Persons with Multiple Disabilities Exercise Adaptive Head and Hand-Eye Responses Using...

ORIGINAL ARTICLE

Persons with Multiple Disabilities Exercise AdaptiveHead and Hand-Eye Responses Using Technology-AidedPrograms: Two Single-Case Studies

Giulio E. Lancioni & Mark O’Reilly &

Nirbhay Singh & Jeff Sigafoos & Doretta Oliva &

Francesca Campodonico & Russell Lang

Published online: 1 April 2012# Springer Science+Business Media, LLC 2012

Abstract The present single-case studies assessed the effectiveness of technology-aided programs to help two persons with multiple disabilities exercise adaptiveresponse schemes independently. In Study I, exercise concerned head movements(i.e., head and neck posture/muscle control) by a 12-year-old girl who tended to keepher head turned/bent to her left. In Study II, exercise concerned touching one or twoobject cues on a computer monitor (i.e., a preliminary form of hand-eye coordination)by a 15-year-old boy. The technology involved microswitches to detect the occur-rence of the target responses and a computer/control system to record their occur-rences and activate preferred stimuli contingent on them. Results showed largeincreases in the responses targeted for each of the two participants during theintervention phases of the studies. The importance of using technology-aided pro-grams as tools for enabling persons with profound and multiple disabilities to practicerelevant responses independently was discussed.

J Dev Phys Disabil (2012) 24:415–426DOI 10.1007/s10882-012-9279-z

G. E. Lancioni (*)University of Bari, Bari, Italye-mail: [email protected]

M. O’ReillyMeadows Center for Preventing Educational Risk, University of Texas at Austin, Austin, TX, USA

N. SinghAmerican Health and Wellness Institute, Verona, VA, USA

J. SigafoosWellington Victoria University, Wellington, New Zealand

D. Oliva : F. CampodonicoLega F. D’Oro Research Center, Osimo, Italy

R. LangTexas State University, San Marcos, TX, USA

Keywords Adaptive responses . Technology . Response exercise . Multiple disabilities

Persons with severe/profound multiple disabilities (i.e., intellectual, motor, and sen-sory impairments) can spend most of their time in a wheelchair and receive dailyprograms involving physiotherapy and general stimulation (Dillon and Carr 2007;Green and Reid 1999; Lancioni et al. 2010; Shih et al. 2011; Tam et al. 2011).Physiotherapy tends to rely heavily on specific maneuvers of the therapist to promoteand support adaptive postures and responses and inhibit abnormal (interfering)postural and movement components (Cherng et al. 2007; Jansen et al. 2004; Ketelaaret al. 2001; Tsorlakis et al. 2004). The impact of this approach on improving thepersons’ adaptive motor condition/schemes or enhancing their ability to coordinatemotor responding with visual cues may largely depend on a systematic use ofexercise sessions (i.e., specific time periods directed at helping the persons practicethose schemes or coordination of specific responses and environmental cues) (Buggand Head 2011; Cotman and Berchtold 2007; Lancioni et al. 2004, 2008b).

The use of exercise, which is largely justified by the notion of experience-dependent plasticity (Begnoche and Pitetti 2007; Damiano and DeJong 2009), mayprove easier to apply and more effective if embedded in intervention programs thatensure the persons’ motivation to be actively engaged. Such motivation would enablethe persons to comply with the exercises and eventually perform them independently.This independence would emphasize the persons’ self-determination and improvetheir social status and, at the same time, would reduce the staff’s direct timeinvestment, making their supervision job more practical and affordable (Brown etal. 2009; Findorff et al. 2005; Nordberg et al. 2007).

A program may succeed in supporting the persons’ motivation and independentperformance only if it relies on assistive technology (Chantry and Dunford 2010;Lancioni et al. 2011). Such technology could involve (a) microswitches or othersensor devices to monitor the persons’ responding, (b) a microprocessor-basedcontrol system that records such responding and activates brief periods of preferredstimulation contingent on its occurrence, and (c) stimulus events/sources linked to thecontrol system and activated briefly in case of responding (i.e., as mentioned above)(Holburn et al. 2004; Lancioni et al. 2008a; Mechling 2006). This technology wouldbe expected to be accurate in detecting responding, and rapid and reliable in provid-ing stimulation contingent on its occurrence (i.e., thus ensuring the persons’ motiva-tion to respond independently of staff intervention) (Lancioni et al. 2008a, 2011).

