Physical & Occupational Therapy In Pediatrics

ISSN: 0194-2638 (Print) 1541-3144 (Online) Journal homepage: http://www.tandfonline.com/loi/ipop20

Power Mobility Training for Young Children with Multiple, Severe Impairments: A Case Series Lisa K. Kenyon, John P. Farris, Cailee Gallagher, Lyndsay Hammond, Lauren M. Webster & Naomi J. Aldrich To cite this article: Lisa K. Kenyon, John P. Farris, Cailee Gallagher, Lyndsay Hammond, Lauren M. Webster & Naomi J. Aldrich (2016): Power Mobility Training for Young Children with Multiple, Severe Impairments: A Case Series, Physical & Occupational Therapy In Pediatrics, DOI: 10.3109/01942638.2015.1108380 To link to this article: http://dx.doi.org/10.3109/01942638.2015.1108380

Published online: 06 Jan 2016.

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Date: 19 August 2016, At: 13:00

Physical & Occupational Therapy in Pediatrics, Early Online:1–16, 2015  C 2015 Taylor & Francis Group, LLC ISSN: 1541-3144 print / 1541-3144 online DOI: 10.3109/01942638.2015.1108380

Power Mobility Training for Young Children with Multiple, Severe Impairments: A Case Series Lisa K. Kenyon1 , John P. Farris2 , Cailee Gallagher1 , Lyndsay Hammond1 , Lauren M. Webster1 , & Naomi J. Aldrich3 1

Department of Physical Therapy, Grand Valley State University, Grand Rapids, Michigan, USA, 2 Padnos College of Engineering & Computing, Grand Valley State University, Grand Rapids, Michigan, USA, 3 Department of Psychology, Grand Valley State University, Allendale, Michigan, USA

ABSTRACT. 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. KEYWORDS.

Case series, cerebral palsy, power mobility

Young children with neurodevelopmental conditions are often limited in selfmobility such as rolling, crawling, or walking to explore and learn from their environment. In typical development, it is not until after the emergence of crawling that an infant begins to more fully attend to his/her environment.1 Passive mobility, such as being pushed in a stroller, does not provide infants with the degree of Address correspondence to: Lisa K. Kenyon, PT, DPT, PhD, PCS; Associate Professor, Physical Therapy Program, Grand Valley State University, 301 Michigan Street NE, Grand Rapids, MI, USA. 49503; E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ipop. (Received 13 May 2015; accepted 28 September 2015)

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stimulation and challenge needed to promote development of the spatialcognitive skills necessary to understand the relationship between oneself and the environment.7 Self-produced locomotion and associated decision-making processes within have been linked to the development of spatial knowledge and navigational skills.7,1 Limitations in the use of self-produced locomotion may result in the development of secondary impairments in such areas as spatial cognition, communication, social development, and other domains influenced by the emergence of independent mobility.1,16,35 Power mobility options such as adapted ride-on toys and power wheelchairs are increasingly suggested as a way to provide self-generated locomotion.19,21 Power mobility may help young children who have severe motor impairments to develop cognitive and psychosocial/play skills while increasing initiation, self-exploration, and independence.2,12,9,3,29 Livingstone and Paleg suggest that power mobility use is an effective and appropriate intervention for children 12 months of age and older who lack efficient, independent, self-generated locomotion.21 These authors further suggest that power mobility may be beneficial for children who might never become capable, community drivers.21 Children with multiple, severe physical impairments may require more support and specialized positioning than can be provided in adapted ride-on toys and yet they may not qualify for purchase of a power wheelchair with customized seating. Power mobility devices such as those shown in Figure,1 may help to address this problem by providing a short term solution that allows children to practice their power mobility skills.15,13,14 Developed with input from local clinicians, various prototypes of our Play and Mobility Device (PMD) for smaller, younger children and our Power Wheelchair Trainer (Trainer) for larger, older children were designed and built through a partnership between the Department of Physical Therapy and the School of Engineering at Grand Valley State University. The prototype versions of both the PMD and Trainer consists of a motorized platform with a control system that interfaces with both a traditional joystick and a variety of switches to adapt the power access system to meet the unique needs of each child (Figure 1). The PMD utilizes a mid-wheel drive configuration powered by one 12-volt lead acid battery and includes a commercially available forwardfacing car seat that can be tilted back into three different semi-reclined positions. In contrast, the Trainer is a larger device that utilizes a rear-wheel drive configuration powered by two 12-volt lead acid batteries. The Trainer requires children to be positioned in their own customized, manual wheelchair. Wheelchair tie-downs are used to secure the child’s manual chair to the Trainer platform thereby allowing the child’s manual chair to be temporarily converted into a power mobility device. Multiple safety features are included in both devices. A tethered attendant control unit allows the therapist to assume control of either device as needed. Emergency stop buttons are available on both devices and on each attendant control. The driving speed of the devices is determined by the therapist and can be set to meet the individual needs of each child. The purposes of this case series were to (1) describe the outcomes of using an alternative power mobility device to provide power mobility training to three young children with multiple, severe physical impairments; (2) develop power mobility

