Real-world environmental enrichment rehabilitation paradigm in people with severe traumatic brain injury: a pilot feasibility study.

BACKGROUND: The use of Environmental Enrichment (EE) has been widely studied in animal models. However, the application of the same in humans is limited to rehabilitation settings. OBJECTIVE: To investigate the feasibility of a community-based EE paradigm in adults with brain injury. METHODS: Six individuals diagnosed with traumatic brain injury enrolled in the study. The Go Baby Go Café instrumented with a body weight harness system, provided physical and social enrichment as participants performed functional tasks for 2 hours, three times a week, for 2 months. Feasibility and safety outcomes were recorded throughout sessions. Clinical measures including 10-meter walk, timed up and go, jebsen hand function, 6-minute walk, and trail making tests were obtained pre and post intervention. RESULTS: All participants completed the study. The attendance was 100% and adherence was 87%. Positive changes in clinical measures were statistically significant for the timed up and go (p = 0.0175), TUG-cognitive (p = 0.0064), 10-meter walk (p = 0.0428), six-minute walk (p = 0.0196), TMT-A (p = 0.034). Changes in JHFT were not significant (p = 0.0506), with one subject recording values counter to the trend. CONCLUSION: The Café was a comprehensive EE-based intervention that was feasible, safe, and has the potential to enhance motor and cognitive function in individuals with brain injury.

Feasibility of a home-based environmental enrichment paradigm to enhance purposeful activities in adults with traumatic brain injury: a case series.

PURPOSE: To assess the feasibility, safety, and functional recovery of an Environmental Enrichment (EE) inspired paradigm for enhancing daily activities in people with traumatic brain injury. METHODS: Two TBI-Caregiver dyads participated in the six-month study. A preinstalled harness provided the support structure that enabled the family to perform task-specific functional and cognitive goals. The pre- and post-intervention evaluations included the safety, feasibility, and clinical outcomes such as the 10-m walk test, the Timed Up and Go test, the Jebsen Hand Function test, the Six-Minute Walk test, and the Trail Making Test. The Actigraph GT9X recorded the Caregiver-TBI step count during days spent in harness and out of harness. RESULTS: The study was feasible, safe, and both TBI subjects improved in functional outcomes. Analysis of Actigraph GT9X yielded mixed results. CONCLUSION: A partnership with caregivers and adults with TBI to design an EE-focused community program could improve functional activities in real life. To optimize this intervention, caregivers will likely need an alternate approach to record time spent in the harness.IMPLICATIONS FOR REHABILITATIONThe complexities of the real world encourage meaningful activities and participation.Autonomy in everyday activities is an important long-term objective for adults with brain injury.Community-tailored harnesses designed to prevent falls encourages physical activity and social interaction.

Exploratory analysis of a developmentally progressive modified ride-on car intervention for young children with Down syndrome.

BACKGROUND: Children with Down syndrome (DS) may have limited opportunities to engage in self-directed mobility and play due to motor delays. A recent modified ride-on car innovation is the sit-to-stand (STS) model, which incorporates functional standing and walking training with the experience of powered mobility. AIMS: This study aimed to: (1) describe total dosage and daily usage of three modified ride-on car modes (seated, standing, and power-push) by young children with DS; (2) examine the ability of young children with DS to independently activate the modified ride-on car in seated and standing modes; (3) describe the age of onset of selected motor milestones of the sample in comparison to DS norms. MATERIALS AND METHODS: Eight young children with DS (8.6 ± 2.0 months) used three modes of the modified ride-on car over a 9-month intervention. RESULTS: All eight children independently activated the modified ride-on car in seated and standing modes. Most motor milestones were achieved earlier in this sample than expected for DS norms, including the onset of independent walking. CONCLUSIONS AND IMPLICATIONS: The developmentally progressive nature of the intervention and high dosage may have been instrumental in encouraging the onset of independent activation and earlier motor milestones.IMPLICATIONS FOR REHABILITATIONYoung children with Down syndrome were able to achieve independent activation in seated and standing modified ride-on cars.Developmentally progressive modified ride-on car interventions may facilitate motor skill development, but future work utilizing a randomized control group is needed to examine the potential motor developmental benefits of the STS model and power-push mode.The developmentally progressive nature of the intervention may have been instrumental in encouraging the onset of independent switch activation in both seated and standing modes, as well as the high dosage and adherence rates compared to previous studies.

