How a diverse research ecosystem has generated new rehabilitation technologies: Review of NIDILRR's Rehabilitation Engineering Research Centers.

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.

Development and evaluation of the environment and communication assessment toolkit with speech-language pathologists.

Communication dysfunction that results from dementia can be exacerbated by environmental barriers such as inadequate lighting, noisy conditions, poor or absent environmental cues, and visual clutter. Speech-language pathologists (SLPs) should address these environmental barriers as part of a comprehensive treatment plan for clients with dementia. The Environment and Communication Assessment Toolkit for Dementia Care (ECAT) was evaluated by SLPs to determine: (1) changes in awareness of environmental factors prior to and after training; (2) impact of the ECAT on practice as measured by changes in the number of environmental modifications recommended and made prior to and after training; (3) utility of the information as measured by the helpfulness, amount of new information, and usefulness of the ECAT; and (4) usability of the ECAT materials based on ease of use. The SLPs used the ECAT with clients with dementia who had functional limitations and required substantial assistance with daily activities. Results indicate that the ECAT is an effective tool for SLPs, providing information about the impact of the environment on communication and supplying sufficient resources to make recommendations and implement effective interventions. The ECAT successfully increased awareness of environmental modifications, influenced the practice of recommending environmental modifications, and had utility in diverse aspects of clinical practice.

A model of job activity description for workplace accommodation assessment.

Workplace accommodations to enable employees with disabilities to perform essential job tasks are an important strategy ways for increasing the presence of people with disabilities in the labor market. However, assessments, which are crucial to identifying necessary accommodations, are typically conducted using a variety of methods that lack consistent procedures and comprehensiveness of information. This can lead to the rediscovery of the same solutions over and over, inability to replicate assessments and a failure to effectively meet all of an individual's accommodation needs. To address standardize assessment tools and processes, a taxonomy of demand-producing activity factors is needed to complement the taxonomies of demand-producing person and environment factors already available in the International Classification of Functioning, Disability and Health (ICF). The purpose of this article is to propose a hierarchical model of accommodation assessment based on level of specificity of job activity. While the proposed model is neither a taxonomy nor an assessment process, the seven-level hierarchical model provides a conceptual framework of job activity that is the first step toward such a taxonomy as well as providing a common language that can bridge the many approaches to assessment. The model was designed and refined through testing against various job examples. Different levels of activity are defined to be easily linked to different accommodation strategies. Finally, the levels can be cross-walked to the ICF, which enhances its acceptability, utility and universality.

Collective making: Co-designing 3D printed assistive technologies with occupational therapists, designers, and end-users.

In this study, we conducted four participatory workshops to facilitate co-designing 12 writing assistive technology (AT) interventions with occupational therapists, industrial designers, and an end-user with physical impairments. We observed participants' activities during the workshops and held a post-workshop follow-up reflection session where we invited the OTs and the end-user to share their experience about the co-design activities and co-created devices. The study findings revealed characteristics of the clinical-technical-individual co-design contributions that are conducive to the collective making of usable and useful AT prototypes. We propose CoDEA (Codesigning Assistive Technologies), a potential framework that offers to follow four stages of co-experimentation, co-development, co-evaluation, and co-refinement and define specific roles and activities of OT-designer-user in each step to co-design 3D printed ATs successfully. We recommend utilizing a comprehensive approach to co-designing ATs by using prototyping toolkits/3D printing together with a designerly way of thinking to achieve state-of-the-art AT solutions.

Effects of telerehabilitation on physical function and disability for stroke patients: a randomized, controlled trial.

BACKGROUND AND PURPOSE: To determine the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on physical function, and secondarily on disability, in veterans poststroke. METHODS: We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans with stroke from 3 Veterans Affairs medical centers. Veterans with a stroke in the preceding 24 months were randomized to the STeleR intervention or usual care. The STeleR intervention consisted of 3 home visits, 5 telephone calls, and an in-home messaging device provided over 3 months to instruct patients in functionally based exercises and adaptive strategies. Usual care participants received routine rehabilitation care as prescribed by their physicians. The primary outcome measures were improvement in function at 6 months, measured by both the motor subscale of the Telephone Version of Functional Independence Measure and by the function scales of the Late-Life Function and Disability Instrument. RESULTS: The 2 complementary primary outcomes (Late-Life Function and Disability Instrument Function and Telephone Version of Functional Independence Measure) improved at 6 months for the STeleR group and declined for the usual care group, but the differences were not statistically significant (P=0.25, Late-Life Function and Disability Instrument; P=0.316). Several of secondary outcomes were statistically significant. At 6 months, compared with the usual care group, the STeleR group showed statistically significant improvements in 4 of the 5 Late-Life Function and Disability Instrument disability component subscales (P<0.05), and approached significance in 1 of the 3 Function component subscales (P=0.06). CONCLUSIONS: The STeleR intervention significantly improved physical function, with improvements persisting up to 3 months after completing the intervention. STeleR could be a useful supplement to traditional poststroke rehabilitation given the limited resources available for in-home rehabilitation for stroke survivors. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00384748.