The two single-case studies reported here served to assess whether technology-aided programs, such as those mentioned above, would support exercise engagementby two persons with multiple disabilities. In Study I, exercise concerned head move-ments (i.e., head and neck posture/muscle control). The participant was a child whokept her head frequently turned/bent to her left (i.e., close to her left shoulder)(Lancioni et al. 2008b, 2009). In Study II, the exercise concerned touching one ortwo object cues on a computer monitor (i.e., a preliminary form of hand-eye coordi-nation). The participant was an adolescent who hardly used his residual vision fororienting/guiding his hand responses (Pizzamiglio et al. 2008). The studies were toextend preliminary evidence on the usability of technology-aided programs for

416 J Dev Phys Disabil (2012) 24:415–426

promoting exercise of adaptive response schemes by persons with multiple disabil-ities (Lancioni et al. 2012).

Study I

Method

Participant

The participant (Lynn) was 12 years old and had congenital encephalopathy withhydrocephalus and blindness. She presented with spastic tetraparesis and was con-fined to a wheelchair, did not have recognizable communication means, could nothandle objects, did not possess self-help skills or sphincteric control, and dependedon her caregiver for any interaction with her environment. While sitting in thewheelchair, she tended to turn/slide her head to her left (close to her shoulder). Herlevel of intellectual disability had been reported to be in the profound range, but noformal assessments had been carried out due to her condition, which made testingimpossible. She attended a center for persons with multiple disabilities in which shereceived personal care as well as physiotherapy and general stimulation (e.g., musicand vibration inputs). One of the goals of staff/physiotherapists and parents was todeal with her head and neck position problems. They realized that a technology-aidedprogram directed at helping her exercise her head and neck control on her own (i.e.,independent of external prompting) would be a necessary supplement to physiother-apy. Her parents had signed an informed consent for her involvement in this study,which had been approved by a scientific and ethics committee.

Position, Target Response, Technology, and Stimuli

Lynn sat in her wheelchair throughout the sessions of the study. The target responseconsisted of Lynn bringing her head to a central (or central-right) position on theheadrest of the wheelchair. This required her to control (and strengthen) her neckmuscles. The technology included three optic sensors/microswitches (i.e., mini pho-tocells) and a computer system. The microswitches were fixed at the left corner of thewheelchair headrest (i.e., to detect the inappropriate, left bending/sliding posture ofher head and neck), and at the center of the headrest and slightly to the right of it (i.e.,to detect appropriate postures of the head and neck). The computer system recordedthe occurrences of the target response and also regulated the delivery of stimulicontingent on them during the intervention phases of the study (Lancioni et al.2011). A target response was recorded if Lynn moved her head (a) from the firstmicroswitch (i.e., left corner of the wheelchair’s headrest) to any of the other twomicroswitches, and (b) from the second (central) microswitch to the third (slightlyright) microswitch. The computer system also recorded the total amount of time ofinappropriate head and neck posture per session.

The stimuli selected for the study included popular songs, recordings of hermother’s singing and of staff and family members’ talking, and vibrotactile input.

J Dev Phys Disabil (2012) 24:415–426 417

These stimuli had been recommended by Lynn’s mother and staff personnel andconfirmed through a brief stimulus preference screening procedure, which involved5–10 nonconsecutive presentations of (a) one or two 10-s clips of the songs, of themother’s singing, and of the talking of family and staff, and (b) 10-s vibratory inputsat two different body positions. The results of the screening confirmed that Lynnreacted positively (e.g., alerted/oriented and smiled) in more than 60 % of thepresentations.

Experimental Conditions

The study was carried out according to an ABB1AB1 design, in which the Arepresented baseline phases and the B and B1 intervention phases (Barlow et al.2009). A 3-week post-intervention check was also included. Sessions lasted 10 minand were carried out three to eight times a day depending on the participant’savailability. The target responses as well as the total amount of inappropriate headand neck posture time per session were automatically recorded through the electroniccontrol system. Response prompting (i.e., verbal and physical guidance) was avail-able prior to the sessions and during the sessions if periods of non-responding of 30–60 s occurred. Responses performed after prompting were subtracted from the sessiontotal, automatically recorded through the computer system, by the research assistantin charge of the sessions. Interrater agreement on recording these prompt-relatedresponses was checked in 22 sessions. Agreement, with the two raters reporting thesame number of prompt instances (which could also be zero), occurred in all sessions.

First Baseline (A) Phase This baseline phase included five sessions in which micro-switches and computer system were present, but no stimulation occurred for responseoccurrences. A new response occurrence was recorded only if the interval from theprevious was at least 10 s (i.e., an interval matching the stimulation time used in thenext B phase).

Intervention (B) Phase The intervention (B) phase included 47 sessions, in which themicroswitches and computer system were available and the occurrences of the targetresponse were followed by 10 s of preferred stimulation. A new occurrence wasrecorded only if the 10-s stimulation for the previous one was ended.