In-Home Mobility Training With a Portable Body Weight Support System of an Infant With Down Syndrome.

PURPOSE: To report on the feasibility of an open-area, portable body weight support system (PBWSS) for in-home use and overground mobility training in an infant with Down syndrome. SUMMARY OF KEY POINTS: The family used the PBWSS on average 4 days/week and for a mean duration of 27.9 minutes/day. Within sessions, the infant's mobility in the open area was greater with PBWSS assistance. The infant's mobility increased whereas variable trends were noted in the infant's motor, language, and cognitive development. CONCLUSIONS: The long-term and frequent use of the PBWSS by this family provided opportunities to practice on emerging motor skills and exploratory actions that may have had a positive effect on her mobility and overall development. RECOMMENDATION FOR CLINICAL PRACTICE: High-dose, body weight-supported training on emerging motor skills is feasible in the infants' natural environments. Future studies using a large sample will quantify the effects.

GEARing smart environments for pediatric motor rehabilitation.

BACKGROUND: There is a lack of early (infant) mobility rehabilitation approaches that incorporate natural and complex environments and have the potential to concurrently advance motor, cognitive, and social development. The Grounded Early Adaptive Rehabilitation (GEAR) system is a pediatric learning environment designed to provide motor interventions that are grounded in social theory and can be applied in early life. Within a perceptively complex and behaviorally natural setting, GEAR utilizes novel body-weight support technology and socially-assistive robots to both ease and encourage mobility in young children through play-based, child-robot interaction. This methodology article reports on the development and integration of the different system components and presents preliminary evidence on the feasibility of the system. METHODS: GEAR consists of the physical and cyber components. The physical component includes the playground equipment to enrich the environment, an open-area body weight support (BWS) device to assist children by partially counter-acting gravity, two mobile robots to engage children into motor activity through social interaction, and a synchronized camera network to monitor the sessions. The cyber component consists of the interface to collect human movement and video data, the algorithms to identify the children's actions from the video stream, and the behavioral models for the child-robot interaction that suggest the most appropriate robot action in support of given motor training goals for the child. The feasibility of both components was assessed via preliminary testing. Three very young children (with and without Down syndrome) used the system in eight sessions within a 4-week period. RESULTS: All subjects completed the 8-session protocol, participated in all tasks involving the selected objects of the enriched environment, used the BWS device and interacted with the robots in all eight sessions. Action classification algorithms to identify early child behaviors in a complex naturalistic setting were tested and validated using the video data. Decision making algorithms specific to the type of interactions seen in the GEAR system were developed to be used for robot automation. CONCLUSIONS: Preliminary results from this study support the feasibility of both the physical and cyber components of the GEAR system and demonstrate its potential for use in future studies to assess the effects on the co-development of the motor, cognitive, and social systems of very young children with mobility challenges.

Mobility in pictures: a participatory photovoice narrative study exploring powered mobility provision for children and families.

