People with severe or severe to profound intellectual disability and visual or visual and motor impairments tend to be passive and isolated, with limited or no opportunities to control environmental events (and stimulation) around them [1-5]. Their situation may be largely shaped by their inability to locate, recognize, and operate conventional stimulation sources (eg, television and music devices), their lack of self-determination, their poor motor condition, and a general disinterest in activity engagement [4,6-8]. The negative implications of this situation can include a reduced level of environmental stimulation, limited physical activity, and possibly incorrect body postures, that is, a range of conditions that can further hinder people’s rehabilitation prospects, general well-being, and quality of life [9-15].

The literature available suggests that several stimulation approaches may be potentially useful in curbing, at least partially, the impact of those negative implications. Two common stimulation approaches involve the use of environmental enrichment and multisensory rooms, respectively. Environmental enrichment consists of an increase in the level of environmental stimulation regulated by staff or other personnel in charge of the context [10,14,16-18]. This approach is considered functional for (1) countering the most feared of the negative implications mentioned above, that is, the risk of low stimulation input (with consequent personal impoverishment), and (2) improving the participants’ quality of life [10,19]. Multisensory rooms are structured areas equipped with multiple stimulation sources that are designed to engage the participants’ senses and thus enrich their sensory input and possibly provide them with a feeling of satisfaction [20-23].

A third stimulation approach is characterized by the fact that the stimulation is mediated by direct staff and caregiver involvement (intervention). One strategy used within this approach includes an increase in social (verbal and physical) contact between participants and personnel sharing the same context [24-27]. Another strategy exposes the participants to simple stories whose narration by staff is accompanied by the presentation of stimulation events that underline the content of the stories [28-31].

A fourth stimulation approach, contrary to those mentioned above, ensures that the stimulation is controlled by the participants through their own responses and the use of microswitch (sensor) technology [11,13,32,33]. Specifically, the participants are taught to activate a microswitch device through a specific response (eg, a simple hand movement or a hand-stretching movement involving the use of objects). Such a response becomes instrumental in enabling them to access brief periods of preferred stimulation. The distinctive aspects of this approach are that the participants (1) are actively involved in seeking stimulation (rather than being automatically exposed to it) and (2) are required to increase their physical engagement (ie, through their microswitch activation responses) and thus counter their passivity and detachment.

A final stimulation approach differs from the fourth in that its goal is not limited to bringing the participants to seek environmental stimulation through their own responses but also aims to promote their postural control [34]. For example, participants may be (1) taught to perform specific (functional) arm and hand responses to activate microswitch devices and access preferred stimulation and (2) required to maintain a correct posture during the stimulation to ensure that this continues without interruptions [34,35].

In light of the above, one might argue that the last 2 approaches can be considered advantageous because they allow the participants to have an active role in seeking environmental stimulation and because they promote the participants’ physical engagement and possibly postural improvement. In essence, these approaches can be viewed as valuable complements to standard occupational therapy and physiotherapy within daily contexts [4,9,12]. With regard to this point, it may also be noted that these approaches rely on the use of basic technology and are only marginally demanding on staff time [4,36,37].

The present study was aimed at assessing 2 intervention programs serving as extensions and advancements of the last 2 approaches described above. The first program was directed at 4 participants who presented with severe intellectual disability and blindness. These participants were led to alternate periods in which they could activate preferred music stimulation pieces with periods of mild physical engagement in which a functional response requiring some physical effort was to be repeated several times. Each music stimulation piece lasted 1 minute. Each physical engagement period required the participants to place 6 to 10 objects (ie, common and age-appropriate objects) in a tall carton, which was in front of them. The performance of every response involved forward and upward arm and shoulder stretching (ie, movements that physiotherapists had recommended as useful and appropriate for the participants).

The second program was directed at 5 participants who presented with severe to profound intellectual disability, visual and motor impairments, and postural problems (ie, a tendency to tilt their torso and head forward). These participants were led to alternate stimulation periods such as those described for the previous group of participants with physical engagement periods. During the latter periods, the participants were required to perform upward and sideward arm-stretching responses (ie, responses that physiotherapists considered useful because of the nature of the movements involved and because they were antagonistic to the participants’ postural problems). The participants’ posture was monitored throughout the sessions. Loss of correct posture during a stimulation period made the stimulation inaudible until the correct posture was regained.

