DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY REVIEW

Practice considerations for the introduction and use of powermobility for children

ROSLYN LIVINGSTONE1 | GINNY PALEG2

1 Sunny Hill Health Centre for Children, Vancouver, BC, Canada; 2 Montgomery County Infants and Toddlers Program, Rockville, MD, USA.

Correspondence to Roslyn Livingstone, Therapy Department, Sunny Hill Health Centre for Children, 3644 Slocan St, Vancouver, BC V5M 3E8, Canada. E-mail: rlivingstone@cw.bc.ca

PUBLICATION DATA

Accepted for publication 24th June 2013.

Published online

ABBREVIATIONS

AACPDM American Academy of Cerebral

Palsy and Developmental

Medicine

RCT Randomized controlled trial

AIM The aim of the study was to support clinicians in recommending and justifying power

mobility for children of different ages and abilities, and with different needs. The study

comprised three distinct parts: a literature review; a Delphi consensus; and clinical practice

considerations.

METHOD A scoping review of eight electronic databases and manual searches carried out in

February 2011 identified 15 themes or transferable messages among 27 articles meeting

initial inclusion criteria and these formed the basis of a draft paper. Informal consensus at

two international conference presentations refined and modified the paper to include 10

messages supported by 24 articles. The literature review was updated in May 2012 and a

modified Delphi process sought to formalize the consensus process with an international

panel of 16 expert clinicians and researchers using a priori criteria of 80% agreement.

RESULTS Evidence from studies was classified using the American Academy of Cerebral

Palsy and Developmental Medicine guidelines, with evidence from most studies being

classified as either level IV or level V, apart from one study each with evidence classified as

level II and level III. Expert consensus on the content and wording of nine transferable

messages may raise evidence overall to level III.

INTERPRETATION This paper suggests that power mobility may reasonably be considered as

an effective and appropriate intervention for children lacking efficient, independent mobility

from around 12 months of age including children who may never become competent drivers

and children lacking independent mobility only in early childhood.

The onset of crawling has a widespread and significanteffect on children’s overall development.1,2 In a similarmanner, using a power mobility device has been shown totrigger emotional and visual–perceptual development.3

Children typically take independent steps and freelyexplore their environment by 12 to 15 months of age,whereas children with physical disabilities may have limitedopportunities to learn about the properties and principlesof their own bodies in space. Lack of purposeful movementand a limited ability to affect the environment can result inpassive, dependent behavior.4 Power mobility allows chil-dren with physical disabilities to move around more effec-tively and efficiently in their environment. Children mayalso use other mobility aids, such as walkers and manualwheelchairs, but these are considered functional only ifthey enable the child to keep up and participate with his orher peers.

Despite a developing body of research evidence, powermobility continues to be underutilized even though it isthe most effective means of providing independent mobil-ity to children with severe physical disabilities.5 Althoughclinicians may be motivated to incorporate researchevidence into their practice, they often do not have the

time or skills to evaluate the available research. Systematicreviews can be an effective means of identifying the bestresearch evidence, but clinical practice guidelines may bemore helpful for integrating such evidence into clinicalpractice.6

In 2010, the authors were invited to participate in a bestpractice workshop on use of power mobility for children atthe International Interdisciplinary Conference on Postureand Wheeled Mobility in Glasgow, Scotland. At thatconference, current published opinion on the topic wasdiscussed and workshop participants recommended devel-opment of a paper that would support clinical practice andclarify ‘appropriateness’ for power mobility. Specific rec-ommendations included an up-to-date literature reviewwith levels of evidence and inclusion of the child andfamily perspective.

LITERATURE REVIEW AND PAPER DEVELOPMENTMETHODSSince a standard systematic review protocol would be toorestrictive a method to address the broad range of concernsand perspectives to be included in this paper, a scop-ing methodology was used.7 An electronic search of the

© 2013 Mac Keith Press DOI: 10.1111/dmcn.12245 1

following databases was completed in February 2011 andupdated in May 2012: OT Seeker, Physiotherapy EvidenceDatabase (PEDro), EBM Reviews, CINAHL, MEDLINE,EMBASE, PsycInfo, and ERIC. Key terms included power(ed) mobility, power(ed) wheelchair, and child(ren), as wellas relevant medical subject headings for each database suchas wheelchair/powered. Reference lists of articles werereviewed to identify additional studies, a hand search wasundertaken to find known studies, and known researcherswere contacted to identify or clarify details of unpublishedstudies.

Studies published in English were included if theyinvolved at least one child with a disability who was belowthe age of 19 years and addressed the use of a powermobility device with regard to the age of introduction,impact on development, and influences on successful use.The term ‘power mobility device’ included power wheel-chairs, powered ride-on toys or cars, powered scooterboards, and powered standers. All types of studies wereincluded, from randomized controlled trials (RCTs) to sin-gle case studies. Qualitative or mixed methods designswere also included to ensure representation of the childand family perspective. No restrictions were placed on thedate of publication or the publication status, as someimportant early research studies were known to have beenpublished in conference proceedings or reports.

Titles and abstracts were read for all 107 articles orreports that met our initial wide-ranging criteria. Over90% of these articles were also read in their full-text ver-sion. Descriptive or magazine articles, non-systematicreview articles, or those that had a technology or equip-ment development focus were excluded. Surveys or cross-sectional designs were included if they addressed the childand family perspective or outcomes related to the child’suse of power mobility devices. Those surveys reviewingservice provision or provider perspectives were excluded.

