INTRODUCTION AND PURPOSE
The onset of independent, self-generated mobility patterns, such as crawling and walking, and the related ability to actively explore the environment have a far-reaching effect on development.1,2 Children with severe mobility limitations, however, may lack effective independent mobility and may be denied the inherent developmental and functional benefits of independent mobility.3,4 Power mobility devices, such as power wheelchairs and adapted ride-on toys, are increasingly suggested as ways to ameliorate the effect of mobility restrictions, thereby promoting activity-related skills and subsequent participation for infants and children with mobility limitations.3,4
Mobility devices, including power mobility devices, enable individuals with disabilities to achieve mobility, realize equal opportunities, benefit from human rights, and live in dignity.5 The 2006 United Nations Convention on the Rights of Persons with Disabilities (CRPD)6 delineates the responsibility of nations to ensure access to personal mobility options that provide individuals who have disabilities with the greatest possible level of independence. Article 20 of the CRPD6 specifically asserts that nations must provide training in the use of mobility devices (including power mobility devices) as a way to ensure independence for persons with disabilities. The 2008 World Health Organization Guidelines on the Provision of Wheelchairs in Less-Resourced Settings7 further emphasizes the need for mobility device training and outlines a care pathway that specifically states the need to train wheelchair users in safe and appropriate execution of wheelchair skills.
Despite recent research supporting power mobility use in infants and children,3,4 little research has been dedicated to exploring the effectiveness of specific training methods used to teach children how to use a power mobility device.8 Training methods, such as the Wheelchair Skills Program,9 the Power Mobility Indoor Driving Assessment,10 and the Power-Mobility Community Driving Assessment,11 were designed for use in adult populations and may not adequately reflect the developmental and learning needs of infants and children.8 Power mobility training methods developed specifically for use with children are often composed of a list of the skills necessary to operate a power mobility device and provide limited information regarding how to best facilitate the acquisition of power mobility skills in children.8 Although reviews have been conducted related to the outcomes of power mobility training,3 the only review of power mobility training methods for children was published in 2010.8 Given the directives to ensure adequate training related to the use of power mobility devices,6,7 the purpose of this review was to summarize and appraise the existing evidence related to power mobility training methods used in research studies conducted with children 21 years and younger.
METHODS USED TO CONDUCT THE REVIEW
A research librarian with experience and training in conducting reviews was consulted regarding development of an appropriate search strategy. Three Doctor of Physical Therapy (DPT) students conducted a literature search of relevant electronic databases. See Supplemental Digital Content 1 (available at: http://links.lww.com/PPT/A191) for search details.
Only primary source quantitative studies written in English and published in peer-reviewed journals were included in the review. Mixed-method studies were included if the quantitative methods and data could be isolated. Inclusion criteria were as follows: inclusion of at least 1 subject 21 years and younger, power mobility training methods described in sufficient detail to be reproduced, and outcomes related to power mobility training or use. Exclusion criteria were as follows: power mobility outcomes that were indistinguishable from the outcomes of other technologies, outcomes that could not be specifically attributed to children 21 years and younger, and a sole focus on the development of technology or measurement tools.
Selection of Studies
Screening, eligibility, and inclusion of studies were conducted by the 3 DPT students. Once duplicate titles were removed, the DPT students independently examined the titles of the remaining studies to determine whether each study was “not relevant,” “possibly relevant,” or “relevant.” For studies identified as “possibly relevant” or “relevant,” this process was repeated using the published abstracts of each study. If the abstract appeared “possibly relevant” or “relevant,” a full-text version of the study was obtained. Using the full-text version of all “relevant” or “possibly relevant” studies, the DPT students then independently determined whether each identified study met the inclusion/exclusion criteria for the review. In addition, reference lists of full-text studies were manually searched and a hand search of relevant pediatric physical therapy journals was conducted. Disagreements were resolved through discussion and consensus with the first author.
