POWERED MOBILITY DEVICES ASSESSMENT AND COGNITIVE IMPAIRMENT:A SYSTEMATIC REVIEW OF STRATEGIES ASSESSMENT AND MEASURES
Trioschi D.1,2,3, Paolini C.2,4, Agusto R. 2,512345-

Sunrise Medical – Italian Team – Education in Motion Team
Occupational Therapy Course at University of Modena and Reggio Emilia, Italy
Occupational Therapy Course at University “Cattolica Sacro Cuore”, Claudiana - Bolzano, Italy
Nursing home “Casa Famiglia Mattioli Garavini Onlus”– Reggio Emilia, Italy
Azienda USL di Parma

This publication is copyrighted. Consultation for private use is permitted, for the reproduction of content is required
the authorization of authors.
Contact: devis.trioschi@sunrisemedical.it
To mention this publication:
Trioschi D., Paolini C., Agusto R. (2019), “POWERED MOBILITY DEVICES ASSESSMENT AND COGNITIVE IMPAIRMENT: A
SYSTEMATIC REVIEW OF STRATEGIES ASSESSMENT AND MEASURES”. In ESS conference proceedings 2018, Dublin; EIM Education In Motion, Sunrise Medical, December 2019
Often, when we evaluate a powered mobility devices (PMD) for a child with disabilities, as well as motor issues we mustalso consider cognitive issues. Many clinicians ask themselves how to get around these issues, and often ask certain
questions:'Can children with cognitive impairments access these mobility technologies? Are there tools that can help clinicians in theevaluation of powered mobility devices? What are the tricks you can use to personalise the power wheelchair (PWC) and
improve safety?'
This publication aims to answer these questions via a systematic review of the scientific literature, and accompanying
discussion of the results.

Abstract
Objectives: to summarize and examine studies about power mobility assessment for individuals with cognitive andmotor impairments exploring strategies and measures.
Method: A search of the literature including articles published from 1999 to 2015 was conducted using one electronic
database. Studies involving individuals with cognitive impairments and the need of PMD (Powered Mobility Devices)
assessment; key terms included power(ed) mobility, power(ed) wheelchair, and database-specific terms. Three reviewers
independently screened titles, abstracts, and full-text articles. Inclusion criteria: Studies that included a description ofstrategy assessment or measure of power mobility skills for users with cognitive and motor impairments.
Results: Of 1111 titles, 7 articles met inclusion criteria. Some cognitive functions seem predictive variables or more related
to powered mobility skill. Several studies refer to powered mobility skill measures even for individuals with cognitive
impairments to organize an appropriate PMD training.
Conclusions: There is not a minimum score (at neuropsychological tests) to exclude anyone from the use of PMD before
an appropriate training by AT professionals, at all ages.
Keywords: POWERED MOBILITY DEVICE, POWERED MOBILITY, POWERED WHEELCHAIR, SYSTEMATIC
REVIEW, TRAINING, ASSESSMENT, COGNITIVE IMPAIRMENT, COGNITIVE FUNCTIONS,PSYCHOLOGICAL TEST

Background
Mobility is a foundational skill for participation in the roles and activities of daily life [1]. The identification of apowered mobility device (PMD; e.g., powered wheelchairs, electric scooter, balancing wheelchair) is a complex process,which requires validated strategies. However, in the Italian context, this process is rarely supported by validatedinstruments: in many instances it depends exclusively on the expertise of the single operator/service or refers to thetechnicians [2,3,4,5]. One of the main barriers to the introduction of validated measures in clinical settings is the possibility
to include them in well-consolidated practices. Increasingly, professionals in the field of rehabilitation are requested to
employ validated tools in each phase of the service delivery process [6], from the identification and selection of the device
to the evaluation of the outcomes of the intervention, in particular when the PMD assessment is for a person with motorand cognitive impairments.
We think appropriate to reconsider these issues and devote time and resources to the assessment process because thenumber of people with disabilities who use wheelchairs is constantly growing and wheelchair has become a gradually more
accepted solution [2,6,7]. Furthermore, users that are often not satisfied with their mobility aids and its services [8, 9] also
remind us that to provide an adequate service is essential having a process centered on resources, activities and desires ofthe person with disability [10].
To pursue the best "matching" between the person and the PMD it is essential to consider several factors related bothto the person with disabilities and to their context: among personal factors certainly an important role have the cognitive
aspects that often put the clinicians decisively in crisis [10, 11].
The purpose of this systematic review was to summarize and examine studies about power mobility assessment forindividuals with cognitive and motor impairments exploring strategies and measures.