AIM: Rehabilitation professionals are increasingly recognizing mobility as a basic human right and endorsing the efficacy of early powered mobility for children with mobility impairments to foster independence, promote socialization with peers and facilitate participation in family and community life. However, the relationship between mobility and technology provision, when considered in the context of lived experiences of children with mobility impairments and their families, is complex and understudied. Perceptions of these experiences from children's own points of view are especially limited, as is the use of participatory research methods in describing these experiences. The purpose of this study was to empower children and families as co-researchers, investigating their experiences and perspectives of powered mobility provision processes and early use of their mobility technology in their own words and images.  Methods: Two families in a major Midwest metropolitan area- one who was receiving a powered wheelchair and one who was receiving a modified powered ride-on toy car- participated as co-researchers from 2015-2016, documenting their experiences with a research camera and narrating their photos to describe meaningful or important aspects of their respective powered mobility provision processes and early use of their devices. RESULTS: Four themes emerged: (1) Dys/Function of Mobility Technology; (2) Daily Life, Play and Participation; (3) Emerging Self/Advocacy and (4) Complex Family/Industry Interplay.  Conclusions: These themes and experiences may inform further innovation in powered mobility practices, generate new hypotheses about the role of technology in shaping disability identity and demonstrate the feasibility and impact of using participatory methods more broadly in rehabilitation research. Implications for Rehabilitation Participatory methods may be a useful and underutilized research tool in describing the impact of powered mobility provision processes on child and family experiences of technology and disability. Empowering children and families as co-researchers is important to move the field of powered mobility technology forward in creating innovative, accessible and socially welcoming devices and processes. It is important to capture the similarities and differences in child and family perceptions and experiences within different models of powered mobility provision, such as traditional powered wheelchair prescription and crowdsourced ride-on toy car modification. Powered mobility provision processes and the perceptions and experiences of children and families move beyond business or medical transactions and may help shape disability identity and pride. A disability studies framework may be useful in analyzing the complexities of technology provision and the nuanced interplay between bodies and technology.

Means-end problem solving in infancy: Development, emergence of intentionality, and transfer of knowledge.

Behaviors and performance of 23 typically developing infants were assessed longitudinally at 6, 9, 12, 18, and 24 months in two means-end tasks: pulling a towel or rotating a turntable to obtain a supported object. With age, infants performed more goal-directed behaviors, leading to increased problem-solving success. Intentionality emerged earlier in the towel task than in the turntable task (6.9 vs. 10.8 months). Potential knowledge transfer between the tasks was first observed at 9 months. This study provides insight into the development of means-end learning, the emergence of intentionality, and potential transfer of knowledge in tasks involving a similar concept (support) but requiring different modes of action for success (pulling vs. rotating).

Standing Tall: Feasibility of a Modified Ride-On Car That Encourages Standing.

PURPOSE: The purpose of this study was to determine the feasibility of infants with Down syndrome to use a modified ride-on car with seated and standing modes. METHODS: Participants included 4 infants with Down syndrome. Families were asked to provide at least 8 minutes of modified ride-on car driving per day, at least 5 times per week throughout the 9-month intervention. RESULTS AND CONCLUSIONS: Families demonstrated a variety of adherence rates to the intervention. Infants demonstrated independent activation of the modified ride-on car in seated and standing modes and enjoyed driving. The modified ride-on car intervention was feasible and warrants further testing to address barriers that influence adherence to the intervention.

Use of an In-Home Body Weight Support System by a Child With Spina Bifida.

PURPOSE: To examine the feasibility of a new open-area body weight support system (BWSS) to act as both an "assistive" and a "rehabilitative" device within the home. INTERVENTION: A 5-year-old boy with spina bifida used the BWSS during self-selected activities for 10 weeks. Feasibility, behavioral, and clinical assessments provided a quantification of his activity in and out of the BWSS. OUTCOMES: On average, the child used the device on 2.7 days/week and for 67 minutes/day during intervention. When in the BWSS (assistive role), the child's locomotor activity and engagement in adapted sports activities increased. When not in the BWSS (rehabilitative role), the child's functional mobility and ambulatory ability increased. WHAT THIS CASE ADDS: The use of the open-area in-home BWSS was feasible for regular home use and associated with an increase in functional mobility for a child with spina bifida.

Sitting Together And Reaching To Play (START-Play): Protocol for a Multisite Randomized Controlled Efficacy Trial on Intervention for Infants With Neuromotor Disorders.

