Effective Mobility for Children ΑΑΑΑΑΑΑ

8/12/2019 Effective Mobility for Children

1/36

Effective Mobility for Childrenwith Motor Disabilities

What? Why? When? How?

Paradigm Shift in Rehabilitation 3 Traditional Philos o phy

Emerging PhilosophyEffective Mobility: What? 5Effective Mobility: Why? 5

Outcomes: Traditional Approach5

Walking: At What Cost?The Reality of WalkingOutcomes:Restricted Locomotion7

Theories of Motor Developmentand Motor Learning8

Classi cations of Motor Conditions10Gross Motor Functional

Classi cation System Classi cation: Prescribing Wheeled Mobi lity Devices Classi cation: Potential for Independent Walking Model of Service Delivery14

Charlene Butler, EdD

Model of Disablement14 Disability Movement16 Civil Rights Laws17 Availability of Powered Devices18Effective M obility: When? 18 Theory of Child Development19

Importance of Self-Produced Locomotion20 Neuroscience: Developing Mind

and Brain21 Hi Tech Tots22 Wheelchair ToddlersEffective Mobility: How? 24 Assistive Technology24 Outcomes:Powered Mobil ity Conclusions: Powered Mobility Augmentative Mobility29 Service Animals.30Principles of Management 30

Contents
http://www.global-help.org/


2/362

Author: Charlene Butler, EdD

Charlene is a special educator with aunique background of training andexperience in education, child psychology,physical therapy, medicine, assistivetechnology and research. She pioneered

the use of powered mobility by very youngchildren with motor impairments. Herprimary clinical and research interest hasbeen in use of assistive technologyto promote the overall development andachievement of independence of childrenwith cerebral palsy and other motorimpairments.

She was a teacher in a modelprogram for children with motordisabilities for 25 years where she workedin close collaboration with therapists,nurses and a variety of physicians. Shewas a health educator for the Birth DefectsClinic at Seattle Childrens Hospital, and asa consultant to teachers and familiesabout the complex needs of thesechildren.

Charlene has extensive internationalexperience. She networked innovativeideas for the care of disabled children in

13 Mediterranean, African, and SoutheastAsian countries as a Fellow of theInternational Exchange of Experts and

Information of the World Rehabilitation

Fund. She led delegations on childhooddisability to China and India for the Peopleto People Ambassador Program. Sheserved on several editorial boards for

journals published in the US and India.She is a Past President of the

American Academy for Cerebral Palsy andDevelopmental Medicine where she ledthat Academys effort to develop andestablish a methodology suitable forsystematically reviewing interventions forcerebral palsy and other complexdevelopmental disabilities.

Special Acknowledgement

The author wants to especially thank her colleagues, Johanna Darrah, PhD, PT, and LesleyWiart, PhD, PT of the University of Alberta, Canada, for their contribution to the ideasexpressed in this publication.


3/363

Paradigm Shift in Treatmentand Management

No one would disagree that effectivemobility is an obvious and compelling needof all people. Yet, it has not previouslybeen a priority of our management ofpeople who have a childhood motordisability such as cerebral palsy,myelomeningocele, muscular atrophy anddystrophy, arthropgryposis, osteogenesisimperfecta, phocomelia, polio, juvenilerhumatoid arthritis, or an injury-relatedmotor impairment.

Organized efforts to help children withmotor disabilities began just after WorldWar II with the polio epidemic and soonbegan to include children with other motordisabilities. What we now regard as thetraditional rehabilitation approach evolvedduring those first 35 years of treatment.

Traditional PhilosophyTraditionally, these childhood motordisabilities were fundamentally understoodas an impairment of motor developmentand function. The core concept inrehabilitation for these children wasnormalization of movement. The primarygoal of rehabilitation was the acquisition,use, and maintenance of normal movementpatterns with walking as the most widelyand highly valued achievement. Even whenthe prognosis for walking was poor orlimited, primary, if not exclusive, attentionwas given to therapy, casting, bracing,

Effective Mobility for Children withMotor Disabilities

What? Why? When? How?

Last Resort


4/364

surgery, and ambulatory aids, in thehope of eventually achieving someform of walking. Life for the child andfamily revolved around theseinterventions. Walkers, crutches,canes, walking frames, and orthoticswere acceptable aids because they

were walking aids. Whatever level orquality of walking the child achievedwas to be used in all situations. Therewas a belief that if the child did notuse it (i.e. walking), he or she would

lose it. Moreover, it was expectedthat this achieved walking would bemaintained throughout adult life.

Wheelchairs were acceptableonly when all other efforts andtechniques to produce ambulation hadfailed. In other words, wheelchairswere viewed as the last resortratherthan as an aid to locomotion.Moreover,a wheelchair was thought tobe inappropriate for any person at anyage who could walk at all, regardlessof how much of a struggle it was towalk or how long it took to getsomewhere. These concepts hadbecome widely accepted--evenentrenched--by the late 1970s and

framed the traditional philosophy ofpediatric rehabilitation.

However, a paradigm shift isunderway that is changing theemphasis from walking to effectivemobility for these children. ThomasKuhn first used the term, paradigm

shift, in his book The Structure ofScientific Revolutions to describe abasic change in assumptions within aruling theory of science. A paradigmshift is a radical change in thinkingfrom an accepted point of view to anew one, necessitated when newscientific discoveries produceanomalies in the current conceptualview.

Emerging PhilosophyThe paradigm of pediatric rehabilitationhas been shifting from normalization ofmovement to normalization of overallchild development and independence.The goal of rehabilitation is becomingthe achievement of meaningfulfunction and participation in age-appropriate activities and occupationsthroughout life. Meeting this goal

Paradigm Shift

Traditional Paradigm Emerging Paradigm

From motor disability developmental disability

From normalization of motor normalization of overalldevelopment and movement development and independence

From achievement and main- achievement and maintenancetenance of walking of mobility

From remediating impairment bypassing impairment


5/365

depends directly on being able to meetthe required mobility demands.

Effective Mobility: What?Effective mobility is locomotion that isfunctional, timely and energy-efficient.In other words, it is moving easily andindependently from one place toanother. It may include a variety ofwheeled and ambulatory aids thataugment whatever movement a person

may have.

Effective Mobility: Why?

Two conditions need to be present fora paradigm shift to occur. First,evolving practice and research fails tosupport the traditional thinking.Second, there needs to be a criticalmass of people who begin to questionthe traditional assumptions. This iswhat is happening in our thinkingabout mobility for children withchildhood motor disabilities. There have been severaladvances in knowledge from the fieldsof healthcare, education andpsychology as well as in the society atlarge that are responsible for the

paradigm shift from walking to mobility.

First, our clinical experience andscientific studies demonstrated thatthe traditional approach had yieldeddisappointing outcomes.

Outcomes of Traditional Approach

Walking: At What Cost?By the 1980s, studies of energyexpenditure and efficiency had

demonstrated that there are significantphysiologic penalties imposed byabnormal gait. Replicated evidenceled to acceptance of the followingrealities for children and adults.1) When prolonged exercise is

performed at greater than 50% ofan individuals maximal aerobiccapacity, available oxygen isinsufficient to meet the energy

demands of the muscles, and theindividual cannot sustain activitywithout exhaustion.