MethodA search of the literature including articles published from 1999 to 2015 was conducted using one electronic database(Medline). Studies involving individuals with cognitive impairments and the need of PMD assessment. Our clinicalquestion were “What cognitive functions are related to PMD driving?”, “Are there any tests related to PMD driving skills
for people with cognitive problems?”.
Keywords agreed by the three reviewers are summarized in Table I. Study selection was verified by three reviewers,
two occupational therapists and one social educator. The three reviewers used a 3-step selection process: specificinclusion/exclusion criteria were applied to assess titles (1° step), abstracts (2°step), and full-texts (3 ° step). The selected
full text has been summarized in a table and discussed in a focus group by three reviewers and 1 PMD user.
Inclusion criteria: studies including PMD assessment with cognitive impairment, at all ages; description of measureused to assess power mobility skill and/or cognitive function.
Exclusion criteria: studies the were non -English language; involving participants whose ages were not specifies;
focusing only on technology development; using complex measurement technology not feasible in clinical setting (e.g.
robot device, computerized assessment).
In each step the reviewers assigned a score (2= relevant), (1=quite relevant), (0=no relevant) to titles and abstracts. Only
the titles with a total score (sum of the three reviewers score) greater than 2 had access to the next phase. Only the abstracts
with a total score greater than 2 had access to the third phase for reading the full text.
Table I: key terms#

Term
Power wheelchair

TARGETPowered wheelchair
Electric wheelchairPowered mobility
Electric mobility
Self-help devices [MESH]

INTERVENTION

Wheelchair [MESH]
Psychological Tests [MESH]
Neuropsychological Tests [MESH]
Evaluation studies as topic [MESH]
Cognitive assessment
Neuropsychological evaluation
Cognitive functions

Results
The electronic database search identified 1111 titles, 35 of them received a ≥ 2 score and were selected for the 2°step,
21 abstract obtained a score ≥ 2 and were selected for the 3° step. Then, 7 studies were considered relevant and are included.
The study selection process is summarizes in Image I: Flowchart of study selection process.
Table II summarizes the study design, authors, participant and sample, interventions, outcomes and findings in the
included studies.
Problem solving and spatial relations appeared to be a good predictor of successful powered mobility. [12] Verbal recall,visual construction ability and global cognition are predictive variables correlated to the indoor use of PMD and the use ofindoor and outdoor PMD was predicted by verbal recall. However there is not a minimum score (at neuropsychologicaltests) to exclude anyone from the use of PMD before an appropriate training by AT professionals, at all ages. [12, 13, 14].
The use of PMD, even in protected contexts, can improve the independence, socialization and quality of life for people
with profound cognitive disabilities [13, 15, 16, 17].
Several studies report on programs and measures to plan the PMD training, such as Wheelchair Skills Program(WSP) and the Wheelchair Skills Test (WST) that was used, even for individuals with cognitive impairments [18,19]. The
measures may be suitable as guides for progressing use of PMD skills [14]. Authors emphasize the importance to haveexpert clinicians dedicated to PMD/AT assessment process.

Image I: Flowchart of study selection process

Table II: Qualitative summary of included studies
Study
author andcountry
L Nilsson,
M Eklund,P Nyberg;
Lund,
Sweden,Oct 2011

Methods

Interrater
reliability

RCT,
L Nilsson,data
M Eklund,P Nyberg, H analysis
Thulesius;
Lund,
Sweden,Nov/Dec
2011

