ON Time Mobility: Advocating for Mobility Equity

The use of adapted motorized vehicles with controlled acceleration: Focus on child's acceptance

Mobility is essential for the development of children with disabilities. The Adapt Project uses motorized adapted cars to promote independent movement and positively impact child development. To evaluate whether the perception of acceleration influences children's initial adaptation to the device. This case study involved an initial intervention and a three-month follow-up after delivering the adapted car. First, the child was evaluated using the car without and with acceleration control, assessed with the FLACC and ALP scales. Second, follow-up sessions were conducted with active maternal participation. Third, qualitative interviews were conducted, and the QUEST 2.0 scale was applied to assess satisfaction. Rapid acceleration movements increased pain perception, while slow movements minimized discomfort. The child progressed from level 1 to levels 3 and 4 on the ALP scale, and the QUEST 2.0 scale demonstrated high satisfaction (4.91), highlighting safety, comfort, and technical support, after 3 months of usage. Adaptations to the device and family engagement were essential for device acceptance and motor-cognitive development. Acceleration control improved comfort and safety, enabling greater autonomy and interaction, emphasizing the importance of user-centered approaches in assistive technologies.

On-time power mobility and physical activity in toddlers with motor delays: A randomized controlled trial using body-worn sensors

This study conducted a secondary analysis to objectively measure the effects of modified ride-on cars (MROCs) training in different postures on physical activity (PA) levels in children with motor delays. Data from 39 participants were analyzed in a randomized controlled trial. The participants included those using MROC in standing postures (n = 11, mean age = 22.87 months), MROC in sitting postures (n = 16, mean age = 19.53 months), and a control group that received conventional therapy (n = 12, mean age = 23.30 months). PA intensity was measured using an ActiGraph GT3X on the participants' wrists and right hip at weeks 1, 6, and 12 of the 12-week intervention period. This trial was registered at ClinicalTrials.gov (NCT02527356). The demographic data were similar across the groups. No significant differences were found in the interaction, group, or time effects for any of the positions (p > 0.05). The PA levels were consistent in at least light PA intensity range. MROC training may yield PA levels comparable to those of conventional therapy. Variations in activity and motor impairment severity could affect outcomes. Future studies should investigate factors such as task characteristics, motor delay severity, PA cutoff points, and training dosage that may influence PA intensity.

Quantifying toddler exploration in different postures with powered mobility

Access to powered mobility can support play and development for toddlers with disabilities. Using powered mobility in a standing posture has been theorized to support development of muscle coordination, balance, head and trunk stability, and transition to ambulation. The purpose of this study was to quantify and characterize joystick control, bodyweight support, and muscle activity while using the Permobil Explorer Mini in seated and supported standing postures. Nine children with mobility disabilities participated in four visits where they completed two, 15-20 minute play sessions, one in each posture, with a break between. We found that all toddlers engaged with the joystick in both postures, with individual differences in favored directions and control patterns. Participants had similar loading through their feet in both postures, but had slightly higher muscle activity in standing, especially while driving. These results demonstrate that young children with disabilities quickly engage with joystick-based powered mobility in seated and standing postures, with important individual differences that can inform future design of devices and interventions to support play and development.

Tiny drivers, big decisions: parental perceptions and experiences of power mobility device trials for young children with cerebral palsy

PURPOSE

To explore parental perceptions and experiences at three timepoints [baseline (T0), post-intervention period 1 (T1), and post-intervention period 2 (T2)] across a 16-week study involving their children's use of two power mobility (PM) devices: an Explorer Mini (EM) and a modified ride-on car (mROC).

MATERIALS AND METHODS

Data for this phenomenological qualitative study were gathered as part of a multi-site randomized, counterbalanced AB crossover clinical trial, wherein all child participants used PM device A (EM) and PM device B (mROC) for eight weeks each. Trained researchers conducted in-person, audio-recorded semi-structured parental interviews at T0, T1, and T2. Data from each timepoint were individually analysed using the constant comparative method.

RESULTS

Twenty-four child-parent participant dyads partook in the larger clinical trial. The parent participant within each dyad completed three qualitative interviews (one per timepoint), resulting in a total of 72 interviews (24 at each timepoint). At each timepoint, unique themes representing the parent participants' journey across the study emerged. Main themes were: T0 - "Anticipation", "Adjustment", and "Recognizing Strengths"; T1 - "Benefits and Barriers", "Expectations", and "Importance of Device Trials"; T2 - "One Size Doesn't Fit All, But All Are Worth Trying", "Environmental Affordances Enable Learning", and "Enabling Abilities and Participation".