2) People, with and without motordisabilities, walk at a speed that ismost efficient in terms of energyexpenditure. To maintain thiscomfortable level of energyexpenditure in free walking, motordisabled persons move more slowly.


6/366

3) The more abnormal the gait pattern,the greater the energy expenditureand the slower the speed.

4) Walking with crutches, braces,parapodia, or walkers greatlyincreases energy cost and slowsspeed, regardless of the type of

motor impairment or age.5) Any ambulation aid that increases

effort is likely to be abandoned.6) Wheelchairs allow individuals to

travel at a speed comparable to thatof unimpaired walkers withequivalent energy expenditure.

The magnitude of the physiologicpenalty of abnormal gait is significant.For example, research has shown that

walking in children withmyelomeningocele to be twice asstrenuous as propelling a wheelchair.Children with thoracic and upperlumbar lesion levels who walkedwithout aids worked at maximalaerobic capacity. The ones who walkedwithout orthotic devices or upperextremity aids, had the highest energyexpenditure. Their speed of freewalking was much slower (average of26 meters per minute) than that thespeed of unimpaired walkers (range of69-73 meters per minute). Rapid onsetof fatigue occurs with this level ofexertion. Children with lower lumbarlevels required 85% of maximalaerobic capacity to walk compared with30% maximal aerobic capacity used byunimpaired children. Similarly, research comparingchildren with no motor disability andchildren with cerebral palsy found thatthose with spastic diplegia had three tosix times higher energy expenditureeven at slower than normal walkingspeeds. Even the children withhemiplegia who had higher energycosts.

Results from other cerebralpalsy research may explain whyteenagers wantand needto walkless and use a wheelchair. The rate ofenergy expenditure at self-selectedwalking speed in unimpaired peopledecreases with age while their aerobic

and physical working capacitiesincrease. The opposite happens inpeople with spastic diplegia: their rateof energy expenditure increases whileaerobic and physical workingcapacities decrease. Children, youth,and adults who walk with an abnormalgait and who complain of fatigue ordifficulty in keeping up are not lazy.They are experiencing an extremephysical exertion. When walking requires near-maximal aerobic capacity, classroomperformance may also suffer fromexercise-induced fatigue. This riskincreases as growth accelerates,school campuses are large, andstudents move between classesfrequently during the day. A small butrobust study demonstrated thatadolescent students with myelomenin-gocele who walked with crutches or awalker between classes at school hadmean heart rates that exceeded 60%to 75% of maximal heart ratefollowing walking, and they showedsignificant decline in visual-motorperformance test measures. Bycontrast, both heart rate and visual-motor performance improved whenthese study participants usedwheelchairs to get around theirschool.

Children with neuromotordisabilities such as cerebral palsy andmyelomeningocele are already at riskfor poor academic achievementbecause, in addition to their motorimpairment, they have visual-perceptual problems, poor handfunction, learning disabilities, and/or


7/367

function are the major challenges inthe care of adults with cerebral palsy.

Outcomes of Restricted

Locomotion

Motor-impaired youngsters who lackthe necessary movements to engageand act upon their environment misslearning opportunities. But even moreimportant, their inability to influencetheir environment (i.e, to affect oralter it through their own actions) canlead to a condition called learned

attention deficit disorders. High energyconsumption compromises themfurther.

Some people began to argue thatthe high cost of the traditionalapproach was not justified. Moreover,it made many young people think they

were lazy or failures when theyeventually retreated to wheelchairs.In 1997, Dr. Eugene Bleck, notedpediatric orthopedic surgeon, wrote inOrthopedic Management of CerebralPalsy, that These data indicate howimpractical is it to encourage (or force)disabled children to walk long distanceswith assistive devices. They need toavoid undue fatigue in order to

accomplish other tasks of daily living asas school work, learning, social life andcommunity integration.

The Reality of Walking A review of walking in individuals withcerebral palsy by Bottos in 2003showed that indoor-only ambulatorsthat relied heavily on walking aids hadoften stopped walking in teenage yearsbecause of the extraordinary time andfatigue associated with walking. Byabout age 25, community ambulatorswho relied on walking aids had lostambulatory capacity due to

physiological burn-out syndrome.This occurs when an individualsphysiological system, constantlystressed and working to the maximum,becomes overburdened. By about 45,even mildly motor impaired individualswith cerebral palsy, who had becomeindependent walkers on their own aschildren, experienced debilitating painfrom joint deterioration. A 2009working conference supported by theAmerican Academy for Cerebral Palsyand Developmental Medicine found thatsevere pain, chronic fatigue and apremature decline in mobility and

Reality of Walking (Cerebral Palsy)

Never achieved by some

Loss or deterioration in many

Teenage years: extraordinary energycost

Mid-20s: physiological burn-out syndrome

Mid-40s: painful joint deterioration


8/368

helplessness in which children give uptrying to control their own world.

Repeated failure in exploring andmastering situations can lead to a self-perception of incompetence andpassive resignation that extinguishesfurther attempts. Studies have

indicated that a sense of helplessness(or incompetence) becomes well-established in a child by four years ofage. Moreover, motor-impairedchildren have an ongoing risk forprogressive delays in perceptual,spatial, and social development. Severely restricted locomotion isassociated with long-term, negativeeffects on psychological development,even in non-disabled children whosemobility was restricted during earlychildhood for medical or other reasons.The most frequent outcome ofrestricted locomotion was a pattern ofpassive, dependent behaviorspecifically a lack of curiosity andinitiative that persisted into later life.These are personality traits that areassociated with poor academicachievement and social interaction.

Theories of Motor Development andMotor Learning

For many years, neuromaturationtheory had held that motordevelopment and learning occurredthrough pre-programmed brainmaturation. Use of normal patterns

was believed to produce normalmovement whereas use of abnormalpatterns was expected to lead to moresevere abnormal movement andpostures. The implications fortreatment were the following:1) Reducing the childs motor

impairments would automaticallyimprove the childs functional motorskills.


9/369

2) Walking was the movement solution of choice forevery child and every situation.

3) Only normal patterns of movement wereacceptable.

As neuroscience failed to support this theory, newtheory arose that better explains what has beenobserved.

Currently, dynamic systems theory and motorlearning theory both emphasize that motorperformance is influenced by the interaction of apersons abilities, the functional task they want toachieve and the environment in which they aremoving. The implications for treatment that arisefrom these are quite different.1) Intervention should attempt to change each or all

of these three elements, i.e., the childs ability/impairment, the functional task, and the

environment.2) There are a variety of appropriate ways to achievesuccessful completion of a functional andmeaningful task, which also applies to typicalmovement. An example is this adapted throw inby a soccer player to get more power behind theball.

3) Optimal motor performance may be achieved bymovement patterns that were previouslyconsidered abnormal. For example, W-sitting wasrigorously not permitted for children with cerebralpalsy in the past. Now it is being suggested thatW-sitting may be an innovative and efficientmovement solution for these children.

4) Optimal motor performance may be achieved withmobility devices, even powered ones.