The programs were developed by the authors, who have long experience working with and developing technology-aided solutions for people with intellectual and multiple disabilities. The authors operated in continuity with previous research work in the area, as indicated above, and in collaboration with staff personnel and caregivers. Each of the 2 programs was implemented according to a single-case research design. The technology used for the programs included commercial components such as a smartphone, pressure and proximity sensors, an interface to connect the sensors to the smartphone, the MacroDroid app, and a mini speaker.

Staff considered the participants’ involvement in the study to be a beneficial and pleasant experience for them (ie, an experience that extended their daily rehabilitation and care treatment by promoting self-determination, enriching stimulation input, and facilitating physical activity). The participants’ condition did not allow staff to ask them for or obtain their clear consent to be involved in the study. In light of this, their legal representatives read and signed a consent form on their behalf. The consent form specified that there was no compensation for the participants’ involvement, that participants could be withdrawn from the study at any time, and that their data would be deidentified. The study was approved by the Ethics Committee of the Lega F. D’Oro, Osimo (AN), Italy (P031020252). All procedures applied during the study were in line with internationally recognized ethical standards and complied with the 1964 Helsinki Declaration and its later amendments.

Table 1 reports the chronological age, Vineland age equivalents for daily living skills (personal subdomain), and sensory-motor impairments for the 9 participants. The first 4 (identified with the pseudonyms of Eloise, Grace, Jackson, and Margot) were involved in program 1, and the last 5 (identified with the pseudonyms of Matias, Colton, Alina, Hazel, and Graham) were involved in program 2. Their chronological age ranged from 27 to 59 years. The Vineland age equivalents for daily living skills (personal subdomain) measured via the second edition of the Vineland Adaptive Behavior Scales [38,39] varied between 1 year and 7 months and 4 years. The participants had a diagnosis of congenital encephalopathy and intellectual disability, which was combined with blindness or severe visual impairment. Four of the last 5 participants also presented with motor impairments that precluded any ambulation or allowed only limited levels of supported ambulation. While no recent IQ scores were available, the psychological records of the rehabilitation and care centers that the participants attended reported the participants’ level of intellectual disability to be in the severe range (first 4 participants) or the severe-to-profound range (last 5 participants).

The participants were included in the study based on a number of conditions, which had been preliminarily verified. First, they tended to be passive and dependent on staff to access environmental stimulation and engage in physical activity (eg, using objects or performing functional body movements). Second, they seemed to enjoy different types of music stimulation. Third, they were considered capable of responding to simple verbal instructions concerning basic actions such as touching or putting away objects. Fourth, staff were favorable to the programs and the technology involved, which had been illustrated to them in advance.

A quiet room in the participants’ daily contexts, fitted with a desk at which the participants sat, served as the setting for the baseline and the program sessions (see below). The participants’ regular occupational room served as the setting for the control sessions (see below). Sessions were typically carried out once per day, 5 or 6 days a week. A total of 4 research assistants implemented the sessions. They had a university education and were experienced in applying technology-aided programs with people with extensive disabilities and using various data recording procedures.

Different music pieces (songs and other music stimuli) recommended by staff were evaluated to determine whether they would be used during the study. The evaluation was carried out via a stimulus preference screening procedure. The procedure required that 3 brief segments of each music piece suggested by staff for the individual participants be presented nonconsecutively (at least 10 times per segment) over different screening occasions. Only the music pieces whose segments were considered (ie, by the research assistant and staff member involved in the screening procedure) to produce positive reactions (eg, alerting and smiling) in at least 50% of their presentations were retained for use in the study [4,13].

