Computer Assistive Devices and Environmental Controls

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Chapter 23 Computer Assistive Devices and Environmental Controls

This chapter provides an overview of assistive technology (AT) devices and services, including definitions, history, and legislation. It also discusses the use of AT by people with communication disorders, impaired mobility, hearing and visual impairments, and cognitive and learning disabilities. It describes the selection of appropriate technology and training in its use, suggests ways to avoid the abandonment of AT by clients and caregivers, and discusses the principles of clinical assessment and physician responsibility. Finally, it briefly discusses the future in terms of research and development, and application of emerging technologies to the needs of people with disabilities.

Defining Assistive Technology

The term assistive technology is fairly new, although history records the use of tools to enable people with disabilities to walk, eat, and see as far back as the sixth or seventh century BC.^14,¹⁷ Public Law 100-407²⁵ defines AT as “any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized that is used to increase or improve functional capabilities of individuals with disabilities.” This definition also includes a second component defining AT services as “any service that directly assists an individual with a disability in the selection, acquisition or use of an AT device.” Public Law 100-407 specifies the following:

• Evaluate individuals with disabilities in terms of their goals, needs, and functional abilities in their customary environments.

• Purchase, lease, or otherwise provide for the acquisition of AT by persons with disabilities.

• Select, design, fit, customize, adapt, apply, retain, repair, or replace AT devices.

• Coordinate and use other therapies, interventions, or services with AT devices, such as those associated with existing education and rehabilitation plans and programs.

• Provide training or technical assistance for persons with disabilities or, if appropriate, their families.

• Provide training or technical assistance for professionals (including individuals providing education or rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of children with disabilities.²⁵

Since 1988, this definition has also been used in other federal legislation authorizing services or supports for persons with disabilities. The Individuals with Disabilities Education Act ³ (IDEA) and Reauthorization of the Rehabilitation Act²⁴ are both examples of legislation that further codifies Public Law 100-407.

History, Legislation, and Utilization of Assistive Technology

Education: The Individuals with Disabilities Education Act

IDEA originated in 1997 and was reauthorized most recently as Public Law 108-446 by the 108th Congress. IDEA strengthens academic expectations and accountability for the nation’s 5.8 million children with disabilities. One important impact of IDEA legislation is that it specifies that AT devices and services be provided to children from birth to 21 years of age to facilitate education in a regular classroom if such devices and services are required as part of the student’s special education, related services, or supplementary aids and services (Code of Federal Regulations, Title 34, Sections 300.308) (Box 23-1). For students with disabilities, AT supports their acquisition of a free and appropriate public education. All individualized education plans developed for children needing special education services must indicate that AT has been considered as a way “to provide meaningful access to the general curriculum.”²⁷ AT devices and services included as a component of an individualized education plan must also be provided at no cost to the student or parents. The school, however, can use other public and private funding sources that are available to fund the AT (34 CFR).

BOX 23-1 Summary of the Individuals with Disabilities Education Act Assistive Technology Requirements

• Assistive technology (AT) must be provided by the school district at no cost to the family.

• AT must be determined on a case-by-case basis; if needed to ensure access to free and appropriate public education, AT is required.

• If the individual education plan team determines that AT is needed for home use to ensure free and appropriate public education, it must be provided.

• The student’s individual education plan must reflect the nature of the AT and the amount of supportive AT services required.

• A parent is accorded an extensive set of procedural safeguards, including the provision of AT to the child.

Part C of IDEA also includes children before they start school. It covers the needs of children as soon as their developmental differences are noted. It intends that infants and toddlers receive services in the home or in other places, such as preschool settings, where possible. The services provided for these children are described in individualized family service plans. Individualized family service plans include parents, extended family, and early childhood interventionists and other related services personnel in planning and identifying goals and necessary services. IDEA also recognizes that coordination is needed to help families and children with the transition from infant and toddler programs to preschool programs. As a result, students with disabilities are being educated in preschool settings along with typically developing children in an effort to help all children reach the same developmental milestones.

The Americans with Disabilities Act and the Reauthorization of the Rehabilitation Act

The American Rehabilitation Act with Disabilities Act (ADA) was originally passed in 1990, and clarified the civil rights of persons with disabilities and specified equal access to public places, employment, transportation, and telecommunications. The ADA built on the foundation of the Rehabilitation Act of 1973 (updated in 2003 as the Reauthorization of the Rehabilitation Act) in recognizing the role of employment in enabling individuals with disabilities to become economically self-sufficient and integrated into communities. The ADA was amended in 2008, and these amendments became effective January 1, 2009. The amended ADA retains the original Act’s basic definition of “disability” as an impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment.^38,³⁹ However, it changes the way that these statutory terms should be interpreted in several ways. Most significantly, the amended Act does the following:

• Directs the Equal Employment Opportunity Commission (EEOC) to revise that portion of its regulations defining the term “substantially limits”

• Expands the definition of “major life activities” by including two nonexhaustive lists:

• The first list includes many activities that the EEOC has recognized (e.g., walking) as well as activities that the EEOC has not specifically recognized (e.g., reading, bending, and communicating).

