19/03/13 Assistive Technologies : Catalysts for Adaptive Function

Physical Medicine and Rehabilitation Secrets , Third

Edition
Bryan J. O'Young, Mark A. Young, and Steven A. Stiens
Chapter 25 , 201-206
Copyright 2008, 2002, 1997 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 25

Assistive Technologies
Catalysts for Adaptive Function
1

How is assistive technology (AT) employed as a therapeutic

tool?
AT is a potent tool utilized to modify disablement. It may be used by people with
disabilities to increase independent function and participation in preferred activities. AT
can help to minimize disability and disablement by catalyzing activity and participation.
A person with a disability benefits from AT in several important dimensions: within his
or her own body (e.g., cochlear implant to enhance hearing), in direct contact (e.g.,
wheelchair to improve mobility), and in the intermediate environment (e.g., a ceiling-
mounted track lift to facilitate transfers and propulsion from bed to toilet and
surrounding space). Because rehabilitation physicians are often obligated to approve
and sign off on AT prescriptions, a full understanding of the prescribed technology is
essential.

Stiens SA: Personhood, disablement, and mobility technology: Personal control of

development. In Gry DB, Quatrano LA, Lieberman M (eds): Designing and Using
Assistive Technology: The Human Perspective. Towson, MD, Paul Brookes, 1998, pp
2949.

Is there an official definition for assistive technology?

The U.S. government defines AT in Public Law 100-407 (Assistive Technology Act,
2004) as Any item, piece of equipment or product system whether commercially off the
shelf, modified, or customized that is used to increase or improve functional
capabilities of individuals with disabilities. This definition highlights a most important
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pointthat AT is used to improve function. Human function can be broken down into the
broad categories of sensing, processing, and effecting. Each of these functions can
either be augmented by, or substituted for, using AT. Examples of AT range from
robotic arms and power wheelchairs to voice recognition software and eyeglasses. The
legal definition of AT also includes those services necessary to effect implementation of
AT, reflecting the importance of including these services in any AT prescription and/or
plan and the concerns that without these services, AT will be abandoned.

Young MA, Levi S, Tumanon RC, et al: Independence for people with disabilities: A
physician's primer on assistive technology. Md Med 1(3):2832, 2000.

Provide three examples of accessible electronic and information

technology?

Accessible electronic and information technology (E&IT) systems allow people with
disabilities such as color blindness, learning disabilities, and limitations in arm and
hand function, vision, and hearing to access everything from e-mail to distance learning
courses and electronic shopping with or without their AT. Accessibility in the arena of IT
can be considered analogous to building ramps in the environment. Examples of
information systems include accessible Web portals and Internet sites. These sites
employ accessibility features, including text equivalents for nontext features (e.g., audio,
video, graphics). A blind person, with the help of a screen reader program (one form of
AT), will be able to hear the textual description of a picture on an accessible website.
(See Chapter 6 for more details about AT solutions for blindness.) Similar
modifications work for multimedia products such as CDs, videotapes, and DVDs.

Access IT, Technical Assistance Project, University of Washington: INTER REF

www.washington.edu/accessit

Are employers and schools required to provide AT?

Under the Americans with Disabilities Act and various state laws, employers are
required to make reasonable accommodations for qualified employees with disabilities
who are otherwise able to perform the essential functions of the job. AT is considered
one kind of reasonable accommodation and may include assisted listening devices,
specialized software, or other technology in addition to nontechnology-based
accommodations such as breaks for fatigue and modifications of desks. For children
with disabilities, section 504 of the Rehabilitation Act requires that they receive
reasonable accommodation so that they can participate in the least restrictive
educational environment; and the Individuals with Disabilities Education Act (IDEA)
requires that qualified students with disabilities receive those services necessary for
them to proceed toward the goals of their individualized education plans. AT must be
considered in plans under both Section 504 and IDEA.

What is an environmental control unit (ECU)?

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ECUs are a form of AT that controls an object or objects in a person's environment.

Commonly used ECUs include controls for doors, house lights, televisions, home
appliances, and hospital-type beds, among others. (Always remember that AT and
ECUs refer to the disabled population only. The same types of devices employed by a
nondisabled person are not referred to by these terms.) ECUs are comprised of five
elements: the switch device, control device, connection, target device(s), and feedback
device. The control device detects a signal from the switch, then transforms the signal
and sends it through a connection to a target device to perform a function. The user is
then alerted that the function has successfully been engaged or completed through
feedback, such as the channel on the TV changing.