Background: There is limited research examining the efficacy of early physical therapy on infants with neuromotor dysfunction. In addition, most early motor interventions have not been directly linked to learning, despite the clear association between motor activity and cognition during infancy. Objective: The aim of this project is to evaluate the efficacy of Sitting Together And Reaching To Play (START-Play), an intervention designed to target sitting, reaching, and motor-based problem solving to advance global development in infants with motor delays or neuromotor dysfunction. Design: This study is a longitudinal multisite randomized controlled trial. Infants in the START-Play group are compared to infants receiving usual care in early intervention (EI). Setting: The research takes place in homes in Pennsylvania, Delaware, Washington, and Virginia. Participants: There will be 140 infants with neuromotor dysfunction participating, beginning between 7 to 16 months of age. Infants will have motor delays and emerging sitting skill. Intervention: START-Play provides individualized twice-weekly home intervention for 12 weeks with families to enhance cognition through sitting, reaching, and problem-solving activities for infants. Ten interventionists provide the intervention, with each child assigned 1 therapist. Measurements: The primary outcome measure is the Bayley III Scales of Infant Development. Secondary measures include change in the Early Problem Solving Indicator, change in the Gross Motor Function Measure, and change in the type and duration of toy contacts during reaching. Additional measures include sitting posture control and parent-child interaction. Limitations: Limitations include variability in usual EI care and the lack of blinding for interventionists and families. Conclusions: This study describes usual care in EI across 4 US regions and compares outcomes of the START-Play intervention to usual care.

Prematurity may negatively impact means-end problem solving across the first two years of life.

Preterm infants are at risk for delays in motor, perceptual, and cognitive development. While research has shown preterm infants may exhibit learning delays in the first months of life, these delays are commonly under-diagnosed. The purpose of this study was to longitudinally evaluate behavioral performance and learning in two means-end problem-solving tasks for 30 infants born preterm (PT) and 23 born full-term (FT). Infants were assessed at 6, 9, 12, 18, and 24 months-old in tasks that required towel pulling or turntable rotation to obtain a distant object. PT infants performed more non-goal-directed and less goal-directed behavior than FT infants throughout the study, resulting in a lower success rate among PT infants. PT infants showed delayed emergence of intentionality (prevalence of goal-directed behaviors) compared to FT infants in both tasks. Amount and variability of behavioral performance significantly correlated with task success differentially across age. The learning differences documented between PT and FT infants suggest means-end problem-solving tasks may be useful for the early detection of learning delays. The identification of behaviors associated with learning and success across age may be used to guide interventions aimed at advancing early learning for infants at risk.

Modified Ride-On Car Use by Young Children With Disabilities.

PURPOSE: The purpose of this single-subject case series study is to determine the effect of modified ride-on car use in natural environments on mobility. METHOD: Three children younger than 2 years diagnosed with various disabilities participated in this 24-week study using a modified ride-on car in their home and community. RESULTS: All 3 children demonstrated an ability to independently use the modified ride-on car and enjoyed doing so. Two of the 3 children demonstrated clinically significant gains in mobility skills as measured by the Pediatric Evaluation of Disability Inventory. CONCLUSIONS: Modified ride-on car use is an emerging powered mobility device option for children younger than 2 years. Further research is needed to demonstrate the potential long-term gains of early powered mobility access to young children with disabilities.

Go baby go café: a case study on an immersive rehabilitation environment to improve functional outcomes and quality of life.

PURPOSE: To determine the effectiveness of involving traumatic brain injury survivors in a novel "enriched rehabilitation environment" in which physical, cognitive, social and speech impairments are simultaneously addressed during training within a functioning business. METHOD: Participant was a 34-year old with a history of a severe head injury 17 years ago due to a motor vehicle accident. A novel intervention was provided within the Go Baby Go Café at the University of Delaware during her two hour shifts, three times a week for 2 months. RESULTS: The participant showed improvement in hand function, dynamic mobility, gait speed and cognitive ability. Additionally, changes were also noted across different domains like social activities, feeling of well-being, gross motor function and quality of life. CONCLUSIONS: The Café may be a viable environment for comprehensive intervention. Participation in the Café was associated with wide spread gains in scores on a variety of physical, cognitive, quality-of-life outcomes. Implications for rehabilitation Long-term impairments after traumatic brain injury often impairs activities of daily living, community integration and return to work. The Go Baby Go Café, installed with an overhead harness system serves as an "Immersive Environment" to address various impairments all at once in a real-world setting. Individuals with impairments can benefit from this rehabilitation technique, which is structured to improve changes across the International Classification of Functioning Disability and Health spectrum.

Why We Move: Social Mobility Behaviors of Non-Disabled and Disabled Children across Childcare Contexts.