Power Mobility Training for Young Children with Multiple, Severe Impairments

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FIGURE 1. (A) Play & mobility device; (B) power wheelchair trainer (Trainer).

training methods for use with these children; and (3) determine the feasibility of various outcome measures to assess the impact of power mobility training. METHODS Participants The participants were three children ages 17 months, 2 years, 5 months, and 3 years, 5 months with cerebral palsy (Gross Motor Function Classification System [GMFCS] levels IV and V).31 Table 1 provides participant characteristics and desired parental outcomes for power mobility training for each participant. When appropriate, the Communication Function Classification System (CFCS), and the Eating and Drinking Ability Classification System (EDACS) were used to classify the participants’ function. Informed consent for physical therapy services and permission to publish this case series were obtained from each participant’s parent or legal guardian.11,33

4

2 years, 5 months

3 years, 5 months

2

3

Male

Male

Female

Gender

Spastic athetoid quadriplegic cerebral palsy, multiple congenital cardiac anomalies including a bicuspid aortic valve, aortic valvar stenosis, patent ductus arteriosus, and multiple VSDs all s/p initial repair Spastic triplegic cerebral palsy (left extremities more involved); left-sided neglect; chronic lung disease; shunted hydrocephalus

Spastic quadriplegic cerebral palsy; cortical visual impairment; seizures

Diagnoses Significant limitations in the ability to manipulate objects even with assist

Significant limitations in the ability to manipulate objects even with assist

Difficulties manipulating objects; requires some assist

V

IV

Hand Function

V

GMFCS Level

CFCS Level III

Ineffective communication even with family members CFCS Level V

Communication Ability

To increase use of the more involved upper extremity; To increase awareness of his left body space; To augment mobility and help the participant to interact with his environment

To develop cause and effect skills; To learn how to use a switch; To use power mobility device to interact with twin during play activities during sessions All feedings via a G-tube

EDACS Level V

To develop cause and effect skills; To learn how to use a switch

Desired Parental Outcomes for Power Mobility Training at the Onset of the Case

All feedings via a G-tube

Eating and Drinking Ability

GMFCS: Gross Motor Function Classification System; CFCS: Communication Function Classification System; EDACS: Eating and Drinking Ability Classification System; VSDs: ventral septal defects; G-tube: gastrostomy tube.

1 year, 5 months

1

Participant Number

Age at Onset of Case

TABLE 1. Participant Characteristics and Parent Goals for Power Mobility Training at the Onset of the Case

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TABLE 2. Pre- and Post-Intervention Scaled Scores and Standard Error Scores for Each Domain of the PEDI-CAT Participant 1

Daily Activities Scaled Score (SE) Mobility Scaled Score (SE) Social/Cognitive Scaled Score (SE) Responsibility Scaled Score (SE)

Participant 2

Participant 3

Pre

Post

Pre

Post

Pre

Post

30(6.3) 41(3.7) 40(3.3) 25(6.9)

30(6.3) 43(3.2) 46(2.3)∗ 25(6.9)

33(3.8) 34(5.6) 47(2.0) 25(6.9)

33(3.8) 46(3.3)∗ 50(1.8)∗ 25(6.9)

43(1.2) 41(3.8) 58(1.1) 25(6.9)

45(1.0)∗ 49(2.8)∗ 59(1.1)∗ 32(3.2)

PEDI-CAT: Pediatric Evaluation of Disability Inventory–Computer Adaptive Test; SE: Standard error. ∗ Denotes that the post-intervention score exceeded the standard error measure between test administrations.