The TechSAge Minimum Battery: A multidimensional and holistic assessment of individuals aging with long-term disabilities.

BACKGROUND: People with disabilities acquired in early to mid-life are living longer, contributing to growing numbers of older adults who are aging with disability, an understudied population likely to be underserved. OBJECTIVES: This paper demonstrates the usefulness of the TechSAge Minimum Battery as a holistic assessment of health for people aging with disabilities. METHODS: Survey data of socio-demographic and health characteristics were collected from 176 older adults with long-term vision, hearing, and/or mobility disabilities. A series of descriptive and bivariate analyses were conducted to illustrate the heterogeneity of the sample. An in-depth analysis of the subsample with vision difficulty was conducted to highlight the tool's value in assessing detailed contextual information for a specific disability. RESULTS: Prevalence of health conditions (M = 4.1; SD = 2.5), prescription medications (M = 4.1; SD = 3.9), and serious functional difficulties (M = 1.6; SD = 0.85) indicated a fair degree of comorbidity, but with considerable variation in number and type among individuals. Subjective health ratings were high overall, but lower scores were correlated with additional comorbidities (r = -0.31-0.40, p =<.001). Analyses of the subsample with vision difficulty demonstrated heterogeneity in functional capacity, degree of impairment, duration, and use of supportive aids. CONCLUSIONS: Findings highlighted the heterogeneity among people aging with disability and demonstrated the importance of capturing multi-dimensional factors inclusive of an individual's capacity, context, and personal factors, which the Minimum Battery provides in an integrated assessment. Potential healthcare applications of the tool are discussed with implications for bridging aging and disability services.

Effects of bilateral swing-away grab bars on the biomechanics of stand-to-sit and sit-to-stand toilet transfers.

PURPOSE: Kinetic characteristics of transfers to and from a toilet performed using bilateral grab bars are not fully quantified to inform grab bar design and configuration. The purpose of this study was to (1) determine effects of bilateral swing-away grab bars on peaks of ankle, knee and hip joint moments during grab bar assisted stand-to-sit and sit-to-stand transfers; and (2) determine effects of three different heights and widths of swing-away grab bars on the same kinetic characteristics. METHODS: Healthy subjects (N = 11, age 25-58 years) performed stand-to-sit and sit-to-stand transfers with and without grab bars. In transfers with grab bars, 9 grab bar configurations were tested by varying their height from the floor (0.787 m, 0.813 m, 0.838 m; 31″-33″) and width, the distance of each grab bar from the toilet's centerline (0.330 m, 0.356 m, 0.381 m; 13″-15″). Motion capture, force plate and inverse dynamics analysis were used to determine lower limb joint moments. RESULTS: The use of bilateral grab bars generally reduced the peak magnitude of extension moments at lower limb joints during stand-to-sit and sit-to-stand transfers (p < .05), except the ankle joint moments during stand-to-sit transfers. Relatively few differences in peak joint moments were found between studied grab bar widths or heights. CONCLUSION: The obtained results suggest that the studied ranges of grab bar configurations reduce moment demands on the leg joints and thus decrease difficulty and required lower limb muscle effort to perform the transfers. Implications for Rehabilitation Maximizing the benefits of assistive technology in the built environment requires a careful assessment of their spatial and configurational dimensions, especially in respect to the needs and abilities of the intended users. Examining the kinetic characteristics of transfers to and from a toilet using the swing-away grab bars is useful for informing grab bar design and configuration recommendations for assisted living and skilled nursing facilities. Our findings suggest that the swing-away grab bars located at certain ranges are a reasonable alternative to the grab bars mandated by the current Americans with Disabilities Act (ADA) Accessibility Guidelines. Future research investigating the effects of grab bars on transfer performance should consider additional factors, such as a wider range of abilities and transfer methods of the users.

