Use of everyday technology to promote ambulation in people with intellectual and multiple disabilities

1. Introduction

People with severe or profound intellectual disabilities often present with serious communication and occupational problems, which limit their opportunities of interaction with their caregivers and other possible communication partners and also prevent them from developing an active and functional role within their daily context [1, 2, 3, 4]. The possible presence of blindness or motor impairment complicates the situation of these people further and can lead them to a very detached and sedentary life [5, 6]. In effect, they may fail to engage in activities and/or simple ambulation unless prompted and guided by staff or caregivers [7, 8].

This situation is undoubtedly deleterious and needs to be addressed for the psychological, social, and physical well-being of the people [9, 10, 11]. Accordingly, programs have been developed to promote their activity engagement through the support of various technology aids [12, 13, 14].

Programs have also been developed to promote ambulation. For example, Lancioni et al. [15, 16] and Stasolla et al. [17] reported programs aimed at fostering ambulation with physical support in people with multiple disabilities (i.e., intellectual disabilities and motor or sensory-motor impairments). Their programs were based on the use of (a) walkers to ensure the physical support the participants required as well as (b) microswitches (sensors) to monitor the participants’ step responses and trigger a computer or other electronic device to providing stimulation in relation to those responses.

Lancioni et al. [18, 19, 20] reported programs aimed at promoting basic forms of independent ambulation (i.e., ambulation free of walkers or other support devices) through the use of automatically regulated stimulation events. In particular, optic sensors linked to an electronic control device could be used (a) at specific distances from one another (e.g., 0.5 or 1.0 m) on the wall of a corridor/room along which the participant was to walk or (b) on the participant’s shoes. In the first case, a sensor was activated as soon as the participant passed by the area where the sensor was located. In the second case, a sensor was activated as soon as the participant performed a step response. Activating a sensor led to the occurrence of stimulation events of different lengths that the participants were known to enjoy.

The aforementioned intervention programs aimed at fostering supported and independent ambulation provided fairly encouraging data (with the participants increasing the number of step responses performed during the intervention sessions and/or reducing the time required to walk preset distances). Notwithstanding the encouraging data, no definite statements can be made about the programs, as only few participants were included in the evaluations. This study was aimed at extending the evidence available in the area by (a) exposing new participants with intellectual and sensory or sensory-motor disabilities to intervention and (b) setting up an intervention program based on the use of everyday technology. Specifically, a smartphone with the MacroDroid application was used in combination with mini speakers or a tablet (see below) for monitoring the participants’ step responses and providing them with preferred stimulation and possibly encouragements/prompts.

2. Method

3. Results

Figure 2 reports the participants’ ambulation data during the baseline and intervention phases. The black squares represent mean frequencies of step responses per session computed over blocks of two sessions during the baseline and four sessions during the intervention. Blocks with a different number of sessions (i.e., at the end of the intervention phase) are marked with a numeral that indicates how many sessions they include.

During the baseline phase, the participants’ mean frequency of step responses varied between 26 (Casper) and 61 (Gavin) per session. The mean frequency of prompts from the research assistants varied between slightly over 3 (Gavin) and about 7 (Casper) per session. During the intervention phase, the participants’ mean frequency of step responses varied between 100 (Casper) and 157 (Gavin) per session. After the initial 25 intervention sessions, the participants’ response frequency per session ranged between 58 (Casper) and 224 (Logan). The mean frequency of smartphone’s encouragements/prompts (i.e., for the first three participants) was around 0.5 per session. Prompts from the research assistants were fairly sporadic. The Kolmogorov-Smirnov test indicated that the difference between the baseline and intervention step-response frequencies was statistically significant ( 0.01) for each of the participants.

4. Discussion

The data reported indicate that the intervention conditions were effective in increasing the ambulation behavior of all four participants. These results (a) extend the evidence available about the effectiveness of technology-based interventions for fostering ambulation in people with intellectual and multiple disabilities [17, 18, 20] and (b) add new evidence about the usability and effectiveness of everyday technology devices for supporting such interventions. In light of these results, a few considerations may be forwarded.