5) One size does not fit all, that is to say, walking isnot the only movement solution for all children atall times. There should be different movementoptions for different children and for differentenvironments whether impaired or not.


10/3610

In rehabilitation, children are helped todiscover their most functionalmovement patterns and to develop ansystem of movement options fromwhich they may choose, depending onthe task and environment.

Classications of Motor ConditionsTraditionally, classification of a motordisability has been based on the typeor degree of motor impairment. Forexample, cerebral palsy is classified bythe different types of abnormalmovements that may be seen (e.g.,spasticity or athetosis) and by thedistribution of these abnormal

movements throughout the body (e.g.,quadriplegia or hemiplegia).Experience and research have shownsuch a classification to be neither agood predictor of walking ability incerebral palsy, nor to be useful inproviding guidance about whatinterventions to pursue.

Functional classification systemsthat are more appropriate forrehabilitation purpose have appearedfor management of cerebral palsy.One categorizes children by their grossmotor abilities and the other byprognosis for achieving andmaintaining independent walking.

Gross Motor Function ClassicationSystem (GMFCS)

Palisano, Rosenbaum and others at theCanChild Centre for ChildhoodDisability Research developed this five-level classification system based onself-initiated movement with particularemphasis on sitting, transfers andmobility. The focus is on determiningwhich level best represents the childsor youths present abilities andlimitations. The level of motor functionis determined by functional limitations

and the need for hand-held mobilitydevices (i.e., walkers, crutches andcanes) or wheeled mobility, and to alesser extent, the quality ofmovement. It reflects ordinaryperformance, not best performance,and does not judge potential for

improvement.

Levels of GMFCS

Level I. Walks without limitations

Level II. Walks with limitations

Level III. Walks using a hand-heldmobility device

Level IV. Self-mobility with limitations,may use powered mobility

Level V. Transported in manualwheelchair

Distinction Between Level I and II - Compared with children and youth inLevel I, children and youth in Level IIhave limitations walking longdistances and balancing; may need ahand-held mobility device when firstlearning to walk; may use wheeledmobility when traveling long distancesoutdoors and in the community;require the use of a railing to walk upand down stairs; and are not ascapable of running and jumping.Distinction Between Level II and III -

Children and youth in Level II arecapable of walking without a hand-held mobility device after age 4(although they may choose to use oneat times). Children and youth in LevelIII need a hand-held mobility deviceto walk indoors and use wheeledmobility outdoors and in thecommunity.


11/3611

Distinction Between Level III and IV - Childrenand youth in Level III sit on their own orrequire, at most, limited externalsupport to sit, are more independent instanding transfers, and walk with ahand-held mobility device. Children andyouth in Level IV function in sitting

(usually supported) but self-mobility islimited. They are more likely to betransported in a manual wheelchair oruse powered mobility.Distinction Between Level IV and V - Childrenand youth in Level V have severelimitations in head and trunk control andrequire extensive assisted technologyand physical assistance. Self-mobility isachieved only if the child/youth can use

a powered wheelchair. The GMFCS is widely used inclinical practice and research to measurethe effectiveness of interventions onmotor function.

Classication by Potential for MobilityIndependence

Bottos proposed a functionalclassification system intended to guideclinical management of children withcerebral palsy. This classificationcontains four categories thatdifferentiate children by prognosis formobility independence--a prognosis thatcan be made in early childhood. Foreach category, the key rehabilitationconcerns are identified. These concernsare the problems that will likely developover time and cause further limitation

for the child or family. Interventionstrategies to reduce or avert thoseexpected problems are recommended foreach category.Children whose prognosis is for completedependence on caregivers - There are twokey rehabilitation concerns for this groupwith severe physical and mental im-pairments. One is that the relationshipbetween the child and caregiver will

Prognosisfor

IndependentMobility

RehabConcerns

InterventionStrategies

Dependenton cargivers

Symbioticrelationship

Deformity

Assistivedevices andequipment

Variety ofcaregivers

Normal liferhythm

Preventdeformities

Independence

achieved onlythroughpoweredmobility

Functional

mobility Functionalsitting,transfers,standing

Deformity

PT to develop

balance, preventdeformities

Assistivedevices

Early provisionof poweredmobility

Mixedindependence

(walking + wheeledmobility,manual and/or powered)

Limitedmobility

Physio-logicalburnout

Deformity

PT to age 8 for walking

Walking aidsand orthoses

Possible orthosurgery

Wheeleddevices, possiblypowered

PT to preventdeformities

Independent walking

Pain,possiblylimitingfunction inadulthood

Periodic PT inadulthood forbalance andgait, monitormusculoskeletalstaus/deformity Assistivedevices over ages40-45


12/3612

become increasingly symbiotic andunhealthy. Often it is the mother whoassumes care of the child. This child,then adolescent and finally adult, maybe cared for, fed and so on, on themothers lap, or in close proximity tothe mother. The youngster mayincreasingly refuse physical separation

making management ever moredifficult. The second rehabilitationconcern is the high risk of physicaldeformities. Deformities may make itimpossible for one person to physicallymanage the child alone, especially asweight and height increases with age.When the child is predominantly heldby someone, the prevention ofdeformity is made very difficult orimpossible. Use of assistive devices

and equipment, such as suitable chairsand supports is an interventionstrategy that can help preventdeformity and reduce symbiosis. Forexample, use of a customized chair forfeeding or toileting will provide headand trunk support and symmetricalposture. When using these chairs, thechild can begin to experience theseparation of self, physically andpsychologically, from the mother.Similarly, early integration intopreschool is importantnot foracademic achievement but to reducesymbiosis and participate in a normaloccupation of childhood. The child willexperience physical separation inleaving home in the morning, sayinggoodbye to his or her parents, andreturning to them in the afternoon.While at school, the child will becomeaccustomed to a variety of caregivers.While these interventions cannot free

the child from caregiver dependence, itdoes reduce dependency on oneunique caregiver and, hence,contributes to an overall improvementin the quality of life of the family.Children whose prognosis is thatindependent mobility will only be achievedthrough the use of wheeled devices forlocomotion, most likely powered ones - Thekey rehabilitation concerns for thisgroup are lack of functional mobility as

well as functional sitting, transferringand standing, and for development ofdeformities. Intervention focus should,therefore, be on early provision ofadequate assistive devices andequipment, including powered devices.Physical therapy should be focused on

developing balance and stamina forsitting, standing and transferring aswell as the prevention of deformities.Children whose prognosis is mixedindependence - They have the possibilityof independent walking indoors, but itwill not be functional outdoors. Therehabilitation concerns are that onlylimited walking will be achieved andthat physiological burnout willeventually occur with deterioration ofwalking. Intervention for this groupshould be multifaceted. They shouldhave intensive and prolonged physicaltherapy along with the use ofappropriate orthoses, and possiblyeventual orthopedic surgery, topromote independent walking.However, interventions to promotewalking in children with cerebral palsyshould be limited to the earlychildhood years because we now knowthat the probability of a child walkingafter age 7-8 is remote, at least inspastic types. Prevention ofdeformities should be a part of thetherapeutic program at all ages. Until,and even if, walking is achieved,assistive mobility devices should beprovided and used. These may bemanually propelled or powereddevices, or both. The purpose of usingmobility devices is to widen motorindependence, to reduce excessiveenergy expenditure, to avoid earlyphysiological burnout with theconsequent loss of independentwalking in teenage years, and toreduce risk of eventual jointdeterioration and pain.