A retrospective analysis of recommendations for workplace accommodations for persons with mobility and sensory limitations.

Many studies of workplace accommodations have primarily focused on a particular disability or functional limitation. The need exists for a broad-based study of the types and frequency of accommodations recommended for a variety of functional limitations, including multiple limitations. The researchers conducted a retrospective analysis of 266 persons who received vocational rehabilitation assessment to determine the frequency and types of recommended workplace accommodations. Computer systems/components and special tools/furnishings were the most frequently reported types of recommendations, regardless of functional limitation, whereas adaptive strategies were least likely to be suggested. In general, most job accommodation recommendations targeted the individual work space and were intended to assist in the completion of specific job tasks. Findings indicate that recommendations for workplace accommodations were surprisingly similar across all functional limitation groups.

Needs Assessment-mHealth Applications for People Aging with Multiple Sclerosis.

Multiple sclerosis (MS) is a complex inflammatory disorder of the central nervous system. It is characterized by a large number and variety of symptoms, with cognitive changes and mobility limitations being the most significant ones related to disability. A majority of individuals diagnosed with MS experience a major decline in their abilities due to the progression of MS after 5 years post-diagnosis. Following this period, they need to learn how to cope with the functional limitations caused by the disease and how to age with MS due to an early onset of age-related problems. As a result, they have to manage the effects of the condition on their lives every day. Self-management can help mitigate the symptoms associated with MS. Mobile health (mHealth) apps provide potential support for self-management of the condition as they represent robust technologies that have potential to include all the interventions proven to be useful to manage multiple health problems. However, none of the mobile applications on the market for people with MS present the holistic and integrative app that provides their users with a variety of the valuable functional features for the self-management of their health. Furthermore, there is a lack of literature on needs and concerns of individuals aging with MS to inform the design of the mobile technologies and related functional features of the MS-specific mobile apps. The purpose of this paper is to report the results of a qualitative study with individuals aging with MS, to (1) understand their health and wellness self-management needs, and (2) recognize the opportunities to meet those needs through mobile technologies and specific functional features. A systematic review of the functional features in MS-specific mobile applications is presented with the purpose to understand the current state of the utility of mobile apps and to identify two applications with the most versatile functionality.

Closing the Capacity-Ability Gap: Using Technology to Support Aging With Disability.

There is a critical need to develop supports for older adults who have a wide range of abilities, including those aging with long-term impairments. Without appropriate support, many individuals will be functioning below optimal levels and will face participation barriers. Technology holds great promise to provide individualized support for a wide range of abilities and for a variety of domains. To ensure technology interventions are designed well and meet research-documented user requirements, we need more specific, actionable models to provide guidance for those developing and designing interventions. In this paper, we present the TechSAge Aging and Disability Model to bridge models from the aging and disability literatures and to disambiguate the population of individuals aging into disability from those aging with disability (i.e., pre-existing impairments). We also present the TechSAge Technology Intervention Model to support aging with pre-existing impairments, which provides direction and touch points for technology interventions. These models reflect the complex and dynamic interaction between age-related changes and an individual's prior capabilities and limitations. We describe the need for these models with respect to filling a gap in the disability and aging literature by highlighting the importance of differentiating between age-related changes and long-term impairments when designing interventions. We also show the need for quantitative and qualitative data to refine the models given complexities of the current state of the literature and survey data. The TechSAge Technology Intervention Model can be used to drive and inform technology redesign and development.

Development and validation of a remote home safety protocol.