The technology system used for the programs involved (1) a smartphone operating on Android and fitted with a light sensor, (2) a Bluetooth Encore Plus interface (leonardoausili.com), which was linked to 2 pressure sensors and a proximity sensor, and (3) a Bluetooth mini speaker (JBL Go 3) amplifying the smartphone’s volume. The smartphone was connected to the internet and fitted with the Encore Plus and MacroDroid apps. The pressure sensors consisted of small Buddy buttons, circles with a diameter of 6.3 cm (leonardoausili.com). The proximity sensor consisted of a Big Candy Corn, a triangle with a side of about 10 cm (leonardoausili.com). In program 1, the pressure sensors were on the desk while the proximity sensor was fixed to the carton in which the participants were to place common, age-appropriate objects taken from a container (Figure 1). The smartphone was in the desk drawer. In program 2, the pressure sensors were on the desk, the proximity sensor was on a small shelf that the participants were to touch, and the smartphone was attached to the back of their chair (Figure 2) or to their wheelchair’s headrest.

In program 2, the smartphone on the back of the chair or wheelchair’s headrest served to record whether the participants’ torso or head posture was correct or incorrect. The closer the participant’s torso or head was to the smartphone’s light sensor, the lower the level of light reaching the sensor. Based on this relationship, the smartphone was programmed to record the posture as correct up to a prefixed level of light reaching the sensor. Beyond that level, the posture was considered incorrect. This smartphone and light sensor functioning was successfully tested prior to the study by 2 judges (a staff member and a research assistant), who compared the smartphone’s (correct or incorrect) posture recording with video images of the posture collected simultaneously. Testing was conducted for each participant under environmental illumination conditions that remained stable during the baseline and program sessions.

A session with either program started with the smartphone instructing the participants (via the mini speaker) to listen to music (eg, to select the name of a singer or the name of a band). Figure 3 provides a summary of the system’s functioning. The participants could touch (activate) one of the pressure (music) sensors available in front of them, thus sending a signal to the smartphone. The smartphone, using the Encore Plus and the MacroDroid apps, (1) detected and discriminated the signal and (2) presented, via the mini speaker, a 1-minute music piece consistent with the sensor activated. In program 2, the piece was audible to the participants if their posture (as determined by the smartphone fixed on the back of their chair or headrest) was correct and inaudible if their posture was incorrect. In the latter case, the smartphone instructed them to straighten their body or raise their head. As the participants regained the correct posture, the music piece became audible again.

Following the end of the music piece, an activity period started during which the music sensors were unresponsive. The smartphone instructed the participants to put an object in the carton (program 1) or touch the shelf (program 2). These responses activated the proximity sensor fixed near the carton’s opening (program 1) or on the shelf (program 2). Proximity sensor activation led the smartphone (supported by the Encore Plus and the MacroDroid apps) to (1) count each response (ie, an object placed in the carton or a shelf-touching response), (2) provide a one-word positive feedback statement for each response, (3) follow each feedback statement with the instruction to take another object (program 1) or touch the shelf again (program 2), and (4) determine when the participants had produced the number of responses programmed for the activity period (ie, had placed 6-10 objects in the carton or touched the shelf 6-9 times). Once the programmed number was reached, the smartphone instructed the participants to listen to music (ie, as above) and made the proximity sensor on the carton or shelf unresponsive. The instruction to listen to music or to place an object in the carton or touch the shelf was repeated at intervals of 10 seconds until the participants responded to it. The session continued with new opportunities to access preferred music pieces followed by activity periods according to the conditions described above. A session was programmed to include 7 music pieces and 6 activity periods. During the 6 activity periods, the participants were expected to place a total of 36 to 60 objects in the carton or to touch the shelf a total of 36 to 54 times.

The four measures recorded during both programs involved (1) the number of music pieces activated independently of research assistants’ guidance, (2) the number of objects placed in the carton or of shelf-touching responses performed independently of research assistants’ guidance, (3) the length of the sessions, and (4) the participants’ indices of happiness (eg, behaviors such as alerting or orienting to the music, smiling, and making music-based rhythmic movements [4,11,40-43]). The fifth measure, recorded only during program 2, concerned the amount of session time the participants spent in a correct posture. With the exception of indices of happiness, the measures were also recorded during the baseline phase that preceded the programs. Indices of happiness were recorded during 25-30 program sessions and as many control sessions (see below).