13/3613

Children whose prognosis is to becomeindependent walkers on their own - Theprimary rehabilitation concern is for

joint deterioration and debilitating painin adulthood. Intervention should,therefore, focus on strategies toimprove balance and gait as walking

develops, prevent deformities, and tomonitor musculoskeletal evolution overthe years. Assistive devices may playan important role even in the case ofthese relatively mild forms of cerebralpalsy. Using wheeled devices may beused as a preventative measure inpeople over the ages of 40-45 to reduce

joint deterioration and , thus, preservethe capacity of independent walking foras long as possible. If and whenwalking deteriorates, mobility deviceswill increase an individuals overallfunctional independence.

Classication for Early Powered Mobility

Hayes proposed a four-partclassification to identify children withrepresentative diagnoses who will needpowered devices, in early childhood ifthey are to have effective mobility.Children who will never walk - They willhave no opportunity for independentlocomotion without wheeled devices,most likely powered devices.Children with inefcient walking - They willwalk but be unable to do so at areasonable rate of speed withacceptable endurance for all activitiesso will need multiple modes of mobility.

They may walk with aids, use a manualwheelchair, and a powered device,depending on the circumstances.Children who will eventually walk - They willrequire non-ambulatory mobility duringmuch of childhood. They will need anefficient mobility device during earlychildhood development and untilfunctional walking becomes possible.Because these children have insufficient

Children Who

RepresentativeDiagnoses

Will neverwalk

Severe cerebral palsy withspastic quadriplegia or

athetosis, spinal muscularatrophy types I and II,multiple limb deciency,spinal cord injury

Haveinefcentmobility

Ataxia, spastic diplegiaand milder forms ofquadriplegia and athetoidcerebral palsy,myelomeningocele, and

juvenile rheumatoidarthritis

Willeventuallyambulate

Spastic diplegia cerebralpalsy or arthrogryoposisin which evenual surgicalcorrections may makewalking possible;osteogenesis imperfectarequiring protection

during childhood

Have lostmobility

Neurological sequelaefrom trauma andinfectious disease,progressive disorderssuch as Duchennemuscular dystrophy

muscle power or fragile bones,powered devices will be needed.Children with permanent loss of independentwalking - They will need a wheelchair orother device to restore self-producedmobility. While some children may beable to wheel a manual wheelchair,

most will need powered devices forfunctional mobility.


14/3614

Model of Service Delivery

Traditionally, we worked in a servicedelivery system in which expertsdictated which interventions childrenwould get and when and how thoseinterventions would be provided. Thiswas directly influenced by the medicalinterests and specialities of thehealthcare professionals involved.

About 1980, a shift from expert-centered care to client-centered carebegan to occur. In pediatricrehabilitation, this approach is calledfamily-centered care. Family-centeredcare is based on the concept of familyempowerment. Basic tenets are that

the family knows the child best, thefamily is the constant in the childs life,and that families can function wellgiven adequate social support andresources. Therefore, in family-centered care, healthcare professionalscollaborate with families to identify theneeds and abilities of the child in thecontext of the family, provideinformation to families on available

treatment options, and work inpartnership with families to implementintervention strategies.

The emergence of family-centered care changed the extent offamilies involvement in the definitionand implementation of services forchildren. Empowerment of families tomake decisions about and provide carefor their child became a main goal of

rehabilitation.

Model of Disablement

A model of disablement provides theframework for describing, measuring,and managing disability. Before 1980,a medical model guided rehabilitation.This model described and manageddisability as an impairment of body


15/3615

structures and functions. Successfulrehabilitation was determined bymeasuring for changes in muscle tone,muscle mass, bone density, joint rangeof motion, and so on.

In 1980, however, the WorldHealth Organization (WHO) advanced abiopsychosocial model of health statusand disability that grew out of the workof adults with disabilities, healthcareclinicians and researchers and policy-makers from around the world. TheInternational Classification of Function-ing, Health and Disability (ICF) provideda new framework to discuss and classifythe contribution of a personsphysiological status, their functionalabilities, and the environment on theirhealth status or disability. TheInternational Classification ofFunctioning, Health and Disability (ICF)recognizes three components in whichdisablement occurs. One is impairmentin body structures and functions, whichwas the only component in the medical

model of disablement under which wehad previously worked. Anothercomponent, activity and participation,is a component in which peoplefunction in everyday life and are mostlikely to experience their disability asthey live their lives. A third com-ponent is environmental factors,whichalso have a significant impact ondisability: (1) the natural environmentand human-made changes to it, (2)access to products and technology, (3)support and relationships, (4)attitudes, and (5) services, systems,policies and laws. Successful rehabilitation is alsodetermined by measuring for changesin meaningful function such aseffective locomotion, playing a game,or accomplishing activities of dailyliving. Successful rehabilitation is alsodetermined by measuring for changesin the environmental factors such asparental attitudes about walking,accessibility to technology, or access tohousing and transportation.


16/3616

The ICF reminds us thatdisability is a product of influencesfrom all three areas and that a causeand effect relationship cannot beassumed. A person can have animpairment but not have restrictedfunction, and environmental factors

can cause a disability.After 25 years of use andrevisions, the InternationalClassification of Functioning, Health,and Disability has now been formallyadopted by more than 90 nations ofthe world. It provides a commonlanguage to discuss all the factors thatcontribute to a persons healthstatus.

The Disability Movement

A social-political movement led byindividuals with disabilities, which isnow active throughout the world, alsochallenged the traditional restorativemodel of rehabilitation. Persons withdisabilities rejected the idea of

normalcy that was implicit intraditional rehabilitation in favor of

differently-abled. They championedthe right to be proud of their individualdifferences and to be fully acceptedand participating members of society.

They made us realize thatbarriers to functioning were not simplybecause of an impairment in a person.It is often the architectural barriers,societal attitudes, legal restrictions andlack of civil rights within a communitythat limit activities and participation ofdisabled people in society, togetherwith lack of access to adequatetechnology.

Our perception of what ispossible changed dramatically aspeople with disabilities broke out of thesocietal perceptions that had severelylimited their lives, and as their storiesof being differently-abled found their

way in the popular press. We learnedabout people with motor disabilitiesthat drove vehicles, skied, sailed, wentscuba and sky diving, hiked, climbedmountains, traveled, playedbasketball, had successful careers,lived independently, married, had and

raised children. Specially designedequipment made it possible, but morefundamentally we, as rehabilitationspecialists, came to see that it is notimportant how you drive a car, or farmyour land, or play in the snow, orexplore the beach--but that you do it.

Today there are many how-tobooks, Internet websites and chatrooms, organizations, and specializedcommercially-available equipment thatpromote participation in many aspects


17/3617

of life previously believed to beinappropriate or impossible for personswith disabilities. We even began tosee how beautiful differently-abledcan be.

