Disabilities | Free Full-Text | Assessment and Intervention for Tool-Use in Learning Powered Mobility Intervention: A Focus on Tyro Learners

Human activity involves many forms of tool use and related tool-use learning [1,2]. The term “tool” can be used in a broad sense to encompass a wide variety of both concrete (hand, switch, joystick, etc.) and abstract (methods for assessment and intervention, etc.) tools [3,4,5,6]. Those who are beginners in tool-use learning, young infants, children, and persons of any age who have cognitive limitations, can be thought of as tyro learners (tyro as defined in the Merriam-Webster Dictionary and Cambridge Dictionary). Tyro learners grow consciousness of new activities, starting from the very beginning of the learning continuum [7,8]. For children and adults who are tyro learners, exploring how to use a powered mobility device, such as a powered wheelchair [9,10,11,12,13], modified ride-on toy car [14,15], and other powered devices [16,17,18,19,20], is often less about learning to drive [21,22], and more about Driving to Learn [8,23,24,25]. The self-produced mobility afforded by a powered mobility device offers opportunities to explore tool-use learning and interact with the surrounding environment [26,27], thereby potentially enhancing development and learning, providing a foundation for future goal-directed, tool-use activities [6,7,8]. The potential for these benefits supports powered mobility device use in tyro learners, as an effective and appropriate intervention, even though they may never become independent, competent powered wheelchair users [8,28,29,30,31,32,33,34].

All individuals, who are learning to use a powered mobility device, pass through a floating continuum, represented by exploratory, operational, and functional powered mobility learner groups [35]. Tyro learners, often, remain in the exploratory- or operational-learner groups, for prolonged periods of time. As compared to functional-learner groups, exploratory- and operational-learner groups are more dependent on others, to set up and provide powered mobility learning opportunities, and, often, require additional encouragement and motivation, when exploring and learning how to use a powered mobility device [6,7,8,33,34,35,36,37].

Developed through work with tyro learners [8,25,28,29], the Assessment of Learning Powered mobility use tool, version 2.0 (ALP), is a powered mobility implementation package focused on assessing and progressing an individual’s understanding of how to use a powered mobility device [6,7,37]. The ALP tool is comprised of the ALP instrument for assessment and the ALP facilitating strategies for intervention. The ALP instrument defines eight phases in the process of learning (from Phase 1—Novice to Phase 8—Expert), encompassed within three stages of learning (Explore Functions, Explore Sequencing, Explore Performance). The ALP instrument is used in tandem with the ALP facilitating strategies, such that a learner’s actual stage and phase of learning, as identified through the ALP instrument, are used to guide and select the specific ALP-facilitating strategies that will best support the learner. In this manner, the ALP tool provides each learner with the precise level of challenge needed to progress their understanding across the continuum of learning to use a powered mobility device [6,7]. The ALP instrument has been shown to have excellent inter-rater reliability (linear-weighted kappa of 0.85) [38].

As outlined in Table 1, research suggests that the process-based approach [8,28,29], reflected in the ALP tool [7], may be beneficial in supporting powered mobility device use learning in tyro learners, who belongs in exploratory and operational powered mobility learner groups [6,7,35,37]. Task-based approaches [39,40,41,42,43,44,45,46], those involving production of specific powered mobility tasks, may be beneficial for integrative learners focused on integrating both patterns of operation and powered mobility device use into their everyday lives, who are functional powered mobility learners/users [35].

The perception–action experiences provided through engagement in exploration of self-produced mobility are powerful drivers of cognitive developmental change and learning about the world [2,3,13,33,34,47,48]. Numerous researchers have studied powered mobility, as a means for independent mobility [49,50,51,52,53,54]. For tyro learners, learning by driving a powered mobility device, also, provides the opportunity to explore tool-use learning [6,8,37]. A tool can be thought of as something used to carry out a particular action or function. Depending on how they are used, a part of our body, an object, and a device can all be tools. Tools range in complexity from simple, one-part tools, such as a spoon, to complex, multi-part tools, such as a smartphone [6,8]. Regardless of what tool is being used, the phases and stages in the process of learning to use a tool are similar in nature [6,7] and involve a growing consciousness, or understanding, of how to use and relate to the tool, when integrating it in everyday activities [7,8].