CONCLUSION

This study provides insights into how parental perceptions about power mobility may shift over time, thereby assisting clinicians in implementing ON Time Mobility. The study further highlights how PM use can positively impact socialization and participation and how PM use may provide children with a mobile learning environment.

Short-Term Powered Mobility Intervention Is Associated With Improvements in Development and Participation for Young Children With Cerebral Palsy: A Randomized Clinical Trial

OBJECTIVE

The objective of this study was to evaluate the effects of 2 short-term powered mobility interventions across developmental domains, participation, and perceptions of intervention implementation for young children with cerebral palsy and their families.

METHODS

This randomized, crossover clinical trial compared 2 powered mobility interventions: the Explorer Mini (Permobil AB, Timra, Sweden) and an adapted ride-on toy car. Analyses included 24 children aged 12 to 36 months, recruited from 3 sites. Each device was trialed in the home for an 8-week period for a total of 16 weeks. Three in-person study visits took place at baseline, crossover, and study completion, and 2 additional virtual check-ins were conducted for each device trial period. Outcome measures included all domains of the Bayley Scales of Infant and Toddler Development, Fourth Edition (Bayley-4); Child Engagement in Daily Life (CEDL) participation questionnaire; and t3 perceptual implementation measures: Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure. Analyses included descriptive statistics, 2 by 3 group × time analysis of variance, and post hoc t tests as warranted.

RESULTS

Statistically significant mean improvements were observed in all domains of the Bayley-4 and in the self-care subscale of the CEDL regardless of device order. Caregivers ranked both devices as acceptable and feasible to implement, although the Explorer Mini was ranked slightly more favorably than the adapted ride-on toy car, with a device order effect being observed.

CONCLUSION

Short-term powered mobility intervention may advance multiple domains of development and participation for young children with cerebral palsy. Caregivers rated 2 different powered mobility devices favorably as part of their child's early intervention strategies.

IMPACT

This study enhances the quality of evidence available to clinicians and families to support decision-making about powered mobility intervention for young children with motor disabilities, especially those who may be reluctant to begin powered mobility due to stigma or concern for motor skill development.

LAY SUMMARY

In this study, children with cerebral palsy used 2 different powered mobility devices over 16 weeks. The goal of the study was to understand how powered mobility device use affected the children's movement, communication, learning, and social interactions. The goal was also to understand how caregivers felt about the intervention and device options.

Quantifying Parental Perceptions of Their Experiences With Their Young Children's Use of Power Mobility Devices

PURPOSE

To quantify and explore parental perceptions of their experiences with their child's use of the Explorer Mini (EM) and a modified ride-on car (mROC) in young children with cerebral palsy.

METHOD

Data were gathered throughout a multisite, randomized, counterbalanced AB crossover 16-week clinical trial, wherein all participants used device A (EM) and device B (mROC) for 8-weeks each. Semistructured parent interviews were conducted at baseline (T0), post-intervention period 1 (T1), and post-intervention period 2 (T2). The Linguistic Inquiry and Word Count program was used to objectively analyze the transcribed interviews.

RESULTS

Twenty-four child-parent dyads participated in the study. Parental perceptions were related to children's gross motor abilities, cognitive development scores, and device use order (EM-mROC or mROC-EM).

CONCLUSIONS

Parents were positive about a potential means of helping their children. While most preferred the EM, opinions were contingent on the PM device, device use order, and child-centered factors.

Lessons learned from a pediatric powered mobility lending program

PURPOSE

To evaluate children's characteristics and impact of a powered wheelchair lending program including comparisons of diagnostic sub-groups, and validation of a predictive model of powered mobility proficiency.

METHODS AND MATERIALS

This retrospective study included 172 children who participated in the ALYN powered mobility lending program from 3/2009-7/2022. Demographics and functional levels were measured via questionnaires; driving proficiency was evaluated when the wheelchair was returned, and parents and children were interviewed following their participation in the program.

RESULTS

Two diagnostic groups were identified: cerebral palsy (CP) (n = 136, median = 9.75 yrs) and other neuromuscular diseases (NMD) (n = 30, median = 5.83 yrs). They differed significantly in the age they commenced PM training, the male/female ratio, walking ability and access mode. Fifty-seven percent of the participants with CP achieved powered mobility proficiency, a rate that was significantly lower than the 73% proficiency found for the NMD group. Four significant predictors were identified: communication, manual wheelchair operation, access mode and go-stop upon request. They predicted proficiency in approximately 80% of cases. Overall feedback from the parents and children indicated that their personal and family's quality of life improved as a result of their child's ability to use a powered wheelchair.