LM
Nilsson, P J
Nyberg;Sweden,Apr 2003

Casestudies

Participants

Assessment

Intervention

Frequency andduration ofinterventions

Key outcomes

Key findings

The participants
The first author was
Kappa value of 0.85 Very good inter-rater
Driving toon the 24 video Learn Method: one of the raters. Other /comparing the 3
reliability of thesequences were 
3 independent raters
raters’ assessment
assessment tool. The“Growing
all engaged inwith that of the first tool is reliable and has
Conscious were all occupational
the Driving totherapists living inauthor.
clinical usability inness of
Learn project.
different parts of theHigh degree ofoccupational therapy
Joystick
16 participants
country, had no
usability forpractice.
Use”
with profound 
connection to each
assessing phases ofOne
cognitive
joystick use. Minimalquestionnai other, had been OTs
disabilities, 7
for more than 10 years
differences between
re duringparticipants withand had different
experienced andtheother degrees ofprofessional
inexperienced raters.
assessment
cognitive
experience of PWOne
disabilities andprovision. They
questionnai
one infant withassessed the videore after the
typicalassessment clips using “Growing
development.
Consciousness ofJoystick Use”.
45 children and Growing
Free driving in PW
1 hour for each 8 participants with Participants were
adults withand the facilitators
session, but it profound cognitive empowered by attaining
Awareness of
profoundused the constantly
depended on the disabilities reached increased control over
Facilitating
cognitive
developing strategies
participant’s goal-directed driving tool use, improving
Strategies
disabilities.
to stimulate each
endurance and or higher.
their autonomy andReference groups Mutual
participant’s curiosity, level of alertness.
quality of life.
included 17
mutual interaction, andThe frequency
Interactions
typically
initiative to explore
varied according toAmong Actors
developing
and experiment withthe participant’s
in the Process
infants and 64
joystick and powered
health status, theparticipants with Growing
wheelchair functions.
facilitator’slesser degrees of Consciousness
motivation tocognitive
continue, theof Joystick Use
disability.
availability of an
appropriate PW
Identification ofand any important
Phases inchanges in the
Learning Tool
participant’s
Use.
circumstances.
2 preschool
Video recordings The first author carried Training session Description of theTraining in a PW canchildren with(at T1= time of out the intensive
30-90 minutes one changes of theincrease wakefulness
profoundinstructions and training with the PW. to three times for a children’s behaviours and alertness, stimulatecognitiveat T2= 12-month Manually guided
week for 4 months in PW and the effects a limited use of thedisabilities
follow up visit) actions werein a special
observed during the arms and hands andaccompanied by verbal playroom in the
training period.
promote theField notes
descriptions of theclinic. After 4
understanding of very
activity. The PW was months, thesimple cause-effectIn-depth
only set in motion
training was
relationships.
interviews.
when the child had his transferred at homehand on the joystick.
where parents andassistants carriedout the training.
2 visit by theauthor (at thedelivery and after
12 months).

AD
Mountain,
RL Kirby,
GA Eskes, C
Smith, H
Ducan, DA
MacLeod
DA, K
Thompson;Apr 2010

Prospecti
ve
uncontro
lled pilot
study
using
withinparticipa
ntcomparison.

Studyauthor andcountry
B Cullen, B
O’Neil, J J
Evans;
Scotland,Oct 2007

Methods

Prospectivefollow
up study

M Bottos, C Casestudies
Bolcati, L
Sciuto, C
Ruggeri, A
Feliciangeli;
Bologna,
Italy; 2001

D Tefft, P
Guerette, J
Furumasu;
California,
USA, 1999

Stepwiseregressionanalysis

Inpatients
WST-P version(N=10, 6 with 3.2 (t1, t2=3
visuospatialdays afterneglect), all with training)a primarydiagnosis ofstroke.

Participants

Assessment

Participants received 5 5 training session Powered wheelchair Many people withwheelchair skills(WSTP), each of skills were tested
stroke, with or without
training session of up which was up to 30 before and after
visuospatial neglect can
to 30 minutes eachminutes intraining using thelearn to use poweredusing Wheelchairduration, aimed at Wheelchair Skills
wheelchairs safely and
Skills Training
improving the Test, Powereffectively with
Program (version 3.2). wheelchair skills
appropriate training.
Mobility version 3.2
that the participant(WST-P).
had difficulty
performing during
WST-P.

Intervention

Volunteer adults
Baselinewith impaired
cognitive
mobility. Of 155
assessment
approached, 103
Follow up:
had baseline
Self-rated
assessments. Of powerchair use
these 81(79%)
questionnaire
provided
FEW
outcome data.
Mean age was
65.6 years(SD=13.5); 55%
were male.

Participants wereassessed by either the
first or the second
author using thebaseline assessment
materials.

29 children with Performance IQ,
spastic or
Verbal IQ,
dystonic
Gross Motor
tetraplegia (15Functionalmales, 14
Measure, COPM,
females; mean
Furumasu’s
age 6 years 3
Driving Test,months, ageChildhoodrange 3 to 8
Illness Scale
years). All
participants had
severe motor
impairment.

PWC provision: same
type, different sizes of
PWC were available
and they were tailoredto suit younger
children. The
electronic system of
the PWC allows for asmooth start, which
was particularly
important for children
with spastic ordystonic tetraplegia.

