Microswitch-aided programs to support physical exercise or adequate ambulation in persons with multiple disabilities

Research in Developmental Disabilities 35 (2014) 2190–2198

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Research in Developmental Disabilities

Microswitch-aided programs to support physical exercise or adequate ambulation in persons with multiple disabilities Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Gloria Alberti e, Viviana Perilli e, Doretta Oliva e, Serafino Buono f a

University of Bari, Italy Medical College of Georgia, Georgia Regents University, Augusta, USA University of Texas at Austin, TX, USA d Victoria University of Wellington, New Zealand e Lega F. D’Oro Research Center, Osimo and Lesmo, Italy f IRCCS ‘Oasi’ Troina, Italy b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 7 May 2014 Accepted 16 May 2014 Available online

Three microswitch-aided programs were assessed in three single-case studies to enhance physical exercise or ambulation in participants with multiple disabilities. Study I was aimed at helping a woman who tended to have the head bending forward and the arms down to exercise a combination of appropriate head and arms movements. Study II was aimed at promoting ambulation continuity with a man who tended to have ambulation breaks. Study III was aimed at promoting ambulation with appropriate foot position in a girl who usually showed toe walking. The experimental designs of the studies consisted of a multiple probe across responses (Study I), an ABAB sequence (Study II), and an ABABB1 sequence (Study III). The last phase of each study was followed by a post-intervention check. The microswitches monitored the target responses selected for the participants and triggered a computer system to provide preferred stimuli contingent on those responses during the intervention phases of the studies. Data showed that the programs were effective with each of the participants who learned to exercise head and arms movements, increased ambulation continuity, and acquired high levels of appropriate foot position during ambulation, respectively. The positive performance levels were retained during the post-intervention checks. The discussion focused on (a) the potential of technology-aided programs for persons with multiple disabilities and (b) the need of replication studies to extend the evidence available in the area. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Microswitch-aided programs Head movements Arms movements Ambulation Toe walking Multiple disabilities

1. Introduction Persons with multiple (e.g., intellectual and motor or sensory-motor) disabilities can be characterized by largely different conditions and require intervention programs adapted to those conditions (Bindels-de Hens, Van Staa, Van Vliet, Ewals, & Hilberink, 2013; Lancioni, Singh, O’Reilly, Sigafoos, Alberti, et al., 2014; Leung & Chau, 2014; Poon, Koh, & Magiati, 2013). One of the main conditions that can differentiate the person’s requirements and the intervention focus is his or her motor

* Corresponding author at: Department of Neuroscience and Sense Organs, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy. Tel.: +39 0805521410. E-mail address: [email protected] (G.E. Lancioni). http://dx.doi.org/10.1016/j.ridd.2014.05.015 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.

