Chapter 46 Communication devices and electronic aids to activities of daily living
Various forms of assistive devices and equipment have become part of the daily life of most, if not all, people with disabilities. These devices can allow persons with a disability to participate in activities that otherwise may not be available to them while decreasing dependence on caregivers. They can encourage participation in community or social activities that increase quality of life. They facilitate participation in vocational opportunities that allow for economic self-sufficiency. Assistive technology (AT) can help persons with a disability to live independently rather than in a long-term care facility. Patients who are independent with a given activity when using equipment (as opposed to requiring assistance) have been noted to experience higher levels of autonomy and self-sufficiency.36 Two studies have found that equipment was the most efficacious method of reducing and resolving limitations35 (over assistance from caregivers or other people). This chapter addresses equipment options for basic self-care through high-level community, leisure, or vocational pursuits.
Not everyone is an appropriate candidate for assistive devices. Frequently, equipment that is thought to be appropriate is issued (at considerable expense). It then remains unused unless several factors are identified and appropriately addressed.
Clients are generally evaluated by an occupational therapist working in concert with an interdisciplinary team. Equipment that is prescribed must complement and work with equipment prescribed by other disciplines. For example, if a physical therapist issues a walker to a client for ambulation, the occupational therapist can provide a walker basket to assist the client with carrying items during cooking or community activities. Medical status and prognosis provided by the physician have significant impact on technology needs. Nursing staff can provide valuable input on whether the client is using his or her equipment appropriately and independently. A case manager or social worker determines the discharge situation, which has a profound influence on equipment needs. Psychology services assist a client with adjustment to a disability and stress management or can assess a client’s best method of learning.
Clients who have significant difficulty with verbal communication will benefit from augmentative and alternative communication (AAC) (as discussed later in the chapter). A speech and language pathologist who specializes in AAC can be a valuable member of the team to address this area. They also may play a significant role in remediation/compensation of cognitive deficits that can impact use of technology.
An evaluation will determine the client’s needs. Physical deficits, including range of motion, muscle weakness, and pain limitations on physical activities, are among the most common indicators that an assistive device may be warranted. Range of motion is assessed through a visual assessment of available range. Strength and pain can be assessed through client report, a manual muscle test, or both. If clients have difficulty reaching the head, devices can ease processes such as hair care or donning a shirt, thus allowing more independence. Clients with difficulty reaching the feet can benefit from a variety of long-handled equipment. Clients with even minimal fine motor or perceptual deficits can benefit from a variety of options that allow for more efficient computer access.
Modifying factors for consideration
Goal areas for the client are the most important factors in using an assistive device. Clients must be motivated to use their device. Clients who self-initiate use of an assistive device will have better outcomes than persons who do not. Client who have a device that addresses a goal area that they have identified will generally use the devices for the long term. For example, a client who has goals to return to work will use a button hook for his dress shirt as opposed to a client who is not returning to work and wears an easier to don pullover shirt.
Cognitive, perceptual, and new learning abilities are critical to independent use of a device. If clients display poor learning ability, they may need to adopt compensatory strategies prior to training with an assistive device. Some technology can be used to supervise or allow clients with cognitive deficits to be more independent or require less supervision (as in the case of an emergency call system).
A client’s psychosocial adjustment to long-term disability is an important factor in using assistive devices because assistive devices typically are a compensatory strategy for a long-term disability. The client who is unrealistic about his or her prognosis may not participate in goals involving the device but instead be fixed on doing things “the normal way.“ Mood, depression, anger control issues, and inability to persist with a difficult task can affect new learning and should be addressed.
There are exceptions for short-term disability. For example, most clients with range of motion precautions following a hip arthroplasty are open to the use of long-handled equipment for bathing and dressing. Some clients will accept the use of an assistive device “in the meantime” while their function remains impaired (if prognosis is unclear, as in motor hemiplegia resulting from a stroke).
It is useful with these clients to emphasize that use of an assistive device will not inhibit return of function. However, clients in these cases are generally not open to devices that require a significant investment to learn. They may be more inclined to have a caregiver perform any tasks that require a significant effort.