• The second list includes major bodily functions (e.g., “functions of the immune system, normal cell growth, digestive, bowel, bladder, neurologic, brain, respiratory, circulatory, endocrine, and reproductive functions”).

• States that mitigating measures other than “ordinary eyeglasses or contact lenses” shall not be considered in assessing whether an individual has a disability

• Clarifies that an impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active

• Changes the definition of “regarded as” so that it no longer requires showing that the employer perceived the individual to be substantially limited in a major life activity, and instead says that an applicant or employee is “regarded as” disabled if he or she is subject to an action prohibited by the ADA (e.g., failure to hire or termination) based on an impairment that is not transitory and minor

• Provides that individuals covered only under the “regarded as” prong are not entitled to reasonable accommodation (For more information regarding the ADA, please see the following website: http://www.eeoc.gov/types/ada.html)

Vocational rehabilitation services are often the key to enabling employment for adults with disabilities. The Rehabilitation Act mandates that AT devices and services should be considered and provided as a means to acquire vocational training, as well as to enter into and maintain employment. It also requires that AT be considered during the development and implementation of the Individualized Written Rehabilitation Plan, the document that guides a person’s vocational rehabilitation process. For example, if an individual has limited sight and needs to fill out paperwork to determine eligibility for vocational rehabilitation services, assistive devices to facilitate reading must be provided at that time. In recent years the Offices of Vocational Rehabilitation have become an important source of funding for AT devices and services to support employment for adults with disabilities.³⁷

Assistive Technology and the International Classification of Functioning

The term disability is not always precise and quantifiable. The concept of disability is not even agreed on by persons who self-identify as having a disability, by professionals who study disability, or by the general public.²³ This lack of agreement creates an obstacle to the study of disability and to the fair and effective administration of programs and policies intended for people with disabilities.⁴^–⁸ ¹⁸ With this issue in mind, the World Health Organization (WHO) developed a global common health language, one that includes physical, mental, and social well-being. The International Classification of Impairment, Disabilities, and Handicaps was first published by the WHO in 1980 as a tool for classification of the “consequences of disease.” The newest version, International Classification of Functioning, Disability and Health (ICF), moves away from a “consequence of disease” classification (1980 version) to a more positive “components of health” classification. This latest version provides a common framework and language for the description of health and health-related domains and uses the following language:

• Body functions are the physiologic functions of body systems (including psychologic functions).

• Body structures are anatomic parts of the body such as organs, limbs, and their components.

• Impairments are problems in body function or structure such as a significant deviation or loss.

• Activity is the execution of a task or action by an individual.

• Participation is involvement in a life situation.

• Activity limitations are difficulties an individual might have in executing activities.

• Participation restrictions are problems an individual might experience in involvement in life situations.

• Environmental factors make up the physical, social, and attitudinal environments in which people live and conduct their lives.⁴¹

The ICF and its language help professionals define the need for health care and related services, such as the provision of AT. It recognizes that physical, mental, social, economic, or environmental interventions can improve lives and levels of functioning for persons with diseases. These might include medical, rehabilitation, psychosocial, or other person-based interventions.⁴¹ It also characterizes physical, mental, social, economic or environmental interventions that will improve lives and levels of functioning. Because AT has the potential to improve daily activities and participation in social and physical environments and thus improve the quality of life of individuals with disabilities, it clearly fits within the ICF. The WHO common health language is used throughout this chapter to discuss the potential impact of appropriate AT.

Overview of Assistive Technology Devices

AT devices are designed to facilitate functional abilities and to meet the needs of humans throughout their varied life stages and roles. It is important to remember that AT device usage and requirements will change over time as individuals mature and take on different life roles. Consequently there is no “one size fits all” technology available.

The Human-Technology Interface

AT devices have the potential to compensate for immobility; low endurance; difficulty reaching, grasping, or accurately touching keys or switches; and problems with seeing or hearing, verbal communication, and the complex skills necessary for reading, writing, and learning. This section focuses on specific categories of AT devices as they are related to these areas of human function.

Considering one’s own interaction with technology gives insight into the issues involved in the concept of the human-technology interface. Devices await activation or input from the people who use them. This commonly occurs through dials, switches, keyboards, handlebars, joysticks, or handgrips. This interface typically requires fine motor control, adequate hearing, vision, or both. People know they have successfully interacted with devices by the physical, visual, or auditory feedback these devices provide (e.g., the sight of brewing coffee, images on a computer monitor, or the sound of a phone ringing).

Individuals with impairments that affect their interaction with items in their environment need special consideration in the design, function, or placement of the devices they want or need to use. It is essential for many individuals to first be seated or positioned by using orthotic or ergonomic seating and positioning interventions, so they can optimally use their residual abilities ¹⁷ (see Chapter 17).

Direct Selection

Once optimal positioning is established, assessment of an individual’s reliable, low-effort, high-accuracy hand movements, vision, communication, and hearing will help an evaluator decide whether the individual is able to use a typical “interface” or needs one that is adapted. Using a typical interface (e.g., a computer keyboard, steering wheel, or television remote control) is typically called direct selection, because all possible options are presented at once and can be directly selected by the individual. For those without the ability to accurately choose an intended item within the available selection set, a different selection method must be considered.