When should an ECU be prescribed?

Simply putas soon as possible. Early use (in the acute care hospital) of an ECU by a
patient with a high spinal cord injury can reduce frustration by putting the patient back in
control, reducing nurse workload, and teaching the patient that rehabilitation has
functional rewards. Adaptive success with AT promotes future steps with other
functional technologies after discharge. In the acute care setting, the ECU can control
the nurse call, TV, and lights immediately by putting the patient into an I can do it
paradigm. With the assistance of ECUs, many persons with severe mobility limitations
and other disabilities have had the option to avoid institutionalization and live safely and
comfortably in their own homes. Children, in particular, learn by doing with AT and
therefore may have less dependent behavior or express less frustration. Geriatric
patients at nursing homes also have been shown to benefit from access to an ECU.
Outcome studies to demonstrate the expected cost savings are needed. Funding from
medical insurance or public programs may be difficult to obtain, and support often
comes from community groups, such as religious organizations or private foundations.
Increasingly effective and adaptable ECUs are available for mainstream applications
off the shelf in home improvement stores.

Define augmentative and alternative communication (AAC).

AAC devices either augment or replace communication. For example, an individual

unable to generate sufficient vocal volume might use a portable voice amplifier to
augment communication. An individual on respiratory support who is temporarily unable
to speak might use a vocabulary board to replace absent speech. For individuals with
more persistent communication deficits, a variety of strategies are available depending
on the individual's developmental stage, communication demands, communication
context, and abilities. Examples range from simple devices on which buttons with
graphics/images are pressed to generate chunks of synthesized speech (e.g., I am
hungry) to elaborate devices that allow the individual to compose complex messages.
Individuals who may be candidates for AAC include children and adults with cerebral
palsy, individuals who have survived strokes or a head injury, and adults with
progressive neuromuscular diseases such as amyotrophic lateral sclerosis (ALS).

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What is the problem with AAC devices?

Unfortunately, for even the most proficient user, AAC is painfully slow. Individuals
without impairment generate spoken speech at rates of 150200 words per minute,
whereas proficient AAC users may generate 1012 words per minute and often must
compose messages prior to speaking. Successful implementation requires significant
support from a speech pathologist who can both program devices and train users and
family members. Methods have been developed to increase the rate of word production
(see question 12). These rate-enhancing systems can require considerable cognitive
ability, and even with rate enhancement, word output rates remain low. As a result of
this disparity, speaking individuals may dominate conversations; new rules of
communication need to be learned by everyone.

Give some examples of AT devices for persons with special

sensory impairments (e.g., hearing and/or visually impaired).

Amplification devices: Have been the mainstay for people who are hard of
hearing. Advances in digital hearing aids have allowed users to manipulate the
spectrum of sound to attenuate noise in public places and hook telephones/cell
phones and other devices directly to their hearing aids. Also, there have been
significant advances in large area amplification, such as classrooms and
theaters.

Telephone devices for the deaf (TDD; commonly referred to by the historic
initials TTY): Use QWERTY keyboards outfitted with text displays for incoming
messages that connect to standard phone lines. Two TDD users can
communicate with each other independently. A deaf user wishing to speak with
any non-TTD user can do so using a voice carry-over relay service, which voices
outgoing messages while textually displaying incoming messages. Relay
services exist in each state, allowing TTD users and people who hear to
communicate. Recently, there have been rapid advances in the use of cell phones
enabled for text messaging as well as Blackberry and Sidekick technology. For
many groups of people who are deaf, these flexible platforms have nearly
replaced TTD.

Low-tech vision aids: There are a number of low-tech vision aids that may be
useful to people with blindness, low vision, or difficulties with recognition (e.g.,
stroke). Examples include talking watches, calculators, and money identifiers.
Kiosks, ATMs, and other public information systems increasingly offer
accessibility features such as speech output. For people with low vision, there are
closed circuit televisions (CCTVs), which magnify print material and allow control
over contrast.

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Screen readers: For visually impaired individuals incapable of reading text,

there are screen readers that can read aloud electronic text, such as word
documents and Web pages.

10

How are AT devices such as ECUs and AAC controlled?