Civil Rights Laws

This disability movement led to thepassage of laws to protect people withdisabilities from discrimination. In theUnited States, Canada and theEuropean Union, there are already anumber of laws that insure access toeducation, employment, governmentservices, public and private buildings,voting, transportation including aircarriers, and housing.

In 2006 the United NationsGeneral Assembly ratified the UNConvention of the Rights of Personswith Disabilities, which urgesrecognition of the civil rights ofdisabled people throughout the world.It defines disability as long-termphysical, mental, intellectual orsensory impairments which, ininteraction with various barriers, may

hinder their full and effectiveparticipation in society on an equalbasis with others. This documentcontains the following principles ofrights for people with disabilities:reasonable accommodation for their

email sentto publication8-10


18/3618

disability, accessibility, nodiscrimination, and right to education,health, participation and voting.

By mid-2010, 87 countries hadsigned this document.

Availability of Powered Mobility

DevicesThe availability and quality of assistivetechnology, in general, and poweredmobility devices, in particular, hasincreased dramatically and expandedin scope in recent years. These makeit possible for many youth and adultsto participate in a wide variety ofoutdoor activities and sports. Once

assistive devices were available only tothose who had capable parents, familymembers or friends who could acquireparts to construct a device or who hadaccess to a specialized rehabilitationcenter. For example, this powereddevice was made by a clever fatherwith a large tree log for the driver andpassenger seats, a joy stick from acomputer, a car battery, and a base heconstructed, and wheels from a cart.

Mobility devices have alsobecome commercially available forchildren at younger and younger ages.Some pediatric wheelchair designsaccommodate the needs of childrenfor them to grow, move in standing aswell as sitting, to access differentlevels of their environment and to playoutside on muddy or uneven terrain.

Effective Mobility: When?

The advances in science and societydiscussed have led to the paradigmshift in rehabilitation away fromachievement and maintenance ofnormal walking as the gold standardform of mobility. We have moved


19/3619

toward valuing effective mobility,however it may be achieved. When should effective mobilitybe considered? There are fourdevelopments in science andtechnology that inform us about itstiming in a childs life. One is the

evolution of a unified theory of childdevelopment.

Theory of Child Development

Advances in developmental psychologyhave changed our understanding aboutthe various domains of childdevelopment. The several domains ofdevelopment (motor, cognitive,

language, emotional, and social) wereinitially thought to be separate lines ofdevelopment that proceedindependently of one another aschildren grow up. The several domainsof development were initially treatedas separate lines of developmentproceeding independently of oneanother. It became apparent,however, that one developmentalacquisition produces experiences thatbring about a host of of newdevelopmental changes in the sameand different domains. These linesintertwine such that any delay orrestriction in one domain ofdevelopment negatively impactsdevelopment in all other domains aswell.

Motor development is of keyimportance, however. It is throughtheir motor skills that very youngchildren learn about things and peoplein their worldand that they can causethings to happen. They becomeinitiators and active participants ratherthan passive recipients of experience.When motor skills are restricted, thenall areas of the childs experience anddevelopment are at riskunless we

Domains of ChildDevelopment

Motor

Social-emotional

Language

Cognitive

Motor Develo men t


20/3620

can intervene in ways to keep thisfrom happening. Through their motorinteractions, young children learnabout things and people in their world.They also learn that they can causethings to happen. They becomeinitiators and active participants rather

than passive recipients of experience.This, in turn, promotes development oftheir attention, motivation, andintelligence. If motor skills do notdevelop normally, then all areas of thechilds experience and developmentbecome restricted.

Importance of Self-ProducedLocomotion

Within the motor domain, the skill ofself-controlled locomotion is especiallyimportant. Theoretically, locomotionhas long been linked to new capacitiesto cope with stressors, new levels ofself awareness, the emergence of asense of competence and of a sense ofinitiative.

Now, research about the

appearance of locomotion inunimpaired development hasdemonstrated that locomotion plays acentral role in the development ofvisual spatial cognitive competencies.It also induces or acceleratesexploratory behaviors, emotionalexpression, attentional resources forproblem solving, a change from beinga passive to an active participant in

social interactions, and the growth ofnew structures in the brain.However, the only two studies,

which investigated locomotorimpairment in youngsters and thevisual spatial cognitive skill of objectpermanence with manual search for a


21/3621

hidden object, had differing results.Both studies were small and moreconclusive research is needed toidentify whether there may bepathways other than locomotion thatinduce this important skill.

Neuroscience: Developing Mindand Brain

The advent of brain imaging is anotherdevelopment that informs us abouttiming of effective mobility.

The core concepts aboutdeveloping mind and brain are these.1) Early experiences shape brain

architecture. They cause

proliferation of neural connectionsfollowed by pruning and formationof more complex circuits in the firstfew years of life.

2) Brains are built on this foundationof early experiences and there arecritical periods for experiences tohave their most positive andpowerful effects.

3) The physical activity in the brain

created by experience is not onlypowerful in changing brainarchitecture, but it also changes thechemistry that encodes the genes inbrain cells. Experiences, positive ornegative, leave a chemicalsignature on the genes, which maybe temporary or permanent.

4) Although the window for brain andbehavior change remains openthroughout life, these brain circuitsbecome increasingly difficult to alterover time. It is easier and moreeffective to influence a babysdeveloping brain architecture byensuring positive conditions forhealthy development than it is torewire parts of its circuitry in lateryears.


22/3622

5) Neurons in children whoexperienced chronic and extremepoverty, neglect, abuse or severematernal depression displayunderdeveloped neural connectionsor weaker brain architecture. Thisresearch has not exploreddeprivation effects from chronic andsevere locomotor restriction yet, butone might expect the brainarchitecture, in these cases, to alsodisplay underdeveloped or differentbrains.

High Tech Tots

Assistive technology such as powered

mobility devices, augmentativecommunication systems,environmental controls, robotic armsand hands, and specialized computeraccess have enabled children of allages with motor disabilities toparticipate in many age-appropriateactivities. In research and clinicalsettings, children as young as threemonths have interacted with

computers. Twelve-month-old childrenhave driven powered mobility devicesto get around and used myoelectrichands to play. Two-year-olds havetalked using sophisticated voice outputsystems.

Even for children with little or nohand control, a multitude ofalternatives for computer access,battery operated toys, environmental

controls (e.g., lights, TV) andwheelchair control is now available.There are alternative keyboards,mouse emulators, mouse-drivenkeyboards, software with wordprediction capabilities, touch screens,screen enlargers, voice recognitionsoftware, and eye-controlled input forcomputer use. The rapidly developingvirtual technologies and robotic


23/36

23

technologies will offer still moreopportunities for experience andcontrol for very young severelydisabled children.