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dimension (Belva & Matson, 2013; Damiano & DeJong, 2009; Giagazoglou et al., 2013; Lancioni et al., 2009; Pergami, Seemaladinne, & Martone, 2012; Shih, 2012). With regard to this dimension, one can identify at least four basic groups of persons. One group includes persons with extensive motor disability who cannot activate any relevant motor scheme/action and cannot have any direct interaction with objects (Holburn, Nguyen, & Vietze, 2004; Lancioni, Bellini, et al., 2012; Mechling, 2006; Mitelman, Joshua, Adler, & Bergman, 2009; Shih, Shih, & Shih, 2011; Tam, Phillips, & Mudford, 2011). A second group includes persons who have a motor disability that precludes any form of ambulation but allows different types of motor actions (head, hand, and arm movements) that can be considered useful forms of physical engagement and exercise (Helton, 2011; Ketelaar, Vermeer, Hart, Van Petegem-van Beek, & Helders, 2001; Lancioni, O’Reilly, et al., 2012, 2013; Palisano et al., 2012; Van Rensburg, 2007). A third group includes persons whose motor disability allows forms of supported ambulation (i.e., ambulation through walker devices fitted with elements that stabilize the persons’ position and partially support their body weight) (Lancioni et al., 2007, 2009, 2010). A fourth group includes persons who (a) do not have forms of motor disability that can interfere with independent ambulation, but (b) are affected by ambulation problems mainly due to their developmental (i.e., intellectual, motivational, and social/emotional) disabilities (Lancioni, Singh, et al., 2012, 2013). Such problems can include, among others, ambulation discontinuity/breaks and toe walking (Accardo & Whitman, 1989; Eiff, Steiner, Judkins, & Winkler-Prins, 2006; Lancioni, Singh, et al., 2013; Oetgen & Peden, 2012; Shulman, Sala, Chu, McCaul, & Sandler, 1997). Research has been carried out within each of the aforementioned groups (Lancioni, Sigafoos, O’Reilly, & Singh, 2013; Leung & Chau, 2010, 2014; Scherer, 2012). For example, intervention programs involving the use of microswitch devices for monitoring minimal forms of behavioral response have been successfully evaluated with persons of the first group (Lancioni, Sigafoos, et al., 2013). Those devices, linked to a computer system and environmental stimulation, have shown the possibility of enabling the persons to gain control of such stimulation (and thus display an active/adaptive role) through the use of responses such as eyelid or lip/chin movements and smiling (Lancioni, Bosco, et al., 2014). Intervention programs involving the use of one or more microswitches for monitoring single or combined body movements (e.g., head turning or head and arms movements) and computer systems for providing stimulation at their occurrence have been successfully assessed with persons of the second group (Lancioni, O’Reilly, et al., 2012, 2013; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2014). Those movements were considered beneficial for the persons (i.e., in terms of their self-determination and of the resulting physical exercise) and, accordingly, the microswitch-aided programs were considered critical supplements to standard physiotherapy (Lancioni, O’Reilly, et al., 2013; Wehmeyer, Palmer, Shogren, Williams-Diehm, & Soukup, 2013). Intervention programs involving the use of microswitches for monitoring step responses, support devices for allowing the emission of those responses, and computer systems for ensuring stimulation contingent on them have been successfully employed with persons of the third group (Lancioni et al., 2010; Lancioni, Sigafoos, et al., 2013). Intervention programs involving the use of microswitch technology and related computer systems have also been successfully employed to reduce breaks in the ambulation process and toe walking of persons of the last group (Lancioni, Singh, et al., 2012, 2013). The positive results obtained with the microswitch-aided programs mentioned above can be considered highly encouraging as to the possibility of facilitating positive changes in the persons’ general behavior. The evidence available (i.e., as to the number of individuals involved in the programs) seems, however, relatively modest particularly with regard to the second and fourth group. Consequently, new research studies with persons of those groups may be largely warranted to determine the strength and representativeness of the data available (Barlow, Nock, & Hersen, 2009; Kennedy, 2005). The present three singlecase studies were an effort in that direction. Study I involved a woman with blindness and severe intellectual and motor disabilities who was unable to ambulate, and spent her time in a wheelchair (i.e., like the persons of the aforementioned second group). She often kept arms/hands down with head and shoulder dropping forward. The microswitch-aided program developed for this woman was aimed at helping her exercise head and arms/hands movements (i.e., through positive stimulation contingent on them), thus countering her inadequate, unhealthy posture. Study II involved a man with intellectual and sensory disabilities, whose ambulation presented with discontinuity/breaks (i.e., like the persons of the aforementioned fourth group). The microswitch-aided program developed for him was to increase his ambulation continuity (i.e., through positive stimulation contingent on step responses). Study III involved a girl with intellectual and sensory disabilities and a difficult emotional situation who presented with toe walking (i.e., like the persons of the aforementioned fourth group). The microswitch-aided program set up for her was to promote adequate foot position during ambulation (i.e., using positive stimulation for the steps in which the foot heel touched the ground or was close to it) (Lancioni, Singh, et al., 2013). 2. Study I 2.1. Method 2.1.1. Participant The participant (Stephanie) was 38 years old and had congenital encephalopathy with blindness and epilepsy, which was largely controlled through medication. She also presented with severe spastic tetraparesis, was unable to stand or walk, and displayed an inadequate posture (i.e., with head and shoulder dropping forward and arms/hands down). She did not possess recognizable forms of communication and lacked sphincteric control. Her level of intellectual disability had been rated to be in the severe/profound range, but no IQ scores or other formal evaluations were available. She attended a center for persons