Appraisal of initially included studies was completedusing standard data extraction forms for quantitative8 andqualitative9 designs. Research on knowledge transfer sug-gests that take-home or actionable messages should betransferred from a body of research knowledge rather thanfrom single studies and these are referred to as ‘transfer-able messages’.10 Some transferable messages had beenpreviously identified by the first author11 and discussed atvarious conference presentations. Both authors then agreedon transferable messages or themes emerging from the lit-erature review. Studies that provided the strongest supportfor these messages became the 27 initially included articles.Additional case studies, cross-sectional studies, and qualita-tive studies were identified, but were not included as theydid not add to the level of evidence (see below and Appen-dix SI, online supporting information), increase the appli-cability of the transferable messages, or support theadditional messages.12–20

The American Academy of Cerebral Palsy and Develop-mental Medicine (AACPDM) guidelines (see Appendix SI

for a summary of levels I–V) were used to determine thelevels of evidence for included studies, including group andsingle-participant designs.21 Two reviewers independentlydetermined evidence levels; where differences occurred,they discussed scores until consensus was reached. Theirconsensus scores are reported throughout. The AACPDMsystematic review protocol was not followed as it wasdeveloped for narrower intervention questions and quanti-tative studies only.

In order to address the original direction recommendedby participants at the best practice workshop in Glasgow, adraft paper was developed, structured around four groups ofchildren who were identified in the literature as being‘appropriate’ for power mobility: children who will neverwalk; children with inefficient mobility; children who losetheir ability to walk or to walk efficiently; and children whoneed mobility assistance in early childhood.22 Two addi-tional sections – learning power mobility skills and support-ing power mobility skills – were included to address the useof power mobility with more complex populations, as well asto address the child and family perspective.

Fifteen transferable messages, addressing common ques-tions or concerns regarding topics such as the age of intro-duction, the impact on development, use with childrenwho have more complex disabilities, and the environmentalinfluences were developed. To assist clinicians in reflectingon the relevance of the evidence presented to their popula-tion and setting, case studies were included to illustrateexamples of children from different age groups with a vari-ety of needs who could benefit from the use of powermobility.

The paper was presented, for informal feedback and dis-cussion, at the International Seating Symposium, Nashville,TN, USA in March 2011. More than 200 individuals par-ticipated in the first workshop and audience response tech-nology was used to allow anonymous voting on themessages. Strong consensus was determined, a priori, to beabove 70%. Any statements falling below this level of con-sensus were removed, modified, or combined according tofeedback from workshop participants during the open dis-cussion period. Further feedback was received from aworkshop involving 50 participants from a wide range ofcountries at the European Seating Symposium, Dublin, inNovember 2011. Audience voting and discussion resultedin rewording and refinement of some transferable messagesand further feedback on the clinical utility of the paper.

In the revised paper, 10 transferable messages supportedby the literature were included. Two references wereremoved following this informal consensus and revision

What this paper adds• This study is the first international consensus on power mobility, combining

research evidence with expert opinion.

• Synthesized evidence provides clinical practice suggestions for power mobil-ity in children of different ages, needs, and abilities.

• Power mobility is also suggested for children who may never become com-petent drivers or who need mobility assistance only in early childhood.

2 Developmental Medicine & Child Neurology 2013

process23,24 as workshop participants voted to eliminate theassociated messages. Much of the research evidence was oflower strength, with only one RCT identified.25 One levelIII single-participant design26 was identified, while fourarticles, achieving evidence level IV, described the resultsof two group27–29 and one single-participant30 design.There were 14 level V studies representing a numberof group31–35 and single36–41 case studies as well as cross-sectional designs.42–44 In addition, five qualitative studieswere included.45–49

Formal feedback on the format, layout, and content ofthe position paper was desired in order to ensure its suit-ability for use in a variety of international settings. A con-sensus of clinical experts is thought to be capable ofverifying that the intervention in question may be reason-ably supported, and equivalent to level III evidence.50 We,therefore, sought to combine expert opinion with the exist-ing lower-level research evidence in a rigorous manner inorder to assist in providing stronger guidance for clini-cians, families, and funders regarding the use and benefitsof power mobility for children.

The literature review was updated in May 2012 beforethe formal consensus process. Newly published studieswere included35 and references updated for studies thathad previously been included as theses or conference pro-ceedings.25,29 The AGREE II checklist51 was used toreduce bias and ensure quality in the development of theclinical practice considerations. See Appendix SII, (onlinesupporting information) for an evidence table of the studiesthat met the final inclusion criteria after the internationalconsensus process.

INTERNATIONAL CONSENSUS PROCESSThis section of the article describes multiple rounds ofexpert reviews that were conducted to achieve consensuson the content and wording of several messages aroundwhich the paper was structured, as well as formal feedbackon the scope, structure, content, and layout of the paper.

DesignThe Delphi technique is a method that uses sequentialquestionnaires or ‘rounds’ to gather information and estab-lish consensus where there is uncertainty or a lack ofempirical evidence,52 providing an efficient and economicalmethod to communicate with a geographically diversepanel of experts. Participants remain unknown to otherparticipants, allowing individuals to express their opinionsopenly, without peer pressure. Between each round, partic-ipants are provided with group level of agreement andtheir own individual ratings to allow the generation ofknowledge and consensus building.52

ParticipantsIndividuals who had published research or opinion piecesin peer-reviewed journals in the last 15 years or who hadprovided education on the use of power mobility with chil-dren at national or international levels in the last 5 years

were approached to participate in the expert panel.To ensure global representation, expert clinicians frominternationally renowned centers were also approached.Twenty-one experts were approached; 19 consented to par-ticipate and 18 completed the first round. The expert panelcomprised 11 occupational therapists, five physiotherapists,one psychologist, and one engineer. Ten participants wereprimarily academics or researchers and eight were primar-ily clinicians. Participants were recruited from Canada, theUSA, the UK, Sweden, and Australia. Human participantsethics approval was obtained prior to the study from theUniversity of British Columbia and Children’s andWomen’s Health Centre of British Columbia ResearchEthics Board.

MethodThis study involved a computer-based, online Delphi sur-vey. Each participant was provided with a copy of the draftpaper and invited to rate the content and relevance of thepaper, as well as their level of agreement with 10 transfer-able messages. Agreement was represented by responses ona five-point Likert scale: 1, disagree strongly; 2, disagree;3, neutral; 4, agree; 5, strongly agree. Narrative commentswere solicited for each statement and on any section of thepaper, as well as suggestions for additional references ormessages.

