Assistive technology assessments in a tertiary-care rehabilitation facility

Introduction
Assistive technology is a wide, changing field that has been defined as "a broad range of devices, services, strategies, and practices that are conceived and applied to ameliorate the problems faced by individuals who have disabilities."[1] A device is described as "any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase or improve functional capabilities of individuals with disabilities."[1]

G.F. Strong Rehab Centre’s Assistive Technology and Seating Service (ATSS) works on a consultative basis with rehabilitation teams to provide an interdisciplinary approach to assistive technology. Although assistive devices themselves play an important role in this process, the ATSS emphasizes a goal-oriented assessment process and the development of appropriate strategies and approaches rather than the simple prescription of one or more devices.

G.F. Strong Rehab Centre is a tertiary-care provincial rehabilitation facility located in Vancouver, British Columbia. It was the first freestanding hospital dedicated solely to rehabilitation in North America. Today there are inpatient and outpatient programs for several diagnostic groups including acquired brain injury and spinal cord injury, with a specialized program in ventilator-dependent quadriplegia.

The ATSS at G.F. Strong has five members with a broad spectrum of education and experience including occupational therapy, speech and language pathology, education, psychology, and computer science. In clinical work, the ATSS consults mainly with occupational therapists and speech and language pathologists on the client rehabilitation team and from the community, providing or assisting in assessments and making recommendations in the following three areas: augmentative communication, environmental control, and computer access.

Augmentative communication
Augmentative communication involves the use of strategies and devices to provide communication capabilities to those who, through cognitive and/or physical impairment, find intelligible speech difficult or impossible to produce. The ATSS works with the client’s speech and language pathologist whose specialized training helps identify the cause of the client’s difficulties. Appropriate devices or strategies can then be assessed.

Environmental control
Environmental control refers to a range of devices and methods for the operation of household appliances such as televisions, stereos, and telephones. Control of doors, lights, windows, and thermostats, among many other things, is also possible. Environmental control hardware can range from an oversized TV remote control to a wheelchair mountable device that learns the infrared codes for a person’s stereo, TV, VCR, and door opener and allows the codes to be transmitted through use of a single switch.

Computer access
Computer access is available through a wide variety of specialized software and hardware products. The ATSS assists the client in wading through the possibilities by focusing on desired computer activities and by devising strategies that employ appropriate tools. It is important to note that voice recognition software, while sometimes a part of the solution, is almost never the sole answer to computer access issues.

Education of clients and clinicians is an ongoing ATSS priority. Clients are educated about the assistive technology they are using so they can train caregivers and assist in trouble shooting. The ATSS maintains a loan bank of approved, commercially available assistive technology items. This equipment is lent to clinicians throughout BC for short periods for use in their assessments. Telephone support of clinicians all over the province is included in our loan program as advice about choice of equipment and assessment strategies accompanies most loans. Support of rehabilitation clinicians goes beyond assistance with specific cases. The ATSS has presented assistive technology workshops for occupational therapists, speech and language pathologists, and special educators as far east as Toronto.

Assessment process
The definitions for assistive technology and assistive technology devices quoted at the beginning of this article are necessarily broad. Everything from a cane to a scooter to an eye-gaze driven computer access system qualifies as an assistive technology device. Assistive technology is an extensive field in which new technologies are constantly being developed. As well, useful products disappear as companies are bought and sold and lose interest in supporting this small market.

It is difficult for care providers and clients to keep up with all this change and to know when a specific piece of equipment is indicated. Our current technophilic culture has great faith in what technology can provide for a disabled person and puts clinicians under pressure to utilize technology-based solutions, but decisions regarding provision of assistive technology devices need to be made carefully. Assistive technology products are often expensive and may be abandoned when they do not live up to expectations.

To avoid abandoned equipment, a well-grounded, systematic approach matching client goals with appropriate solutions is required. During an assistive technology assessment for rehabilitation clients, we do the following:

1. Identify and clarify client goals

2. Determine functional abilities

3. Run equipment trials

4. Review equipment trials

5. Explore the funding process

While there is a linear aspect to this process, many of the steps operate in parallel and are ongoing. Goals and equipment choices will change as functional abilities improve and financial and attendant-care issues are clarified. The process of fitting an assistive technology solution to a set of client-defined goals must include input from an interdisciplinary team of rehabilitation professionals and incorporate the needs of the client, family, caregivers, and clinicians who will be working with the client prior to and after discharge from G.F. Strong. Ideally, this process results in the prescription of the most reliable tools to address specific goals. No-tech or low-tech solutions are used whenever possible.

Case study
The following case study illustrates the approach of the ATSS assessment process and highlights some of the challenges encountered by patients, families, and caregivers.