Aesthetics of the device and body image should be considered. A client with a significantly changed body image (as in the case of a burn survivor) may be confronted by an assistive device. The addition of a piece of equipment that he or she will need to use in daily life (and which may need to be carried with the client) may complicate the psychosocial adjustment. Some clients (especially teenagers or children) benefit from using stickers or designs to make the device “their own.”
A client’s “gadget tolerance” should be assessed. Some people with disabilities prefer not to work with devices in the first place, as with the general population. A client with poor gadget tolerance may avoid assistive devices. A client with significant premorbid experience with technology or gadgets will have both aptitude for learning a new device as well as fewer adjustment issues. This is particularly the case for more complex assistive devices used for the computer and environment. All devices should be easy to clean, store, and maintain.
These factors are important in a client’s adjustment to a device. This is one place where a team approach, including counseling and sensitivity from therapists, will enhance a client’s acceptance of the disability and/or the assistive device.
Funding should be considered for all assistive devices. Some devices are covered by commercial health insurance. Substantial effort may be required to write letters of medical necessity for higher-cost items or items that do not have a clear medical benefit. For items that have significant health implications, justification must be presented to the insurance company. Justification of financial benefit to the insurance company also may be needed. For example, an adapted telephone may be considered medically justified for security purposes, enabling clients to call 911 in an emergency, or for calling doctors for follow-up care. Likewise, client control of a hospital bed may be a medical and financial benefit by giving clients the ability to change their position to prevent costly medical complications from bedsores.
In general, AAC equipment and techniques are paid for by Medicare and Medicaid (government health insurance), with some limitations. Most (but not all) health insurance companies will follow their lead. An AAC will be funded by most insurance companies only if recommended by the physician and a speech language pathologist.
Worker’s compensation usually proves to be a much better funder of most assistive devices. Although justifications may need to be provided, workmen’s compensation will generally fund basic assistive devices through highly expensive and complex computer access programs (along with a computer to run the program), AACs, or electronic aids to daily living (EADLs) as described later in this chapter.
Clients who have vocational or educational goals may have funding available through their state Office of Rehabilitation Services (in the United States). Although the assistive devices or applications must be related to specific return to work or school goals, this agency can be a source of funding for computer access as well as modifications to a work environment that are not well funded by other payers.
For many lower-cost items, some clients will be required to pay out of pocket. Otherwise, alternative funding can be investigated. Some hospitals fund equipment from a charity care fund. Clients with certain diagnoses may be able to acquire funding through organizations dedicated to that diagnosis. Pediatric clients may be eligible for benefits through a variety of charitable organizations. Some clients may belong to community groups or churches that maintain or can raise funds to meet some of these expenses. Some U.S. states maintain programs for clients with disabilities to purchase adaptive telephones. For higher-cost items, some clients may qualify for low-interest loans through state AT programs.
The following sections offer brief descriptions of some of the many commonly used devices. Most of the options are commercially available. However, for particular clients and abilities, creative modifications (necessity is the mother of invention) or investigation of similar devices (with slightly different features) may be needed. The first section addresses assistive devices for daily living skills, such as basic activities of daily living (ADL; dressing, bathing) and complex ADL (home management, cooking, and cleaning). The second section focuses on AT, which is normally powered in some fashion and has specific applications related to the computer, the home electronic environment, and/or communication ability.
An occupational therapist is versed in the use of many lower-technology options that assist with basic or complex ADL. Many larger rehabilitation hospitals have a number of these devices available for trial and resale. These hospitals may offer an ADL apartment that provides clients with an opportunity to trial these devices prior to purchase. Clients who do not have access to these services may be able to find more information on the Internet from vendors, suppliers, and other web sites dedicated to the consumer of assistive devices (see resource list37).