ProcedureEach expert was emailed an invitation to participate in theDelphi process. Experts who provided email consent forfurther contact were emailed the draft paper along with anindividualized link to the survey tool. The draft paperincluded evidence levels to assist experts in making judg-ments about the quality of evidence supporting each state-ment. The first round survey was left open for 5 weeks.

AnalysisIn each of the three rounds, expert ratings were summa-rized in a report by the survey tool, with percentages ofagreement calculated. Content analysis also determinedcommon themes among participants’ responses to open-ended questions. These reports, along with the revisedpaper and participants’ individual responses, were includedwith the second and third round surveys. Expert-suggestedwording changes for the transferable messages and sugges-tions of additional material or refinement of the paperwere considered for incorporation into revised versions.

Round 1Results for round 1Agreement scores for each transferable message are sum-marized in Table I. Only one message had less than 80%of ratings of 4 or 5 on the Likert scale. Message 9 gener-ated some controversy over the definition of ‘competent’.The paper was revised and terms used in the paper such as‘competent’, ‘proficient’, and ‘novice’ were defined basedon research.24

Review 3

Participants were asked whether they preferred havingevidence levels presented with the statements or separatelyin a table. 12 out of 18 agreed or strongly agreed withkeeping the evidence levels with the statements, while fourwere neutral, and two disagreed. However, five out of 18agreed or strongly agreed with the idea of an evidencetable, with seven neutral, and six disagreeing. As a compro-mise, an evidence table was created as an appendix.

Changes to the layout and organization of the paperwere guided by narrative feedback provided by the experts.One participant suggested that the four groupings of chil-dren who can benefit from power mobility were toofocused on physical limitations and diagnoses and, instead,suggested making them more functional.

Round 2Seventeen participants from round 1 continued to partici-pate in round 2. Nine transferable messages were included,as consensus above 80% with strong agreement had beenachieved for message 3 in round 1. Message 4 had alsoachieved strong agreement but wording changes had beensuggested. The survey was left open for 6 weeks.

Results for round 2Consensus above 80% agreement (rating of 4) and strongagreement (rating of 5) was achieved for all statements.Consensus above 80% with strong agreement was achievedfor three messages (1, 2, and 8). Level of agreement onmessage 4 went down from round 1 owing to the changeof wording (see Table II).

Wording changes were suggested for all messages and soall were included in the third round. Message 6 generatedsome controversy as some experts felt that it detracted

from the main purpose and intent of the paper. As regardsthe organization and layout of the paper, the majority ofparticipants (13 out of 17) preferred to retain the originalfour groupings of children. The functional descriptionswere worked into the text to ensure that the diagnoseswere seen as examples and not as limiters.

Round 3Eighteen experts were invited to participate, with 16 com-pleting round 3. Since wording changes had been sug-gested, all transferable messages were included for ratingin this round. Experts were asked to vote on whether ornot they agreed with the removal of message 6 from thepaper. The survey was left open for 7 weeks.

Results for round 3The majority of participants (13 out of 16) agreed with thedecision to remove message 6 from the paper. Somestrongly felt that the content was important to include inthe text but to relate it more broadly to all children withsevere disabilities. Consensus above 80% with ratings of 5was achieved on messages 2, 5, 7, and 8. Consensus above80% with ratings of 4 and 5 was achieved on messages 1,3, 4, 6, 9, and 10 (see Table III).

Discussion and final versions of transferable messagesExpert feedback on overall flow, readability, relevance, andusefulness improved steadily over each round as the paperwas revised and suggestions from participants were incor-porated. The evidence table was revised to reflect only thestudies that were used to support the transferable messages.The transferable messages shown below are the finalversions that were selected to be included in the practice

Table I: Round 1 of Delphi results

Statement1 Stronglydisagree

2Disagree

3Neutral

4Agree

5 Stronglyagree

1. With access to a specialized PMD, it is possible for infants with disabilities tohave augmented mobility experiences at 8mo of age, when their peers arebeginning to move

0 0 0 7/18 11/18

2. Children can begin learning to steer a PMD around 14mo and those able touse a joystick can achieve competent control as young as 18–24mo

0 1/18 2/18 6/18 9/18

3. For children with minimal mobility experience, a PMD can promotepsychosocial development, as well as functional mobility

0 0 1/18 0 17/18

4. For children with inefficient mobility, PM may enhance independence andparticipation in family, school, and community life

0 0 1/18 2/18 15/18

5. Using PM at a young age will not impede development of ambulation orother motor skills

0 0 0 7/18 11/18

6. PMDs for children with progressive neuromuscular disease should includespecialized seating, powered seating functions, and be capable ofaccommodating alternate drive controls and additional assistive technology

0 0 1/18 6/18 11/18

7. Children with conditions that limit early functional mobility may benefit fromPM to promote overall independence and psychosocial development

0 1/18 0 4/18 13/18

8. Children who have poorly established cause–effect may benefit from practicein a PMD

0 0 2/18 4/18 12/18

9. Children with severe intellectual and/or sensory impairments can learn to usea PMD competently

1/18 1/18 2/18 4/18 10/18

10. Time spent practicing and environmental support are very important, and canhave more influence on successful learning of PM skills than differences inchildren’s motor, cognitive, or sensory abilities

1/18 0 2/18 4/18 11/18

PM, power mobility; PMD, power mobility device.

