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Case of Excellence: Nora

We are now introduced to Nora, who is a two-year-old energetic young child who required assistance with meeting her mobility and developmental needs and goals. Nora loves playing in her jump swing, loves anything that goes fast, which includes going on slides and downhill skiing. She lives in Sweden with her mom, dad and 3 older siblings and attends public daycare during the week. She receives physical therapy and occupational therapy services at a pediatric rehab center weekly and has swim lessons. She has a variety of adaptive equipment that she can access, depending on the activity at hand.  These include a static activity chair with a saddle seat, a standing brace or shell, a standing frame, a walker, a crawling board, and an orthosis for her hand.  

We meet Nora when she is first introduced to the Explorer Mini and followed her experiences first-hand for the first three months she interacted and used the device. For Nora’s family and clinical team, they wanted to provide her with a means to be mobile with increasing independence while supervised, to learn about special perception and to be able to explore the environment around her. While Nora is unable to communicate with words yet due to her diagnosis of dyskinetic Cerebral Palsy, it doesn’t stop her from having bright and inquisitive facial expressions.   

Fitness (Body Functions & Structures)

  • Motor dysfunction in all four limbs where her legs are impacted greater than her arms
  • Spasticity in her limbs and trunk that is triggered by excitement.
  • She can support her legs when using her walker, but her trunk balance and coordination is a limitation
  • With her hands she can grab and reach in a dyskinetic manner and partially grip things but tends to use left hand most often.
  • She is starting to make sounds and attempting to talk and form words as well as communicate in a melodic manner.
  • Cognitively her parents report that she can understand what is happening around her and her body is her limitation. Formal evaluations will come as she ages.

Function (Activities)

  • Her activities include play (of course!) and lots of it!
  • Her parents want her to be as active as possible with activities in the house
  • She loves her therapy time especially her swim sessions
  • At home with her siblings they love clapping hands and practicing her reach by taking things from her older siblings.

Friendship (Participation)

  • Nora primarily hangs out her siblings but also has cousins of similar age that live close by
  • At school she loves to interact with her peers and participate in all the same activities and she even has her own sledge (sled)

 Family (Environment) & Fun (Personal factors)

  • She lives with her mom, dad and 3 older siblings in a home in the northern part of Sweden.
  • She attends an inclusive public day care during the week
  • There are additional resources available to support Nora during the day as well
  • At the time of the first interview, she was 81 cm (32 inches) and 10 kg (22 pounds), which is within the recommended range of use for the Explorer Mini.

 

* Images kindly provided by Nora's family and therapists.

Outcomes

Learning stage

After 3 months of use, Nora’s therapist and parents shared with us all the changes that they were able to see her experience through having access to mobility. If we compare some of her changes with the recommendations from “The Guideline for Introducing Powered Mobility to Infants and Toddlers” by Feldner, Plummer & Hendry”, we can note the following changes: Driving to learn: Nora was an operational learner requiring close adult supervision, the training occurred in more than one environment and she could engage in specific play activities. *Image adapted from Field and Livingstone’s Exploratory, Operational and Functional Learner Groups as cited in Felder, Plummer & Hendry, 2022.

Outcomes

Learning Powered Mobility

She primarily presented as an Advanced Beginner but ranged between Beginner and Sophisticated Beginner. Her sessions were curated based on her learning stages, which after three months reflected that she was in an Intermediate learning stage. This is where she started goal-directed movements, started to incorporate familiar and trusted adults for motivation and had greater attention to the external physical environment. *Image adapted from Nilsson & Durkin’s Assessment of Learning Powered Mobility Use Phases and Stages as cited in (Feldner, Plummer, & Hendry, 2022).

Outcomes

Communication and Language:

Shared attention is evidenced by smiling facial gestures, increased awareness and attentiveness, and increased vocalizations by expressing more sounds and mimicking words. She previously expressed frustration when she was unable to mobilize in some of her static devices and now her demeanor is more content when she is in the Explorer Mini. She will also express her discontent when her parents try to help her with something or when she has to get out of the Explorer Mini.

Outcomes

Motor and sensory development:

Not only did her motor and sensory development change related to how she drove to learn, but there was also translation of those skills outside of the Explorer Mini in that she is able to use both of her hands on her therapeutic rocking horse, she increased her use of her weaker hand for tasks. And when she is using her Explorer Mini, her upright and standing tolerance is improved compared to her walker, which allows her more time to explore, take in her surrounds, touch and interact with the world around her.

Outcome 1

“It was when she was in it driving around and then she suddenly noticed her jump swing and she drove to it and really wanted to have it. Sometimes when she drives and accidentally hits the joystick while driving, she has gone back to reach what she wanted, and then it really felt as if she had really got to where she wanted to.” – Dad

Outcome 1 clinical benefits

Research shows that on-time mobility:

  • Allows for self-directed mobility(12)
  • Proportional drive control provides direction-specific exploratory movement for motor and sensory development(6)
  • Aids in the development of visual perception(4)
  • Provides midline position for joystick control to promote visual coordination(5)

Outcome 2

“Nora can be more involved now when they play, before they would sit on the mat and play or train to make her move toward them in the walker, but now with this they have a more playful and fun interaction. It feels more like playing even if it is still actually training.” - Mom

Outcome 2 clinical benefits

Research studies show that on-time mobility:

  • Allows the user to participate with increased frequency in desired activities and life roles (18)
  • Aids in the development of psychosocial skills (16)
  • Aids in the development of verbal and non-verbal communication (17)
  • Aids in the development of functional activities including play (14) 

Outcome 3

“She tries to reach for things more, for example she grabs the papers on the fridge. I think oh, that is great, but at the same time oh, that is so wrong.” -Mom

Outcome 3 clinical benefits

Research shows that on-time mobility:

  • Promotes safe, stable, and upright postures, thereby providing opportunities to develop strength, sitting tolerance and postural control(1)
  • Aids in the development of motor skills(2)
  • Provides midline position for joystick control to encourage bilateral integration, allowing upper extremities to be used together in a coordinated way(3)
  • Aids in the development of cognition(7)
References
Full list of references used to develop this Case Report
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