Expert Recommendations for a Clinical Guide Supporting the Use of Electrical Stimulation in Occupational Therapy Treatment of Spinal Cord Injury.

IMPORTANCE: Clinical application of electrical stimulation (ES) to address functional deficits for those with spinal cord injury (SCI) is not consistent among occupational therapy practitioners, likely because of limited occupational therapy-specific clinical guidelines (OT-CG). Clinicians report the need for evidence-based guidance that supports their practice. OBJECTIVE: To identify occupational therapy practitioners' needs to support ES application in treatment sessions, utility of existing clinical practice guidelines for occupational therapy practitioners, challenges and opportunities to translate research findings into clinical practice, and desirable characteristics for an occupational therapy-specific ES clinical guide. DESIGN: A panel of 7 senior occupational therapy clinicians with ES expertise was convened for two stages. In Stage 1, two focus group discussions were recorded, transcribed, analyzed, and thematically summarized. In Stage 2, panel members completed a member-check survey, and panelists reviewed a proposed outline for an OT-CG ES guide, rating the desirability of each section. SETTING: Online expert panel. PARTICIPANTS: A purposive sample of occupational therapy clinicians eligible to administer ES, actively using ES with SCI, and employed at preeminent SCI centers. RESULTS: An outline for an OT-CG to support consistent clinical use of ES among occupational therapy practitioners was developed. Three themes emerged: difficulty using clinical practice guidelines for electrical stimulation, lack of clinical examples to guide specific electrical stimulation treatment activities, and modifications to existing guidelines. CONCLUSIONS AND RELEVANCE: An outline for a proposed guideline was created; ideally, such a manual would improve treatment fidelity and predictable patient outcomes for those with SCI. What This Article Adds: A novel outline for an OT-CG was developed to provide treatment fidelity, structure to treatment approaches, and a basis for future scholarly study.

Assessing the usefulness of an mHealth strategy to support implementation of multi-faceted adaptive feeding interventions by community-based rehabilitation workers.

To assess the usefulness of an mHealth strategy to support assimilation of adaptive feeding interventions into daily practices of community-based rehabilitation (CBR) workers. The mHealth strategy was evaluated in a 4-week field test. At baseline, all participants received a 1-hour, hands-on training on adaptive feeding techniques. The intervention group (n = 12) subsequently received smartphones pre-loaded with training and demonstration videos; control group members (n = 12) did not. All were instructed to recommend adaptive feeding interventions to families on their caseload when appropriate. Both groups received weekly calls to monitor progress and discussed their experiences in post-study focus groups. The intervention group saw over twice the number of families with a child with cerebral palsy compared to the control group. For intervention group members, on-demand access to the videos increased their overall usefulness in everyday practice, enhanced their self-confidence, clarified their recommendations, and increased credibility with caregivers. In contrast, control group members implemented the adaptive feeding strategies less frequently and less confidently. mHealth strategies are a promising option for supporting geographically dispersed CBR workers implementing multi-faceted assistive technology interventions. The portability of video content reinforced learning, increased implementation of the adaptive feeding interventions, and enhanced communication with consumer.

Comprehensive Needs Assessment to Ensure Appropriate Rehabilitation Training for Community-Based Workers and Caregivers in India.

IMPORTANCE: Rehabilitation researchers and occupational therapy practitioners frequently conduct projects that involve the provision of services or the dissemination of knowledge in low- and middle-income countries (LMICs); however, the needs assessment process underlying these transcultural projects is often underreported. OBJECTIVE: To identify a comprehensive set of feeding-related training needs that reflect the culture, resources, and service delivery practices in the West Bengal region of India and that will be used to develop video-based training modules that are contextually relevant and support decentralized training of community-based rehabilitation workers and caregivers of children with cerebral palsy (CP). DESIGN: Mixed methods design using focus groups and observations. SETTING: Community setting in rural, suburban, and urban locations in West Bengal, India. PARTICIPANTS: Caregivers of children with CP and community-based rehabilitation workers with experience working with children with CP. OUTCOMES AND MEASURES: Focus groups and in-home mealtime observations. RESULTS: Several findings suggest training priorities that were not anticipated. Caregivers commonly fed children by means of hand feeding while sitting on the floor. Children were fed a limited variation of food consistencies, often in positions of neck hyperextension. Water was frequently used to stimulate swallowing. Caregivers struggled to help children with oral hygiene practices after meals. CONCLUSIONS AND RELEVANCE: A thorough needs assessment yielded insights that can favorably alter the trajectory of transcultural service and research projects. For occupational therapists who provide advice on practice, continuing education, or research in a transcultural project, the findings underscore the value of engaging local stakeholders and using firsthand observation. WHAT THIS ARTICLE ADDS: The rigorous, multistakeholder needs assessment process described herein can serve as a road map for researchers and occupational therapy practitioners conducting transcultural projects in LMICs.