First, ambulation increase can be considered a valuable objective to pursue with people with intellectual and multiple disabilities, who tend to be sedentary and passive [26, 27]. Pursuing such an objective through an intervention approach largely based on technology support, and thus requiring only minimal staff supervision, can be viewed as practically and socially relevant. In fact, staff resources in rehabilitation and care centers are often limited and consequently staff could hardly afford to provide extensive supervision on a regular basis. Moreover, extensive staff supervision would emphasize the participants’ dependence and harm their social image [28, 29].

Second, an intervention approach based on the use of preferred stimulation contingent on step responses may be viewed as largely positive/motivating for the participants and easily acceptable for the context. Accordingly, the participants would be expected to have an increase in their frequency of step responses based on the pleasure connected to performing those responses (and the willingness to extend such an experience) more than on any other environmental variable [30, 31]. Although this enjoyment/satisfaction aspect was not documented, an indirect sign of its existence seemed to be the participants’ convincing ambulation performance throughout the intervention phase (i.e., a performance that required only few smartphone’s encouragements/prompts and rare prompting from the research assistants).

Third, while the positive stimulation may have been critical to determine the participants’ intervention data, the fact that the stimulation was delivered from specific spatial areas may have contributed to facilitate the orientation and sense of security of the first three participants [32, 33]. For Logan and Gavin, the alternating presentation of the stimulation at the two ends of the hallway after prearranged time intervals was apparently instrumental to allow them to walk in one direction and then in the other without difficulties, thus avoiding the need to use a very long hallway or to rely on staff guidance to turn (change direction).

Fourth, the technology used to support the participants’ ambulation was particularly simple, easy to access, and largely affordable [34, 35]. In reality, the first three participants only used a relatively inexpensive smartphone (Samsung Galaxi A10), which was fitted with MacroDroid and combined with two mini speakers. The fourth participant used a smartphone and a tablet both fitted with MacroDroid. While the technology is easily accessible, some attention is required to set it up for the study. Setting it up implies (a) storing auditory files in the smartphone and visual files in the tablet, and (b) programming the MacroDroid application. Such programming serves to make the MacroDroid (a) record the smartphone’s shake events (i.e., the participant’s step responses), (b) trigger the smartphone’s delivery of auditory stimulation or the tablet’s delivery of visual stimulation in relation to the step responses recorded, and (c) trigger the smartphone’s presentation of encouragements/prompts in case of no responding for a preset period of time.

5. Study limitations and conclusion

One limitation of the study is the small number of participants included. Moreover, the last participant presented clear differences compared to the first three. New research with additional participants (some comparable to the first three participants and others to the last participant) would be needed to determine the robustness of the technology and appropriateness of its arrangement during the intervention phase [36, 37]. A second limitation concerns the fact that the participants’ enjoyment/satisfaction during the intervention sessions was not assessed. This assessment could be important to ascertain whether the stimulation available for the step responses was the critical variable motivating the participants’ responding by making them satisfied of (happy about) the intervention conditions [38]. A third limitation is that no check was made of whether the smartphone could be placed in a position other than the participant’s ankle so as to ensure that even people not tolerating the smartphone at their ankle could be involved in the intervention process. Conceivably, smartphone’s shake events can be produced by step responses even if the smartphone is placed in a pocket attached to the side of the participants’ pants at the calf or knee level. A fourth limitation is the absence of a social validation of the technology used. A social validation involving staff personnel as well as family members as raters would be crucial to find out their opinion about the technology’s potential as well as about the technology’s acceptability within daily contexts [39, 40].

In conclusion, the results obtained in this study suggest that everyday technology could be successfully used to increase the participants’ ambulation level and thus might represent a practical tool within contexts for people with intellectual and multiple disabilities. Notwithstanding the positive results reported, caution is required in drawing conclusions given the limitations of the study mentioned above. New research will have to address those limitations and possibly upgrade the technology to improve its usability with participants with different needs and characteristics.