Basic self-care devices
Feeding is one of the first activities clients will return to after the onset of disability. If grip is impaired, lighter-weight utensils or utensils with a built-up handle can benefit clients. Clients with an arthritic grip may benefit from these devices to decrease future negative impact on the joints and to reduce pain. Clients with quadriplegia due to spinal cord injury may lack isolated finger control or grip and may benefit from the use of a universal cuff to hold utensils. Many common splints for clients with spinal cord injury can be adapted with a specialized slot to hold utensils or other tools. Utensils with a swivel handle can allow clients with limited supination/pronation to obtain food or soup from a plate. A rocker knife can allow persons to use one hand to cut their food using a rocking motion that will not move the food as a “sawing” motion would. Clients who are unable to hold a standard cup because they lack isolated finger motion may benefit from use of a mug/cup with a T-shaped handle. A long straw or tubing attached to a gooseneck or other mount such as Loc-Line (gooseneck-type mount with a flexible straw inside) can be used for drinking.
Mobile arm supports (MAS) are used by persons with limitations in shoulder movement and for feeding. The MAS is a portable device that can attach to a wheelchair It helps with hand-to-mouth movements by assisting with raising the arm against gravity. Several adaptations with the MAS allow clients to more adequately obtain food with their utensil, raise the utensil to their mouth, and reach for a cup. Combined with the proper adaptive feeding devices and splints, many clients with quadriplegia or other upper extremity dysfunction require only setup with a MAS to feed themselves. Clients using a MAS will require minimal shoulder flexion/abduction and minimal elbow flexion to allow for successful use (Fig. 46-1).
Hygiene and grooming
Clients who cannot reach the face for hygiene and grooming may benefit from an MAS. A universal cuff or other wrist hand orthosis can be adapted to hold lipstick applicators, hair brushes, combs, and toothbrushes. Some people with limited shoulder motion (but intact grip) may benefit from use of a long-handled comb or brush. As with feeding, many clients will benefit from built-up handles or lightweight utensils. Clients with hemiplegia normally will have sufficient grip and range of motion in their uninvolved upper extremity to brush their dentures or apply shaving cream to a shaving brush when the device is stabilized with a suction cup. Although these items can be useful, they may require extra sink space and can be unreliable or break more easily. Thus, some clients may develop one-handed methods.
Upper extremity dressing
Most clients with significant bilateral upper extremity dysfunction probably are not able to participate physically (with orthoses or not) with their dressing. They can and should be active participants through direction of the task. However, those who have adequate function in one arm will benefit from adaptive methods to don their clothing. Hook-and-loop fasteners can be used in place of standard buttons or ties. An orthosis such as a button hook with a zipper pull can allow people to access buttons and zippers with one hand. It can benefit clients with impaired grip (Fig. 46-2).
Lower extremity dressing
In clients with balance difficulties or weakness in the lower extremities, clothing management (pulling pants or a skirt up or down for dressing or toileting) can be accomplished using a walker or grab bar to stabilize their balance. Many clients will benefit from equipment to dress their lower extremities. A dressing stick can be used to start pants or a dress over the feet and pull the clothing item up to mid-thigh in clients with hip range of motion precautions following an arthroplasty. A sock aid and long-handled shoe horn can be used to allow clients to don socks/shoes. Elastic shoelaces or hook-and-loop straps can eliminate shoe tying. Clients may find donning pants or skirts with elastic waistbands easier than manipulating belts or fasteners.
Many appliances are useful for toileting. Clients with limited reach may be able to use tongs for perineal cleansing. Similarly, clients with limited reach may benefit from a long-handled sponge or brush for washing their feet or other areas. Some people will consider using a bidet for cleaning themselves. An elevated toilet seat can allow standing or sitting with greater ease. Clients with limited mobility may benefit from use of a male urinal or a freshette (www.freshette.com) for women. A bedside commode can facilitate clients toileting themselves in a timely manner as opposed to use of a standard toilet in another room.
Safety during bathing and toileting should always be addressed. Bathroom safety devices as addressed have been demonstrated to decrease the risk of falls and injuries in elderly people.4 Bathtub transfers have been noted as one of the most difficult transfers for seniors. This can be an even greater challenge for persons with a mobility deficit due to disability. A well-placed grab bar or tub seat can help prevent potentially serious falls for all people but even more so for persons with a disability. Despite the safety advantages offered by access to bathing and toileting aids, these devices are woefully underutilized. Naik and Gill28 found that only 54% of people with a disability related to their bathing had access to bathing aids that could facilitate function and enhance their safety.