Measures All domains of the Pediatric Evaluation of Disability Inventory–Computer Adaptive Test (PEDI-CAT) were administered pre- and post-intervention.10 The PEDICAT utilizes caregiver report to assess abilities in four domains: Daily Activities, Mobility, Social/Cognitive, and Responsibility. The PEDI-CAT is a valid and reliable measure for use with children birth through 20 years of age and can be used across all clinical diagnoses. In this case series, the Speedy (“Precision”) CAT version of the PEDI-CAT was completed for each participant by the same parent or guardian at both pre and post-intervention. The Speedy CAT version utilizes computer adaptive technology to obtain a precise estimate of a child’s score while administering 5–15 items per domain. Pre-intervention scaled scores and standard error scores for each domain of the PEDI-CAT are provided for each participant in Table 2. The Dimensions of Mastery Questionnaire (DMQ, version 17) was used to evaluate the effects of power mobility training on participants’ mastery motivation (i.e., intrinsic psychological motivation to attempt a challenging task).4,26 The DMQ is a caregiver report measure that assesses both instrumental (i.e., drive to concentrate and persist in attempts to master a challenging skill) and expressive (i.e., emotional reactions during or immediately after the challenging task) elements of mastery motivation in children 6 months to 19 years of age.26,22 Each age-specific form includes 45 items rated according to how typical the behavior is of the child on a 5-point scale from “(1) Not at all Typical” to “(5) Very Typical.” For this case series, DMQ subscales assessing Cognitive Persistence (objectoriented), Social Persistence (with adults), and Total Expressive Mastery Motivation (mastery pleasure and negative reactions to failure) were used. Higher scores on the instrumental subscales of cognitive and social persistence reflect greater perseverance within object-related challenges or social interactions with adults, whereas higher scores on the total expressive subscale reflect greater emotional experiences and expressiveness related to mastery (i.e., more pleasure with success and more negativity with failure).26 The DMQ has been found to be valid and reliable in children with and without disabilities.22,24,26 Consistent with the age of the participants at the start of the case, the Infant DMQ was utilized with Participant 1 and the Preschool DMQ was utilized with Participants 2 and 3. Pre-intervention scores for each participant and the age norms for each subscale are provided in Figure 2.

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FIGURE 2. Participants’ pre- and post-intervention scores on the three subscales of the Dimensions of Mastery Questionnaire (DMQ) compared with age-related norms.