Wheelchair Toddlers

Ruth Everard is the originalwheelchair toddler. Born withsevere spinal muscular atrophy,Ruth could nevertheless locomoteindependently from the age of 21months, accessing different heightswhile either standing or sitting, andcould play outside in uneventerrain. The unique powered devicebuilt by her father made thispossible. Her language, social-emotional and cognitivedevelopment followed a normalpath. She attended normal schoolsand participated in all activities ofchildren her age. Ruth traveledwith a same-age female friend andcompanion to the United Statesbefore starting college. Now 31years old, Ruth has graduatedOxford University and qualified as asolicitor in London, where she livesindependently. There is a small but growingbody of research demonstrating thatchildren of toddler age can drivepowered devices independently andsafely after learning in a relativelyshort time when given ampleopportunity to practice. There are 14research studies, which were publishedbetween 1983 and 2009, with 141children who had varying typesorthopedic and neuromusculardisorders that severely limited theirlocomotion. They ranged in age from7 months to 7 years of age althoughmost were 3 years old or less. What we know now makes itclear and imperative that provision ofeffective mobility not wait. It cannot


24/3624

wait until a child eventually achievessome form of walking later inchildhood or until it is accepted by theparents and healthcare professionalsthat walking will not happen or that itis not sufficiently effective. Moreover,it does not have to await a child

getting older.

Effective Mobility: How?

Assistive Technology How young disabled children canachieve effective mobility dependslargely on the use of assistivetechnology.

Assistive technology is the study,development and application ofdevices, machines and techniques forassisting human function or bypassingphysical limitations. For manychildren, powered mobility will benecessary.

There is compelling logic,theory and clinical experience tosuggest that a rehabilitation approachbased on assistive technologies willaddress important issues in themanagement of motor disabilities fromearly childhood onward. But is thereevidence that it will empower andenable the overall development ofyoung children and allow them to

Mobility Cannot Wait


25/3625

achieve independence and maintain itas adults?

Research Outcomes of Powered MobilityThe advent of powered devices forvery young children has allowed us toexplore whether alternative forms of

locomotion induces or acceleratesdevelopment, as does walking andcrawling.

This author reviewed studies ofpowered mobility that have includedyoung children. There were 34 studiespublished in English-language,healthcare journals through August,2010.

The main body of this evidenceaddressed questions about learning todrive and about effects of the use ofpowered mobility. Fifteen studiesconducted in the US, Sweden, Canada,and Italy explored the followingquestions:1. At what age can children acquire

and safely use powered mobility?2. Does powered mobility reduce a

childs efforts to walk?3. Does powered mobility promote

development in other domains?Breed and Ibler, in 1982, were

first to report that children couldachieve powered mobility. Theydescribed a case series of 27 childrenwith cerebral palsy, including one asyoung as 4 years old, who had learnedto drive a motorized wheelchair.

In 1983, two publicationsdemonstrated that even very youngchildren could achieve poweredmobility and do so rapidly. Zazula andFoulds reported on a baby boy, bornwith no legs, who had been given apowered cart when he was 11 monthsof age. At 18 months old, he wasindependently mobile at home and inhis community. The same year,Everard described a 22-month-old girlwith spinal muscular atrophy who

achieved functional and skillful drivingwithin 6 weeks of being given accessto a powered wheelchair made by herfather.

In 1984, two more studies werepublished. Butler, et al reported a caseseries of very young children with

various motor disabilities (aged 20 to37 months) that had achieved drivingcompetency based on 7 driving skills.Twelve of 13 of these children hadlearned at home with surprisingly littlepractice time spread over a relativelyfew days and with only parentalsupervision. They then used thispowered mobility to participate in age-appropriate activities and drove safelywhile playing and exploring. Also that year, Paulsson andChristoffersen reported on a caseseries of 12 disabled children, 2 ! to 5years old, who had becomeindependently mobile using motorizedcarts. These investigators werespecifically interested in thepsychological and intellectual effects ofindependent mobility and foundpositive effects of this poweredmobility to be increased self-confidence and curiosity and positiveeffects on family life. Despite fears thatpowered mobility would negativelyimpact potential for walking, motordevelopment instead increased. The effects of powered mobilityon self-initiated behaviors investigatedby Butler were reported in 1986. Sixchildren who were 23-38 months oldhad achieved independent mobilitywith a powered wheelchair in 3 weeksor less. Self-initiated communication,interaction with objects and spatialexploration increased as soon as eachchild acquired independent locomotion.It stimulated the childrens attempts tomove about on their own. In 1987, Douglas and Ryanpublished the first report of a severely


26/3626

impaired preschooler who had tocontrol operation of the wheelchairusing a mouth operated joystick. Hehad some problems learning to drive,but once he became independentlymobile, his emotional, intellectual, andbehavioral development improved

notably.A decade passed with no furtherpublications. Research activity pickedup again in 1998. Chiulli et aldescribed adapted ride-on poweredtoys given to a 3-year-old withcerebral palsy and a 4-year-old, postpolio. Independent mobility providedby this equipment gave each child aboost of self-esteem andindependence. In 2001, Bottos and hiscolleagues reported their investigationof the effects of powered mobility onindependence in 29 children withcerebral palsy who were 3-8 years old.Level of independence improvedsignificantly after provision of poweredwheelchairs. However, measures ofmotor impairment, IQ, and quality oflife did not show change. Almost allparents said they were skeptical aboutpowered mobility before the studybegan, but afterward changed theirminds.

Bottos follow-up of those 29children four years later showed that72% of them were still using theirpowered wheelchair for locomotionindependence at home, at school and/or in the community. Parents of the28% who were not cited technical

problems as the reason.In 2002, Wright-Ott and hercolleagues described significantchanges in young children during amobility camp at which they used avariety of powered mobility devicesthat allowed them to actively andindependently explore theirenvironment. The investigatorsreported increased vocalizations,

increased arm and hand movements,greater motivation to explore,improvements in sleep, and happierdispositions in these children.

That same year, Deitz et alreported higher frequencies of self-initiated movements, changes ininitiation of contact with others,greater participation in educationalprograms, and increased ability tointeract meaningfully with peers whenthe children used powered mobility.When their wheelchairs were removed,these improved behaviors revertedback to baseline levels.


27/3627

In 2003, Jones et al reported onpowered mobility in a 20-month-oldgirl with spinal muscular atrophy. Shedrove safely after 6 weeks.Developmental gains were measuredin all domains. Before intervention,she had been developing at a slower

rate than occurs in normal childrenwhile, after intervention, herdevelopmental rate doubled that ofnormal children. Her mother alsodescribed significantly increasedindependence.

Jones also reported arandomized controlled trial in 2005 inwhich 12 disabled children, ages 15-30months, were matched and then

assigned to the experimental condition(i.e., access to powered mobility) orthe control group. Results of themeasures showed that theexperimental group had significantlygreater improvement in receptivelanguage, social skills and self-care/caregiver assistance than the controlgroup.

Finally, in 2009 Lynch et alreported a 7 month-old child withspina bifida. During a 5-month trainingperiod, the infant improved in alldriving variables. The infants BayleyIII cognition and language scores also

increased at a rate greater than hischronological age. The body of evidence containsfour studies that addresses thequestion, How do children and theirfamilies perceive powered mobility? In 1996, Berry et al published the

perceptions of 36 mothers of theirchildren (5-23 years old). Childrenwho had been completely dependenton their caregivers gained independentmovement, although environmentalbarriers limited their use. Themothers described freedom for theirchild and themselves as well asincreased participation in games withpeers. Many described the powerchairs as their childs legs.

