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

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

2. 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

3. Literature Review • May 2007 • CINAHL and MEDLINE • Hand searching • Inclusion • Children with CP • Powered mobility intervention

4. Power mobility toys

5. Scooterboard

6. 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

7. 0 / 20 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

8. Level IV • Children in Level IV achieve 90% of their motor development by age 3.5 years (Rosenbaum et al., 2002)

9. 0 / 20 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

10. Level V • Children in Level V achieve 90% of their motor development by 2.7 years (Rosenbaum et al., 2002)

11. Importance of independent mobility • Self-produced locomotion plays a crucial role in cognitive and psychosocial development

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 0 / 20 Do you think children with CP under 2 years are able to use powered mobility? • Yes • No Cross-Tab Label

21. 0 / 20 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

22. Myth Young children with CP are not ready to use this expensive type of equipment X

23. 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

24. Results • Intervention group had significantly greater improvement : • receptive language (Batelle Developmental Inventory) • social function functional skills (PEDI) • self-care caregiver assistance (PEDI)

25. 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

26. 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

27. 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

28. Results • Significant improvement in social skills • Increased amount of physical play and significantly improved quality of play • No change in language or cognitive development

29. 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

30. 0 / 20 Would you prescribe a power wheelchair for a child with CP who can walk with a walker? • Yes • No Cross-Tab Label

31. 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

32. 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

33. 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

34. 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

35. Changing Perspectives?

36. 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

37. 0 / 20 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

38. Myth Children need certain cognitive and prerequisite skills before being ready to try powered mobility X

39. 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)

40. 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

41. 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.

42. 0 / 20 Would you use powered mobility with a child who doesn’t have established cause & effect? • Yes • No Cross-Tab Label

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

44. 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.

45. 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.

46. 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.

47. 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

48. 0 / 20 Would you ever recommend a power wheelchair for a child who requires 1:1 supervision? • Yes • No Cross-Tab Label

49. 0 / 20 Would you ever use powered mobility with a child who has a marked visual impairment? • Yes • No Cross-Tab Label

50. 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