4 Developmental Medicine & Child Neurology 2013

Table II: Round 2 of Delphi results

Statement1 Stronglydisagree 2 Disagree 3 Neutral 4 Agree

5 Stronglyagree

1. With access to a specialized PMD, it is possible for infants withdisabilities to have augmented mobility experiences as early as8mo of age

0 0 0 3/17 14/17

2. Children can begin learning to maneuver a PMD as early as 14moand those able to use a joystick may demonstrate competent controlas young as 18–24mo

0 0 1/17 2/17 14/17

4. For children with inefficient mobility, PM may enhance independencein mobility and meaningful participation in family, school, andcommunity life

1/17 3/17 1/17 2/17 10/17

5. Using PM at a young age has not been shown to impede developmentof ambulation or other motor skills

0 1/17 1/17 3/17 12/17

6. PMDs for children with progressive neuromuscular disease shouldinclude specialized seating, powered seating functions, and be capableof accommodating alternate drive controls and control of other assistivetechnology devices through the drive method

0 0 2/17 4/17 11/17

7. Children with conditions that limit early functional mobility maybenefit from PM to promote overall independence and psychosocialdevelopment

0 1/17 1/17 3/17 12/17

8. Mobility experience in a PMD may support skill development forchildren learning cause–effect relationships

1/17 1/17 1/17 0 14/17

9. Children with severe intellectual and/or sensory impairments can learnto use a PMD competently with appropriate practice and environmentalsupport

0 1/17 1/17 2/17 13/17

10. Successful learning of PM skills may depend at least as much onpractice time and support within the child’s environment as the child’smotor, cognitive, or sensory abilities

0 1/17 0 3/17 13/17

PM, power mobility; PMD, power mobility device.

Table III: Round 3 of Delphi results

Statement1 Stronglydisagree 2 Disagree 3 Neutral 4 Agree

5 Stronglyagree

1. With access to a specialized PMD, it is possible for infants withdisabilities to have augmented mobility experiences below8mo of age

0 2/16 1/16 5/16 8/16

2. Children can begin learning to maneuver a PMD below 14moof age and those able to use a joystick have demonstratedcompetent control as young as 18–24mo

0 1/16 0 0 15/16

3. For children with minimal mobility experience, a PMD cansupport overall development as well as functional mobility

0 0 3/16 3/16 10/16

4. For children with inefficient mobility, PM may enhanceindependence and meaningful participation in family, school,and community life

0 0 2/16 2/16 12/16

5. There is no evidence that using PM at a young age impedesdevelopment of ambulation or other motor skills

0 0 1/16 1/16 14/16

6. PMDs for children with progressive neuromuscular diseaseshould include specialized seating, powered seating functions,and be capable of accommodating alternate drive controls andcontrol of other assistive technology devices through the drivemethod. REMOVAL

0 2/16 1/16 7/16 6/16

7. Children with conditions that limit early functional mobilitymay benefit from PM to promote independence andsupport overall development

0 0 0 1/16 15/16

8. Mobility experience in a PMD may support development ofself-initiated behavior and learning

0 0 1/16 0 15/16

9. Many children with severe intellectual and/or sensoryimpairments can learn to use a PMD competently withappropriate practice and environmental support

0 1/16 1/16 2/16 12/16

10. Successful learning of PM skills may depend at least as muchon practice time and quality of learning support within thechild’s environment as the child’s motor, cognitive, or sensoryabilities

0 1/16 0 3/16 12/16

PM, power mobility; PMD, power mobility device.

Review 5

considerations paper. These are not necessarily the versionincluded in round 3, but the version for which there washighest consensus.

With access to a specialized power mobility device, it ispossible for infants with disabilities to have augmentedmobility experiences as early as 8 months of ageFor this message, the strongest consensus occurred inround 2: 14 out of 17 experts strongly agreed and theremaining three agreed. Some participants suggested that8 months of age was not early enough for some types ofdisability, but consensus was not as high following achange to ‘below 8 months of age’. Concerns wereexpressed that power mobility may be detrimental toinfants below 8 months of age (R Kermoian, personalcommunication 2012). This message is supported by levelV case study evidence.39,40

Children can begin learning to maneuver a powermobility device below 14 months of age and those ableto use a joystick have demonstrated competent control asyoung as 18 to 24 monthsConsensus was strongest in round 3 for this message, with15 out of 16 experts strongly agreeing. This message reflectsthe majority of early power mobility research that focusedon age of use and included only children able to use joy-sticks.31,32,37,38 One early case study36 described a child withno limbs learning to use a power mobility device using bodymovement and switches. A recent RCT25 also included chil-dren with cognitive and communication limitations, as wellas children using head controls and switches.

For children with minimal mobility experience, a powermobility device can promote overall development as wellas functional mobilityIn round 1, 17 out of 18 experts strongly agreed with thismessage, so it was not included in round 2. However, par-ticipants suggested wording changes of ‘psychosocial’ to‘overall’ and ‘promote’ to ‘support’. In round 3, only 10out of 16 strongly agreed and three agreed. Of six expertswho voted neutral or ‘agree’ in round 3 instead of ‘stronglyagree’ as they had in round one, two comments favoredchanging back to the word ‘promote’ and one commentedagainst ‘overall’ with preference for ‘psychosocial’. Gener-ally, comments were in favor of having the more inclusiveterm ‘overall’, rather than the term ‘psychosocial’. Conse-quently, ‘overall’ was retained in the final version. A recenttheoretical paper53 provides support for this decision. Thismessage is supported by one level II study,25 one level IIIstudy,26 three level IV studies,27–30 two level V studies,35,40

and two qualitative studies.45,46

For children with inefficient mobility, power mobility mayenhance independence and participation in family,school, and community lifeThis is the version used in round 1, where it had the high-est consensus, with 15 out of 18 experts strongly agreeing,

two agreeing and one person voting neutral. One partici-pant suggested adding the words ‘in mobility’ to ‘indepen-dence’ but other participants disagreed and consensus wasnot as high in round 2. Only 12 out of 16 experts stronglyagreed with the addition of the word ‘meaningful’ before‘participation’ in round 3. This message is supported bylevel V42 and qualitative evidence.47,48

There is no evidence that using power mobility at ayoung age impedes development of ambulation or othermotor skillsConsensus was highest for this version in round 3, with 14out of 16 experts agreeing strongly, one person agreeing,and one person voting neutral. In previous rounds, otherversions of this message were felt to be too strong in rela-tion to the level of evidence. This message is supported byone RCT,25 one level IV,27 and one level V study.33

The following statement was removed: ‘power mobilitydevices for children with progressive neuromuscular diseaseshould include specialized seating, powered seating func-tions and be capable of accommodating alternate drivecontrols and control of other assistive technology devicesthrough the drive method’. This was removed because itwas supported by weak level V evidence43 and related toonly one population, whereas the statement itself was rele-vant to children with a wide variety of complex disabilities.Participants felt that this message detracted from the mainflow and purpose of this paper, but the content wasincluded in paragraph relating to all children with complexdisabilities.