Toward a national system of assistive technology outcomes measurement.

For more than two decades the assistive technology outcomes literature has featured repeated calls for clinical research to demonstrate the impact of device recommendations, as well as substantial discussion of tools for measuring AT outcomes. Unfortunately, data are still not routinely collected in most AT service delivery settings, which undermines the field. This paper describes a framework for developing a national cloud-based system of AT outcomes measurement that emerged from structured discussions with clinicians, researchers, and manufacturers. Such a system would: (a) allow collection and upload of outcomes data by geographically dispersed researchers, practitioners, and consumers; and (b) enable policymakers, third-party funders, consumers, practitioners, and researchers to retrieve outcomes data for specific disability and/or device groups.

Use of Electrical Stimulation for People With Spinal Cord Injury: A Survey of Occupational Therapy Practitioners.

IMPORTANCE: When working with clients who have experienced spinal cord injury (SCI), occupational therapy practitioners can face challenges in achieving desired results during functional activity when using electrical stimulation (ES) interventions. In an effort to understand current practice, a survey study was conducted. OBJECTIVE: For people with SCI, ES elicits positive physiological effects; however, no implementation guidelines exist for upper extremity application of ES for this population. Therefore, we surveyed occupational therapy practitioners about their use of ES with clients who have cervical-level SCI. DESIGN: A 33-item, 20-min online survey was used. PARTICIPANTS AND SETTING: We queried 57 occupational therapy practitioners with active caseloads in regional rehabilitation centers specializing in SCI, both outpatient and inpatient. RESULTS: For clients with SCI, occupational therapy practitioners used ES most often for grasp-and-release, reaching, and grip or pinch activities using a broad range of parameter settings. Among respondents, 43% did not use a specific treatment protocol; 27% used research evidence to guide selection of parameters. CONCLUSIONS AND RELEVANCE: Findings suggest that ES treatment parameters are not uniformly applied, introducing potential unknown effects on client outcomes and undermining treatment fidelity. WHAT THIS ARTICLE ADDS: Our survey of occupational therapy practitioners regarding their practice and use of ES interventions with this population revealed variation in application of ES treatment parameters. Understanding different treatment approaches and justification used when applying ES to clients with SCI is an important first step in unifying and promoting best practice and maximizing patient outcomes.

Self-reported difficulty and preferences of wheeled mobility device users for simulated low-floor bus boarding, interior circulation and disembarking.

BACKGROUND: Low ridership of public transit buses among wheeled mobility device users suggests the need to identify vehicle design conditions that are either particularly accommodating or challenging. The objective of this study was to determine the effects of low-floor bus interior seating configuration and passenger load on wheeled mobility device user-reported difficulty, overall acceptability and design preference. METHODS: Forty-eight wheeled mobility users evaluated three interior design layouts at two levels of passenger load (high vs. low) after simulating boarding and disembarking tasks on a static full-scale low-floor bus mockup. RESULTS: User self-reports of task difficulty, acceptability and design preference were analyzed across the different test conditions. Ramp ascent was the most difficult task for manual wheelchair users relative to other tasks. The most difficult tasks for users of power wheelchairs and scooters were related to interior circulation, including moving to the securement area, entry and positioning in the securement area and exiting the securement area. Boarding and disembarking at the rear doorway was significantly more acceptable and preferred compared to the layouts with front doorways. CONCLUSION: Understanding transit usability barriers, perceptions and preferences among wheeled mobility users is an important consideration for clinicians who recommend mobility-related device interventions to those who use public transportation. Implications for Rehabilitation In order to maximize community participation opportunities for wheeled mobility users, clinicians should consider potential public transit barriers during the processes of wheelchair device selection and skills training. Usability barriers experienced by wheeled mobility device users on transit vehicles differ by mobility device type and vehicle configurations. Full-scale environment simulations are an effective means of identifying usability barriers and design needs in people with mobility impairments and may provide an alternative model for determining readiness for using fixed route buses or eligibility for paratransit.