A powered mobility device is a complex, multi-part tool, involving coordination of three distinct tools: a part of the body (a hand, foot, eye, etc.), an access method (switch/es, joystick, eye-tracking technology, etc.), and the powered mobility device itself [55]. Development of conscious awareness, in how to integrate the use of these three tools together, is a process encompassing learning, as described in the ALP instrument [7]. Controlled execution of actions, with a part of the body (tool 1), and an understanding of the function/s of the access method (tool 2) and the device (tool 3), are necessary to move and control the operation of the powered mobility device (ALP stage 1, explore function). Accurate action on the access method is required to develop a pattern for how to move and control the operation of the powered mobility device in space and time (ALP stage 2, explore sequencing). Functional navigation and integrated use of the powered device in the physical and social environments requires understanding of situations and judgement (ALP stage 3, exploring performance). The path that each learner follows through this tool-use learning process may differ in terms of individual abilities, pace, oscillation across ALP phases, trajectory over time, and motives for development and learning [7,8].

Tyro learners, who are provided with repeated opportunities to explore powered mobility use, may develop their abilities and grow their understanding of tool use [7,8,25,37]. Many tyro learners are motivated to explore, by the experience of independently changing their own position in space [8]. This self-produced change of position provides a new perspective of the situation and changes the tyro learner’s relationships to others and objects in their surrounding environment [6,8]. These repeated powerful experiences develop the tyro learner’s sense of agency and control, and provide opportunities for acquiring comprehensive knowledge about the world [8,56]. The achievements gained through tool-use learning in a powered mobility device may transfer to other tool-use situations, expanding the tyro learner’s opportunities to explore and use other assistive technologies for goal-directed tool-use activity and communication [8,37].

The development of the ALP tool was published by the open-access Journal of Rehabilitation Research and Development (JRRD), and the complete ALP tool is provided as an online resource to Nilsson and Durkin on their webpage [7]. The ALP instrument is found in the JRRD online Appendix 1, and the ALP facilitating strategies are found in the JRRD online Appendix 2 [7]. A brief overview of the prominent elements, of the ALP instrument and ALP facilitating strategies, for each of the three ALP stages, are outlined in Table 5 (ALP stage 1), Table 6 (ALP stage 2), and Table 7 (ALP stage 3).

Foundational concepts within the ALP tool relate to promoting an atmosphere of mutual respect and collaboration with the goal of empowering the learner [7,8,36,37,38]. The clinician/educator sets up as well as prepares the environmental and social circumstances for powered mobility assessment and intervention, to meet the specific needs of the learner and invites the learner to engage in an allowing co-constructive partnership [6].

As noted in Table 5, Table 6 and Table 7, the ALP instrument for assessment defines eight phases of learning, from Phase 1 (Novice) to Phase 8 (Expert). Categories of observation with each ALP phase include Attention, Activity and Movement, Understanding of Tool Use, Expressions and Emotions, and Interaction and Communication. These five categories, with their indicators, structure the clinician’s/educator’s observations of the learner’s occupational performance (behaviors, acts, actions, emotional expressions, interactions, communication).

In this manner, the clinician/educator is able to infer the learner’s actual phase of tool-use understanding [6,7,38,57]. The “Attention” category reflects the learner’s ability to regulate and shift their attention. “Activity and Movement” focuses on the learner’s performance of activity and motor control. “Understanding of tool use” pertains to the learner’s level of consciousness/understanding, regarding the operation of the powered mobility tool/s and is the primary, observable cognitive component, within each ALP phase. “Expression and Emotions” provides insights into the learner’s motivation, whilst “Interaction and Communication” addresses the expression of interpersonal relationships and social interplay amongst the powered mobility device, the environment, and available social partners. Indicators for each of these observational categories are described in detail, for each of the eight ALP phases, in JRRD online Appendix 1 [7].