The human operator controls the AT through movement, muscle activation, or voice. If a
person can move it, AT can use it. The effectiveness of each control point is related not
only to gross and fine motor control, but also to a person's cognitive and sensory ability.
Movements interact with the AT device by way of switches. These switches or control
interfaces can take numerous forms. Simple switches may vary dramatically in size to
allow for problems with motor control. Each switch can have multiple positions or can
be placed in series with another device, such as a scanner.

One important example is the sip-and-puff switch, which involves blowing into and
sucking on a straw to activate the switch. It is generally indicated for persons with
unreliable head movements and profound loss of motor control of the body. It may also
be indicated if repetitive head movements are uncomfortable or cause overuse
syndromes. Persons with C1 and C2 spinal cord injuries typically use sip and puff,
whereas persons with C3 and C4 spinal cord injuries may opt to use chin controls or
mouthsticks. Microswitches requiring minimal effort are increasingly popular, as are
switches that can be activated by electromyography.

11

How can AT be used to access a computer?

Computers themselves may serve as AT. For example, a lightweight notebook

computer may provide a mode for notetaking and remembering. There are a variety of
ways to modify interactions with the computer. For example, input may be
accommodated by using modified keyboards, substituting voice for keyboard,
substituting sip-and-puff Morse code for keyboarding, using on-screen keyboards
activated by eye gaze, or pointing devices manipulated with the mouth, a head-
mounted laser, or trackable dot. The display can be manipulated to increase contrast,
size of text, or even size of the display itself. For people who are easily distracted (e.g.,
those with attention deficit disorder, survivors of brain injury), the display environment
may be simplified so that the focus is on salient tasks. Computer output can be
modified so that the contents of the screen are sent to a Braille display employing
electromechanically raised dots or speech output. Pointing devices can be
accommodated so that a joystick or trackball replaces the mouse, or mouse buttons
can be separated and activated by other types of switches. For people with very limited
options, single switches and scanning of the computer desktop and/or on-screen
keyboard can provide very slow access.

12

How can speed of input be increased?

For AAC devices and computer access, the rate of typing or ability to access the

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graphical interface is critical. For people with a disability who can only access a single
switch, scan technology can be used to select letters or icons on a screen. The user is
presented with rows of letters that are highlighted sequentially. The switch is hit when
the row with the desired letter is highlighted. The individual letters are then scanned,
and the switch is hit when the desired letter is highlighted. For icon selection, quadrants
of the screens are sequentially highlighted and selected to isolate individual icons. For
individuals who can use more than a single switch, it is possible to increase the rate of
typing. A very fast way of typing for single switch users is Morse code; however, this
strategy is not widely popular.

When input speed is below 10 words per minute, word prediction should be
considered. Word prediction can also be useful for individuals with reading disabilities
who have difficulty generating the correctly spelled word but can recognize the word in a
list. In word prediction, as one starts typing, the system anticipates the word or phrase
and proposes a series of choices in a list. Once the preferred choice appears, one
clicks on the choice, and the word or phrase moves into the text.

13

How is voice recognition used in AT?

Voice recognition has improved dramatically. Under the best of circumstances,

speakers who are fluent and use a standard voice can achieve dictation rates of well
over 100 words per minute with nearly 100% accuracy after as little as 15 minutes of
training the system to their voice. However, for most users, dictation rates are
substantially lower, and error rates are much higher. Voice recognition systems can
often be used entirely hands-free but are most effective when the user can incorporate
some keyboard and mouse commands. With an expert programming the system,
individuals on ventilators may be able to use voice recognition systems.

Voice recognition presents some unique cognitive challenges. It adds a cognitive load
that may be difficult for patients with limited cognitive resources. Also, proofreading
becomes an entirely different task because the errors are not in spelling but rather in
word choice. The reliability of voice recognition decreases with fluctuations in voice
quality and increases with background noise or when the user has a noticeable accent.
Because voice recognition accuracy increases as the size of the vocabulary
decreases, this technology can be very effective for applications that can be supported
with a limited number of words or commands (e.g., an environmental control unit). This
technology can be liberating or disabling and must be carefully and appropriately
recommended. The demands of commercial industry and perpetual improvements in
microprocessor technology will ensure that voice recognition technology continues to
improve.

14

How can the Internet aid AT?