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with multiple disabilities in which she was provided with general stimulation (e.g., objects and physical contact) and physiotherapy. Physiotherapy was to help her perform some basic movements including head and arms lifting. Staff and family were favorable to the use of a technology-aided program that would support/motivate her independent performance of those movements (i.e., through the automatic delivery of positive stimulation). Her legal representative had signed an informed consent for her participation in this study, which had been approved by a scientific and ethics committee. 2.1.2. Setting, responses, technology and stimuli All sessions occurred in a quiet area of the center that Stephanie attended, while she sat in her wheelchair. The response scheme that Stephanie was to exercise combined head lifting and arms upward/backward (Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2014). The performance of this complex scheme was prepared through the establishment of head lifting alone, which was then followed by the establishment of arms upward/backward alone. Head lifting consisted of the participant raising her head until it touched the headrest of her wheelchair. The microswitch used for head lifting was an optic sensor embedded in the wheelchair’s headrest. Arms upward/backward consisted of Stephanie moving both arms upward/ backward to reach panels fixed at the sides of her wheelchair’s back. Such movement was detected by optic microswitches located on the panels. A computer system was available to record microswitch activations and regulate the presentation of preferred stimuli (see below). The stimuli included a variety of songs, which had been recommended by staff and selected after stimulus preference screening (Lancioni, Singh, et al., 2013). Screening involved 10–20 non-consecutive presentations of brief song samples. Songs were selected when the two research assistants conducting the screening agreed that their related samples produced positive reactions, such as orienting and smiling, in more than 50% of the presentations. 2.1.3. Experimental conditions The study was carried out according to a multiple probe across responses design (Barlow et al., 2009). The initial baseline sessions served to assess the spontaneous level of head lifting and arms upward/backward. Then intervention focused on head lifting. Once this response had increased, new baseline and intervention occurred on arms upward/backward. When this second response also had increased, baseline and intervention focused on the combination of the two responses (i.e., the complex scheme). Four weeks after the end of this last intervention phase a post-intervention check was carried out. Sessions lasted 10 min and occurred three to five times a day. The computer system automatically recorded the responses (see above). Prompting (i.e., verbal and physical guidance) was provided by a research assistant before the start of the sessions as well as during the sessions if Stephanie failed to respond for 30–60 s. The research assistant who implemented the sessions recorded the responses emitted as a consequence of prompting and subtracted them from the computer tally at the end of the sessions. Interrater agreement on recording those responses (with two raters reporting the same number of prompted responses, which could also be zero) occurred in each of the 18 sessions used to assess it (see Lancioni, Bellini, et al., 2012). 2.1.3.1. Baseline I: head lifting and arm upward/backward.. This phase included five sessions on head lifting and two sessions on arms upward/backward. At each session, Stephanie had the microswitch for the response assessed and the computer system. No stimulation was available. 2.1.3.2. Intervention I: head lifting. This phase included 35 intervention sessions and was preceded by five practice sessions, which helped Stephanie (i.e., through extensive prompting) familiarize with the head response and the stimulation available for it (i.e., 8–10 s of preferred songs). During the 35 intervention sessions, Stephanie received prompting as described in Section 2.1.3. Moreover, she received 8–10 s of preferred stimulation for each response performed. 2.1.3.3. Baseline II: arms upward/backward.. This phase included two sessions on arms upward/backward (i.e., matching those of Baseline I). 2.1.3.4. Intervention II: arms upward/backward.. This phase included 22 intervention sessions and was preceded by six practice sessions. Conditions were as in Intervention I except that the response targeted was arms upward/backward. 2.1.3.5. Baseline III: complex scheme combining head and arms responses.. This phase included three sessions focused on the complex response scheme (combining the two responses targeted before). The microswitches for the head and arms responses were available. A complex response was recorded only if both microswitches were activated. No stimulation was available. 2.1.3.6. Intervention III: complex scheme combining head and arms responses.. This phase included 77 intervention sessions and was preceded by six practice sessions (see previous intervention phases). Response conditions were as in Baseline III with the exception that responses were followed by preferred stimulation. 2.1.3.7. Post-intervention check.. Following the end of Intervention III, Stephanie continued to receive sessions such as those available during that phase. Ten of those sessions, occurring 4 weeks after the end of such phase, were used as postintervention check.