Children with conditions that limit early functionalmobility may benefit from power mobility to promoteindependence and support overall developmentRound 3 had the highest consensus for this version, with15 out of 16 experts strongly agreeing, and one agreeing.This message is supported by one level V case study.40

Mobility experience in a power mobility device maysupport development of self-initiated behavior andlearningThis message was changed significantly in each round andconsensus steadily rose, with round 3 having the highestconsensus: 15 out of 16 experts strongly agreed and oneperson was neutral. This message is supported by bothqualitative and case study evidence.34,35,45,49

Many children with severe intellectual and/or sensoryimpairments can learn to use a power mobility devicecompetently with appropriate practice and environmentalsupportThis message was definitely more controversial, but con-sensus rose from 10 out of 18 strongly agreeing in round 1to 12 out of 16 strongly agreeing and another two agreeingin round 3. One expert was neutral and another disagreed.This statement is supported by level IV,27 level V,35 andqualitative evidence.45,49

6 Developmental Medicine & Child Neurology 2013

Successful learning of power mobility skills may dependat least as much on practice time and quality of learningsupport within the child’s environment as the child’smotor, cognitive, or sensory abilitiesAgain, this was controversial, but consensus rose from 11out of 18 experts strongly agreeing in round 1, to 12 out of16 strongly agreeing and another three agreeing in round 3,with only one person disagreeing. This statement is sup-ported by level IV,27 level V,44 and qualitative evidence.45

LimitationsDevelopment of this paper was limited by the size anddiversity of the international panel. Unfortunately, we wereunable to secure more participants from some Europeancountries owing to language barriers and we did not secureany participants from Asia. A limitation common to Delphisurveys is the subjective process used to identify the partic-ipants. To attempt to reduce bias, we endeavored to con-tact all individuals who had published research or opinionpieces in peer-reviewed journals in the last 15 years andgave them the option to participate.

By including participants biased toward a particularviewpoint, our results may have been skewed. However,the clinicians and researchers who participated had a mini-mum of 5 years’ experience of working with children usingpower mobility. They came from a variety of different dis-ciplines, backgrounds, and clinical settings, as well as fromdifferent countries. They had definite opinions and theDelphi process provided them with opportunities to con-tribute their ideas and to modify their opinions as theyworked through the group process.

ConclusionThe resulting international consensus practice consider-ations paper is intended to provide guidance for clinicians,families, and funders regarding the use and benefits ofpower mobility for children. It describes different groupsof children who can benefit from the use of power mobilityand provides guidance on the use and expectations for chil-dren at different ages and with different needs and abilities.The paper also provides some guidance on environmentalinfluences that can affect the successful introduction anduse of power mobility with children.

PRACTICE CONSIDERATIONSThe aim of the development of these practice consider-ations was to combine evidence-based literature withexpert opinion in order to make recommendations on deci-sion-making and justification for power mobility use withinfants, children, and adolescents. It has been structured inthree sections. The first describes different groups of chil-dren who benefit from the use of power mobility, andincludes six transferable messages. The second sectiondiscusses issues of ‘readiness’ and the process of learningpower mobility skills for children with complex develop-mental needs. The benefit of power mobility experiencefor children who may never develop competent driving

skills is included in this section, along with two transfer-able messages. The final section discusses the environmen-tal influences on the development of power mobility skilland includes one transferable message.

For the purposes of this paper, the term ‘power mobilityskills’ describes the development of skills from the explor-atory behavior of the novice through to learning to controlthe functions of the power mobility device, to competentuse in daily life. The term ‘competent’ is used to describea child who has learned to operate the power mobilitydevice, i.e. they can avoid obstacles and maneuver in a safeenvironment. Proficient use, defined as the ability to usejudgment and focus on the activity rather than on control-ling the device, can take many years.24

The field of rehabilitation is undergoing a paradigmshift from considering power mobility as a final option,reserved for older children once all other forms of mobilityhave been tried and found ineffective, to a therapeuticmodality that can be used to support development, explo-ration, and participation for a wide range of infants andchildren with disabilities. Children and their families mayuse a variety of mobility solutions depending on the envi-ronment or activity.54 Although not all children willbecome competent or proficient power wheelchair users,clinicians should consider power mobility as an acceptedintervention even for very young children who do not havethe ability to move and explore independently. The aim ofthis intervention is to address the secondary effects of lackof mobility on other areas of development such as sociali-zation, cognition, visual–perception, and language.

Children’s use of power mobility should be commensu-rate with age-appropriate and developmental expectations.An infant using a power mobility device should be in a safeenvironment or have adult supervision and assistance.Older children with cognitive or sensory limitations mayneed adult supervision or assistance in the community (asthey would if able to walk) but may learn to use a powerwheelchair to meet their independent mobility needs.

General considerations for all children when introducingpower mobilityThe child’s postural abilities and needs for support whenusing the proposed device need to be identified. Rememberthat the child is likely to need more support when in amobile system than when in a stationary seat. Postural sup-ports should enhance the child’s abilities to use his or herhands (or other body parts) to activate the power mobilitydevice.55,56

Any limitations within the child’s visual, perceptual,or sensory system need to be identified. Visual, perceptual,or sensory limitations do not preclude the consideration ofpower mobility, but may require an alternative approach totraining, compensatory strategies, and/or technology.14

The child’s developmental level needs to be considered.Children functioning at around a 2-year-old cognitive levelmay start by driving the power mobility device in circles,31

but would quickly move on to attempt to purposefully

Review 7

drive to a toy or person and are expected to become profi-cient drivers in time. Some children with more complexphysical, cognitive, or sensory limitations move relativelyquickly from the exploratory behaviors of the novice toattempting to move toward a goal, but may require alonger training period and more supervision to developcompetent driving skills.25 Other children functioning atvery early developmental levels may never move beyondthe exploratory behaviors of the novice but power mobilityexperience can stimulate overall development in areas suchas initiation, head and hand control, visual attention, andchild-directed exploration that are also important out-comes.46 Knowing the child’s developmental level guidesclinicians as to the most appropriate device, approach, orexpectations for power mobility.