Effects of transit bus interior configuration on performance of wheeled mobility users during simulated boarding and disembarking.

The emergence of low-floor bus designs and related regulatory standards in the U.S. have resulted in substantial improvements in public transit accessibility. However, passengers using wheeled mobility devices still experience safety concerns and inefficiencies in boarding, disembarking, and interior circulation on low-floor buses. This study investigates effects of low-floor bus interior configuration and passenger crowding on boarding and disembarking efficiency and safety. Users of manual wheelchairs (n = 18), powered wheelchairs (n = 21) and electric scooters (n = 9) simulated boarding and disembarking in three interior layout configurations at low and high passenger crowding conditions on a full-scale laboratory mock-up of a low-floor bus. Dependent measures comprised task times and critical incidents during access ramp use, fare payment, and movement to and from the doorway and wheeled mobility securement area. Individual times for unassisted boarding ranged from 15.2 to 245.3 s and for disembarking ranged from 9.1 to 164.6 s across layout and passenger crowding conditions. Nonparametric analysis of variance showed significant differences and interactions across vehicle design conditions, passenger load and mobility device type on user performance. The configuration having electronic on-board fare payment, rear-bus entrance doorways and adjacent device securement areas demonstrated greatest efficiency and safety. High passenger load adversely impacted efficiency and frequency of critical incidents during on-board circulation across all three layouts. Findings have broader implications for improving transit system efficiency and quality of service across the spectrum of transit users.

Development and preliminary evaluation of the caregiver assistive technology outcome measure.

INTRODUCTION: Assistive technology is often recommended with the aim of increasing user independence and reducing the burden on informal caregivers. However, until now, there has been no tool to measure the outcomes of this process for caregivers. OBJECTIVES: To describe the development of the Caregiver Assistive Technology Outcome Measure (CATOM), a tool developed to measure the impact of assistive technology interventions on the burden experienced by informal caregivers, and to undertake preliminary evaluation of its psychometric properties. METHODS: Based on an existing conceptual framework, existing measures were reviewed to identify potential items in a preliminary version of the measure. Cognitive interviewing was used to identify items needing clarification. A revised CATOM and manual were then reviewed by clinicians. After revising some items based on the interview findings, the measure was piloted as part of an intervention study examining the impact of assistive technology on the users' informal caregivers (n = 44). RESULTS: Based on a review of 12 existing measures, a 3-part measure was developed and questions were refined based on cognitive interviews with informal caregivers and feedback experienced assistive technology practitioners. For the activity-specific and overall portions of the measure, the 6-week, test-retest intraclass correlations coefficients were 0.88 (95% CI 0.64-0.96) and 0.86 (95% CI 0.60-0.95), respectively. The CATOM data correlated as hypothesized with other measures. CONCLUSION: The CATOM is a promising measure with good content validity and encouraging psychometric properties.

Consumer perspectives on assistive technology outcomes.

PURPOSE: The current study explored domains of assistive technology (AT) device outcomes that are most valued by AT users. A secondary objective was to identify elements in the device acquisition process that affect outcomes. METHOD: Focus groups were conducted at geographically dispersed locations within the USA. The groups were moderated by experienced AT practitioners who followed a detailed procedure emphasizing a nominal group facilitation technique. RESULTS: Twenty-four adult AT users, representing a range of ages and disability populations, participated in four focus groups. Many had over 15 years of experience with multiple device types. Qualitative analysis yielded 13 threads that embodied salient outcome domains (e.g. independence, subjective well-being, participation in work and school, cost-effectiveness) and key factors associated with the device acquisition process (e.g. lengthy periods of frustration, variable quality of service providers). Ironically, these data were evoked only after the term "outcomes" was omitted from focus group questions. CONCLUSIONS: AT outcomes studies are needed that report data regarding (a) the impact of AT on participation, (b) costs of AT provision and (c) key elements in the AT service delivery process. Future studies will be further strengthened to the extent that their methodologies actively assimilate consumer perspectives. Implications for Rehabilitation Consumers highly value the impact of AT devices on their independence, subjective well-being and participation in work and school. The process of acquiring assistive technology devices is often lengthy and frustrating for consumers. Future AT outcomes research should report descriptive data regarding service delivery processes, as well as long-term impacts for consumers. Practitioners and researchers should avoid the use of potentially confusing professional jargon when administering surveys to consumers.