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2.2. Results Stephanie’s data during the baseline and intervention phases are summarized in Fig. 1. The light-gray, black, and dark-gray bars indicate mean frequencies of occurrence for head lifting, arms upward/backward, and complex scheme (i.e., head-arm combination) per session, over blocks of sessions, respectively. The number of sessions included in each block/bar is indicated by the numeral above it. During Baseline I, Stephanie’s mean frequencies were below five per session for head lifting and near zero for arms upward/backward. During Intervention I, the mean frequency of head lifting increased to over 35 per session. Baseline II showed no changes in the frequency of arms upward/backward. During Intervention II, the mean frequency of this response also increased to over 30 per session. During Baseline III and Intervention III, the mean frequencies of the complex response scheme (i.e., head-arm combination) were slightly below 5 and 35 per session, respectively. The post-intervention check (not reported in the figure) showed data matching those of Intervention III. 3. Study II 3.1. Method 3.1.1. Participant The participant (Scott) was 23 years old, had congenital encephalopathy related to chromosomal abnormality. He had also suffered perinatal hypoxia, which probably worsened his overall neurological condition. He was blind and affected by moderate hearing loss, and did not possess speech abilities or any other recognizable form of communication. He did not have self-help skills and lacked sphincteric control. His intellectual disability was reported to be in the severe/profound range, but no IQ scores or other formal evaluations were available. He walked satisfactorily when accompanied by staff, but tended to be discontinuous and show breaks when required to walk independently, following a rail or a wall. He attended a day center in which he was involved in brief periods of activity and interaction with staff. Family and staff sought intervention strategies that could help him move with continuity so as to reach activity places and be positively engaged. His legal representative had signed a formal consent for his involvement in this study, which had been approved by a scientific and ethics committee. 3.1.2. Setting, ambulation sessions, and measures The setting was a connection area of the center Scott attended. Ambulation sessions (a) involved five travels from one end of the connection area to the other, with the use of a rail, and (b) occurred four to eight times a day. At the end of a travel, Scott found a small activity table with objects he could use. The length of the travels was nearly 7 m. The measures recorded during the sessions concerned the time required to complete the single travels and whether prompting occurred during them (see below). Interrater agreement was checked for about 25% of the travels. Agreement on both measures (with a discrepancy of 10 s allowed for travel duration) was reported for more than 95% of those travels.

45

BASELINE I

18

17

30 15 0

5

2

1

2

INTERVENTION II

11

11

4

5

INTERVENTION III 38 39

3

2 3

BASELINE III

Mean Frequencies

INTERVENTION I

BASELINE II

3.1.3. Technology and stimuli The technology involved optic microswitches attached to the heels of Scott’s shoes, a control (computer) system and several vibratory devices. The control system was inside a little bag hanging at Scott’s back. The vibratory devices were placed at his waist, shoulders, and wrists. Each step (i.e., each microswitch activation) turned on two vibratory devices for 1 s (i.e., during the intervention phases; see below). The devices being turned on changed every 10–20 s. Each travel started with a research assistant providing Scott with a familiar object serving for the activity to be carried out (see below). At the end of each activity, Scott received a brief hand massage by the research assistant. Then the sequence for a new travel and activity started, as described above. Hand massages represented a form of stimulation normally used by staff. Vibratory stimulation [(Fig._1)TD$IG]was chosen after a stimulus preference screening similar to that described in Study I.