Which children need power mobility?Four different groups of children can benefit from powermobility22: (1) children who will never walk; (2) childrenwith inefficient mobility; (3) children who lose the abilityto walk or to walk efficiently; and (4) children who needmobility assistance in early childhood.

Children who will never walk and need functionalmobilityChildren in this group have a poor prognosis for func-tional mobility without the use of power mobility. Thegroup includes, but is not limited to, children with the fol-lowing diagnoses: cerebral palsy (CP), Gross Motor Func-tion Classification System57 (GMFCS) levels IV and V;spinal muscular atrophy types I and II or congenital mus-cular dystrophy; multiple limb deficiencies or severearthrogryposis; congenital high-level spinal cord lesions;and osteogenesis imperfecta types II, III, and VIII.Case example. ‘Lisa’ is a 2-year-old female with congenitalmuscular dystrophy. The joystick on her power wheelchairwas modified to increase sensitivity and was positioned inthe middle to allow her to use both hands. She becamecompetent in power mobility skills within 6 hours and herparents felt confident that she would be able to use apower wheelchair in their home and community with age-appropriate supervision. A pediatric, international stan-dard-compliant58 power wheelchair with tilt was orderedto allow the family to transport the device in a wheelchair-accessible vehicle.

Children who have inefficient mobilityChildren in this group have a limited ability to walk ormaneuver a manual wheelchair but need more effectivemobility through the use of power mobility for energy con-servation and efficiency. This group includes, but is not lim-ited to, children with the following diagnoses: CP (GMFCSlevels III and IV, and some adolescents at level II); C6 or C7spinal cord injuries; thoracic myelomeningocele; and osteo-genesis imperfecta types IV–VII. Children with arthritis ormedical conditions may also have inefficient mobility attimes.

In children with a disability, walking ability peaks wellbefore adolescence59 and gait often worsens and requiresmore energy as these children age.60 Very small numbersof children with CP are able to propel manual wheelchairsefficiently6 and power mobility may enhance participationat school, outdoors, and in the community.61 To achieveefficient mobility and meaningful participation, a childmust be able to maintain the same speed (without undueeffort) and access the same activities and environments ashis or her peers.Case example. ‘Chase’ is a 12-year-old boy with thoracic-level myelomeningocele. He has been an efficient manualwheelchair user for a number of years and plays wheelchairbasketball and sledge hockey. However, his kyphoscoliosishas progressed rapidly and Chase is experiencingchest pain when seated in an upright position for longperiods.

Chase is on a waiting list for spinal instrumentation sur-gery and, after this, will not be allowed to manuallymaneuver his chair for at least 6 months. A power wheel-chair with tilt has been prescribed for his use at school andoutdoors, while he continues to use his manual wheelchairin the home. Following surgery, Chase will be a full-timepower wheelchair user for at least 6 months and long termmay use power mobility outdoors and in the community toenhance participation with peers.

Children who lose the ability to walk or to walkefficientlyThese children may have a prognosis for increasing disabil-ity or have lost the ability to walk as a result of illness orinjury. This group includes, but is not limited to, childrenwith the following diagnoses: neuromuscular diseases (e.g.Duchenne muscular dystrophy, limb girdle dystrophy, typeIII spinal muscular atrophy, Friedreich ataxia), acquiredbrain injury, and spinal cord injuries. These children havealready experienced independent mobility at a young ageand, therefore, power mobility is used to maintain partici-pation in family, school, and community life.

With progressive neuromuscular diseases, children canusually operate a standard joystick initially62 and learnpower mobility skills quickly.38 Children with acquiredbrain injury often have more complex learning needs.63

Children with high-level spinal cord injuries are usuallyunable to access a standard joystick.12 Access options forthese children typically involve movements of the head orface and include a chin joystick, mouth switches or amouth joystick, sip and puff, or proximity head array. Anassessment by a clinician specialized in alternative accessmethods for power mobility may be helpful.

Clients with muscular dystrophy gradually lose the abil-ity to use a standard joystick but can regain full indepen-dence by using alternative driving methods.62 It isimportant to select a power wheelchair that will meet theclient’s needs for speed and outdoor performance and elec-tronics that can accommodate changing needs, as well asintegrating power seating functions, medical equipment

8 Developmental Medicine & Child Neurology 2013

(ventilator, suction, G-tube pumps, etc.), electronic aids todaily living, and computer access.43

Case example. ‘Nikki’ was diagnosed with limb girdle dys-trophy at 8 years of age. Although she was able to walk inde-pendently and to maneuver a manual wheelchair, her muscledisease progressed rapidly and an indoor/outdoor powerwheelchair with tilt-in-space and expandable electronics wasrecommended. The funder declined the expandable elec-tronics and reluctantly agreed to include tilt.

Three years later, Nikki is completely wheelchair depen-dent. She has a rapidly progressive scoliosis and uses con-toured seating. She constantly uses her tilt system tochange position and increase comfort. Recline and lateraltilt options are being considered to address respiratory andpain issues. Nikki is also having difficulty exerting enoughpressure to operate the standard joystick. The funder willnow have to pay for an expensive upgrade to the electron-ics in order to accommodate the provision of a more sensi-tive joystick and integration of seating functions throughthe driver control.