Data Extraction, Levels of Evidence, Rigor, and Assessment of Risk of Bias
Data extraction, determination of level of evidence, evaluation of rigor, and assessment of the risk of bias were each performed independently by the DPT students and the first author. The McMaster's Critical Review Form for Quantitative Studies was used for data extraction.12 The Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence13 or the Levels of Evidence for Single-Subject Research Designs (SSRDs)14 were used as appropriate to determine the level of evidence for each included study. Methodological rigor was evaluated using methods described by Medlicott and Harris.15 This 10-criteria scale evaluates the following design attributes: randomization, subject inclusion and exclusion criteria, similarity at baseline, repeatability of the intervention methods, outcome measure reliability and validity, blind assessment, account for attrition, long-term follow-up (≥6 months), and adherence to a home program. One point is assigned for each criterion present in a study. For the outcome measure reliability, outcome measure validity, and blind assessment criteria, fractions of points are assigned for criteria that are partially met. For example, a study with 1 reliable outcome measure out of a total of 4 outcome measures would receive a score of 1/4 for the outcome measure reliability criterion. A third of a point was awarded for use of each level of blinded assessment: assessor, treatment, and subject. If a home program was not included in the study, a rating of “not applicable” was assigned for this criterion and the total number of criteria is reduced from 10 to 9. Final decisions regarding methodological rigor scores and levels of evidence were assigned following discussion and consensus among researchers.
Overall Appraisal of the Evidence
To assist in the process of knowledge translation, the Evidence Alert Traffic Light Grading System (EATLS)16 was used to provide an overall appraisal of the available evidence. The EATLS16 uses the colors of traffic lights to denote the overall level of evidence related to a particular intervention—green: go (high-level, quality evidence exists to support use of the intervention); yellow: caution needed: measure (low-level, low-quality evidence, or conflicting evidence exists; when using the intervention, therapists should measure the outcomes to confirm that the patient goals are met); and red: stop (high-level, quality evidence exists that the intervention is ineffective; do not use this approach).
The PRISMA flow diagram of the literature search and screening processes is included in Supplemental Digital Content 2 (available at: http://links.lww.com/PPT/A192). The initial electronic database search in June 2015 identified 24 654 titles, with an additional 19 titles identified through the manual and hand searches. After removal of duplicates, 14 300 titles remained and were screened for inclusion. A second database search on January 2016 identified 1321 additional titles. A total of 1037 titles remained and were screened for inclusion after duplicates were removed. Between the 2 searches, a total of 1524 study titles were determined to be “relevant” or “possibly relevant.” Of the 1524 abstracts screened, 128 abstracts were determined to be “relevant” or “possibly relevant” and full texts were retrieved for these studies. A total of 26 studies met the inclusion/exclusion criteria and were included in the review.17–42 Rationales for excluding individual studies from the review are provided in Supplemental Digital Content 3 (available: at http://links.lww.com/PPT/A193).
Two of the 26 studies primarily focused on participants older than 21 years; however, both of these studies provided identifiably separate data and specific outcomes regarding a subject 21 years and younger.24,42 Marchal-Crespo et al37 reported on both a case report and a randomized controlled trial (RCT) and contained identifiably separate participants and results. It was evaluated as 2 separate studies, bringing the total number of studies to 27. Supplemental Digital Content 4 (available at: http://links.lww.com/PPT/A194) details the characteristics of the 27 studies included in this review. A total of 216 children, 5 months to 21 years, were included in the 27 studies. Although 6 studies included participants who were developing typically or nondisabled,19,23,26,32,33,37 the majority of participants were, for example, children with motor impairments related to diagnoses such as cerebral palsy, spinal muscular atrophy, arthrogryposis multiplex congenital, or Down syndrome.17,18,20–25,27–32,34–42 There was a variety of diagnoses and descriptions of participants with motor impairments. The sample sizes were from 1 subject to 28.
Levels of Evidence
A majority of the 27 studies (70.4%) were case reports, case series, or mixed-methods case study designs, and were level IV on the basis of the OCEBM.13 One study (3.7%) used a nonrandomized, within subjects, pretest/posttest design, and was level III. Five studies (18.5%) were RCTs and were level II. Two SSRDs (7.4%) were level V on the basis of the levels of evidence for SSRDs.14
Methodological Rigor and Risk of Bias
Scores related to each of the criteria for methodological rigor are in Supplemental Digital Content 5 (available at: http://links.lww.com/PPT/A195). Per standards by Medlicott and Harris,15 a total score of 8 to 10 is “strong,” a score of 6 to 7 is considered “moderate,” and a score of 5 or less is considered “weak.” The rigor scores were between 2 and 7.8 (mean 3.7; median 3.3). Two RCT studies29,33 had “moderate” methodological rigor. The remaining 25 studies had “weak” methodological rigor. None of the studies scored in the “strong” range. Common weaknesses were lack of randomization or not reporting randomization methods, lack of blinded assessment, use of outcomes measures that were not reliable and valid, and lack of long-term follow-up. Methodological details are included in Supplemental Digital Content 6 (available at: http://links.lww.com/PPT/A196).17–52
Overall Appraisal of the Evidence
Given the large number of low level, poor quality studies, the EATLS16 rating for use of power mobility training methods is yellow: caution needed: measure.