6

7

8

9

10

Blocks of Sessions [ STEPHANIE ] Fig. 1. Stephanie’s data. The light-gray, black, and dark-gray bars indicate mean frequencies of occurrence for head lifting, arms upward/backward, and complex scheme per session, over blocks of sessions, respectively. The number of sessions included in each block/bar is indicated by the numeral above it.

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3.1.4. Experimental conditions The study included an ABAB sequence (in which A represented baseline phases and B intervention phases) and a postintervention check (Barlow et al., 2009). 3.1.4.1. Baseline I and II. The two baseline phases included 12 and 19 sessions, respectively. During those sessions, Scott did not receive any stimulation for his ambulation steps. The research assistant intervened with prompting (i.e., physical guidance) if Scott had breaks longer than 30 s during the travels. At the end of each travel, he carried out the programmed activity (which consisted of placing the object transported and two others into a container) and then received a brief hand massage. 3.1.4.2. Intervention I and II. The two intervention phases included 58 and 51 sessions, respectively. Scott received vibratory stimulation for each step, as described in Section 3.1.3. Intervention I was preceded by four practice sessions, in which Scott was provided with all the prompting needed to ensure that he would ambulate and experience the occurrence of vibratory stimulation contingent on his step performance. 3.1.4.3. Post-intervention check. Following the end of Intervention II, Scott continued to receive sessions such as those available during that phase. Five of those sessions, occurring 4 weeks after the end of such phase, were used as postintervention check. 3.2. Results Scott’s data during the baseline and intervention phases are summarized in Fig. 2. The bars indicate mean percentages of independent travels (i.e., travels without prompting from the research assistant) per session over blocks of sessions. The number of sessions included in each block/bar is indicated by the numeral above it. The black squares indicate the mean time required per travel within the same blocks of sessions. During Baseline I, the mean percentage of independent travels was about 25 and the mean time per travel was nearly 120 s. During Intervention I, the mean percentage of independent travels was about 80 and the mean time per travel was about 80 s. During Baseline II, there was a decline in the mean percentage of independent travels and an increase in the mean time per travel. During Intervention II, the mean percentage of independent travels increased to above 90 and the mean time per travel decreased to below 65 s. The performance during the postintervention check (not reported in the figure) showed continuity with regard to both measures.

4. Study III 4.1. Method 4.1.1. Participant The participant (Nicole) was 10 years old and had congenital encephalopathy due to complications during the gestational period. She presented with (a) intellectual disabilities (estimated to be in the severe/profound range), (b) visual impairment (due to bilateral coloboma) that reduced her ability to see small objects but did not interfere with her ability to travel within familiar areas, and (c) moderate hearing loss, which was largely compensated by hearing aids. She was also described as being emotionally variable/unstable and to display hand stereotypies. She did not possess recognizable forms of communication, required help for activities, and did not have sphincteric control. She was able to walk without support, but mostly on her toes. A staff person normally walked with her (i.e., in physical contact with her). Her toe walking did not seem to have medical explanations (e.g., reduced joint motion or muscle shortening). She attended an educational center for persons with multiple disabilities. Staff and family were eager to improve her walking (i.e., to reduce toe walking). The family also had signed a formal [(Fig._2)TD$IG] consent for her involvement in this study, which had been approved by a scientific and ethics committee. INTERVENTION II INTERVENTION I

100

6

6

20

19

BASELINE II

19

10

9

17

17

17 150

75

100

50 50

25 0

1

2

3

4

5

6

7

8

9

10

0

Mean Time (in seconds)

Mean Percentages

BASELINE I

Blocks of Sessions [ SCOTT ] Fig. 2. Scott’s data. The bars indicate mean percentages of independent travels per session over blocks of sessions. The number of sessions included in each block/bar is indicated by the numeral above it. The black squares indicate the mean time per travel within the same blocks of sessions.