AIM: Environmental assessments and subsequent modifications conducted by healthcare professionals can enhance home safety and promote independent living. However, travel time, expense and the availability of qualified professionals can limit the broad application of this intervention. Remote technology has the potential to increase access to home safety evaluations. PURPOSE: This study describes the development and validation of a remote home safety protocol that can be used by a caregiver of an elderly person to video-record their home environment for later viewing and evaluation by a trained professional. METHODS: The protocol was developed based on literature reviews and evaluations from clinical and content experts. Cognitive interviews were conducted with a group of six caregivers to validate the protocol. RESULTS: The final protocol included step-by-step directions to record indoor and outdoor areas of the home. The validation process resulted in modifications related to safety, clarity of the protocol, readability, visual appearance, technical descriptions and usability. CONCLUSIONS: Our final protocol includes detailed instructions that a caregiver should be able to follow to record a home environment for subsequent evaluation by a home safety professional. Implications for Rehabilitation The results of this study have several implications for rehabilitation practice The remote home safety evaluation protocol can potentially improve access to rehabilitation services for clients in remote areas and prevent unnecessary delays for needed care. Using our protocol, a patient's caregiver can partner with therapists to quickly and efficiently evaluate a patient's home before they are released from the hospital. Caregiver narration, which reflects a caregiver's own perspective, is critical to evaluating home safety. In-home safety evaluations, currently not available to all who need them due to access barriers, can enhance a patient's independence and provide a safer home environment.

Beyond ADA Accessibility Requirements: Meeting Seniors' Needs for Toilet Transfers.

PURPOSE: To identify the optimal spatial and dimensional requirements of grab bars that support independent and assisted transfers by older adults and their care providers. BACKGROUND: Although research has demonstrated that toilet grab bars based on the Americans with Disabilities Act (ADA) Accessibility Standards do not meet the needs of older adults, the specific dimensional requirements for alternative configurations are unknown. METHODS: A two-phased study with older adults and care providers in residential facilities was conducted to determine the optimal requirements for grab bars. Seniors and caregivers in skilled nursing facilities performed transfers using a mock-up toilet. In Phase 1, participants evaluated three grab bar configurations to identify optimal characteristics for safety, ease of use, comfort, and helpfulness. These characteristics were then validated for using ability-matched samples in Phase 2. RESULTS: The optimal configuration derived in Phase 1 included fold-down grab bars on both sides of the toilet (14" from centerline [CL] of toilet, 32" above the floor, and extended a minimum of 6" in front of the toilet) with one side open and a sidewall 24" from CL of toilet on the other. Phase 2 feedback was significantly positive for independent and one-person transfers and somewhat lower, albeit still positive, for two-person transfers. CONCLUSION: The study provides substantial evidence that bilateral grab bars are significantly more effective than those that comply with current ADA Accessibility Standards. Findings provide specific spatial and dimensional attributes for grab bar configurations that would be most effective in senior facilities.

The effects of in-home rehabilitation on task self-efficacy in mobility-impaired adults: A randomized clinical trial.

OBJECTIVES: To examine the effect on mobility self-efficacy of a multifactorial, individualized, occupational/physical therapy (OT/PT) intervention delivered via teletechnology or in-home visits. DESIGN: Randomized, clinical trial. SETTING: One Department of Veterans Affairs and one private rehabilitation hospital. PARTICIPANTS: Sixty-five community-dwelling adults with new mobility devices. Thirty-three were randomized to the control or usual care group (UCG), 32 to the intervention group (IG). INTERVENTION: Four, once-weekly, 1-hour OT/PT sessions targeting three mobility and three transfer tasks. A therapist delivered the intervention in the traditional home setting (trad group n = 16) or remotely via teletechnology (tele group n = 16). MEASUREMENTS: Ten-item Likert-scale measure of mobility self-efficacy. RESULTS: The IG had a statistically significantly greater increase in overall self-efficacy over the study period than the UCG (mean change: IG 8.8, 95% confidence interval (CI) = 3.8-13.7; UCG 1.2, 95% CI = -5.8-8.2). Descriptively, the IG exhibited positive changes in self-efficacy for all tasks and greater positive change than the UCG on all items with the exception of getting in and out of a chair. Comparisons of the two treatment delivery methods showed a medium standardized effect size (SES) in both the tele and trad groups, although it did not reach statistical significance for the tele group (SES: tele = 0.35, 95% CI = -2.5-0.95; trad = 0.54, 95% CI = 0.06-1.14). CONCLUSION: A multifactorial, individualized, home-based OT/PT intervention can improve self-efficacy in mobility-impaired adults. The trend toward increased self-efficacy irrespective of the mode of rehabilitation delivery suggests that telerehabilitation can be a viable alternative to or can augment traditional in-home therapy.

Development of an evidence-based conceptual framework for workplace assessment.