Specific Power Mobility Training Methods
The duration of training varied with some studies providing 1 day of training,19,26,37 and 1 study providing training over a 12-month period.29 Frequency of training also varied with opportunities for daily power mobility training18,24,28,29,40 or training 1 time per week.31 Individual training sessions were from 10 minutes26 to 60 minutes.30,31 Positive outcomes related to attainment of power mobility skills as measured with a range of outcome measures (including for example, the Wheelchair Skills Checklist,18 checklists developed from the Pediatric Powered Mobility Program,22 and the Power Mobility Scale44). Positive developmental outcomes were reported by Jones et al28,29 using the Battelle Developmental Inventory (BDI),47 by Lynch et al36 using the Bayley III, and by Douglas and Ryan20 using therapist observation. Positive improvements in functional skills as assessed skills via the Pediatric Evaluation of Disability Inventory (PEDI)48 or the Pediatric Evaluation of Disability Inventory—Computer Adaptive Test (PEDI-CAT)49 were reported by Jones et al,28,29 Huang et al,25 Logan et al,34 and Kenyon et al.31 All studies either explicitly or implicitly stressed the need for age-appropriate supervision and for increased supervision in some children. Adverse events were not reported.
Although the specific power mobility training methods used varied, 7 commonly occurring approaches to power mobility training were identified: goal-directed mobility, incorporating play, natural environments, self-exploration, skills-based programs, technology-augmented power mobility devices, and virtual reality and computer-based gaming. Supplemental Digital Content 7 (available at: http://links.lww.com/PPT/A197) provides a summary of these approaches by level of evidence and methodological rigor. A majority (63%) of studies incorporated more than one of these approaches into power mobility training methods.
Incorporating Play. Incorporating play into power mobility training methods was the most commonly used approach (48.2% of studies),19,20,22,25,29–31,34,35,37,38,40,41 including 60% of the 5 RCTs.19,29,37 The RCT with the highest level of methodological rigor (Jones et al29 at 7.8/10) used play as a training approach and had parents provide daily opportunities for participants to play in their power wheelchairs. Play activities included knocking over cardboard boxes with the power mobility device, playing dress-up, and games such as hide and seek, follow the leader, and tag. Use of play in power mobility may relate to the need for mobility training to be purposeful and also may be supported by concepts related to emergence of mobility in infants who are developing typically.1,2,53,54
Virtual Reality and Computer-Based Gaming. A virtual reality and computer-based gaming approach to training was used in 22.2% of studies,17,24,26,27,33,39 including 40% of the 5 RCTs27,33 and a level III study.26 The study with the second-highest level of methodological rigor in the review (Linden et al33 at 6.3/9) used this approach with children who were developing typically. In all studies using this approach, children were allowed to practice power mobility in a computer-generated environment or through use of a computer-based game. This permitted children to practice power mobility skills without needing a power mobility device and to practice navigational skills without the safety risks inherent in real-world settings.
Technology-Augmented Power Mobility Devices. Technology-augmented power mobility devices, which lessened the demands of power mobility use, were used in 14.8% of studies,19,37,38,42 including 40% of the 5 RCTs.19,37 The methodological rigor of these studies was from 4/9 to 2/9. Studies by Marchal-Crespo et al37 (both the RCT and the case report) and McGarry et al38 used smart wheelchairs that enabled children to drive on a predetermined path laid out on a floor. The chair used by McGarry et al38 included sensors that helped with collision avoidance when the path-following feature of the chair was not in use. Zeng et al42 used a robotic power wheelchair that provided guidance along virtual pathways programmed in computer software. Rather than rely on sensors, the RCT by Chen et al19 developed a power mobility device that used a modular haptic feedback approach to locate itself, plan a path to a goal, set a force field to train children to drive toward the goal, and prevent the child from running into obstacles.