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4.1.2. Setting, ambulation sessions, and measures The study was carried out at the center that Nicole attended (i.e., using long hallways familiar to her). Ambulation sessions (a) involved five travels each of which covered a distance of about 25 m, and (b) typically occurred twice a day. At the end of each travel, Nicole could sit for 1–2 min and could listen to the radio, as she often did while sitting. The measures recorded during the sessions concerned (a) the total number of ambulation steps and (b) the number of ambulation steps with adequate foot-ground contact (i.e., those followed by stimulation during the intervention phases; see below). Research assistants counted the total number of steps performed during the session travels using video-recordings of such travels. The technology used during the study (see below) recorded the steps with adequate foot position. Interrater agreement on the total number of steps per session (which was assessed for 20% of the sessions by dividing the smaller reported number by the larger reported number and multiplying by 100) exceeded 95%. 4.1.3. Technology and stimuli The technology involved optic microswitches attached to the heels of Nicole’s shoes, a control (computer) system, an MP3 fitted with preferred songs and brief verbal reminders (see below), and a bracelet that could light up with flickering lights. The control system and MP3 were in a small bag fixed at Nicole’s waist. An optic microswitch was activated as the foot heel, to which it was attached, was near (less than 2 mm from) the ground. Microswitch activations turned on the MP3 with preferred songs and the bracelet with flickering lights for slightly over 1 s (i.e., during the intervention phases of the study). This ‘‘on’’ time allowed the stimulation to be virtually continuous if Nicole ambulated at a regular speed with adequate foot position. The use of songs and flickering lights as positive/motivating stimuli was based on staff recommendations and a stimulus preference screening similar to that described in Study I. 4.1.4. Experimental conditions The study included an ABABB1 sequence (in which A represented baseline phases and B and B1 intervention phases) and a post-intervention check (Barlow et al., 2009). 4.1.4.1. Baseline I and II. The two baseline phases included four and three sessions, respectively. Nicole had the technology but received no stimulation and, at the end of each travel, sat on a chair with the radio (see Section 4.1.2). Prompting (i.e., verbal and physical guidance to foster adequate foot position) was available only during Baseline I. It could occur once per travel after a sequence of steps performed with inadequate foot position. The research assistant walked on Nicole’s side with one hand touching her shoulder during both baseline phases. 4.1.4.2. Intervention I and II. The two B phases included 21 and 20 sessions, respectively. The research assistant walked on Nicole’s side with one hand touching her, as in baseline. Nicole received stimulation for all ambulation steps performed with adequate foot position. She also received a brief verbal reminder to walk with feet down from the MP3 after the initial 15 s of each travel. The first B phase was preceded by six practice sessions. Only in these sessions, prompting was used to help Nicole familiarize with the performance of correct steps and the presence of contingent stimulation. 4.1.4.3. Intervention III. The third intervention (i.e., the B1) phase included 59 sessions. Conditions were as in the second B phase, except that the research assistant and the child were not in physical contact but held the two extremities of a 40-cm stick. 4.1.4.4. Post-intervention check. Following the end of the B1 phase, Nicole continued to receive sessions such as those available during that phase. Five of those sessions, occurring 4 weeks after the end of such phase, were used as postintervention check.