BACKGROUND: Social mobility is defined as the co-occurrence of self-directed locomotion and direct peer interaction. Social mobility is a product of dynamic child-environment interactions and thus likely to vary across contexts (e.g., classroom, gymnasium, and playground). PURPOSE: The purpose of this present study was to examine differences in children's social mobility: (1) across contexts by age and (2) between non-disabled and disabled children. METHOD: Participants (n = 55 non-disabled and three disabled children; Mage = 3.1 years, SD = 1.4) were video recorded within a university-based early learning center. Children were recorded for 20 min in each context: classroom, gymnasium, and playground. A 15-s momentary time sampling method was used to code social mobility, the simultaneous occurrence of self-directed locomotion, and direct peer interaction. This variable was calculated as percent time within each context. RESULTS: A planned Friedman's rank ANOVA (n = 55), stratified by age, indicated that older children (3-5 years old) differed across contexts in their social mobility [χ2(2) ~ 7.3-10.5, p < 0.025], whereas younger children (1-2 years old) were similar across contexts. Social mobility was significantly lower in the classroom compared with the playground and gymnasium (with no difference between the latter contexts) for older children. Visual analysis confirmed that disabled children (n = 3) engaged in substantially less time in social mobility (average 0-1%), compared with non-disabled, age-similar peers (2-3 years old average 1-12%) across all contexts. CONCLUSION: A substantial gap exists between non-disabled and disabled children for social mobility. There is an increase in magnitude and variability of social mobility around age three that suggests the gap between non-disabled and disabled children will continue to widen.

Infant born preterm have delayed development of adaptive postural control in the first 5 months of life.

UNLABELLED: Infants born preterm are at increased risk of developmental disabilities, that may be attributed to their early experiences and ability to learn. The purpose of this paper was to evaluate the ability of infants born preterm to adapt their postural control to changing task demands. METHODS: This study included 18 infants born at 32 weeks of gestation or less whose posture was compared in supine under 2 conditions, with and without a visual stimulus presented. The postural variability, measured with root mean squared displacement of the center of pressure, and postural complexity, measured with the approximate entropy of the center of pressure displacement were measured longitudinally from 2.5 to 5 months of age. RESULTS AND DISCUSSION: The infants looked at the toys in midline for several months prior to adapting their postural variability in a manner similar to full term infants. Only after postural variability was reduced in both the caudal cephalic and medial lateral direction in the toy condition did the infants learn to reach for the toy. Postural complexity did not vary between conditions. These findings suggest that infants used a variety of strategies to control their posture. In contrast to research with infants born full term, the infants born preterm in this study did not identify the successful strategy of reducing movement of the center of pressure until months after showing interest in the toy. This delayed adaptation may impact the infants ability to learn over time.

Modified Ride-on Car Use by Children With Complex Medical Needs.

PURPOSE: The purpose of this report was to determine the feasibility of short-term modified ride-on car (ROC) use for exploration and enjoyment by children with complex medical needs. METHODS: A single-subject research design was used (n = 3; age, 6 months to 5 years). Children were video-recorded using their modified ROC. RESULTS: All children successfully learned how to independently drive a modified ROC. Two of the 3 children demonstrated high levels of enjoyment during use of a modified ROC. CONCLUSIONS: Modified ROC use is a feasible and enjoyable powered mobility device for children with complex medical needs.

Playskin Lift: Development and Initial Testing of an Exoskeletal Garment to Assist Upper Extremity Mobility and Function.

BACKGROUND: A person's ability to move his or her arms against gravity is important for independent performance of critical activities of daily living and for exploration that facilitates early cognitive, language, social, and perceptual-motor development. Children with a variety of diagnoses have difficulty moving their arms against gravity. OBJECTIVE: The purpose of this technical report is to detail the design process and initial testing of a novel exoskeletal garment, the Playskin Lift, that assists and encourages children to lift their arms against gravity. DESIGN: This report details the design theory and process, the device, and the results of field testing with a toddler with impaired upper extremity function due to arthrogryposis multiplex congenita. RESULTS: The Playskin Lift is an inexpensive (<$30 material costs), easy to use (5/5 rating), comfortable (5/5 rating), and attractive (4/5 rating) device. While wearing the device, the child was able to contact objects more often throughout an increased play space, to look at toys more while contacting them, and to perform more complex interactions with toys. LIMITATIONS: This report details initial testing with one child. Future testing with more participants is recommended. CONCLUSIONS: These results suggest that by considering the broad needs of users, including cost, accessibility, comfort, aesthetics, and function, we can design inexpensive devices that families and clinicians can potentially fabricate in their own communities to improve function, participation, exploration, and learning for children with disabilities.