Bathing using a shower chair or bench can allow more independence for clients with impaired transfers. A long shower hose attached to a hand-held shower will benefit these clients. People with decreased endurance will benefit from using a chair, especially while shampooing hair (as the energy expenditure of reaching overhead while standing may preclude shampooing for these clients.) Clients with decreased hand function will benefit from use of a shower mitt (washcloth sewn into or with a pouch to hold soap), liquid soap dispenser, soap on a rope, or suction soap holder.
Clients who are unable to hold a book or other reading material may benefit from a number of devices. A book holder with an elastic string can hold pages in place while other pages are being turned. Clients unable to reach a book holder may be able to use a mechanical page turner. These devices can be accessed by either switches or joysticks to activate a combination of rollers and a sticky substance to allow the page to be grabbed and turned. These devices usually are expensive and can be unreliable for certain kinds of books or magazines. If clients are unable to look down (i.e., cervical spine is immobilized), they may benefit from use of prism glasses, which reflect light at a 90-degree angle and allow clients to read a book in their lap. Clients with low vision may benefit from book magnifiers that use external screens or closed circuit television systems that allow for contrast of text on anything from books to bills to prescriptions labels. A number of books are available for reading on a computer (given consistent access to the computer as described later). Commercially available books frequently are available in electronic format designed for reading on a computer screen. Many books that are past their copyright are available for free downloading, and some web sites for downloading copyrighted books are designed for people with disabilities.34
For clients who are alone at any time, independent control of lighting is critical to preventing falls. Touch lamps or lights that are activated by sound can be used to improve lighting during a transfer. Halogen lamps or other extremely bright lights should be used in poorly lit areas. X-10 (smarthome) technology can activate overhead lights or other household appliances through a small console or wireless remote. Consideration should be given to removing scatter rugs or taping them down to prevent tripping.
A variety of telephones can assist persons with placing and receiving calls. Clients who cannot hold a standard telephone (because of impaired grip) can use a built-up handle or palm hook on the receiver. A speakerphone or a telephone with a headset can allow for access. Clients who have difficulty with hitting multiple buttons to dial in a timely manner can use speed dial functions. A cordless phone can be used by clients if access is needed from the bed or other areas. Cellular telephones are readily available for the same purpose. People who need more features than the readily available commercial options may benefit from other options discussed later in the chapter.
Clients can use a variety of call systems. Clients who are nonverbal may benefit from use of a hand bell or other device. If clients need a device that will sound for farther distances, a wireless doorbell available at most hardware stores may work. Clients activate the button to sound a doorbell placed in a central location where the caregiver can hear it. If clients with limited upper extremity function cannot push the small button, then they may benefit from a personal pager.7 This device allows larger buttons such as switches (see section on switches) to activate a pager. Some clients who can manipulate an intercom can call for assistance. An intercom can be latched on or a baby monitor can be used; however, many people prefer other options so that they do not have to listen to the client’s activities (e.g., telephone conversations or television shows).
If clients are alone during the day, they need a system that allows them to summon assistance from outside the home. Clients who can operate a cordless phone can attach one to their wheelchair with hook-and-loop closure. If clients are at risk for falling while alone, a button worn as a pendant or wristwatch can be used to activate an emergency call system. A monitored emergency call system will contact a 24-hour monitoring service. The service will automatically receive the call along with previously provided information about the client’s condition and contact numbers. Clients who can speak to the monitoring service (with the included speaker phone) can instruct the service to take appropriate action (call neighbor, call 911, etc.). If clients are unable to speak, the service will follow a prearranged plan. Some studies have found that use of an emergency call system can decrease utilization of hospital days and increase the amount of time that elderly persons can remain in the home (as opposed to a long-term care facility).19 If clients are physically unable to push the pendant, alternate switches can be used (see section on switches).