Effects of an assistive technology intervention on older adults with disabilities and their informal caregivers: an exploratory randomized controlled trial.

OBJECTIVE: The aim of this study was to demonstrate experimentally that an assistive technology (AT) intervention improves older AT users' activity performance and satisfaction with activity performance and decreases their caregivers' sense of burden. DESIGN: This study was a delayed intervention, randomized control trial. Baseline data were collected on 44 community-dwelling AT user-caregiver dyads in Vancouver, British Columbia, and Montreal, Quebec. The primary outcome measures for AT users were the satisfaction and accomplishment scales from the Assessment of Life Habits. The primary outcome measure for caregivers was the Caregiver Assistive Technology Outcome Measure, which assessed burden associated with dyad-identified problematic activities. RESULTS: After the intervention, assistance users in the immediate intervention group reported significantly increased satisfaction with activity performance (P < 0.001) and improved accomplishment scores (P = 0.014). Informal caregivers in the immediate intervention group experienced significantly decreased burden with the dyad-identified problematic activity (P = 0.013). Participants in the delayed intervention group experienced similar benefits after the intervention. Improvements for both groups were mostly maintained 4 mos after the conclusion of the intervention. CONCLUSIONS: This is the first experimental study to demonstrate that the provision of AT decreases caregiver burden. If confirmed and extended by subsequent research, the findings have significant policy and practice implications and may enable health care providers to advocate for improved access to AT provision and the related follow-up services.

How assistive technology use by individuals with disabilities impacts their caregivers: a systematic review of the research evidence.

Informal caregivers are a critical yet frequently unacknowledged part of the healthcare system. It is commonly presumed that providing assistive technology will decrease the burden of their care provision; however, no review has evaluated the evidence behind this assumption. Therefore, a systematic review was undertaken to evaluate evidence of the impact of assistive technology use by care recipients on their informal caregivers. Data sources included EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsychINFO, PubMed, and active researchers in this area. Twenty-two studies met the specified inclusion criteria. Collectively, the findings suggest that assistive technology use helps caregivers by diminishing some of the physical and emotional effort entailed in supporting individuals with disability. However, confidence in this causal connection is limited because of the study designs that were used. This undermines the understanding of the impacts of assistive technology use on the users' informal caregivers.

Low-floor bus design preferences of walking aid users during simulated boarding and alighting.

Low-floor buses represent a significant improvement in accessible public transit for passengers with limited mobility. However, there is still a need for research on the inclusive design of transit buses to identify specific low-floor bus design conditions that are either particularly accommodating or challenging for passengers with functional and mobility impairments. These include doorway locations, seating configuration and the large front wheel-well covers that collectively impact boarding, alighting and interior movement of passengers. Findings from a laboratory study using a static full-scale simulation of a lowfloor bus to evaluate the impact of seating configuration and crowding on interior movement and accessibility for individuals with and without walking aids are presented (n=41). Simulated bus journeys that included boarding, fare payment, seating, and alighting were performed. Results from video observations and subjective assessments showed differences in boarding and alighting performance and users' perceptions of task difficulty. The need for assistive design features (e.g. handholds, stanchions), legroom and stowage space for walking aids was evident. These results demonstrate that specific design conditions in low-floor buses can significantly impact design preference among those who use walking aids. Consideration of ergonomics and inclusive design can therefore be used to improve the design of low-floor buses.

Activities of suppliers and technicians during the provision of complex and standard wheeled mobility devices.