26 children with
Cognitive
physicalassessment
disabilities
battery based on
between the ages
5 Piagetianof 20 and 36
cognitive
months weredevelopmental
evaluated on thedomains.
cognitiveassessment andparticipated in
the wheelchairtraining andassessment
program.

Cognitive assessment
battery by 2 clinicians.
Training andassessment based on
power mobility
program (Furumasu etal. 1996).

Frequency andKey outcomes
Key findings
duration ofinterventions
Baseline
Rate of day-to-day Powered wheelchairassessments and powerchair use, and use was predicted by
one month after the users’ perceptions of cognitive measures.
delivery a follow how well theRates of use wereup telephone powerchair allowed relatively low, despite
contact.
to perform functional users’ reports that thetasks.
PW facilitated theirRate of indoor use everyday functioning
well.
was predicted byverbal recall, figure
coping and global
cognition. Total rateof use was predictedby verbal recall.
Initial no
Several dimensions The majority oftreatment period: 6 of disablement:children (21 of 27)
to 8 months. Impairment,reached a level ofTreatment period 6 Functional
driving competence,
to 8 months. Limitation/Activity, which allowed them toDisability/Participati move around with oron. The level of
without minimal adultsupport.
independence
Achievement of thisimprovedsignificantly after competence wascorrelated to the time
PWC provision,
spent in the PWC.
while motor
impairment, IQ and PWCs can aid
quality of life did independence andsocialization and thenot.
majority of children canachieve a good-enoughdriving competence,even those with severe
learning disability or
motor deficit. PWCs
should not be viewed asa last resort but as ameans of providing
efficient selflocomotion.
6 sessions based on Stepwise regression
power-mobility analysis was used to The cognitive domains
training program, determine which of of spatial relations
each of which lasts the cognitive skills and problem solving
1 hour.
predicted wheelchair were found to be
mobility
significant andperformance.
accounted for 57% of
the variance inwheelchair skills.

Limitations
This review included only English-language studies and was conducted using one electronic database (Medline); studies
in other languages, or in other sources, manual and electronic, may have been missed. The authors did not rate quality andstrength of evidence in individual studies that were included in the review and they did not use a technique for assessing
the risk of bias. The authors state that they had a written guide that included a search strategy and inclusion/exclusion
criteria but the protocol has not been registered (on electronic database e.g. PROSPERO) before starting the study.

Conclusion
PMD driving tests are an essential step in the assessment process and are essential to set up a custom device and training.
There is evidence that the use of power wheelchair has a positive impact even on adults and especially on children withmotor and cognitive impairments. Even a person with motor and cognitive impairments after an individualized training
program can have a significant increase in drive performance. This systematic review shows the importance to develop
and define a PMD assessment process and training program in many clinical Italian context [20] in order to achieve thebest match between the user and PMD. Furthermore, it is necessary that AT professionals validate procedures andassessment tools, such as WST 4.3 PW [21], that will be further tested for validity and reliability in order to assess its
efficacy in helping health professionals to select the most adequate PMD for users with motor and cognitive impairments.
The advancement of mobility devices and innovative training and equipment provision schemes may development PMD
users inclusion, furthermore, future research will continue the development of strategies and measure to support cliniciansin to PMD assessment process.

Acknowledgements
The authors would like to acknowledge the Regional Centre For AT (Az. USL Bologna) and University of Modena andReggio Emilia; people with disability and their families we work with; and our colleagues at Regional Centre For AT in
Bologna and at University in Reggio Emilia, and beyond who provided inspiration for this study through discussions ofevidence-based practice. This Study was unfunded. The authors have stated that they had no interests that might beperceived as posing a conflict or bias.

References
1.
2.
3.

4.

5.
6.
7.

8.
9.
10.
11.
12.
13.