One solution to the underutilization of workplace accommodations is to use teleconferencing technology to conduct remote assessments, effectively expanding the geographical area that experienced rehabilitation specialists can cover. However, such an effort requires a highly structured and comprehensive assessment protocol. This paper reports on the analysis of 53 existing assessments to develop a conceptual framework for assessment and the use of that framework to evaluate the applicability of 10 work-related assessment protocols for remote tele-assessment. While none of the 10 protocols were found to be sufficiently comprehensive for our purposes, the conceptual framework itself will serve as an important tool to structure a new comprehensive protocol that will be developed. Moreover, the framework can also be used by providers of workplace assessments to evaluate the suitability of any assessment protocol to meet the needs of any particular individual or workplace situation.

Using remote assessment to provide home modification services to underserved elders.

PURPOSE: Although remote home assessment would enable specialists to prescribe home modifications for anyone, anywhere, the strategy is dependent on the ability to provide specialists with the same information as an in-home assessment. The purpose of this paper is to document that remote assessment is feasible and concurs largely with traditional in-home assessment based on expert judgment. DESIGN AND METHODS: We compared two new remote assessments, a "zero-tech" paper-and-pencil protocol and a "high-tech" televideo protocol, to traditional in-home assessments to determine the equivalence of the remote and in-home assessments. We determined equivalence by comparing each of the remote assessments to a traditional in-home assessment in the same home. In-home assessments were conducted by home-modification specialists in all homes. Data collection for the remote protocols was conducted by individuals inexperienced in home modification. Assessment data from the remote protocols were analyzed by specialists to diagnose problems and prescribe solutions. RESULTS: The overall rates of correct problem identification (i.e., Sensitivity + Specificity) were significant (p =.000) for both the remote paper-and-pencil (96.4%) and remote televideo (87.1%) protocols. Similarly, rates of agreement in recommendations of solutions were significant (p =.000) for both remote assessments (78.8% and 77.4%, respectively). IMPLICATIONS: The need for home-modification services, particularly in rural areas, far exceeds the capacity of specialists to provide them. Our findings suggest that remote assessments can potentially be used to identify mobility and safety problems in the home as well as to recommend solutions to those problems. As a result, remote home assessment has the potential to provide underserved elders with access to home-modification services that have heretofore eluded them.

A randomized controlled trial on Stroke telerehabilitation: The effects on falls self-efficacy and satisfaction with care.

We determined the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on falls-related self-efficacy and satisfaction with care. We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans from three Veterans Affairs Medical Centers. Participants who experienced a stroke in the past 24 months were randomized to the STeleR intervention or usual care. Participants in the intervention arm were administered an exit interview to gather specific patient satisfaction data three months after their final outcome measure. The STeleR intervention consisted of three home visits, five telephone calls, and an in-home messaging device provided over three months to instruct patients in functionally based exercises and adaptive strategies. The outcome measures included Falls Efficacy Scale to measure fall-related self-efficacy and a Stroke-Specific Patient Satisfaction with Care (SSPSC) scale, a measure separated into two subscales (satisfaction with home care and satisfaction with hospital care) was employed to measure the participants' satisfaction. At six months, compared with the usual care group, the STeleR group showed statistically significant improvements in one of the two SSPSC scales (satisfaction with hospital care, p = .029) and approached significance in the second SSPSC scale (satisfaction with home care, p = .077). There were no improvements in fall-related self-efficacy. Core concepts identified were: (a) beneficial impact of the trained assistant; (b) exercises helpful; (c) home use of technology. The STeleR intervention improved satisfaction with care, especially as it relates to care following their experience from the hospital. With the limited resources available for in-home rehabilitation for stroke survivors, STeleR (and especially its exercise components) can be a useful complement to traditional post-stroke rehabilitation.

Personalized technology to support older adults with and without cognitive impairment living at home.

Although persons with dementia (PWD) and their family caregivers need in-home support for common neuropsychiatric symptoms (NPS), few if any assistive technologies are available to help manage NPS. This implementation study tested the feasibility and adoption of a touch screen technology, the Companion, which delivers psychosocial, nondrug interventions to PWD in their home to address individual NPS and needs. Interventions were personalized and delivered in home for a minimum of 3 weeks. Postintervention measures indicated the technology was easy to use, significantly facilitated meaningful and positive engagement, and simplified caregivers' daily lives. Although intervention goals were met, caregivers had high expectations of their loved one's ability to regain independence. Care recipients used the system independently but were limited by cognitive and physical impairments. We conclude the Companion can help manage NPS and offer caregiver respite at home. These data provide important guidance for design and deployment of care technology for the home.