First Intervention (B1) Phase This intervention phase included 24 sessions. Condi-tions varied from the B phase in two ways. First, the 10-s stimulation scheduled forthe occurrence of a target response would be interrupted prematurely if the firstmicroswitch at Lynn’s left signaled that she displayed inappropriate head and neckposture. Second, a new occurrence of the target response was recorded if thishappened after the stimulation for the previous response was terminated (i.e., irre-spective of whether this had been prematurely interrupted).

Second Baseline (A) Phase This baseline phase included six sessions. Conditionswere as in the first baseline with the exception that any new occurrence of the targetresponse was recorded (i.e., in line with the previous B1 phase).


Second Intervention (B1) Phase This intervention phase included 32 sessions. Con-ditions matched those of the first B1 phase.

Post-intervention Check Lynn continued to receive sessions such as those availableduring the B1 phases. Seven of those sessions occurring about 3 weeks after the endof the second B1 phase were used as the post-intervention check.

Results

Lynn’s data are summarized in Fig. 1. The black squares indicate mean frequencies ofoccurrence of the target response, independent of prompts from the research assistant,during blocks of three sessions. Blocks of two sessions are marked with arrows.Empty circles represent the mean amount of inappropriate head and neck posture timeper session (i.e., monitored by the optic microswitch at the left corner of the wheel-chair’s headrest), computed over the same blocks of sessions. During the firstbaseline (A) phase, the mean frequency of responses per session was below 10.The mean amount of time with inappropriate head and neck posture per session wasabout 6 min. During the intervention (B) phase, the mean number of responses persession was about 28. The mean amount of time with inappropriate head and neckposture per session was about 3.5 min. During the first B1, the mean frequency ofresponses per session was about 50. The mean amount of time with inappropriatehead and neck posture per session decreased to below 2 min. The second baseline (A)phase showed a response decline and an increase in the amount of time withinappropriate head and neck posture. The second B1 showed data similar to thoseof the first B1. Comparable data were also obtained at the post-intervention check.Target responses with prompting from the research assistance (i.e., not independentand thus not reported in the figure) occurred almost exclusively within the firstbaseline and the B phase.

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Fig. 1 The figure summarizes Lynn’s data. The black squares indicate mean frequencies of occurrence ofthe target response independent of prompts during blocks of three sessions. Blocks of two sessions aremarked with arrows. Empty circles represent the mean amount of inappropriate head and neck posture timeper session (i.e., monitored by the optic microswitch at the left corner of the wheelchair’s headrest),computed over the same blocks of sessions


Study II

Method

Participant

The participant (Martin) was 15 years old and had a diagnosis of Down’s syndrome.He could ambulate only small distances with caregiver’s support and presented withepilepsy that was only partly controlled through medication, absence of any specificform of communication, lack of sphincteric control and of self-help skills. He wasreported to have moderate visual impairment and to make limited use of his vision inreaching objects. His level of intellectual disability had been reported to be in theprofound range, but no formal assessments had been carried out due to his condition,which made testing impossible. He attended an educational center for students withmultiple disabilities in which he was exposed to general physiotherapy includinghand-reaching exercises in relation to visual cues. A technology-based program thatcould guide and motivate him to perform those exercises (possibly promoting basicforms of hand-eye coordination) independently was considered highly desirable byhis staff and family. His family had signed an informed consent for his involvement inthis study, which had been approved by a scientific and ethics committee.

Position, Technology, Response and Stimuli

Martin sat in his chair in front of a 20-inch monitor (i.e., an optical-touch screenmonitor) connected to a computer system. The monitor presented the visual cues, thatis, red squares of 7 cm×8 cm in size. Eventually, their size was reduced (see below).Two levels of technology were used. The first level showed one visual cue at eachtrial, at one of six possible locations (i.e., close to the corners and in the upper andlower central areas of the monitor). A cue would stay on until Martin had respondedto it, that is, had touched it (brought his hand over it). The computer system wasprogrammed to control the presentation of the aforementioned cues, to recordMartin’s responses, and to activate stimulus events contingent on the responsesduring the intervention phases of the study. The position of the cues on the monitorwas determined by a semi-random schedule. During the intervention, a response (i.e.,touching the cue) caused the cue to disappear and a 10-s period of preferredstimulation to begin. Following the end of the stimulation a new cue appeared.During baseline, a response did not cause any immediate consequence. The cue thatMartin touched was replaced by a new one, 10 s after the response. The second levelof the technology presented a difference that required increased visual-motor coor-dination from Martin. Touching the cue that was on the monitor did not cause a 10-sstimulation period, but rather the appearance of a second cue in any of the other fivepossible positions. Martin was to touch this second cue also. Only when he had doneso, the system (a) started a 10-s interval leading to the next trial (baseline) or (b)presented a 10-s stimulation (intervention).