PURPOSE: The objective of this time-motion study was to document the type and duration of activities performed by wheelchair suppliers during the provision of wheeled mobility and seating devices. METHOD: Researchers observed eight rehabilitation technology suppliers and four rehabilitation technicians over two weeks in two metropolitan areas. RESULTS: Data were collected on 500 client interactions, resulting in 864 activities that were classified as complex rehabilitation technology (CRT) or standard wheeled mobility equipment (STD). Data indicate that the majority of the activities were relatively short (median = 0.25 hours) but the distribution of activity durations was highly skewed. A difference existed in activity time across device complexity (p = 0.039), with CRT-related activities averaging about 0.1 hours longer in duration than STD activities. When assessing mobility types independently, activity times across device complexity differed for manual and power wheelchair at p = 0.0001 and p = 0.086 levels, respectively. When activities were tabulated into daily episodes for each client, CRT manual wheelchair times were higher than STD (p = 0.003), whereas power wheelchair episode times showed no difference across device complexity (p = 0.245). CONCLUSION: The results illustrate that the activities undertaken by suppliers during wheelchair provision vary widely and device complexity and device type impacts the types and duration of these activities. [Box: see text].

A tool for rapid assessment of product usability and universal design: development and preliminary psychometric testing.

BACKGROUND: While there are many available tools and methods to evaluate product usability, few have been tested on user groups with disabilities and even fewer systematically consider universal design principles. OBJECTIVE: This paper describes the development and preliminary psychometric testing of the Rapid Assessment of Product Usability & Universal Design (RAPUUD), a 12-item user-report tool based on the seven principles of universal design. METHOD: A preliminary set of items was created to elicit ratings of diverse product characteristics (e.g., physical effort, cognitive effort, assistance required, safety). Data were gathered from 61 participants who rated the usability of products they use in their own environments. RESULTS: Each item elicited a full range of responses, with no apparent floor or ceiling effects. Collectively, the 12 items achieved a high internal consistency (Cronbach's α=0.80). The data indicate that the tool was sensitive to differences in functional abilities, as well as differences in product characteristics. The instrument was usable for a range of consumer products, though not all items were appropriate for each and every product. CONCLUSION: The results suggest that the instrument could become a pragmatic tool for designers to identify usability problems experienced by a diversity of user populations.

Treatment theory, intervention specification, and treatment fidelity in assistive technology outcomes research.

Recent reports in the rehabilitation literature have suggested that treatment theory, intervention specification, and treatment fidelity have important implications for the design, results, and interpretation of outcomes research. At the same time, there has been relatively little discussion of how these concepts bear on the quality of assistive technology (AT) outcomes research. This article describes treatment theory, intervention specification, and treatment fidelity as interconnected facets of AT outcome studies that fundamentally affect the interpretation of their findings. The discussion of each is elucidated using case examples drawn from the AT outcomes research literature. Recommendations are offered for strengthening these components of AT outcomes research.

Development and evaluation of a new taxonomy of mobility-related assistive technology devices.

OBJECTIVE: This article reports on the development of a new taxonomy for mobility-related assistive technology devices. DESIGN: A prototype taxonomy was created based on the extant literature. Five mobility device experts were engaged in a modified Delphi process to evaluate and refine the taxonomy. RESULTS: Multiple iterations of expert feedback and revision yielded consensual agreement on the structure and terminology of a new mobility device taxonomy. The taxonomy uses a hierarchical framework to classify ambulation aids and wheeled mobility devices, including their key features that impact mobility. Five attributes of the new taxonomy differentiate it from previous mobility-related device classifications: (1) hierarchical structure, (2) primary device categories are grouped based on their intended mobility impact, (3) comprehensive inclusion of technical features, (4) a capacity to assimilate reimbursement codes, and (5) availability of a detailed glossary. CONCLUSIONS: The taxonomy is intended to support assistive technology outcomes research. The taxonomy will enable researchers to capture mobility-related assistive technology device interventions with precision and provide a common terminology that will allow comparisons among studies. The prominence of technical features within the new taxonomy will hopefully promote research that helps clinicians predict how devices will perform, thus aiding clinical decision making and supporting funding recommendations.

Mobility-related assistive technology device classifications: implications for outcomes research.