In 2004, Wiart et al investigatedthe question with five mothers andfound they had initially seen poweredmobility as a last-resort option.However, with powered mobility, theyobserved significant changes in theirchildren including increased personalcontrol, independence, andopportunities to participate in ageappropriate meaningful acts.Furthermore, the increasedindependence positively affectedothers attitudes toward their children


28/3628

and allowed them to develop morelegitimate relationships with peers.

In 1989, Kibele interviewed 5adults with cerebral palsy whoreported that their worst memories oftheir therapy experiences as childrenwere their ongoing inability to achieve

walking and the repeated feeling offailure this gave them. Alternatively,their best memories were usingmobility devices which gave themfeelings of success. In 2002, Skar interviewed 8children between the ages of 6-11 whoused wheelchairs and walking aids.The younger children perceived theseassistive technologies as a natural partof themselves.

Another 7 studies involvingabout 300 more children in the US,Canada and England have pursuedother lines of research inquiry:

1) Can we predict successfulpowered mobility?2) Are there benefits of poweredmobility training even for childrenwith profound cognitive limitations?3) What is the current status ofreferral and provision of poweredmobility for young children?

While these studies are not directlypertinent to this discussion, they docontain important statements.

In a 2002 study, Nisbetconcluded Not to allow children theopportunity to engage in the samechildhood occupations as his or herpeers by unnecessarily limiting thechilds mobility goes against theoccupational and enabling focus of theprofession of occupational therapy... Itmay also be suggested that not topermit a disabled child equalopportunities for mobility on a par withhis or her peers is to engage indiscrimination.

Similarly in 2003, Staincliff foundfound discrimination at work in the

referral and eligibility policy related topowered wheelchairs for childrenunder 5 in England and stated that

National Health Service provision ofpowered wheelchairs for childrenneeds to be reviewed in light of clinicalevidence and childrens rights.

Perhaps these comments signify thebeginning of a yet another shift inperspective: from assistive technolo-gies being regarded as an interventionoption to assistive technologies beingregarded as childrens rights issue.

Conclusions From Powered Mobility

The evidence from powered mobility isstill limited by the numbers of studiesthat have been done, the number ofparticipants the studies have involved,the types of outcomes theinvestigators have measured and thestrength of the studies. Though thebody of evidence is neither extensivenor robust, all the evidence suggeststhat powered mobility had positivedevelopmental effects for all thedomains of development as well asincreasing independence and reducingcaregiver burden--with no evidence tothe contrary. The strongest evidence,in terms of research design, andtherefore, the confidence we can haveabout it, is for psychosocial andlanguage outcomes and for caregiverburden. These are Level II on a scalein which is Level I represents thestrongest evidence to Level V, theweakest. Less strong is the evidencefor positive effects in the motordomain (Level III, IV, V), specificallyfor arm-hand function, self-initiatedmovement and spatial exploration.There is Level V evidence thatpowered mobility stimulated ratherthan extinguished attempts atambulation. There is also Level V


29/3629

evidence of improvements in sleep,and happier dispositions.

Augmentative Mobility

It is not a simply a matter of giving achild a walking aid, a wheelchair or

powered device, however. We need tothink in terms of developingcomprehensive, functional mobilitysystems that augment or add towhatever movement a person has.This is, in fact, the situation for almostall people. Few people use walking forall their movement from one place toanother. Most people augment theirwalking with mobility devices such ascars, bicycles, motorcycles, scooters,skates and skateboards, carts andwagons. They use these devices to gofrom one place to another morequickly and to arrive without beingfatigued. They also use these devicesbecause different types of locomotioncan be fun and exhilarating. Similarly,people with locomotor impairmentsneed comprehensive, functionalsystem of mobility for all theiractivities. For example, this 10-year-old uses a walker inside her home andsometimes in her school classroom.She has had tendon releases to giveher better foot position for standingand walking, and she works with aphysical therapist to improve herbalance and strength. She uses apowered wheelchair to keep up withfriends on the school campus and inher community. Although she doesnot have effective mobility with amanual wheelchair, she has onebecause it can be transported in thefamily car providing at least some self-controlled mobility upon arrival. Otherelements of her system mayeventually include a specializeddevices for sports or outdoor activities


30/36


31/36


32/3632

are not functional, powered devicescan provide functional mobility.7. Develop comprehensive systems ofmovement. Recognize the motordisability is likely to change anddeteriorate as people grow and age.Abnormal movements and fixed

contractures cause altered loading of joint cartilage, disturbed growth andbony deformity. These further limitfunction and mobility, and eventuallycause degenerative arthritis and pain.Understanding this sequence isimportant in planning managementand preventing adverse motoroutcome.8. The overall goal is to enable and

empower individuals with disabilities toparticipate as fully and independentlyas possible in every activity andoccupation of life. Realization of moreindependent and productive lifeopportunities depends directly on theindividuals ability to meet the mobilityand communication demands. Whenprognosis for functional, independentwalking or talking is limited, thenintervention must provide alternativemeans to achieve independent mobilityand communication.9. Value and promote the concept ofbeing differently-abled. This meansdoing things in a different waydoingthem by means of normal andabnormal patterns of movement,compensatory movements, non-technical aids, assistive technologies,animals and robots.10. There are a variety of ways toachieve successful completion of afunctional and meaningful task. Inaddition to changing the motorcircumstances of the child, modify theenvironment of the activity or the taskitself.11. Empower families to makedecisions about and care for the child,


33/3633

but avoid overwhelming them. Protectthe health and well being of themarriage and the family. Help thefamily and support groups throughinformation, perspective, support andfriendship. Recognize that alltreatments have a cost in time,

money, and energy to the child andthe family.12. Steer the family away frominterventions that are unproven orunrealistic, likely to drain theirresources, and that may lead todisappointment for them and the child.The history of medical managementincludes many treatments that wereeither harmful or ineffective. Extensive

bracing, misguided operations, andexhaustive therapies are examples oftreatments once in vogue and laterabandoned as evidence failed tosupport their effectiveness.13. When a family insists on trying anunproven intervention, help them toproceed scientifically. Help themdetermine the specific outcomes theproponents of the treatment say willoccur and in what time frame. Help thefamily evaluate these expectedoutcomes against the costs (time,money, energy) and any risks of thetreatment. Help them understand thateven if it is possible to someunderlying motor impairment ofmuscle, nerve, or bone, this will beimportant only if it significantlyincreases the childs function. Forexample, a decrease in spastic muscletone will not automatically give thechild a higher level of function. Finally,help the family set up a way they cangather objective evidence aboutwhether, and the extent to which, thetreatment is proving effective for theirchildincluding some way to measurewhether the child is also morefunctional and independent. Encouragethe family to stop an intervention that

is not making a significant differencein the life of the child or family.