Using telerehabilitation to identify home modification needs.

Teleconferencing technology has great potential for providing cost-effective in-home assessment for home modification services from anywhere to anyone in need. Despite its enormous potential, the use of this technology as a means to deliver these specific services had not been investigated. This project investigated the use of televideo technology to provide remote home assessment services to patients prior to discharge so that they could function as independently as possible in their own homes after being discharged from a specialty clinic. Specifically, an assessment protocol that could be implemented using video-conferencing technology was developed and feasibility of the remote assessment process was determined by validating it against the standard of practice, an in-home assessment by a home modifications specialist. Independent in-home and remote home assessments were completed by two occupational therapists who specialize in home modifications. The results were compared for agreement in identification of specific accessibility problems in and quantitative measurements of the home. The remote assessment correctly identified a total of 51 of the 59 problems (86.4%) identified by the in-home assessment and only identified five problems (8.9%) that were not identified by the on-site assessment. In addition, 54 of 60 (90%) of the quantitative measurements from the remote assessment matched those from the in-home assessment. Findings suggest that remote telerehabilitation assessments have the potential to enable specialists to diagnose potential accessibility problems in home environments and prescribe appropriate modifications regardless of the location of the client, home, or specialist.

An investigation of noncompliant toilet room designs for assisted toileting.

OBJECTIVE: By comparing an Americans with Disabilities Act Accessibility Guidelines (ADAAG) compliant design with alternative designs, this pilot study resulted in recommendations for designing patient bathrooms to facilitate assisted toileting. BACKGROUND: The ADA Accessibility Guidelines were developed primarily to address the needs of disabled populations, such as returning Vietnam veterans, with sufficient upper body strength to transfer independently directly from a wheelchair to the toilet. However, the majority of older persons with disabilities (90%) stand to transfer to the toilet, rather than laterally moving from the wheelchair to the toilet. METHODS: The research used a repeated measures research design to evaluate caregiver responses during assisted toileting for various toilet configurations. The study included 20 patients who were transferred onto and off of a toilet for each of four different configurations by one or two caregivers. Toileting trials were videotaped and analyzed by an occupational therapist. Additionally, caregivers completed five-question, self-report surveys after each toileting trial. RESULTS: Survey data indicate that staff members prefer the largest of the tested configurations, where the centerline of the toilet is 30 inches from the sidewall, rather than the 18 inches required by the ADAAG, and where there are two fold-down grab bars provided. Caregivers perceived the grab bar locations as better for helping them safely transfer subjects in a modified (non-ADAAG) configuration, and also that the grab bar style in a modified configuration (non-ADAAG) improved safety when transferring subjects. CONCLUSIONS: Although caregivers were observed to safely transfer residents to and from the toilet for all configurations tested, regulations regarding accessibility of patient bathrooms should acknowledge the perceived benefits of increasing the distance from the sidewall to the centerline of the toilet to as much as 30 inches and allowing two fold-down grab bars instead of the required sidewall and back-wall grab bars. KEYWORDS: ADA, toilet room design, healthcare design, evidence-based design, human factors, safety, staffPreferred Citation: Sanford, J., & Bosch, S. (2013). An investigation of noncompliant toilet room designs for assisted toileting. Health Environments Research & Design Journal 6(2), pp 43-57.

New technology-based functional assessment tools should avoid the weaknesses and proliferation of manual functional assessments.

BACKGROUND: Formal functional assessment tools for use with older adults have been in widespread use since the 1960s. Instruments have been designed to assess a wide range of different aspects of a person's everyday life. This article seeks to document the evolution of the tools used in such a way as to inform the development of the field. STUDY DESIGN AND SETTING: The Medline, CINHAL, and Science Direct databases were searched for relevant literature relating to the functional assessment of older adults. After analysis of initial results, a second-stage search was conducted to find literature relating to the use and validation of instruments found initially. RESULTS: Four categories of functional assessment instruments were identified for the purposes of this article: basic activities of daily living (ADLs), instrumental ADL, global health scales, and performance-based tests of functional ability. These categories and several of the most widely used tools therein are discussed chronologically to document the evolution of the field. CONCLUSIONS: With the advancement of technology has come the possibility to perform functional assessments in new ways. This outline of the evolution of functional assessment should be of considerable use as researchers seek to design new functional assessments for older adults.