The stimuli occurring contingent on the responses of touching one cue or two cuesin succession (i.e., automatically activated by the computer system) during the


intervention phases of the study included cartoon images and other visual feedbacks,such as illumination of optical fibers, with music and songs, and vibrotactile input ondifferent parts of the body. Those stimuli, which had been recommended by staffpersonnel, were confirmed through a brief stimulus preference screening procedurecomparable to that described in Study I.

Experimental Conditions

The study was carried out according to an ABABA1B1A1B1 sequence in which A andB represented the baseline and intervention phases with the first level of thetechnology and A1 and B1 baseline and intervention phases with the second levelof the technology, respectively (Barlow et al. 2009). A post-intervention check wascarried out about 3 weeks after the end of the second B1 phase. Sessions lasted 10 minand were carried out two to six times a day depending on the participant’s availability.The responses were automatically recorded through the computer system as in Study I.Similarly, conditions concerning response prompting (i.e., physical guidance of theresponse) and interrater agreement on recording prompt-related responses matchedthose of Study I.

First and Second Baseline (A) Phases The two baseline (A) phases included six andfive sessions, respectively. Martin sat in front of the computer monitor, which showeda red square cue, as described above. His responding did not cause any stimulation.After a period of 10 s, a new cue replaced the one touched by the previous response.Lack of responding to a cue for 30–60 s led the research assistance to use responseprompting (i.e., physical guidance to help Martin touch the cue).

First and Second Intervention (B) Phases The two intervention (B) phases included37 and 114 sessions, respectively. All conditions were as in the baseline (A) phases,except that (a) Martin’s responses were followed by 10 s of preferred stimulation asdescribed above, and (b) the size of the red square cues was reduced to 6 cm by 6 cmwithin the first half of the second B phase.

First and Second Baseline (A1) Phases The two baseline (A1) phases included 12 andseven sessions, respectively. During these sessions, touching the red square cue onthe monitor caused the appearance of a second cue in any of the other five possiblemonitor positions. Touching the second cue did not cause any stimulation. After 10 s,the monitor reset with the appearance of a new cue.

First and Second Intervention (B1) Phases The two intervention (B1) phases included29 and 78 sessions, respectively. Conditions were as during the A1 phases with theexception that touching the first and second red cues appearing on the monitor led to10 s of preferred stimulation.

Post-intervention Check Martin continued to receive sessions such as those available atthe end of the second B1 intervention phase. Seven of those sessions occurring about3 weeks after the end of the intervention were used as the post-intervention check.


Results

Martin’s data are summarized in Fig. 2. The black squares represent mean frequenciesof independent responses per session (i.e., without any prompting from the researchassistant) over blocks of five sessions. Blocks of two to four sessions are marked withan arrow. During the first baseline (A) phase, the mean frequency of responses persession was below six. During the first intervention (B) phase, the mean frequencyincreased to about 22 responses per session. During the second baseline (A) phase,there was a drop in responding. During the second intervention (B) phase, the meanfrequency of responses increased to about 31 per session. The introduction of smallerred squares did not alter responding. During the first A1 phase, the mean frequency ofresponding was about seven per session. During the first B1 phase, the meanfrequency of responses increased to about 27 per sessions. The second A1 and B1

phases largely replicated the data of the first A1 and B1 phases. The data of the post-intervention checkwere comparable with those of the second B1 phase. Target responseswith prompting from the research assistance (i.e., not independent and thus notreported in the figure) occurred almost exclusively within the baseline (A and A1)phases and the first B and B1 phases.

General Discussion

The data of the two studies indicate that the use of the technology-aided programsenabled the two participants to practice/exercise adaptive response schemes indepen-dently. These data, which are in line with preliminary findings in the area (Lancioni etal. 2012), may be considered very encouraging and practically relevant. In fact,extensive exercise opportunities may be necessary for persons with multiple disabil-ities to reduce or postpone their risks of motor/physical degeneration (e.g., Lynn) orto improve basic motor and visual responses and possibly facilitate some coordina-tion between them (e.g., Martin). Both programs indicate that procedural changes(increased demands) can be planned for the participants with apparently morerelevant engagement and possibly more extensive benefits for them. Although the

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Fig. 2 The figure summarizes Martin’s data. The black squares represent mean frequencies of independentresponses per session (i.e., without prompting from the research assistant) over blocks of five sessions.Blocks of two to four sessions are marked with an arrow


post-intervention check covered a relatively short period of time, one could assumethat the engagement and related benefits may be maintained in the long-term if thestimuli used as consequences of the responses continue to be motivating/reinforcing(Kazdin 2001). In light of the results, several considerations may be put forward.