CONCLUSIONS

A lending program provides children with opportunities to improve mobility skills in an appropriate powered wheelchair. Children who can communicate verbally, propel a manual wheelchair, use a joystick and go-stop upon request are significantly more likely to become proficient drivers; however, many who were unable to complete these tasks also improved and even became proficient drivers.

Off to the park: a geospatial investigation of adapted ride-on car usage

PURPOSE

Adapted ride-on cars (ROC) are an affordable, power mobility training tool for young children with disabilities. Previous qualitative research has identified environmental factors, such as weather and adequate drive space, as barriers to families' adoption of their ROC. However, we do not currently know the relationship between the built environment and ROC usage.

MATERIALS AND METHODS

In our current study, we quantified the driving patterns of 14 children (2.5 ± 1.45 years old, 8 male: 6 female) using ROCs outside and inside of their homes over the course of a year using a custom datalogger and geospatial data. To measure environmental accessibility, we used the AccessScore from Project Sidewalk, an open-source accessibility mapping initiative, and the Walk Score, a measure of neighborhood pedestrian-friendliness.

RESULTS

The number of play sessions with the ROC ranged from 1 to 76; 4 participants used it less than 10 times and 4 participants used it more than 50 times. Our findings indicate that more play sessions took place indoors, within the participants' homes. However, when the ROC was used outside the home, children engaged in longer play sessions, actively drove for a larger portion of the session, and covered greater distances. Most children tended to drive their ROCs in close proximity to their homes, with an average maximum distance from home of 181 meters. Most notably, we found that children drove more in pedestrian-friendly neighborhoods and when in proximity to accessible paths.

CONCLUSIONS

The accessibility of the built environment is paramount when providing any form of mobility device to a child. Providing an accessible place for a child to move, play, and explore is critical in helping a child and family adopt the mobility device into their daily life.

Supported Standing and Supported Stepping Devices for Children with Non-Ambulant Cerebral Palsy: An Interdependence and F-Words Focus

Children functioning at Gross Motor Function Classification System (GMFCS) levels IV-V cannot maintain an aligned standing position or take steps without support. Upright positioning and mobility devices have psycho-social significance for these children and their families, enhancing use of vision, communication, functioning and emotional well-being. Standers and supported stepping devices facilitate opportunities for biomechanical loading, potentially helping to build and maintain muscle and bone integrity, and they promote physical development. However, families are often required to choose between these two devices for their young child. This study aims to synthesize evidence for use and benefits of both supported standing and stepping devices through the lens of two contemporary theoretical frameworks to support clinical reasoning and implementation. The F-words for childhood development (functioning, family, fitness, fun, friends, future) and the interdependence-Human Activity Assistive Technology (iHAAT) models were combined to illustrate the complex interactions between the child, family, caregivers, peers and contextual factors when implementing standing and stepping devices with children at GMFCS levels IV and V. Supported standing and stepping devices provide complementary benefits, and both may be necessary starting at 9-15 months. We propose they both be included ON-Time, along with other age-appropriate positioning and mobility devices, to promote more equitable developmental opportunities for children with non-ambulant cerebral palsy.

Caregiver perspectives on powered mobility devices and participation for children with cerebral palsy in Gross Motor Function Classification System level V

AIM

To describe caregiver experiences, perceptions, and device preferences between a modified ride-on car (MROC) and an Explorer Mini, including perceived changes in participation, barriers, and benefits for young children with cerebral palsy (CP) classified in Gross Motor Function Classification System (GMFCS) level V.

METHOD

A subset of data were analyzed from a larger multisite study. Semi-structured interviews were conducted with 10 caregivers of children with CP in GMFCS level V across a 16-week trial with two mobility devices. Each interview was audio-recorded, transcribed verbatim, and analysed using constant comparison methods.

RESULTS

Seven of 10 caregivers preferred the Explorer Mini over the MROC. Four themes emerged. One related to the perceived benefits and barriers of each device (ease and convenience is essential) and three related to perceived changes in participation: (1) autonomy enacted through mobility; (2) belonging and being present; and (3) participation recognized as an area of growth.