The first 2 measures were recorded by the research assistants during the baseline and by the technology system during the programs. During the programs, the system’s recorded number of music pieces activated, of objects placed in the carton, and of shelf-touching responses performed would be modified (reduced) if research assistants’ guidance had occurred in the process. The length of the sessions and the time spent in a correct posture were recorded by the technology system throughout the study. The indices of happiness were recorded from videos of the sessions using a partial-interval strategy in which 10-second intervals were used for observing and 5-second intervals were used for recording [4].

Interrater agreement was assessed over (1) all baseline sessions for the first 2 measures and (2) 50% of the program and control sessions for indices of happiness with the involvement of a reliability observer. The percentage of agreement on the first 2 measures (computed by dividing the number of sessions in which research assistants and the reliability observer had scores differing by no more than 1 unit by the total number of sessions and multiplying by 100%) was 100% for all participants. The percentage of agreement for indices of happiness (computed for the single sessions by dividing the number of intervals with agreement by the total number of intervals and multiplying by 100%) ranged between 87.5% and 100%, with means exceeding 93% for all participants.

The findings suggest that the programs assessed in this study were helpful in improving the situation of people with intellectual disability and visual or visual and motor impairments. All participants learned to activate music stimulation and to engage in recommended forms of mild physical activity. The participants involved in program 2 also showed an improvement in body posture. Taken as a whole, these findings seem to confirm and extend previous data in the area [33,35,51,52] and to provide new encouraging evidence about the possibility of developing technology-aided programs to help participants with extensive disabilities become responsible for increasing their stimulation input and enhancing their physical activity and postural control. In light of these findings, several considerations are in order.

First, helping people with extensive disabilities manage their access to environmental stimulation and the performance of functional physical actions may be considered relevant from a rehabilitation standpoint and from a practical standpoint. Regarding the rehabilitation aspect, one can argue that the participants’ behavioral activation and self-determination not only curb the risks of stimulation impoverishment and limited physical activity but also likely provide a basis for the participants’ developmental progress, well-being, and satisfaction [15,53-57]. Regarding the practical aspect, one may consider the findings a demonstration that relevant participants’ achievements can be ensured (1) through the support of rather simple and easily accessible technology and (2) with relatively small staff time investment [3,9,36,58-60].

Second, interspersing physical activity with access to preferred music stimulation was thought to be a useful strategy to (1) deal with the participants’ low level of interest in and tendency to avoid such activity (ie, a generally nonpreferred type of engagement) and (2) create a link between the activity and the following preferred stimulation with the likelihood that this would become a reinforcing (motivating) factor for the participants’ activity engagement [61-64]. Pursuing an improvement in body posture could be considered a useful supplement to the goal of increasing physical activity in participants with motor impairments and postural problems. Bringing participants to control their posture through motivational strategies may be the only way to ensure the independence of such control from external supervision [62,64-67]. The aforementioned hypotheses on promoting physical activity and postural control seem to find support in the participants’ performance during the 2 programs. Interpretation of the data reported on postural control may require some caution as the sensor (ie, the smartphone’s light sensor) used to record body posture is not a conventional (validated) instrument for use in that specific assessment area.

Third, while the importance of increasing physical activity in people with extensive disabilities is largely acknowledged [9,10,36,37,51,58-60], the evaluation of the beneficial effects of such an increase is difficult or practically impossible when the activity is mild and lasts for relatively short periods of time. In this case, in fact, one cannot rely on any specific assessment criteria and tools. A similar consideration can be extended to the issue of postural control. Identification of functional assessment criteria and tools may be viewed as an important research objective in this area.

Fourth, the data on indices of happiness show that 8 of the participants found their involvement in the program sessions more satisfactory (enjoyable) than their involvement in the control sessions (ie, sessions featuring common conditions in periods of no specific activity or direct supervision). This evidence, together with the findings that all participants had high and stable levels of performance throughout the program sessions, suggests that (1) the program conditions were largely motivating, (2) the positive impact of the stimulation available in the program sessions exceeded the cost (efforts) of the physical activity or postural control pursued within those sessions, and (3) technology-aided programs such as those reported might help promote participants’ initiative and functional occupational engagement and foster their developmental progress, with possibly positive implications for their quality of life [4,33,37,40,43,57,61,63].