First, the aforementioned need of exercise and the limited availability of staff timeto supervise exercise sessions are two familiar questions within care and education/rehabilitation centers for persons with multiple disabilities (Bugg and Head 2011).The fact that technology-based programs, such as those reported in these two casestudies, can be highly accurate in detecting responding and providing stimulationcontingent on it can be highly encouraging as to their potential to support/motivateexercise engagement within daily contexts (Baker and Moon 2008; Borg et al. 2011;Chantry and Dunford 2010; Lancioni et al. 2008a, 2011). In reality, the use of thoseprograms would be expected to ensure successful daily practice at an affordable staffcost within rehabilitation and care centers. The use of those programs, moreover,would obviously ensure the active role of the participants and their self-determinationwith positive implications for their condition and appearance (Carter et al. 2009;Nota et al. 2007).

Second, the participants’ acquisition and maintenance of an active exercise rolethrough the automatic delivery of positive/reinforcing contingent stimulation couldbe viewed as relevant in terms of the participants’ personal satisfaction. Indeed, theirconsistent responding displayed through the sessions might be taken as a clear signthat they enjoyed those sessions and were happy to be involved in them (Catania2007; Friedman et al. 2009; Jumisko et al. 2009; Makharadze et al. 2010; Sunderlandet al. 2009). Although no specific assessment of the participants’ mood was carriedout in the present case studies and in the previous ones (Lancioni et al. 2012),suggestions were made that mood improved during the sessions with theoccurrence of occasional smiles (Dillon and Carr 2007; Green and Reid 1999;Lancioni et al. 2005).

Third, the technologies used for these studies seem fairly straightforward andrelatively easy to reproduce. Obviously, they would need to be adapted to the generalconditions and response characteristics of each new participant. This requirement islikely to demand that the rehabilitation expert and a technical adviser work in closecoordination to design a functional program and a matching technology for ensuring apositive outcome (Baker and Moon 2008; Borg et al. 2011; Lancioni et al. 2012). Thetype of stimulation available for the participants’ responses is bound to represent apoint of critical importance within the program. Only when the impact (reinforcing/motivating power) of the stimulation is high can one expect the participant to performconsistently (Kazdin 2001; Lancioni et al. 2008a).

Fourth, the responses exercised in these two case studies and the three previouslyreported (Lancioni et al. 2012) represent a fairly narrow range of the responses thatmight be suitable for exercise and improvement (Mechling 2006; Mellstrom et al.2005; Tam et al. 2011). Among other responses that might benefit from a systematicexercise program, one could include leg, foot, and trunk movements, as well as handmovements aimed at tracking/reaching moving cues (i.e., movements/responses thatwould require a relatively advanced form of hand-eye coordination) (Lancioni et al.2004, 2007, 2012; Shimizu et al. 2010). Program/technology conditions for dealingwith the aforementioned responses could be largely modeled on those used in the


current case studies (i.e., using the caution of adapting the package to the generalcharacteristics of each individual participant).

Fifth, the technology-aided programs can be applied for variable periods of theday. The number of sessions available within these two case studies and the previousthree reported (Lancioni et al. 2012) showed cumulative exercise periods of 20 to100 min per day. These data may suggest that: the programs (a) need to be coordi-nated with all other daily activities and requirements, and (b) can have an extensiveuse and possibly a relevant impact making their development and realization cost-effective (Findorff et al. 2005; Nordberg et al. 2007). One could also envisage thepossibility of targeting two or more responses per participant. Obviously, the use ofdifferent responses would require different microswitches and probably the selectionof new stimuli so that different groups of stimuli could be matched with differentresponses (Lancioni et al. 2008a).

In conclusion, the findings stressed the role of technology-based programs inhelping participants with multiple disabilities practice/exercise adaptive responseschemes independently. New research would be critical to (a) find ways of measuringthe impact (benefits) of these programs on the general physical condition of theparticipants, (b) extend the evaluation of the programs with new participants and newresponses, (c) evaluate the mood of the participants during the program sessions,during general physiotherapy maneuvers, and during other parts of the day, and (d)carry out social validation assessments of the programs to determine staff andfamilies’ opinions about their applicability, acceptability, and potential effectivenesswithin daily contexts (Kazdin 2001; Kennedy 2005; Callahan et al. 2008).

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Persons with Multiple Disabilities Exercise Adaptive Head and Hand-Eye Responses Using...

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