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Procedure Decisions regarding access (joystick or switch) for each participant were made based upon the clinical experience of the authors and concepts related to access as outlined by the Wisconsin Assistive Technology Initiative (WATI).8 A round mechanical pressure switch was chosen for each participant due to the auditory feedback it provided, the small amount of force needed for activation, and the size of the switch. Given that the participants did not have experience with power mobility, the number of switches used was determined by questioning the parents of each participant concerning their perceptions of their child’s ability to use a switch, respond to games such as peek-a-boo, and to activate toys through motor activities such as pressing, hitting, batting, or squeezing. Based on parental responses, it was determined that Participant 3 appeared to consistently demonstrate an understanding of cause and effect relationships while Participants 1 and 2 were not yet demonstrating such skills. Based on these determinations, training was initiated with a single switch for Participants 1 and 2 and with 2 switches for Participant 3. Additional switches were added as the participants progressed. All participants used their upper extremities to activate the switch(es) and started training with the switch(es) attached to a small tray mounted on the power mobility device through a universal arm. Placement of the switch(es) was adjusted as needed for each participant based on ease of activation. For Participant 3, the switches were placed on his left side to support his parents’ desired power mobility outcomes to increase both his use of his left upper extremity and to increase awareness of his left body space.32 As training progressed, the switch for Participant 2 was attached to the chest harness of the car seat on the PMD to improve his ease of activation. All of the participants started training using the PMD. Mid-way through the training period, Participant 3 transitioned to using the Trainer as it was felt he was outgrowing the PMD. We identified critical components of power mobility training methods used in previous research from a literature review. Foundational concepts related to the therapist as a responsive partner in the training process and the need to create an engaging, playful environment were combined with suggestions that accidental activation of the joystick or switch may lead to the development of cause and effect skills and eventually stimulate the development of intentional, purposeful driving behaviors in children who have multiple, severe impairments.5,29 These concepts were combined with contemporary theories of motor control and neural plasticity to create power mobility training methods focused on specificity of training and repetition within an individually engaging environment.17,34 To determine each participant’s individual preferences, the Reinforcement Assessment for Individuals with Severe Disabilities (RAISD) was used as a structured interview to gather information from each participant’s parent related to potentially reinforcing stimuli (visual, auditory, tactile, kinesthetic) and activities for each child.6 The Power Mobility Training Tool (PMTT) was used to identify basic power mobility skills for each participant.14 Findings were used to create goals for each participant. Sample goal areas for each participant are included in Table 3. Based on the information from the RAISD and the goals, an individualized, engaging environment was designed to target the emergence of specific power

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1

Participant

• Demonstrate intentional activation of a switch to move the power mobility device in any direction. • Move the power mobility device in the general direction of preferred objects/individuals. Goal Achieved Goal Achieved

Goal Achieved

• Move the power mobility device in the general direction of preferred objects/individuals.

Within a 6-week timeframe, the participant will:

Goal Achieved

• Demonstrate intentional activation of a switch to move the power mobility device in any direction.

Within a 6-week timeframe, the participant will:

Initial Power Mobility Training Goal Areas

Goal Status at End of Timeframe

TABLE 3. Sample Goal Areas for Power Mobility Training for Each Participant

Within a 6-week timeframe, the participant will: • Demonstrate intentional activation of 2–3 switches to move the power mobility device in any direction. • Selectively use specific switches to move the power mobility device in a specific direction. • Purposefully stop the power mobility device in response to verbal or environmental cues. • Maneuver the power mobility device down a 100 foot (30.48 meter) hallway. Within a 6-week timeframe, the participant will: • Intentionally use the power mobility device to interact with his twin sister. • Maneuver the power mobility device down a 100 foot (30.48 meter) hallway. • Purposefully stop the power mobility device in response to verbal or environmental cues.

Goal Areas Added as Participant Progressed

(Continued on next page)

Inconsistent Performance: Progressing towards Goal

Inconsistent Performance: Progressing towards Goal Inconsistent Performance: Progressing towards Goal

Inconsistent Performance: Progressing towards Goal

Inconsistent Performance: Progressing towards Goal

Inconsistent Performance: Progressing towards Goal

Inconsistent Performance: Progressing towards Goal

Goal Status at End of Timeframe

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3

Participant

Goal Achieved Goal Achieved Goal Achieved Goal Achieved

• Turn the power mobility device to the right and to the left to obtain desired objects or to interact with others.

• Maneuver the power mobility device down a 100-foot (30.48 meter) hallway.

• Purposefully stop the power mobility device in response to verbal or environmental cues.

• Use his left hand or reach with his right hand into his left body space to activate on the power mobility device.