Natural Environments. Natural environments were used for power mobility training in 37% of the studies, including the RCT by Jones et al.29 The methodological rigor of these studies was from 7.8/10 in Jones et al29 to between 5/9 and 2/9 in level IV18,21,23,25,28,32,40,41 and level V34 studies. Specific natural environments used included home, school, daycare, and community settings. Conducting power mobility training within a child's natural environment as opposed to in a clinic setting may allow the child more frequent opportunities for practice, as many of the studies carried out in the home environment involved daily use of the power mobility device. Conducting power mobility training in natural, familiar environments may reinforce contemporary theories of motor control by providing saliency53 and may help a child to use power mobility to promote participation and peer interaction as outlined in several included studies.40,41
Goal-Directed Mobility. The goal-directed mobility approach involved intentional placement of a toy, object, or person in an attempt to engage the child to use power mobility in a meaningful and purposeful manner. This approach was used in 33.3% of studies,25,30–32,34–36,40,41 all of which were case reports or case series at level IV25,30–32,36,40,41 or single-subject designs at level V.34,35 Use of this training approach may relate to contemporary theories of motor control and neural plasticity that are focused on the need for mobility training to be purposeful and goal directed.53,54 Goal-directed mobility may also be supported by concepts within developmental psychology and the emergence of mobility in infants who are developing typically.1,2
Self-exploration. Self-exploration in which a child was encouraged to use the power mobility device to explore his/her environment was specifically listed as a training activity in 25.9% of the studies,20,30,32,34–36,41 all of which were at lower levels of evidence (level IV20,30,32,36,41 or level V34,35) and had methodological rigor scores from 3.5/9 to 2/9. Self-exploration activities permit children with mobility limitations to go where they want to go and do what they want to do and may reinforce contemporary theories of motor control by providing saliency53 and may relate to concepts regarding emergence of mobility in infants who are developing typically.1,2
Skills-Based Programs. Skills-based programs focused on practicing specific power wheelchair skills were used in 7.4% of studies,21,22 at level IV with methodological rigor scores of 4/921 and 2/9.22 The Pediatric Powered Mobility Program22 was used in both studies.21,22
None of the studies focused on comparing specific power mobility training methods. The large number of studies at a low level of evidence and the weak to moderate methodological rigor scores of these studies indicates that research in this area is still in an early stage of development. The large number of case reports and case series related to power mobility training also indicates the possibility of a publication bias, as a strong bias for publishing case reports and case series with favorable results has been reported.13 Positive outcomes related to attainment of power mobility skills were reported in all studies. Positive outcomes related to development20,28,29,36 and improved functional skills25,28,29,31,34 were also reported. Adverse events were not reported in any of the studies. Our findings are consistent with the systematic review by Livingstone and Field3 that explored power mobility outcomes in children with mobility limitations.
This review is limited by several factors. Only primary source quantitative studies written in English and published in peer-reviewed journals were included. The exclusion of studies in which power mobility outcomes were indistinguishable from the outcomes of other technologies or where outcomes could not be specifically attributed to children 21 years and younger is also limitations. Furthermore, the weak to moderate methodological rigor, small sample sizes, and the lack of existing high-level, quality research may have affected this review and influenced the ability to make clinical recommendations related to power mobility training methods for use with children.
Implications for Clinical Practice and Research
Although the Yellow EATLS16 rating indicates that therapists should recognize that the evidence supporting power mobility training approaches has limitations, this review provides evidence-based insights into use of various training approaches. For example, the training approaches incorporating play and natural environments were used by Jones et al29 (the RCT with the highest level of methodological rigor in this review). A virtual reality and computer-based gaming approach was used by Linden et al33 (the RCT with the second-highest level of methodological rigor in this review). Conversely, use of a skills-based program had the least supporting evidence (only 2 level IV studies,21,22 both with weak methodological rigor). Therapists may also find the data in Supplemental Digital Content 4 (available at http://links.lww.com/PPT/A194) helpful in identifying which training methods were used with children who are similar to their own patients/clients.
The Yellow EATLS16 level further indicates that therapists should measure outcomes when providing power mobility training and confirm that goals are being met. When goals relate to developmental change, valid and reliable developmental outcome measures such as the BDI47 or the Bayley III46 may be beneficial. If goals pertain to improvement in functional skills, the PEDI48 or PEDI-CAT49 could be used to monitor patient/client progress. For goals related to attaining power mobility skills, outcome measures such as the Wheelchair Skills Checklist,18 checklists developed from the Pediatric Powered Mobility Program,22 or the Power Mobility Scale44 may be helpful. Although such checklists were used in 7 studies 18,21,22,28–30,38 in this review, therapists should note that the validity of these checklists has not been established. Sullivan55 further advises therapists to recognize that evidence-based practice involves integrating the research with child and family values and suggests that the desired outcomes of families and children may differ from the outcomes explored in research studies.