1. Identify and clarify goals
JC is a ventilator-dependent C2 ASIA B spinal cord injured quadriplegic man in his early 20s who recently completed his rehabilitation at G.F. Strong.

When JC first arrived at G.F. Strong, he had to adjust to a new ward and unfamiliar surroundings. The first priority was establishing a reliable call-bell system to summon nursing care. Since he was still in a cervical orthosis and had no active movement in his extremities, his call system needed to be activated by mouth. He used a sip-and-puff system, which involves gently blowing into or sucking on a straw positioned near the corner of his mouth.

Establishing a reliable call system achieved JC’s first assistive technology goal, but he developed many more over time. Some of these goals were immediate, and others had a longer horizon and became more important as he learned more about assistive technology and as his discharge drew nearer.

At G.F. Strong, all members of the rehabilitation team are involved in patient education. Education is especially important in establishing assistive technology goals. Patients, families, and caregivers need to learn about the systems and devices being considered in order to set realistic and achievable goals. The assistive technology specialist ensured that JC was made aware of available assistive technology systems that could achieve his goals and that the systems under consideration were integrated with vocational, educational, and daily care plans.

2. Determine functional abilities
While he learned more about what assistive technology could offer, the team continued to try to identify and improve JC’s functional abilities.

He practised independent breathing with the respiratory therapist. Improving his vital capacity from 200cc to 500cc gave JC better use of his sip-and-puff controls. It also helped improve his voice strength and quality.

Once his cervical spine fracture was stable, the physiotherapist helped JC strengthen his neck muscles and increase his cervical range of motion. His occupational therapist determined that he could now use a mouth stick to push buttons and keys and use head movements to directly access switches. Practising with a mouth stick to access a small computer keyboard and pressure-sensitive mouse pad was initiated as a therapeutic activity.

Assessing his functional abilities also meant determining his cognitive skills and ability to learn. Although his neuropsychological testing showed some deficits, functionally he was able to memorize complex command sequences for various assistive technology devices.

3. Run equipment trials
JC tried several different pieces of equipment while at G.F. Strong. Initially, he used environmental control units accessed from his bed. As his endurance improved, he required access from his power wheelchair and tried various combinations of equipment. As he progressed, he made decisions about which devices he would like to control from his bed and which from his wheelchair.

In addition to working with environmental control systems, JC tried various computer access approaches that exploited his good head control. Voice dictation software was introduced and integrated with the other computer access methodologies being assessed.

Meanwhile on the home front, JC’s family members were making plans to renovate their house to make it wheelchair accessible. The ATSS consultant was contacted by the local builder and community occupational therapist in JC’s home town. He provided information and contacts with specialists in adaptive and accessible housing.

4. Review equipment trials
After the equipment trials, JC determined that he preferred to use a sip-and-puff environmental control system while in bed. In his wheelchair, he would use head switches to activate his environmental control system. He chose a sip-and-puff system for driving his power wheelchair. Power wheelchairs come with ports for environmental control devices, but JC needed these ports for options that allowed him to control the position of his chair in tilt or recline.

His family had expressed interest in an intercom system in the house for JC to summon assistance, but decided on the simpler and more reliable solution of using baby monitors.

Despite having trained with voice dictation software on the computer, JC decided not to use a voice-controlled, computer-based environmental control system. The much lower cost and greater reliability and flexibility of the sip-and-puff and head-controlled systems outweighed the high-tech sexiness of the computer-based system.

At home, JC can control his bedroom television, bedroom telephone, fan, and lights from his bed. From his wheelchair he can control his stereo, the living room television, living room telephone, and patio door, and he can add other devices to his systems over time.

5. Explore the funding process
Funding for assistive technology equipment is limited in British Columbia. As JC did not have any third-party funding, he had to rely mainly on community fund-raising efforts organized by his family. The ATSS specialist helped him apply to the Technology for Independent Living program, a charitable service that works closely with the ATSS. Technology for Independent Living provides basic environmental-control equipment for disabled adult clients of limited financial means in BC. Technology for Independent Living also helps fund augmentative communication systems.

Prioritizing his assistive technology equipment list was an important aspect of JC’s assessment. While efforts had to be made to contain costs, the need for future adaptability had to be considered as well. Since assistive technology equipment tends to be expensive, a simple modular system in which pieces can be added over time was the most fiscally prudent approach.

Mr Speropoulos has been involved in the field of assistive technology since 1985 when he designed software to teach counting to severely disabled children. He has two science degrees and has been with the Assistive Technology and Seating Service at G.F. Strong Rehab Centre since 1992. Dr Townson is associate chief in physical medicine and rehabilitation in the spinal cord injury program at the Santa Clara Valley Medical Center in San Jose, California. She was previously at G.F. Strong Rehab Centre in Vancouver, BC.