[(Fig._3)TD$IG]

INTERVENTION II

INTERVENTION III

Mean Percentages

INTERVENTION I 100

BASELINE I

BASELINE II 11

75

10

50 25 0

2 2

2

1

2

3

4

5

10

30

29

10

7

8

9

10

1 6

Blocks of Sessions [ NICOLE ] Fig. 3. Nicole’s data. The bars indicate mean percentages of correct steps per session over blocks of sessions (or a single session; see Baseline II). The number of sessions included in each bar is indicated by the numeral above it.

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4.2. Results Nicole’s data during the baseline and intervention phases are summarized in Fig. 3. The bars indicate mean percentages of correct steps (i.e., performed with adequate foot position) per session over blocks of sessions. The only exception is the second bar of Baseline II (representing a single session). The number of sessions included in each bar is indicated by the numeral above it. During Baseline I, Nicole’s mean percentage of correct steps was about 10. During the first B phase, the mean percentage of correct steps increased to about 70. That percentage declined during Baseline II and increased again during the second B phase, reaching a mean value greater than 85. Such percentage was maintained (and even improved) during the B1 phase, in which the stick was used, as well as during the post-intervention check (not reported in the figure). 5. General discussion The results of the three studies provide additional encouraging evidence as to the possibility of employing microswitchaided programs to promote positive changes in persons with multiple disabilities. Study I confirmed the utility of the programs in helping persons exercise relevant motor responses on their own, and thus ensuring a supplement to their standard physiotherapy (Lancioni, O’Reilly, et al., 2012, 2013; Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2014; Palisano et al., 2012; Shin & Park, 2012). Study II showed the possibility of improving ambulation continuity/fluency and of making this essential behavioral component part of the person’s occupational engagement, with physical and social benefits for the person and practical advantages for his or her caregivers (Lancioni et al., 2010; Lancioni, Sigafoos, et al., 2013). Study III added some new evidence as to the possibility of treating toe walking of apparently idiopathic origin through behavioral procedures (Barrow, Jaworski, & Accardo, 2011; Lancioni, Singh, et al., 2012, 2013; Oetgen & Peden, 2012). In light of these results, a number of considerations may be put forward. First, the availability of microswitch-aided programs, such as the one reported in Study I, may be considered useful for supplementing conventional physiotherapy (i.e., as mentioned above) and facilitating personal and practical gains. On a personal level, such programs modify the situation of the participant from general passivity (i.e., from being prevalently exposed to the maneuvers of the physiotherapist) to a state of self-determination, in which he or she takes the initiative to perform the response scheme(s) targeted (Carter, Owens, Trainor, Sun, & Swedeen, 2009; Foley & Ferri, 2012; Ketelaar et al., 2001; Shogren & Broussard, 2011; Wehmeyer et al., 2013). The use of the programs for repeated daily sessions may help the participant practice more extensively correct motor/postural schemes with possibly positive health effects (Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2014; Lucas & Phelan, 2012; Segibaeva, Pogodin, Lavrova, Balykin, & Aleksandrova, 2011). The participant’s involvement in the programs can be seen as a satisfactory experience rather than as a tiring imposition. Indeed, the participant’s involvement (continuity of responding) is an apparent expression of his or her motivation fostered by the positive/reinforcing stimulation available for his or her performance (Catania, 2012; Dunst, Raab, Hawks, Wilson, & Parkey, 2007; Kazdin, 2001; Lancioni, O’Reilly, et al., 2013; Pierce & Cheney, 2008). On a practical level, the application of the programs can be seen as (a) mostly affordable for staff and physiotherapists and (b) the only way to help the participant receive extensive practice opportunities in the respect of his or her rights to the best (i.e., most favorable and, possibly, most enjoyable) treatment (Dillon & Carr, 2007; Lucas & Phelan, 2012; Nicolson, Moir, & Millsteed, 2012; Shih et al., 2011; Stewart, Macha, Hebblethwaite, & Hames, 2009; Verdugo, Navas, Gomez, & Schalock, 2012; West, McCollow, Umbarger, Kidwell, & Cote, 2013). Second, the availability of microswitch-aided programs, such as the one reported in Study II, can represent a very useful resource for persons who do not find ambulation motivating, that is, (a) do not particularly enjoy the act of walking, (b) do not have any exciting target to reach, and (c) may experience ambulation as an activity that interferes with their engagement in stereotypies, which remain a source of interest/pleasure (Borrero et al., 2010; Lancioni et al., 2009, 2010; Lancioni, Sigafoos, et al., 2013). Any intervention for these persons has to ensure that the ambulation responses become instrumental to produce stimulation events that can amply compensate for the efforts required by such responses and can compete favorably with the effects of the stereotypies (Borrero et al., 2010). To achieve the aforementioned goal, two basic conditions need to be satisfied. One condition is concerned with the identification of stimuli that can be considered preferred (i.e., stimuli that produce positive interest in the participant) (Pierce & Cheney, 2008). The other condition concerns the careful delivery of those stimuli contingent on the ambulation responses (Catania, 2012; Lancioni et al., 2010). With regard to the issue of preference, careful screening of the stimuli is required (Davies, Chand, Yu, Martin, & Martin, 2013). With regard to the issue of stimulus delivery, the availability of technology may be a necessity (Shih, Shih, & Luo, 2013). In fact, ensuring the monitoring of the responses and the timely application of brief stimulus events (i.e., as observed in Study II as well as previously; see Lancioni et al., 2010) would be expensive in terms of time and probably excessive in terms of effort for staff ¨ stergren, 2011; Chantry & Dunford, 2010; Foley & Ferri, 2012; personnel not assisted by technology aids (Borg, Larsson, & O Lancioni, Singh, et al., 2013; Leung & Chau, 2010, 2014; Nicolson et al., 2012; Scherer, 2012). Third, the availability of microswitch-aided programs, such as the one reported in Study III, may constitute a critically important opportunity for helping persons with toe walking to control their foot position during ambulation and, thus, improve their ambulation performance. This type of improvement might be considered the expression of the person’s involvement and of his or her self-determination (self-control), in contrast with improvements reported secondary to orthopedic intervention, via casting or dynamic splinting procedures (Fox, Deakin, Pettigrew, & Patron, 2006; Lundequam & Willis, 2009; Oetgen & Peden, 2012). Obviously, the present data (as well as the data of Study I and II) need to be taken with