As illustrated in Table 5, Table 6 and Table 7, the ALP phases are encompassed within three stages of learning: stage 1: explore functions (ALP Phases 1–3); stage 2: explore sequencing (ALP Phases 4–5); and stage 3: explore performance (ALP Phases 6–8). Learners in ALP Stage 1 (Table 5) are in an introverted stage of learning and may appear shy and withdrawn. As such, they need time and understanding, to be able to explore the functions of their body in relation to the access method and the powered mobility device as well as to learn concepts related to cause and effect Learners in ALP Stage 2 (Table 6) are in the difficult transitional stage, of exploring the sequencing of the inter-related functions of their body, the powered mobility tools, and the environment. They may appear eager, but will often exhibit frustration because their understanding of what they can do with the powered mobility device outpaces their ability to achieve what they desire to accomplish.

Learners in ALP Stage 3 (Table 7) are in the extrovert stage of learning and exploring performance, so are learning to integrate powered mobility use into their daily activities. These learners are developing and demonstrating higher cognitive functions, within goal-directed powered mobility activities, specific to the learner’s actual ALP phase, within this stage. A flowchart outlining use of the ALP tool is provided in Figure 1, below.

The goal with the first session of powered mobility use is to identify where the learner is in the learning process. During this first session, observations of the learner’s performance are interpreted, to recognize and determine the learner’s most stable or dominant ALP stage and phase, within the session. When determining a learner’s ALP stage and phase, it is recommended that clinicians/educators use a printed copy of the complete three-page ALP instrument [7] (Appendix 1), beginning by identifying the learner’s ALP stage.

Then, using a highlighter or other colored pen, the clinician/educator can highlight the observed indicators of performance within, and even across, the specified phase(s). Observations may be scattered across two or more phases, as oscillation in the learner’s tool-use learning understanding is, commonly, observed during a single session of powered mobility device use, due to variation in the learner’s attention and energy levels. In these instances, the clinician/educator should select the learner’s most stable or predominant ALP phase. Once the ALP phase is identified, the clinician/educator consults the ALP-facilitating strategies [7] (Appendix 2), to select specific strategies that will support the learner.

This most stable and dominant ALP stage and phase is used to guide the setup of the intervention situation in the subsequent session [7]. From there on, the learner’s actual ALP phase in the precise moment during the intervention session guides how the clinician/educator adjusts the challenges in the situation. It is important for the clinician/educator to stay vigilant to as well as follow the learner’s oscillating attention and understanding of the learning situation.

Although the ALP tool is recommended, when engaging young children in powered mobility intervention [34,36,58], tyro learners of any age may begin their exploration of powered mobility use at earlier phases in the learning process [7]. They may, also, remain in each phase for prolonged periods of time [8,25,37,38]. Supporting tyro learners in the earlier phases of the learning process may require a more individualized intervention approach, as compared to supporting integrative learners who are in the later phases of tool-use learning [7,31,35]. For example, in the early phases, tyro learners need support to explore what the tool can be used for and how it can be handled in a goal-directed way, whereas, in the later phases, integrative learners need support to explore how the tool can be integrated into everyday activity and participation.

Determining a learner’s actual stage and phase of learning, to use a powered mobility device, allows clinicians/educators to optimally support and guide the tyro learner’s development of tool-use understanding [7,37,38]. As the ALP tool covers the entire learning process, there are not specific prerequisites or requirements that must be met, before a tyro learner engages in the exploration of learning to use a powered mobility device. To initiate powered mobility device learning, the learner must be awake and agree to engage in the activity, as indicated in whatever way they are able to express their agreement. The powered mobility device is, then, introduced to the learner in a manner and pace that supports the learner’s specific needs and preferences for approaching new situations. Ensuring that the learner feels safe and secure, both emotionally and physically, is paramount. Once the learner is ready to be lifted into and placed in the powered mobility device, they should be encouraged to explore the device and the access method, in their own way. The learner may need time to adjust to new situations and overcome any uncertainties or anxiety. Simple verbal explanations of what can be done with the powered mobility device as well as short verbal prompting or gentle manual guidance may be used to encourage the learner to explore the device functions, in a way that fits their abilities and motives. The resulting learner performance within this initial session is assessed, using the ALP instrument, to determine the learner’s actual consciousness/understanding of tool use. The identified predominant ALP stage and phase are used to select the ALP facilitating strategies, which will guide the powered mobility intervention for the specific learner, as illustrated in Table 5, Table 6 and Table 7.