Children who require mobility assistance in earlychildhoodThese children need efficient, effortless, functional mobilityearly in childhood even if they will later use other means ofmobility. This group includes, but is not limited to, chil-dren with the following diagnoses: arthrogryposis (surgicalintervention may allow walking at older ages); lumbar-levelmyelomeningocele (ambulation and efficient manual wheel-chair use may be achieved in later childhood); osteogenesisimperfecta (interventions such as intra-medullary roddingmay allow walking at older ages); and CP (GMFCS levelIII).Case example. ‘Maya’ is a 3-year-old female with type IVosteogenesis imperfecta. She has had intramedullary rod-ding of her femurs and professionals in her specializedclinic anticipated that she would stand and walk by thisage. However, she has not progressed beyond independentsitting as a result of frequent upper limb fractures. Mayalearned to steer a power wheelchair within a few minutesof practice and a pediatric international standard compli-ant58 power wheelchair with seat elevator was prescribedto give her a means of effortless, independent mobility andincreased access to activities in her environment. Maya’sjoystick was modified to allow it to be easily transferredfrom the left to the right side of her wheelchair owing toher frequent fractures, and a custom foot box was providedfor protection while she develops proficiency.

Transferable messages related to children who canbenefit from power mobilityWith access to a specialized power mobility device, it is possiblefor infants with disabilities to have augmented mobility experi-ences as early as 8 months of age (level V evidence39,40). Thisresearch challenges the lower age limit for consideringpower mobility. In order to limit the impact of physicaldisability on overall development, clinicians should

consider augmenting independent mobility opportunitiesaround the same age as children typically begin to crawl.In these case reports, the specialized power mobility devicewas fitted with a supportive infant seat and could be remo-tely controlled by an adult to ensure safety.Children can begin learning to maneuver a power mobilitydevice below 14 months of age and those able to use a joystickhave demonstrated competent control as young as 18 to24 months (evidence levels II25 and V31,32,36–38). The major-ity of power mobility research addresses the age of success-ful use with most studies having focused on children usingjoysticks. Children who are unable to use a joystick effi-ciently may benefit from an assessment to identify a moreappropriate access method. Children who use alternateaccess methods (that are more cognitively challenging thana joystick), or who have additional visual, perceptual, cog-nitive, or communication disabilities, may require a longertime to learn power mobility skills or may require morespecialized training.For children with minimal mobility experience, a power mobilitydevice can promote overall development as well as functionalmobility. Power mobility experience appears to have abroad impact on development. The supporting evidence isdivided into different domains for ease of understandingbut it should be recognized that these areas are interwovenand all emerge from and have intellectual underpinnings.Evidence for cognition is supported by level V evidence;40

receptive language is supported by levels II25 and V;40

social and play skills are supported by levels IV28,29 andV;41 independence is supported by level IV;27 cause–effectis supported by level V;35 and self-initiated movementis supported by levels III26 and IV,30 and qualitativeevidence.45,46

For children with inefficient mobility, power mobility mayenhance independence and facilitate participation in family,school and community life (level V evidence42 and qualitativeevidence47,48). Children need an efficient means of mobil-ity to move around the classroom and playground and tokeep up with friends in the community. Using a powerwheelchair can help save energy for learning and playingwith others. Adolescents need safe and efficient mobilitychoices and some who can walk or use a manual wheel-chair also use power mobility to enhance participation inschool and community life. The need for exercise shouldbe addressed at other times and by other more effectivemeans.There is no evidence that using power mobility at a young ageimpedes development of ambulation or other motor skills(evidence levels II25, IV27, and V33). Power mobility doesnot appear to negatively affect motor development and ithas been suggested that children may be more motivated touse their motor skills and participate in therapy once theyhave experienced the independence that power mobility canprovide.Children with conditions that limit early functional mobilitymay benefit from power mobility to promote independence andsupport overall development (evidence level V40).

Review 9

Learning power mobility skillsChildren begin power mobility by exploring movementand learning to control direction. Gradually, they start todevelop functional mobility skills. Competence in usingthe chair in daily life emerges first, but proficiency occursonly over time and with experience.24 Readiness assess-ments such as the Pediatric Power Wheelchair ScreeningTest have been used to identify children who will quicklyand easily learn to use a joystick-operated power wheel-chair. This screening is not appropriate for children withmultiple and complex disabilities who may use switches orother access methods.23 Instead of focusing on readinessskills or passing a ‘driving test’, clinicians should consideraugmenting mobility at an early age for children who areunlikely to walk, in order to promote overall developmentand help lessen the secondary effects of immobility.

Transferable messages related to learning power mobilityskillsMobility experience in a power mobility device may support devel-opment of self-initiated behavior and learning (level V evi-dence34,35 and qualitative evidence45,49). For children withdelayed cognitive and physical development, the use of apower mobility device may facilitate overall learning. Move-ment of the device provides immediate feedback, as well asvestibular and visual stimulation, when the child activatesthe joystick or switch. Some of these children may neverdevelop competent use of a power mobility device but stillbenefit from the independent mobility experience.Many children with severe intellectual and/or sensory impair-ments can learn to use a power mobility device competently withappropriate practice and environmental support (level IV27 andV35 evidence and qualitative evidence45,49). These childrenmay need extensive experience and training to be success-ful. Some children will always require adult supervision toensure safety, but a power mobility device can allow spon-taneous exploration in a safe environment which will pro-mote overall development.46 For young children, learningpower mobility skills is not like an adolescent with typicalmobility learning to drive a car, but is similar to a childlearning to walk or to use a tricycle.64 The adult needs tobe a ‘responsive partner’ and to help elicit children’s learn-ing through play rather than interfering with their concen-tration by talking and directing.24 The amount and type oftraining will vary between individuals and will depend ontheir needs, deficits, motivations, and learning styles. Eventhose with severe visual impairment can use power mobil-ity with adaptations such as use of a cane or a specializedwheelchair with sensors.45

Case example of a child with more complexdevelopmental needs‘Oliver’ has dyskinetic CP (GMFCS level V). He is non-verbal and cognitive testing is unreliable; however, hemakes choices through eye gaze. Oliver gains some inde-pendent mobility through a supportive gait trainer, but thiscan only be used indoors on smooth surfaces.