Fifth, the components of the technology system used in the programs, that is, the smartphone, the Encore Plus interface and app, the pressure sensors, the proximity sensor, the mini speaker, and the MacroDroid app, are commercially available and easily affordable. Commercial availability and affordability make the acquisition of the technology and the application of the programs reported in this study feasible for daily contexts [68,69] as well. One clarification that should be provided at this point is that the acquisition of the technology components does not allow one to have a readily usable system. In fact, the usability of the system depends on the programming of its functioning through the MacroDroid app. This programming, albeit not particularly complex, requires a certain level of familiarity with technology issues. A similar point could be made regarding the implementation of the programs. Although not difficult, it requires staff to acquire a clear understanding of the procedural conditions and the technology arrangement. The authors of this study are willing to provide assistance to any context interested in adopting and using the technology system and programs reported.

Sixth, the fact that the system does not require adjustments from one session to the next and the evidence that the participants can be independent of any external assistance during the sessions can lead one to basic considerations about program applicability and sustainability [70-72]. For example, one might argue that (1) the participants involved in this study could continue to use the programs reported over time with relatively small staff time investment, and (2) the same programs could represent a realistic treatment opportunity for other people with extensive disabilities and limited access to stimulation and physical activity (ie, a treatment opportunity that their daily contexts might be able to afford in terms of time cost and technology requirements).

While the results appear promising, some caution may be required in interpreting them given the limitations of the study. The most obvious limitations are the relatively small number of participants, the unavailability of maintenance and generalization data, and the absence of social validation of the programs and the technology system involved. An additional limitation may be the use of an experimental sensor (ie, the smartphone’s light sensor) to record the participants’ posture. With regard to the small number of participants, 2 points may need to be clarified. The first point is that the single-case research designs used with the participants involved in program 1 and the participants involved in program 2 can be considered adequate to support the internal validity of the data reported [44,45,73]. The second point is that new studies (ie, single-case replication studies and/or group-design studies) would be critically important to determine the external validity of the data and thus their level of representativeness [73-76].

To deal with the issues of maintenance and generalization, more comprehensive studies are needed. Those studies would have to (1) extend the data collection periods and include follow-up checks to verify whether the participants’ gains remain stable over time, (2) test the effects of the programs with different groups of people so as to verify whether those effects can be reproduced across participants, and (3) include different contexts in the evaluations (eg, homes, schools, and community and rehabilitation settings) to ascertain the applicability and effectiveness of those programs across settings as well as the sustainability of the programs within those settings [61,63,70,77,78].

To address the social validation question, new studies may need to gather the opinions of staff, family members, and service providers about the acceptability, relevance, and usability of the programs and the technology system on which they rely [79,80]. The process of gathering such opinions may involve 2 steps. The first step would consist of presenting all these personnel with videos of program sessions in which participants use the technology system. The second step would consist of presenting the same personnel with a series of questions concerning the programs and the technology (eg, their impact, social relevance, and applicability) [81-83]. The aforementioned process may be complemented by formal scales assessing the usability of technology (eg, the System Usability Scale) [84,85].

With regard to the recording of body posture, new studies may need to evaluate the usability and practicality of accelerometers, depth cameras, or infrared optical tracking sensors [86-88]. New studies may also consider ways of measuring (1) the impact of mild physical activity such as that adopted in the 2 programs of this study and (2) the level of purposefulness in the participants’ selection of the music pieces (ie, in their decision about the pressure sensor to activate at each music opportunity). To address the first issue, one might need to identify evaluation criteria and instruments more sophisticated than those presently available [9,51,58,64]. To address the second issue, one may need to associate highly preferred music pieces with one sensor and moderately preferred music pieces with the other sensor and verify whether the activation of the former sensor is more frequent than the activation of the latter sensor [13,89-91].

The findings suggest that the programs assessed in this study were helpful in improving the situation of people with intellectual disability and visual or visual and motor impairments. All participants learned to activate music stimulation and to engage in recommended forms of physical activity. The participants involved in program 2 also showed an improvement in body posture. These findings provide new evidence of the possibility of developing technology-aided programs to improve the situation of participants with extensive disabilities. Notwithstanding this evidence, caution is required in making general statements and drawing conclusions based on these findings given the limitations of this study, which need to be addressed through new, carefully planned research efforts.