References

Adults with Cerebral Palsy, DMCNSupplement 4, October 2009, Vol. 51 1998 Yan JH, Thomas JR, Downing JH.Locomotion improves childrens spatial search:a meta-analytic review. Percept Mot Skills. 87(1):67-82. Berry E, McLaurin S Sparling W. (1996)Parent/caregiver perspectives on the use ofpower wheelchairs. Pediatric Physical Therapy8:146-50. Bertenthal B, Campos J (1984) Self-produced locomotion: an organizer ofemotional, cognitive and social development ininfancy. In Barrett K, R Emde R Harmon.Continuities and Discontinuities in

Development New York: Plenum.Bleck EE. (1987) Clinics in DevelopmentalMedicine Nos 99-100: OrthopedicManagement in Cerebral Palsy. Philadelphia,JB Lippincott Bottos M, Bolcati C, Sciuto L, Ruggeri CFeliciangeli A. (2001) Powered wheelchairsand independence in young children withtetraplegia. Developmental Medicine and ChildNeurolog Bottos M, Feliciangeli A, Sciuto L, Gericke CVianello A. (2001) Functional status of adultswith cerebral palsy and implications for

treatment of children. Developmental Medicineand Child Neurology 43:516-28. Bottos M, Groppi A, Biolcati C, Bragliano VSciuto L. (2003) Powered wheelchairs andindependence in young children withtetraplegia II: four years later. In EuropeanAcademy for Childhood Disability edited. Oslo:MacKeith Press. p. 19-20. Bottos M Gericke C. (2003) Ambulatorycapacity in cerebral palsy: Prognostic criteriaand consequences for intervention.Developmental Medicine and Child Neurology45:786-90. Breed A, Ibler I. (1982) The motorizedwheelchair: New freedom, new responsibilityand new problems. Developmental Medicineand Child Neurology 24:366-71. Butler C, Okamoto G McKay T. (1983)Powered mobility for very young disabledchildren. Developmental Medicine and ChildNeurology 25:472-4. Butler C, Okamoto G McKay T. (1984)Motorized wheelchair driving by disabledchildren. Archives of Physical Medicine andRehabilitation 65:95-7.


34/3634

Butler C. (1986) Effects of powered mobilityon self-initiated behaviors of very youngchildren with locomotor disability.Developmental Medicine and Child Neurology28:325-32. Butler C. (1988) High tech tots: Technologyfor mobility, manipulation, communication,and learning in early childhood. Infants andYoung Children 1:66-73.

Butler C. (1991) Augmentative mobility: Whydo it? In K Jaffe. Pediatric Rehabilitation,Physical Medicine and Rehabilitation Clinics ofNorth America p.

Butler C. (1997) Wheelchair toddlers. InButler C, J Furumasu. Pediatric PoweredMobility: Developmental Perspectives,Technical Issues, Clinical ApproachesArlington, VA: Rehabilitation Engineering andAssistive Technology Society of North America.p.

Chiulli C, Corradi-Scalise D Donatelli-Schultheiss L. (1998) Powered mobility aids asvehicles in independent locomotion for youngchildren. Physical Therapy 68:997-9. Clearfield MW. (2004)The role of crawlingand walking experience in infant spatialmemory. J Exp Chd Psych 89(3): 214-41 Clearfield MW, Osborne CN, Mullen M. (2008)Learning by looking: infants social lookingbehavior across the transition from crawling towalking. J Exp Chd Psych 100(4): 307 Deitz J, Swinth Y White O. (2002) Poweredmobility and preschoolers with complexdevelopmental delays. American Journal ofOccupational Therapy 56:86-96. Douglas J Ryan M. (1987) A preschoolseverely disabled boy and his poweredwheelchair: A case study. Child: Care, Healthand Development 13:303-9. Duffy CM, Hill AE, Cosgrave AP, et al. (1996)Energy consumption in children with spinabifida and cerebral palsy: a comparative study.Dev Med Child Neurol. 38:238 243. Everard L. (1983) The wheelchair toddler.Contact 38:19-21. Furumasu J, Guerette P Tefft D. (1996) Thedevelopment of a powered wheelchair mobility

program for young children. Technology andDisability 5:125-9. Gustafson G. (1984) Effects of the ability tolocomote on infants' social and exploratorybehaviors: An experimental study.Developmental Psychology 20:397-405. Hansen L. (2008) Evidence and Outcomesfor Power Mobility Intervention with YoungChildren. Casemakers 4(1) (electronicpublication of Center for Advanced Study ofExcellence in Early Childhood Family andSupport Practices)

Hays R. (1987) Childhood motor disabilities:clinical overview and scope of the problem. InK Jaffe. Childhood Powered Mobility:Developmental, Technical and ClinicalPerspectives Washington DC: RehabilitationEngineering and Assistive Technology Societyof North America.

Jennings K, Connors R Stegman C. (1988)Does a physical handicap alter the

development of mastery motivation during thepreschool years? Journal of the AmericanAcademy of Child and Adolescent Psychiatry27:312-7. Johnston TE, Moore SE, Quinn LT, Smith BT.(2004) Energy cost of walking in children withcerebral palsy: relation to the Gross MotorFunction Classification Syste, DMCN 46: 34-38 Jones M, McEwen I Hansen L. (2003) Use ofpower mobility for a young child with spinalmuscular atrophy. Physical Therapy83:253-64. Jones M. (2005) Effects of power mobility onthe development of young children withsevere motor disabilities. Doctoral Dissertationthesis, University of Oklahoma. Kermoian R. (1998) Locomotor experiencefacilitates psychological functioning:Implications for assistive mobility for youngchildren. In D Gray, I Quatrano M Lieberman.Designing and Using Assistive Technology:The Human Perspective Baltimore, MD:Brookes Press. p. 251-68. Lynch A., Ryu, J.C., Agrawal, S., Galloway,J.C., Power mobility training for an infantwith spina bifida, Pediatric Physical Therapy,Vol. 24, No.4, 2009, 362-368.

Nicholson J Bonsall M. (2002) Poweredmobility for children under five years of age inEngland. British Journal of OccupationalTherapy 68:291-3. Nilsson L Nyberg PJ. (2003) Driving to learn:A new concept for training children withprofound cognitive disabilities in a poweredwheelchair. American Journal of OccupationalTherapy 57:229-33. Norman JF, Bossman S, Gardner P, Moen C.

(2004) Comparison of the energy expenditureindex and oxygen consumption index duringself-paced walking in children with spasticdiplegia cerebral palsy and children withoutphysical disabilities. Pediatric PT16:206-211. Palisano L Rosenbaum P Walter S Russell DGaluppi B. (1997) Gross Motor FunctionClassification System. Developmental Medicineand Child Neurology 39: 214-223. Paulsson K Christoffersen M. (1984)Psychological aspects of technical aids: howdoes independent mobility affect the


35/36


36/36

Multiple medical and societal advances are responsible for a fundamentalshift in management of children with motor impairments--from the search fornormalization of movement to the achievement of meaningful function and

participation in age-appropriate activities and occupations throughout life.Meeting this goal depends directly on being able to meet the required mobilitydemands. Assistive technology, especially powered mobility, makes it possiblefor even very young and severely involved children to have the motor skills thatpromote all other areas of child development.

This HELP publication provides knowledge about the advances in the eldregarding mobility options for children to help clinicians evaluate their ownapproach in light of this new information. Copyright 2009 Global HELP all rights reserved

Summary
http://www.global-help.org/

Effective Mobility for Children ΑΑΑΑΑΑΑ

Documents

Transcript of Effective Mobility for Children ΑΑΑΑΑΑΑ