Within a 6-week timeframe, the participant will:

Initial Power Mobility Training Goal Areas

Goal Status at End of Timeframe Within a 6-week timeframe, the participant will: • Use the power mobility device to explore the environment during play activities. • Maneuver the power mobility device to the right and the left around hallway corners. • Maneuver the power mobility device through a wide doorway (119.5 centimeter, 47 inches)

Goal Areas Added as Participant Progressed

TABLE 3. Sample Goal Areas for Power Mobility Training for Each Participant (Continued)

Inconsistent Performance: Progressing towards Goal

Goal Achieved

Goal Achieved

Goal Status at End of Timeframe

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mobility skills for each participant. A custom-made attendant control unit designed to allow shared control was used during training sessions to selectively modify the direction and motion of the power mobility device and respond to the learning and safety needs of each participant. Shared control is defined as the electronic capability to modify the direction and motion of the power mobility device by combining inputs from both the user and attendant control units without having to stop or interrupt the child’s driving.25 Detailed information on these training methods and how methods were individualized for each participant is available from the authors. Observations related to the number of independent switch activations and to specific goal related activities for each participant were documented on a data collection sheet. All intervention sessions were conducted in a university setting utilizing physical therapy laboratory spaces and hallways for driving activities. Intervention was provided one time per week for 60 minutes over a 12-week period. Due to illness and weather related issues, both Participant 1 and 2 missed two sessions while Participant 3 missed five sessions. RESULTS Results of post-intervention testing for the PEDI-CAT are provided for each participant in Table 2. In the Daily Activities and Responsibility domains, Participant 1 and 2 did not demonstrate a change in scores while Participant 3 demonstrated a slight score increase. Increased scores in the Mobility and Social/Cognitive domains were documented for all participants. Participant 1 showed her largest score increase in the Social/Cognitive domain, whereas Participant 2 and 3 showed their largest score increases in the Mobility domain. Using standard error scores to interpret pre- and post-intervention scores, Participant 1 exceeded the standard error measure between test administrations in the Social/Cognitive domain. Participant 2 exceeded the standard error in both the Mobility and Social/Cognitive domains and Participant 3 exceeded the standard error in three: Daily Activities, Mobility, and Responsibility domains. Post-intervention scores for each subscale of the DMQ are provided for each participant in Figure 2. After power mobility training, Participant 1 exhibited higher scores in social persistence and expressive mastery motivation, Participant 2 increased in all three aspects of mastery motivation, whereas scores for Participant 3 decreased slightly in social persistence with adults and expressive mastery motivation. The number of independent switch activations achieved by each participant during his/her initial and final intervention sessions is presented in Figure 3. Throughout the intervention period, Participant 1 progressed from using one switch to two switches, and finally to three switches during her final three training sessions. Participant 2 was unable to independently activate the switch during his initial session but his abilities increased over the course of intervention. Participant 3 progressed from using two switches at his initial session to using three switches during all other sessions. Although Figure 3 indicates that Participant 3’s ability to achieve independent switch activation decreased between his initial and final intervention sessions, this is somewhat misleading as by the end of the intervention period, he was using more purposeful sustained switch activation to actually drive and maneuver the

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FIGURE 3. Number of independent switch activations for each participant at the initial and final training sessions.

device. At the onset of intervention, driving down a long hallway required him to perform multiple switch activations as he would stop and start repeatedly down the length of the hallway. At the end of the intervention period, however, he was able to sustain activation of the forward switch for a prolonged time to move down this same hallway in one steady action. Therefore, although he was activating the switch less frequently at the end of intervention, he was sustaining switch activation longer and demonstrating more purposeful driving skills. Progress towards goals related to basic power mobility skills for each participant at the mid-point and end of the intervention period are presented in Table 3. The parents of all three participants reported that they felt their child benefited from power mobility training and had achieved their desired outcomes as listed in Table 1. The parents of Participants 1 and 2 both also reported that their child appeared to be more aware of his/her surroundings and more interactive at the end of the intervention period. The mother of Participant 3 stated that her child seemed to better understand what it meant to move and explore independently. Participant 3 also subsequently qualified for a power wheelchair.23

DISCUSSION This case series described the use of an alternative power mobility device with three young children with multiple, severe physical impairments. Consistent with other studies involving young children with mobility limitations, each of the participants appeared to respond well to power mobility use and progressed towards basic power mobility goals.2,12 Participants 1 and 2 progressed from short bursts of seemingly unintentional switch activation at the start of the intervention to