Therapists may also find the information in Supplemental Digital Content 4 (available at: http://links.lww.com/PPT/A194) helpful to explore the possible links between various power mobility training approaches and power mobility outcomes. For example, the Jones et al29 study examined the effects of power mobility on the developmental and functional skills of young children with severe motor impairments. Power mobility training approaches used in the study included incorporating play and natural environments. Statistically significant improvements were found in the intervention group on the BDI47 in receptive communication and on the PEDI48 in the Mobility domain as well as on the Mobility and Self-care Caregiver Assistance scales. In addition, 4 of the 14 children in the intervention group achieved 100% of skills on the Wheelchair Skills Test18 in 12 to 42 weeks whereas 7 mastered between 2 and 6 skills and all but 2 learned to move forward 10 ft in wide areas within 2 to 34 weeks.29 These findings suggest that the power mobility training approaches used in this study (incorporating play and natural environments) may be linked to the developmental and functional improvements observed in the young children with severe motor impairments in the study. Findings from other studies (Huang et al,25 Ragonesi et al,40 and Logan et al34) with lower levels of evidence that also used both incorporating play and natural environments approaches may further strengthen this possible link between the power mobility training methods and outcomes.
As another example, the Linden et al33 study used a virtual reality and computer-based gaming approaches to determine the efficacy of a computer-simulated power wheelchair simulator in training children without physical or cognitive impairments to use a power wheelchair. Although a main effect of time was found and planned comparisons showed a statistically significant change in power wheelchair use for the experimental group but not for the control group, improvements in the experimental group as compared with those in the control group did not reach statistical significance.33 These findings suggest that for the children without physical or cognitive impairments in the study, the virtual reality and computer-based gaming approach may have been effective for some children but not all. Findings from the other studies that also used a virtual reality and computer-based gaming approach (such as the Huang et al26 study involving children without disabilities and the Inman et al,27 Montesano et al,39 Adelola et al,17 and Harrison et al24 studies involving children with disabilities) suggest that the link between the virtual reality and computer-based gaming approach and power mobility training outcomes may not be as strong as the link between the combined incorporating play and natural environments approaches described earlier.
The dearth of high-level, quality evidence for use of child-specific power mobility training methods is particularly concerning given that families of children who use power mobility devices have reported that appropriate power mobility training was a major factor in their child achieving successful use of power mobility.56 Given the growing body of evidence suggesting the effectiveness of power mobility interventions3,4 and various directives to provide training in use of power mobility devices,6,7 there is a need for additional research regarding power mobility training methods for children. Future studies should move beyond research questions related to the effectiveness of power mobility use and specifically explore the use of different training methods. Future studies should randomly allocate subjects to groups each using a different power mobility training method (goal-directed mobility vs use of the Pediatric Powered Mobility Program22 for example). Studies involving comparison of power mobility training in virtual and real-life environments should also be undertaken.
Steps should also be taken to increase the methodological rigor of studies related to power mobility training methods. For example, none of the studies in this review included minimal detectable change (MCD) or minimal clinically important difference (MCID) values for the outcome measures used in the studies. Given the importance of interpreting MCD and MCID values within the specifics of a particular setting and population,57 additional research is needed to establish MCD and MCID values for outcome measures used in pediatric power mobility studies. An additional issue identified by this review was the heterogeneous nature of pediatric populations using power mobility devices. Although RCTs are generally regarded as the gold standard for research,13 the use of group-level, aggregate data in RCTs may mask which subjects responded well to an intervention and which subjects did not.57–59 This may be especially true when the subjects are representative of an heterogeneous population such as children who have mobility impairments.57,58 Single-subject research designs may provide clinically relevant information and may allow for identification of sources of individual variation that impact a child's response to an intervention.57 The scientific rigor of SSRDs can be ensured using guidelines developed by Logan et al14 that include suggestions such as repeating the SSRD across multiple subjects and randomizing allocation techniques.
The overall Yellow EATLS16 for power mobility training methods in the children indicates that therapists should use caution when providing power mobility training interventions and measure outcomes related to established goals in areas such as development, functional skills, or use of a power mobility device. Outcome measures such as the BDI,47 the Bayley III,46 the PEDI48 or PEDI-CAT,49 the Wheelchair Skills Checklist,18 checklists developed from the Pediatric Powered Mobility Program,22 or the Power Mobility Scale44 may be helpful to monitor patient/client progress. There were no adverse events reported, suggesting that power mobility training is a safe intervention when provided with age-appropriate supervision and with regard to the need for increased supervision by some children who have mobility limitations. The combined approaches of incorporating play and natural environments were most strongly linked to positive outcomes in the RCT with the highest level of rigor included in this review (Jones et al29) and in studies with lower levels of evidence (Huang et al,25 Ragonesi et al,40 and Logan et al34).
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