The Internet can be of profound importance to individuals with disabilities. It can provide
a means to communicate with family members, participate in school, perform elements
of jobs, talk with other people with disabilities, conduct research about their condition,
or play games. For people with many disabilities, the Internet can be a barrier-free

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environment. People with disabilities can present themselves in written text, selected
pictures, and music without displacing their adaptive reference to their disability,
functional limitations, or AT. For example, e-mail in combination with appropriate AT
allows deaf students and blind students to talk to each other on campus. For people
with severe dysarthria, the disability can become irrelevant when e-mail is used to
communicate. Providing patients with Internet access and the AT necessary to access
the Internet should be a top priority for clinicians.

15

Can robots be the perfect AT solution?

Perhaps eventually, but not necessarily soon. Robotic technology has been developed
that clearly can be of benefit for people with disabilities; however, high costs and
difficulties with control limit its practicality. Past and present generation robots do not
seem to perform well outside of very controlled environments and fail at some of the
most basic tasks. Some will recall the experiments a few years ago when the most
sophisticated research robots were pitted against two-year-old toddlers. The robots
had great difficulty at tasks, such as picking up a red ball out of a group of other objects,
whereas the feisty tykes accomplished the tasks with ease. In these days of cost cutting
in medicine, cost-benefit analyses will have to demonstrate that routine use of
advanced technologies such as robots is warranted. An alternative to consider for
some limited tasks might be animal-assisted therapy.

Key Points: Assistive Devices

1

ECUs consist of five elements: the switch device, control device, connection,
target device(s), and feedback device.

Internet communication has enhanced the lives of people with disability.

Appropriate AT can significantly enhance a patient's ability to meaningfully

participate in society. Knowledge of this important topic is a key tool for
physiatrists.

Providing Internet/computer access is essential and possible through devices

such as special keyboards or voice activation software for motor impairments
and screen readers for sensory impairment.

16

Are there devices that can help with cognitive problems such as
memory loss?

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Low-tech devices such as memory books have been used for years to serve as
compensatory tools for people with cognitive deficits. Recent advances in technology
associated with personal digital assistants and smart phones make sophisticated
reminding and cueing systems readily available. Unfortunately, because of the
complexity of the interfaces, successful users are likely to be individuals who were
proficient with the devices prior to disability. Rapidly emerging technologies will
combine these devices with ubiquitous computing, wearable sensors, and other
technologies to provide highly flexible, context-driven tools to support memory, task
performance, and appropriate social interaction.

17

Why do AT devices sometimes fail or their users abandon them?

A patient's motivation and potential for use of an assistive device (gadget tolerance)
may be underestimated or overestimated by the caregiver(s) or rehabilitation team.
Often, a potential user or the rehabilitation team will have unrealistic expectations about
a device. The capabilities of, and the skills necessary to use, a device should be
understood before committing to any specific solution. If possible, equipment trials with
adequate provisions for training are helpful. Specialized centers often have sample
devices that are adjustable for individual trials. They are also likely to have therapists or
technicians familiar with the products who can train and comprehensively evaluate the
device with the patient before a final commitment.

Patient preference and self-image should be considered high priorities. Frequently, a

device's aesthetic appearance may be the sole reason it is not used. Items that draw
adverse attention, such as loud alarms used as reminders for pressure relief, rapidly fall
into disuse. Some devices simply do not accomplish their intended goals due to faulty
design. Others can cause fatigue or overuse injury, even with optimal usage techniques.
Devices can be unreliable or prone to mechanical breakdown. In general, the more
complicated a gizmo, the more likely it will break down and the more it will cost to fix it.
When possible, encouragement for use of the device should be provided.
Reassessments should be made at appropriate intervals. It is also important not to
provide too many items at once.

18

How is AT funding appropriated?

Funding of AT depends on the justification. Commercial insurance companies vary

widely in their coverage, and many policies consider AT as durable medical equipment.
Medicaid coverage varies from state to state depending on the exceptions approved
for that state and local policies. Medicare and Medicaid have similar eligibility criteria,
which require demonstration of medical necessity, not experimental, and least costly
alternative. State vocational rehabilitation agencies may purchase AT for clients when
there is a potential vocational outcome, and K-12 schools may purchase AT as part of
the students individualized education plan. For detailed information on funding, go to
INTER REF http://wata.org and click on Funding.

Websites

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INTER REF http://atto.buffalo.edu/

INTER REF www.abilityhub.com/

INTER REF www.resna.org/

INTER REF www.dors.state.md.us/DORS/ProgramServices/AssistiveTech/

INTER REF www.washington.edu/doit/

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