A monitored service usually requires a monthly fee for the duration of service. For persons who require this service for a long period but the expense is a concern, a nonmonitored system can be purchased. When activated by a pendant similar to that used by the monitored system, the nonmonitored system will call a series of up to five numbers in succession. It will continue to call the numbers until an individual answers (the system will not activate for a voice mail service or answering machine). When the individual picks up the phone, a prerecorded message plays (usually indicating the person’s name and address and that the person needs help). This system is dependent on someone answering the phone and taking the appropriate action. A speakerphone can be activated on some systems. 911 can be one of the numbers programmed, and all municipalities can track the location of someone calling and thus send emergency response providers.
A variety of options allow clients to prepare their meal more efficiently. Stoves with dials on the front can be reached by persons in a wheelchair (as opposed to dials located above the stove). A wooden push–pull stick can be used to extend reach when pulling oven racks in and out of the oven. A rope or cord attached to a refrigerator door handle can be used to pull open the door. Clients who are ambulatory may benefit from a rolling cart that can be used to transport items from the stove or refrigerator to a countertop or dining table. Clients who already are using a walker can use a walker tray or basket (Fig. 46-3), although they must be educated to not overload the tray and possibly unbalance the walker. A variety of tools are available to assist persons having limited upper extremity function with food preparation. Cutting boards with a spike protruding up through it will hold food in place so that persons using one hand can cut or chop the food. Other cutting boards come with a variety of stabilizers to hold food in place (Fig. 46-4). A variety of jar openers allow persons with a weak grip to use stronger forearm pronators and supinators to open a tight lid.27 Electric can openers, food processors, and blenders can reduce energy expenditure and time. Clients may prefer to use a microwave oven for food preparation given the decreased time and ease of use over a standard oven. People who have reduced sensation may need protective equipment to prevent burns from a stove or hot containers.
Fig. 46-3 A walker tray can allow a client using a walker to carry objects or containers during meal preparation or other activities.
Clients may perform lighter household cleaning using common cleaning equipment. A long-handled dust brush and dust pan can be used by persons in a wheelchair or by ambulatory clients who have difficulty reaching the floor. Likewise, a sponge mop can be used for light mopping. A lighter-weight canister vacuum with an attached hose is easier to manipulate than an upright vacuum.
Home egress and outdoor options
Clients who are unable to access standard doors have options to make egress possible. Door handles with a lever shape, as opposed to the standard knob, are much easier to use by clients with limited hand function. Doorknob holders may allow persons with a weak grip to use their forearm muscles to turn a doorknob. Keys can be put onto a key holder that adds a longer lever arm and allows clients to use their forearm rotators as opposed to finger pinch for key turning. Power door openers can be installed in a home or office to allow a door to be opened or closed. These openers are available for inner and outer doors. Clients who use a wheelchair or have limited arm placement will benefit from a dowel or a reacher to push elevator buttons. A cellular telephone can be used for a variety of features, including calling for assistance or direction. Various devices can be combined with global positioning satellite (GPS) technology to determine location, both providing direction to clients or locating clients in an emergency.
For clients requiring higher-technology options (for access to telephone, computer, or household electronics) or clients who are unable to speak, many options are available. This section addresses options that are not readily available (such as call systems discussed earlier) or have been designed specifically for people with disabilities. These devices usually are referred to as assistive technology (AT).
EADLs are devices that allow clients to control common household electronics. Clients who are unable to access a standard remote control can operate electronic devices through a number of switch options (which can be activated by head, arm, leg or a variety of other motions) or speech recognition. These devices include a television, stereo system, telephone, lights, and/or fans. They also include options such as call systems, window blinds, power doors, and pet feeders. Computer access refers to options that can allow clients to control a computer. Options for physical impairment, cognitive impairment, and visual impairments are available to help clients access their computer. Clients who are unable to operate a keyboard or mouse may benefit from options such as speech recognition programs that allow for command and control of their computer as well as dictation of text. Clients with significant perceptual impairment can use auditory feedback or magnification options to make the computer screen appear larger. AAC refers to options that are available to assist nonverbal clients or clients with significant speech impairment to communicate with people in their environment. These options range from a simple communication board or single message device to a portable computerized device that can communicate multiple novel messages as well as provide access to a computer and the environment.