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caution because they are based on a single case. Moreover, previous data adopting similar approaches only involved few participants (Lancioni, Singh, O’Reilly, Sigafoos, Oliva, et al., 2014; Lancioni, O’Reilly et al., 2012, 2013; Lancioni, Singh, et al., 2012, 2013). In light of this limited evidence, one cannot specify how extensively the reported program conditions (i.e., intervention sessions) can be stretched within the day and how large/lasting the improvement can be. This question needs to be analyzed in two different ways. One way may consist of investigating whether the person is able to extend his or her selfcontrol over significant parts of the day. This ability might largely depend on whether the stimulation used contingent on correct responding maintains its motivating/reinforcing impact over extended periods of time (Kazdin, 2001; Pierce & Cheney, 2008). The other way may consist of investigating the use of a technology that (a) can also be worn during regular daily activities (i.e., besides the physical exercise or ambulation sessions), or (b) can be put on and off very rapidly so that staff can manage its repeated use in daily contexts. In conclusion, the data of the three studies add to previous evidence and provide an encouraging picture as to the possibility of using microswitch-aided programs to help persons with multiple disabilities carry out physical exercise and improve their ambulation. The technology used within each of the programs constituted a critical component of the intervention package and thus decisive for the outcomes reported. Indeed, one could hardly imagine staff personnel having the time and energy for monitoring the persons’ responses and delivering stimulation accurately on their occurrence (Lancioni, O’Reilly, et al., 2013; Lancioni, Singh, et al., 2013; Nicolson et al., 2012). 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