaum et al., 2002)
40%
15%
30%
15%
1 2 3 4
At what age do you think children in level V achieve most (90%) of their motor development?
1. 2.7 years2. 3.7 years3. 4.7 years4. 5.7 years
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
65%
35%
1 2
Do you think children with CP under 2 years are able to use powered mobility?
1. Yes2. No
40%
15%
35%
10%
1 2 3 4
Have you ever used powered mobility with young children with CP?
1. Yes- under age 32. Yes – under age 53. Yes – but only older
children4. No
Myth
Young children with CP are not ready to use this expensive type of equipment
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
55%
45%
1 2
Would you prescribe a power wheelchair for a child with CP who can propel a manual wheelchair indoors?
1. Yes2. No
65%
35%
1 2
Would you prescribe a power wheelchair for a child with CP who can walk with a walker?
1. Yes2. No
Myths
Using a power chair will prevent a child from walkingA child who has any potential to propel a manual chair or to walk should be encouraged to do so as much as possible
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.
1. Children who cannot sit independently and crawl or bunny hop by age 3 are unlikely to walk
2. 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
3. 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)
1 Walks without Restrictions: limitations are present in more advanced motor skills
2 Walks without Assistive Devices: limitations are present in walking outdoors and in the community
3 Walks with Assistive Mobility Devices: limitations are present in walking outdoors and in the community
4 Self Mobility With Limitations: children are transported or use power mobility outdoors and in the community (are usually joystick drivers)
5 Self 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
28%
11%
28%
33%
1 2 3 4
How do you decide whether a child is ready for powered mobility?
1. Cognitive readiness tests
2. Formal driving tests3. Provide practise
opportunities and evaluate in natural setting
4. Practise with switches and joystick on computer
Myth
Children need certain cognitive and prerequisite skills before being ready to try powered mobility
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.
70%
30%
1 2
Would you use powered mobility with a child who doesn’t have established cause & effect?
1. Yes2. No
Myth
Children need to demonstrate understanding of cause-effect with toys and computers before being introduced to powered mobility
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
60%
40%
1 2
Would you ever recommend a power wheelchair for a child who requires 1:1 supervision?
1. Yes2. No
85%
15%
1 2
Would you ever use powered mobility with a child who has a marked visual impairment?
1. Yes2. No
Myths
Children with multiple and complex disabilities are not able to use power wheelchairs
Children with sensory disabilities can’t use power mobility
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
50%
6%
39%
6%
1 2 3 4
What do you think are the greatest barriers for families when beginning to talk about powered mobility?
1. Emotions (i.e. giving up on walking or fear of losing strength)
2. Attitudes (i.e. viewing the child as looking more disabled)
3. Barriers with environment or transportation
4. Funding
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 - interviewed 5 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?
50%
6%
44%
1 2 3
What is your approach to powered mobility training?
1. Informal – let child use chair in daily life
2. Formal training - following directions, obstacle courses etc
3. Safe environment – play based learning
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
70%
30%
1 2
Would you try powered mobility with a child with CP under the age of 2 if equipment was available?
1. Yes2. No
55%
45%
1 2
Would you prescribe a power wheelchair for a child with CP who can propel a manual wheelchair indoors?
1. Yes2. No
55%
45%
1 2
Would you prescribe a power wheelchair for a child with CP who can walk with a walker?
1. Yes2. No
70%
30%
1 2
Would you ever use powered mobility with a child who doesn’t have established cause & effect?
1. Yes2. No
45%
55%
1 2
Would you ever recommend a power wheelchair for a child who requires 1:1 supervision?
1. Yes2. No
55%
45%
1 2
Would you ever use powered mobility with a child who has a marked visual impairment?
1. Yes2. No
17%
28%
33%
22%
1 2 3 4
What do you think is the best way to assess readiness for powered mobility?
1. Cognitive readiness tests
2. Formal driving tests3. Provide practise
opportunities and evaluate in natural setting
4. Practise with switches and joystick on computer
56%
17%
28%
1 2 3
What do you think is the best way to train powered mobility skills?
1. Informal – let child use in daily life
2. Formal training - following directions, obstacle courses etc
3. Safe environment – play based learning
56%
6%
22%
6%11%
1 2 3 4 5
What are the greatest barriers to use of powered mobility in your area?
1. Therapist attitudes2. Parental attitudes3. Time4. Equipment5. Funding
50%
6%
22% 22%
1 2 3 4
What solutions would be most helpful?
1. Information for parents
2. Information for therapists
3. Easy access to loan equipment
4. Information for managers
56%
28%
17%
1 2 3
Will your practice change as a result of this information?
1. No- I knew all this already
2. I’ll begin providing information to parents sooner
3. I’ll look into options for loaning or using powered mobility equipment
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.