Hardy P. Powered wheelchair mobility: an occupational performance evaluation perspective. Aust Occup Ther J 2004; 51:
34–42.
Spagnolin G. Mobilità e postura in carrozzina nella disabilità dell’adulto. Atti del convegno L’ausilio nel progetto riabilitativodella persona disabile. Abano Terme. 2008 Nov 5-7; 30-31
Trioschi, D, Desideri, L., Agusto, R., et al. (2014). Proposta di programma di valutazione e training delle abilità di guida per
ausili elettronici per lo spostamento. [A proposal for a Programme for power mobility devices (PMD) selection and driving
skills training]. Giornale Italiano di Medicina Riabilitativa, 28(1), Suppl. 2, p.12.
Trioschi D, Bizzarri M, Agusto R, Desideri L e e. Al., Attività e partecipazione con ausili elettronici per la mobilità: quali
strumenti? Dati preliminari perla validazione della WHOM-I (Wheelchair Outcome Measure - Italian Version), GITO
(Giornale Italiano di Terapia Occupazionale), pp. 74-81, Maggio 2016.
Trioschi D, Carrozzina elettronica: controllo ambientale e accesso ai dispositivi informatici. Il Fisioterapista, Edi-Ermes, pp.
6:71-5, nov-dic 2015.
Steel EJ, de Witte LP. Advances in European Assistive Technology service delivery and recommendations for further
improvement.Technology and Disability, 2011;23:131-138.
Russell JN, Hendershot GE, Le Clere F, Howie LJ, Adler M. Trends and differential use of assistive devices. United States.
Advace data from Vital and Health Statistics of the CENTERS FOR DISEASE CONTROLAND PREVENTION/National
Center for Health Statistics (292). 1997 13 nov
Ganesh S, Hayter A, Kim J et al. Wheelchair use by veterans newly prescribed a manual wheelchair. Arch Phys Med Rehabil.
2007 Apr; 88 (4):434-9
Mortenson WB, Miller WC. The Wheelchair Procurement Process: Perspectives of Clients and Prescribers. Can J Occup Ther.
2008 Jun; 75(3):167–175
Mortenson WB, Miller WC, Mille-Pogar J. Measuring wheelchair intervention outcomes: development of the wheelchairoutcome measure. Disability & Rehabilitation: Assistive Technology, 2007; 2:275-85
B. Cullen, B. O'Neill e J. Evans, «Neuropsychological predictors of powered wheelchair use: a prospective follow-up study.,»
Clin Rehabil., vol. Sep, n. n. 22(9), pp. pp. 836-46, 2008.
D. Tefft, P. Guerette e J. Furumasu, «Cognitive predictors of young children's readiness for powered mobility.,» Dev Med
Child Neurol, vol. Oct, n. 41(10), pp. 665-70, 1999 .
M. Bottos, C. Bolcati, L. Sciuto, C. Ruggeri e A. Feliciangeli, «Powered wheelchairs and independence in young children withtetraplegia.,,» Dev Med Child Neurol., vol. vol. Nov, n. 43(11), pp. 769-77, 2001.

14. B. Cullen, B. O'Neill e J. Evans, «Neuropsychological predictors of powered wheelchair use: a prospective follow-up study.,»
Clin Rehabil., vol. Sep, n. 22(9), pp. 836-46, 2008.
15. L. Nilsson, M. Eklund e P. Nyberg, « Driving to Learn in a powered wheelchair: inter-rater reliability of a tool for assessmentof joystick-use.,» Aust Occup Ther J. , vol. Dec, n. 58(6), pp. 447-54, 2011.
16. L. Nilsson, M. Eklund, P. Nyberg e H. Thulesius, «Driving to learn in a powered wheelchair: the process of learning joystickuse in people with profound cognitive disabilities.,» Am J Occup Ther. , Vol. %1 di %2Nov-Dec, n. ;65(6), pp. 652-60 , 2011.
17. L. Nilsson e P. Nyberg, « Driving to learn: a new concept for training children with profound cognitive disabilities in a powered
wheelchair.;,» Am J Occup Ther. , Vol. %1 di %2 Mar-Apr, n. 57(2), pp. 229-33, 2003.
18. Mountain, R. Kirby, G. Eskes, C. Smith, H. Duncan, D. MacLeod e K. Thompson, «Ability of people with stroke to learn
powered wheelchair skills: a pilot study.,» Arch Phys Med Rehabil. , vol. Apr, n. n. 91(4), pp. pp. 596-601, 2010.
19. D. University, «Wheelchair Skills Program,» [Online]. Available: http://www.wheelchairskillsprogram.ca/eng/index.php
20. Desideri L, Trioschi D, Agusto R, Bizzarri M, Spagnolin G, et al. (2016). The Provision of Powered Mobility Devices in
Italy:Linking Process with Outcomes. Technologies 2016; 4(3), 31
21. Trioschi D, Paolini C, (2017). Ausili elettronici per la mobilità e deficit cognitivi: quali evidenze e quali strumenti?. Tecnologie
Riabilitative; rivista n° 15, maggio 2017; 56-60