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increasingly purposeful switch activation over the course of training. As proposed by Nilsson and Nyberg and Nilsson et al., the experience of using power mobility and accidently activating the switches may have stimulated these participants to develop more purposeful driving behaviors.29,28 Power mobility training may also have provided Participants 1 and 2 with vestibular and sensory experiences that increased alertness and awareness and offered opportunities for self-exploration of the environment.29 In contrast, Participant 3 progressed from short bursts of switch use and apparently enjoying bumping into walls and other objects at the onset of the case to more meaningful exploration using a power mobility device by the end of the intervention period. This different response may be related to his apparent grasp of cause and effect prior to the onset of the case. It has been suggested that power mobility training may assist individuals with cognitive disabilities to develop an understanding of cause and effect relationships.28 – 30 Although the Assessment of Learning Powered mobility use (ALP) was not available at the onset of power mobility training, applying the ALP to the outcomes for each participant provides interesting insights into the progress made by each of the participants.27 The ALP is an 8-level scale that describes an individual’s abilities to use a power mobility device. The 8 levels range from Level 1 – Novice, in which an individual has only a vague idea of cause and effect and of using a tool (joystick or switch) to operate a power mobility device, to Level 8 – Expert in which an individual is so skilled with using a joystick or switch to operate a power mobility device that he/she almost drives automatically with little conscious thought to the actual mechanics of driving. At the onset of the case, both Participants 1 and 2 appeared to have been at the lowest level of the ALP (Level 1–Novice). By the end of the intervention period, Participant 1 appeared to have been emerging at a Level 4 – Advanced Beginner in that she was able to hold and release a switch, demonstrate basic cause and effect skills, and was starting to use two or more switches to operate the power mobility device. Participant 2 appeared to have progressed to a Level 3 – Beginner in that he was able to activate and use a single switch to operate the power mobility device. Determining the location of the switch for Participant 2 required multiple sessions and his inconsistent motor function and athetoid movements often interfered with his driving even after this preferred switch location was identified. He may have progressed further if these motor control issues had not been a factor. Participant 3 appeared to have been at a Level 4 – Advanced beginner at the onset of the case and by the end of the intervention period, he appeared to have progressed to a Level 6 – Competent in that he demonstrated coarse use of three switches to maneuver the device and steer in desired directions. Further, his transition from using the PMD to using the Trainer due to growth did not appear to impact his development of power mobility use as measured by the ALP. Using the ALP in future studies may provide additional information regarding power mobility use and the development of cause and effect relationships. The power mobility training methods used in this case series provided a standardized, systematic means by which to individualize the training environment and meet the needs of each participant. The use of shared control appeared to be particularly beneficial, especially for Participants 1 and 2, who did not appear to have a full understanding of cause and effect relationships at the onset of the training.

Power Mobility Training for Young Children with Multiple, Severe Impairments 13 Using shared control, the therapist was able to make minor adjustments to the path of the power mobility device while the child continued driving. These adjustments were used to steer the device away from environmental hazards but also to selectively prevent the participants from becoming frustrated or confused about maneuvering the device. Whereas stopping the movement of the power mobility device and switching back and forth between the user and attendant control units may have been confusing, shared control allowed the participants to move within the environment with the added safety of the therapist acting as a responsive partner in the learning process. The training methods used in this case series are consistent with contemporary theories of motor control and neural plasticity.17,34 Providing an individualized environment that is motivating to a child is consistent with concepts related to the salience of rehabilitation interventions.17 Setting up the environment so that participants repeatedly practiced targeted power mobility skills (such as turning or stopping) reflects concepts of practice, specificity of training, and repetition.17,34 The use of shared control to maintain safety and yet allow for errors is consistent with the need to involve children in problem-solving processes that allow them to learn from their mistakes.17,34 One area that we would change is the frequency of intervention. Conducting training sessions several times per week rather than only once a week might have resulted in greater improvements and should be considered for future studies.17,34 Sessions missed due to weather or illness may have also impacted outcomes. An increased frequency or a longer duration of intervention may have been especially beneficial for Participants 1 and 2 who initially did not demonstrate a priori knowledge of cause and effect relationships. The outcome measures used in this case series were responsive to potential changes associated with power mobility training. The various domains of the PEDICAT reflected changes between pre and post-intervention in all three participants and each participant demonstrated post-intervention PEDI-CAT scores that exceeded the standard error measure between test administrations. This may reflect the ability of the PEDI-CAT to measure changes unique to each participant and suggests that outcomes of power mobility training may not be limited to mobility. The DMQ revealed modest benefits of power mobility training, consistent with changes made by two participants on the PEDI-CAT. Both Participants 1 and 2 displayed increases in the Social/Cognitive domain of the PEDI-CAT as well as in their intrinsic motivation to maintain social interactions with adults as measured by the DMQ. While Participant 1 displayed the greatest increase in social persistence, Participant 2 exhibited his greatest increase in cognitive persistence (a domain he fell well below the age-norm at pre-intervention). This suggests that involvement in power mobility training may have increased the ability of Participant 2 to persist in complex object-centered tasks. Noteworthy for Participant 2 is the increase in one item from the cognitive persistence scale of the DMQ: “Tries to do hard cause and effect toys such as a jack-in-the-box.” Given one of the goals for Participant 2 at pre-intervention was to develop cause and effect skills, his caregiver’s perception of his increased ability to persist with cause and effect toys (pre: 2/5, post: 4/5) may represent a benefit of power mobility for this participant.