Why the time is right for a radical paradigm shift in early powered mobility: the role of powered mobility technology devices, policy and stakeholders.

This article explores the changing landscape of early pediatric powered mobility. We specifically focus on key indicators that suggest pediatric powered mobility technology (PMT) practice for very young children is poised for a radical paradigm shift. This shift will challenge the current purview of PMT design and function, how it is obtained, and its introduction to children and their families. We propose that this positive, yet radical shift is essential in achieving a standard of practice in which PMT provides for early exploration and participation for children with disabilities at an age concomitant with their non-disabled peers, and within socially inclusive environments. To sustain this new standard, we must acknowledge the significant disconnect that currently exists between clinical research supporting the use of PMT with very young children, and barriers to widespread device access, effective user-driven design and positive social perception of PMT. In this article, we discuss three areas that are particularly important for both shift and sustained change: the history and current availability of novel and conventional PMT devices, pediatric PMT policies and the role of children and families as primary stakeholders in PMT practices. Within each area, we suggest barriers, facilitators and future directions. Implications for Rehabilitation The time is right for reframing how powered mobility technology for very young children is conceived, designed, and implemented. In order for multiple innovative devices to survive in the powered mobility industry, it is important to continue to show the benefits of early powered mobility use for both traditional and non-traditional users, and also enact and enforce policy that promotes sustainable access and financial support for powered mobility technology. The experiences of children and families and the realities of everyday use of powered mobility technology must be brought to the forefront of a movement toward user-centered design. Advocacy efforts undertaken in partnership with families, clinicians, researchers, and disability communities are essential in recognizing mobility, and access to early powered mobility technology, as a human right.

Effect of Short-Term Training on Reaching Behavior in Infants: A Randomized Controlled Clinical Trial.

The purpose of this study was to test the effect of short-term training on reaching behavior in infants at the onset of reaching. The study was a single-blind, parallel group design, randomized controlled clinical trial. Thirty healthy infants were randomly assigned to a social control group (n = 15) or a reaching training group (n = 15). Infants began the study up to 3 days after the onset of reaching and were assessed three times across 2 days: pretraining (before training), posttraining 1 (after 1 session of training), and posttraining 2 (after 3 sessions of training). The reaching training group received 3 sessions of training by a physical therapist while the control group received a similar amount of time sitting in the therapist's lap. The data were analyzed using repeated-measures analyses of variance, and independent-samples tests with Bonferroni adjustments. Short-term training resulted in increased frequency of object contacts, shorter and smoother reaches, and improved hand positioning. The few short training sessions likely provided opportunities for infants to explore and learn to select movements from their existing movement repertoire. These results demonstrate that adaptive changes in infants' novel behaviors can emerge rapidly, and highlight the need for increased understanding of how to most effectively time early interventions.

Modified ride-on car for mobility and socialization: single-case study of an infant with Down syndrome.

PURPOSE: Before the onset of walking, children with Down syndrome experience limited mobility yet are never considered candidates for traditional powered mobility devices. The purpose of this single-case study is to quantify the feasibility and family perceptions of including modified ride-on car use as an option for increasing daily mobility, socialization, and fun for a child with Down syndrome. METHODS: A 13-month-old child, Natalie, and her family were video recorded during the 28-week study using her ride-on car in their home and community. RESULTS: Natalie demonstrated and her family reported increased movement, mobility, and socialization over the study period. CONCLUSIONS: Ride-on car use appears feasible, fun, and functional to increase daily mobility for pediatric populations working toward independent walking.