This article evaluates six mobility-related device classifications for their ability to support assistive technology outcomes research. Our evaluation considered classifications that had been created for various purposes, including those created to support third-party reimbursement decisions, consumer education and safety, and research. Classifications were excluded if their scope was limited to a single mobility device domain. The six classifications were analyzed according to a common framework: (1) purpose, (2) completeness, (3) granularity, and (4) research applications. Although each classification addresses three principal mobility device domains (ambulation aids, manual wheelchairs, and powered mobility devices), the analysis revealed a range of detail with which each domain is described. Some classifications were hampered by their use of unclear idiosyncratic terminology, whereas others conflated multiple device features within device categories. The analysis suggests that existing classifications do not fully meet the needs of assistive technology outcomes researchers. Creation of a common taxonomy of mobility devices is needed to serve the needs of the assistive technology outcomes research field.

A conceptual framework of outcomes for caregivers of assistive technology users.

OBJECTIVE: To develop and validate the content of a conceptual framework concerning outcomes for caregivers whose recipients are assistive technology users. DESIGN: The study was designed in four stages. First, a list of potential key variables relevant to the caregivers of assistive technology users was generated from a review of the existing literature and semistructured interviews with caregivers. Second, the variables were analyzed, regrouped, and partitioned, using a conceptual mapping approach. Third, the key areas were anchored in a general stress model of caregiving. Finally, the judgments of rehabilitation experts were used to evaluate the conceptual framework. RESULTS: An important result of this study is the identification of a complex set of variables that need to be considered when examining the experience of caregivers of assistive technology users. Stressors, such as types of assistance, number of tasks, and physical effort, are predominant contributors to caregiver outcomes along with caregivers' personal resources acting as mediating factors (intervening variables) and assistive technology acting as a key moderating factor (effect modifier variable). CONCLUSIONS: Recipients' use of assistive technology can enhance caregivers' well being because of its potential for alleviating a number of stressors associated with caregiving. Viewed as a whole, this work demonstrates that the assistive technology experience of caregivers has many facets that merit the attention of outcomes researchers.

Measuring usability of assistive technology from a multicontextual perspective: the case of power wheelchairs.

Assistive technology (AT) devices enable people with disabilities to function in multiple contexts and activities. The usability of such devices is fundamentally indicative of the user's level of participation in multiple roles and occupations. Seventy people who used power wheelchairs were interviewed using a novel tool, the Usability Scale for Assistive Technology (USAT). The USAT uses a human factors science framework to investigate the wheelchair user's perceived independence in mobility-related activities within home, workplace, community, and outdoors in accordance with the characteristics of the wheelchair, environmental factors, and abilities and skills of the user to operate the wheelchair. Descriptive analysis of the data revealed usability issues with the use of power wheelchairs in all contexts. Users confronted far more significant issues within the community and outdoor environment compared with those at home and in the workplace. These issues have been elucidated and applied to an intervention framework with relevance to a multitude of AT stakeholders.

Conceptualization and measurement of assistive technology usability.

UNLABELLED: The concept of product usability has been discussed in several areas of product research and development. Usability, within the realm of assistive technology (AT) devices, determines how effectively and efficiently AT users with disabilities can function in different contexts and environments. OBJECTIVE: This article conceptualizes and proposes the significance of AT usability and its measurement in entirety from a human factors perspective. Conceptual models that characterize the interaction of the AT user, the AT device, the context and the involved activity is considered to be the hallmark of measurement of AT usability. On that basis, the article highlights the methodology and the initial progress of the development of an AT outcome tool, the Usability Scale for Assistive Technology (USAT), to measure self reported degree of AT usability. METHODOLOGY: In order to identify usability indicators for measurement, a qualitative study was conducted by exploring the experiences of AT users. Ten participants who used either wheeled mobility or computer based AT devices were interviewed with questions based on the theme of a usability framework. RESULTS: The coded interview data generated more than 800 usability indicators specific to the two categories of AT devices. These indicators were mapped to a generic usability criteria list for construction of the USAT-Wheeled Mobility and the USAT-Computer Access. IMPLICATIONS: The USAT, when developed, is projected to be valid and useful for AT outcomes research as well as clinical practice. The use of the USAT will enable researchers and clinicians to comprehensively identify factors that underlie effectiveness and efficiency in AT device use and establish intervention protocols to optimize user-AT interaction.