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Caregiver ratings for Participant 3 indicated decreased social persistence with adults and expressive mastery motivation after power mobility training, domains where he scored well above (i.e., almost at ceiling) and slightly below preschool norms at the onset of training, respectively. Despite the lower rating, Participant 3’s motivation to maintain interactions with adults and effectively respond when faced with a challenging task were above (or consistent with) the preschool norms for the DMQ post-intervention. Given that Participant 3 exhibited increases in three of the four domains of the PEDI-CAT, but remained close to age norms in his intrinsic motivation for persisting in—and responding to—difficult tasks after training, these findings may reflect the PEDI-CAT as a more sensitive measure of the potential benefits of power mobility training for children who are already near or above norms for mastery motivation. Measures such as the ALP or the Canadian Occupational Performance Measure (COPM) may help quantify the outcomes of power mobility.18 It is also possible that physiologic measures such as electroencephalography (EEG) may be useful in quantifying outcomes of power mobility training in children with multiple, severe physical impairments. Using qualitative methodologies such as a parental interview may provide insights on parental views of power mobility use and training.20 Given that a case series lacks the control of a research study, there are many possible alternative explanations for the outcomes reported. The PEDI-CAT and the DMQ were completed by parent report and may have reflected their desires for their children to improve. The improvements reported on the PEDI-CAT and the DMQ cannot be directly attributed to power mobility training. Maturation or other factors may have accounted for the improvements. It is also possible that the participants may have experienced improvement in power mobility skills over a 12-week period without use of the PMD or the Trainer and without participation in an intervention program focused on improving power mobility skills. CONCLUSION Three young children with multiple and severe physical impairments demonstrated improved performance of power mobility following a 12-week intervention program using an alternative power mobility device. Although findings are not generalizable, they provide insights for further research to determine the effects of training on performance of power mobility. Declaration of Interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article. ABOUT THE AUTHORS Lisa K. Kenyon, PT, DPT, PhD, PCS, is an Associate Professor in the Department of Physical at Grand valley State University in Grand Rapids, Michigan, USA. John P. Farris, PhD is a Professor in the Padnos College of Engineering & Computing

Power Mobility Training for Young Children with Multiple, Severe Impairments 15 at Grand Valley State University, Grand Rapids, Michigan, USA. At the time this case series was completed, Cailee Gallagher, Lyndsay Hammond, and Lauren M. Webster were students in the Doctor of Physical Therapy Program at Grand Valley State University, Grand Rapids, Michigan, USA. Naomi Aldrich, PhD, is an Assistant Professor in the Department of Psychology, Grand Valley State University, Allendale, Michigan, USA.

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

Young children with neurodevelopmental conditions are often limited in their ability to explore and learn from their environment. The purposes of this...
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