At age 6, Oliver’s ability to target switches with hishands was erratic and effortful. He was lent an old powerwheelchair with a proportional head control to develop theinitial skill of learning to keep his head up to activate thechair and dropping his head to stop. After 6 months’ train-ing, he tried different types of head control devices andwas most successful with small mechanical switches. Onewas positioned behind his head with right and left turnswitches by his cheeks.

After 5 years, Oliver is a proficient driver. His switcheswere recently changed to a proximity style and arearranged close to the back of his head. He is able to drivethrough doorways and in crowded corridors, showing goodjudgment and safety awareness. His family has a wheel-chair-accessible van and a new, more powerful powerwheelchair has been ordered in preparation for highschool.

Supporting power mobility skillsInitially, parents may view power mobility negatively but,once their child has power mobility experience, mostdescribe positive feelings related to seeing their child experi-encing independence and control.27,47 Families report thatpower mobility leads to increased participation and integra-tion with other children, but they note that appropriatetraining and support are major factors in successful use.65

Aspects of the physical, social, and cultural environment canhave a great influence on power mobility use, as well as per-sonal factors such as motivation, goals, and priorities.

At this time, power wheelchairs are often large and diffi-cult to transport. This can be a major barrier to familiesincorporating one into a child’s life. The development ofless expensive and more child- and family-friendly options,such as ride-on toy cars, may help to reduce this barrier.66

Standard power wheelchairs do not appear to facilitatereach and interaction with toys.29 Development of inexpen-sive, lightweight, child- and family-friendly power mobilitydevices to facilitate participation in play in both the homeand the preschool environment is needed.

To enhance power wheelchair use without contributingto problems of posture and pain, supportive seating, pow-ered seating functions, and adequate suspension are impor-tant features to consider.48 For children with progressiveor severe and complex disabilities, power wheelchairsshould be ordered with electronics capable of accommo-dating alternative access technologies, integration of pow-ered seating functions, and control of other assistivetechnologies, such as communication, computer, or elec-tronic aids to daily living through the drive controls.43

These features are often needed to promote optimal partic-ipation and independence through the power wheelchair.

Clinicians may have difficulty accessing power mobilitydevices for extended trial and training for children who donot immediately demonstrate the ability to maneuver andcontrol the device safely.67 Developing relationships withwheelchair providers in order to borrow power wheelchairsfor longer periods may help address this barrier. Power

10 Developmental Medicine & Child Neurology 2013

mobility experience can also be provided with poweredtoys, cars, standers, and recycled or shared wheelchairsduring therapy sessions.

Transferable message related to supporting powermobility skillsSuccessful development of power mobility skills may depend atleast as much on practice time and quality of learning supportwithin the child’s environment as the child’s motor, cognitive, orsensory abilities (level IV27 and V44 evidence and qualitativeevidence45). To learn any new skill, all children needextensive practice. Identifying where the child is in thelearning process, providing a suitable environment (includ-ing an appropriately programmed power mobility device),and providing learning strategies is critical to success.49

Children who are given more time and experience using apower mobility device, and who are supported in theirlearning by those around them, are more likely to be suc-cessful in developing power mobility skills.

CONCLUSIONUse of power mobility enhances independence and overalldevelopment in young children who do not walk.25,27–29 Inchildren who have inefficient mobility or lose the ability towalk, power mobility enhances activity and participa-tion.47,48 Without efficient, independent mobility, youngchildren are at risk of developing passive, dependentbehaviour26 and older children are at risk of decreased par-ticipation and isolation. Mobility should be effortless andallow children and adolescents the opportunity to partici-pate fully in age-appropriate and meaningful activities.54

All children who lack efficient independent mobility shouldbe considered for power mobility and not excluded on thebasis of age, limited vision, early developmental level,physical access limitations, or the ability to use othermeans of mobility for short distances.

ACKNOWLEDGEMENTS

The authors thank Debra A Field for acting as second reviewer in

determining the levels of evidence for included studies. We thank

the 16 members of the international review panel who took part

in the Delphi process: Jacqueline Casey (School of Health Sci-

ences, University of Ulster, Northern Ireland, UK), Stephanie

Chapman (Chailey Heritage Clinical Services, UK), Josephine

Durkin (Independent consultant Occupational Therapist in Neu-

rodisability, UK), Debra A Field (University of British Columbia,

Graduate Programs in Rehabilitation Science and Sunny Hill

Health Centre for Children, British Columbia, Canada), Jan

Furumasu (Rancho Los Amigos National Rehabilitation Center,

CA, USA), James C (Cole) Galloway (Department of Physical

Therapy, University of Delaware, Newartk, DE, USA), Marlene

Holder (Holland Bloorview Kids Rehabilitation Hospital,

Ontario, Canada), Maria Jones (University of Oklahoma Health

Sciences Center, Department of Rehabilitation Sciences, OK,

USA), Karen Kangas (Clinical Educator and Adjunct Faculty,

Misercordia University, Dallas, PA, USA), Rosanne Kermoian

(Stanford University, CA, USA), Michelle Lange (Access to Inde-

pendence Inc., USA), Sarah McGarry (Princess Margaret Hospital

for Children and Edith Cowan University, Western Australia),

Lisbeth Nilsson (Lund University, Sweden), Paul Nisbet (Com-

munication, Access, Literacy and Learning, Scotland, University

of Edinburgh), Elisabet Rodby-Bousquet (Centre for Clinical

Research, Uppsala University, V€aster€as, Sweden), Tylie Stokes

(Chailey Heritage Clinical Services, UK). Finally, we acknowledge

Dr Susan R Harris for her editorial expertise in preparing this

manuscript for publication.

SUPPORTING INFORMATION

Additional supporting information may be found in the online

version of this article:

Appendix S1: American Academy of Cerebral Palsy and Devel-

opmental Medicine – levels of evidence (December 2008).21

Appendix S2: Evidence table for the studies reviewed.

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