These options allow for vocational purposes, leisure pursuits, communication, and socialization. Clients with disabilities frequently do not have access to the same community resources or social opportunities that most others do; these options will allow for modified participation in these pursuits. The computer can be an equalizer for people with disabilities who are otherwise unable to participate in educational and vocational activities.
Clients who wish to pursue these options will benefit from an AT evaluation with a therapist who specializes in these services. AT is a specialized field that requires significant training to successfully match a piece of AT to a specific client’s needs. The Rehabilitation Engineering Society of North America (RESNA) maintains an assistive technology practitioner (ATP) credential that requires practitioners to acquire a certain level of knowledge. However, many qualified practitioners do not seek this credential. Additionally, because AT includes knowledge of wheelchair seating and positioning, a consumer should interview practitioners about their experience related to computer access, EADLs, and AACs.
AT vendors can provide some knowledge and expertise to clients. Vendors of given pieces of AT will generally have a greater knowledge of their particular devices. However, they are committed to the sale of their pieces of technology and may not consider options available from other vendors. An AT clinician, familiar with the wide range of available technology, can provide an evaluation that will consider the best options available to a given client.
Involvement of the vendor of higher-technology products may be warranted during a trial period of a given device. If the device is computerized or electronically complex, troubleshooting, long-term device maintenance, and information related to the warranty are important to evaluate. If the device breaks down, how quickly will the vendor respond to fix the problem? Will the device need to be shipped to the manufacturer for evaluation and repair (thus leaving the client without access to a device that makes them independent)? Some vendors may make house calls to repair or troubleshoot a device. Different clients in different situations will have different tolerances for the various options available.
Referrals to ATPs in local areas are available through the RESNA web site, as are referrals to state AT projects that may be able to refer to qualified clinicians. As with other options, clients who have very specific and limited needs may be able to determine appropriate equipment by looking through catalogs or obtaining information from the Internet. Clients with more significant impairment or multiple needs usually will benefit from seeking an evaluation with a qualified practitioner.
Other team members who may be involved are rehabilitation engineers. Rehabilitation engineers have specific training in biomedical sciences that allows them to match, modify, or create technology to assist clients to perform a given task. A rehabilitation engineer may be involved in making custom devices that allow clients to access paperwork and multiple office documents through a motorized rotating shelf. They may be involved in working with a wheelchair modification that allows clients to more effectively transport a laptop or portable communication device. Ambulatory clients may benefit from a custom carrying case that will allow them access to a device while they are standing and walking. A cellular phone headset can be modified to allow clients with limited hand function to activate the speech recognition features to place or answer calls. Although some of these products are commercially available, a rehabilitation engineer may be able to provide the custom “tweaking” to make a device truly functional for a given client.
If a client has AAC needs, a speech and language pathologist will be involved in the assessment to determine appropriate devices and techniques. A speech therapist can determine a device or technique that is appropriate for the client’s language level. For example, a child who has never developed language will have very different needs from an adult who has sustained a brain injury (and may have coexisting perceptual or cognitive deficits). The speech therapist can determine the most appropriate device or techniques (as described later in this chapter).
Clients who do not have access to a qualified practitioner or who wish to increase their knowledge can take advantage of various Internet resources. Most AT vendors maintain web sites devoted to their products, offering descriptions, technical specifications, and prices. Clinicians may benefit from resources available through RESNA or the American Occupational Therapy Association.
Closing The Gap is an organization that addresses AT needs and is designed for consumers and their caregivers. They have an online database of AT products and a large bulletin board system for exchange of ideas. The California State University at Northridge and Closing The Gap offer a yearly conference with presentations related to AT and large vendor exhibits. Abledata maintains a web site (www.abledata.com) that contains reviews, purchase options, and other information related to all types of assistive devices. It is notable for its inclusion of products related to leisure activities and a variety of articles related to consumer information for people with disabilities.