INTERPRETATION

Despite limited consideration of powered mobility for this population, caregivers of children in GMFCS level V reported similar benefits and barriers compared to children in other GMFCS levels shown in the literature. Particularly, caregivers perceived positive changes in their child's participation and recognized the ability for continued improvements in participation when using powered mobility.

WHAT THIS PAPER ADDS

Children with cerebral palsy classified in Gross Motor Function Classification System level V are often excluded from powered mobility use and research. Despite this, caregivers reported positive experiences for their children. Caregivers felt that participation in powered mobility led to increased autonomy and overall sense of inclusion and belonging for their children. Most caregivers preferred the Explorer Mini over the modified ride-on car but recognized that both devices had benefits and barriers to use.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools

Children with developmental central hypotonia have reduced muscle tone secondary to non-progressive damage to the brain or brainstem. Children may have transient delays, mild or global functional impairments, and the lack of a clear understanding of this diagnosis makes evaluating appropriate interventions challenging. This overview aimed to systematically describe the best available evidence for tools to identify and evaluate children with developmental central hypotonia aged 2 months to 6 years. A systematic review of systematic reviews or syntheses was conducted with electronic searches in PubMed, Medline, CINAHL, Scopus, Cochrane Database of Systematic Reviews, Google Scholar, and PEDro and supplemented with hand-searching. Methodological quality and risk-of-bias were evaluated, and included reviews and tools were compared and contrasted. Three systematic reviews, an evidence-based clinical assessment algorithm, three measurement protocols, and two additional measurement tools were identified. For children aged 2 months to 2 years, the Hammersmith Infant Neurological Examination has the strongest measurement properties and contains a subset of items that may be useful for quantifying the severity of hypotonia. For children aged 2-6 years, a clinical algorithm and individual tools provide guidance. Further research is required to develop and validate all evaluative tools for children with developmental central hypotonia.

Therapeutic Play Gym: Feasibility of a Caregiver-Mediated Exercise System for NICU Graduates with Neuromuscular Weakness-A Case Series

PURPOSE

To describe the feasibility and effect of caregiver-mediated exercise training using a novel Therapeutic Play Gym in 3 neonatal intensive care unit (NICU) graduates with rare neuromuscular diseases.

SUMMARY OF KEY POINTS

Caregivers of 3 medically complex, technology-dependent NICU graduates could not access community-based rehabilitation services after discharging from lengthy initial hospitalizations. These children, diagnosed with spinal muscular atrophy type 0, untreated X-linked myotubular myopathy, and untreated nemaline myopathy 3 (NEM3), completed monthly consultations with a pediatric clinical specialist and 3 assessment appointments. The caregivers agreed to administer a progressive Therapeutic Play Gym home exercise program at a minimum frequency of 3×/wk for 6 months.

CONCLUSION

A monthly consultative approach was both feasible and effective to safely progress caregiver-mediated home exercise training using a novel Therapeutic Play Gym. Positive training effects emerged in fitness, function, and caregiver-reported quality of life domains.

RECOMMENDATIONS FOR CLINICAL PRACTICE

A strong therapist-caregiver alliance can empower families to perform guided training when community resources are limited. More research is needed to see whether this training model is feasible for children with other conditions; for use in hospital, outpatient, or educational settings; and as an adjuvant exercise treatment for children receiving disease-modifying interventions.

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

Powered Mobility Device Use and Developmental Change of Young Children with Cerebral Palsy

Mobility is a fundamental human right and is supported by the United Nations and the ON Time Mobility framework. The purpose of this study was to understand the effect of a powered mobility intervention on developmental changes of children with cerebral palsy (CP). This study was a randomized, crossover clinical trial involving 24 children (12-36 months) diagnosed with CP or with high probability of future CP diagnosis based on birth history and current developmental status. Children received the Explorer Mini and a modified ride-on car in randomized order, each for 8 weeks. The Bayley Scales of Infant and Toddler Development-4th Edition was administered at baseline, mid-study, and end-of-study. Raw change scores were used for analysis. Total minutes of use per device was categorized as low or high use for analysis based on caregiver-reported driving diaries. Explorer Mini: The high use group exhibited significantly greater positive change scores compared to the low use group on receptive communication, expressive communication, and gross motor subscales (p < 0.05). Modified ride-on car: No significant differences between low and high use groups. Regardless of device, low use was associated with no significant developmental change and high use was associated with positive developmental changes. Mobility access is critical to maximize the development of children with CP and may be augmented by using powered mobility devices. Results may have implications for the development of evidence-based guidelines on dosage for powered mobility use.