Indirect Selection

Scanning is the most common indirect selection method used by persons with significant motor impairments. A selection set is presented on a display (e.g., a series of pictures or letters) and is sequentially scanned by a light or cursor on the device. The user chooses the desired item by pressing a switch when the indicator reaches the desired location or choice on the display.

Switches come in many styles and are selected based on the body part that will be activating them (e.g., elbow or chin) and the task or setting for using them (e.g., watching television in bed or using a communication device while eating). A switch can be as simple as a “wobble” switch that is activated by a gross motor movement such as hitting the switch with the head (Figure 23-1), hand, arm, leg, or knee. Other switches are activated by tongue touch, by sipping and puffing on a straw, or through very fine movements such as an eye blink or a single muscle twitch. Regardless, switch use and timing accuracy can be very difficult for new users and must be taught. One common method to teach switch activation and use is to interface a switch with battery-operated toys and games, or home or work appliances to increase motivation and teach the concepts used in indirect selection.

FIGURE 23-1 A head switch.

Fairly recent developments include eye-gaze switches, which calibrate intentional eye movement patterns and select targets such as individual keys on an onscreen keyboard. Other new developments include brain wave technology (Eye and Muscle Operated Switch [EMOS]) that responds to excitation of alpha waves to trigger a selection.

Displays

The human-technology interface also applies to completing the feedback loop from devices back to the user. Examples include software that enlarges images on a computer display for persons with low vision, installing flashing alarms for persons without hearing, and using devices that convert printed text into synthesized speech or Braille for persons with blindness or learning disabilities.

These human-technology interface concepts apply to all forms of AT, whether it is being used for seating, mobility, communication, computer operation, or control of the environment. Good assessment skills and a focus on clients and their goals and needs are essential for human-technology interface success and prevention of assistive devices abandonment.³³

Assistive Technology for Communication Disorders

Vocal communication allows humans to interact, form relationships, and direct the events of their lives to enable choice and participation. Human communication is based on having both receptive and expressive language abilities and the physical capacity to reliably produce intelligible speech sounds. Communication impairment can result from congenital conditions such as mental retardation, cerebral palsy, developmental verbal apraxia, and developmental language disorders. Other impairments can be acquired through traumatic brain injury, stroke, multiple sclerosis, amyotrophic lateral sclerosis, tetraplegia, ventilator dependence, and laryngectomy resulting from cancer.³ AT devices that meet the needs of persons with many types of speech and language impairment are commonly called augmentative and alternative communication (AAC) devices, because they can either support or substitute for expressive language impairments. More recently the term speech-generating device has entered into the medical vocabulary to differentiate AAC devices from basic computer devices, especially when seeking third-party funding such as that from Medicaid and Medicare.⁸

Some individuals are completely unable to speak or have such severe expressive difficulties that only those very familiar with them are able to communicate effectively with them. Many devices are available for these individuals, ranging from simple, low-tech picture books to high-end, sophisticated electronic devices with digitally recorded or synthetic text-to-speech output capable of producing complex language interactions (Figure 23-2).

FIGURE 23-2 Use of the Liberator, an augmentative and alternative communication device.

Although AAC devices are extremely useful to nonspeaking individuals, they do not replace natural communication. AAC device use should be encouraged along with all other available communication modalities such as gestures, vocalizations, sign language, and eye gaze.²⁸

There are no firm cognitive, physical, or developmental prerequisites for using an AAC device. Instead, comprehensive evaluation techniques are used to match the individual’s abilities and communication needs with the appropriate AAC technologies. A qualified team of clinicians performs this evaluation, with input from the individual, family members, teachers, employers, and others. Because speaking is considered to be a critical human function, many parents and family members wait to seek out AAC devices in the hope that natural speech will develop. Research shows, however, that using an AAC device can actually support verbal language development, and can, in fact, increase the potential for natural speech to develop.³ Children and adults with severe communication impairments can benefit socially, emotionally, academically, and vocationally from using a device that allows them to communicate their thoughts, learn and share ideas, and participate in life activities.²

Nonelectronic Systems

Low-tech, nonelectronic AAC systems are often used in addition to an electronic voice output system (or as a backup system in case an electronic device fails or cannot be used during certain activities, such as during a swimming lesson). Low-tech systems can be made by using digital photographs, pictures from books or catalogs, or by simply using a marker to draw letters, words, phrases, or pictures. Picture library software is also available commercially. These software programs (e.g., BoardMaker and PCS Symbols) incorporate thousands of line drawings and pictures that can be used to quickly and easily fabricate a low-tech, nonelectronic communication system.

Adults with progressive diseases such as amyotrophic lateral sclerosis or multiple sclerosis can also choose to use low-tech picture or alphabet boards as a supplement to verbal communication when they are fatigued, or as their ability to verbally communicate decreases. Many of these adults choose to use both low- and high-tech communication systems depending on their environment and their comfort level with technology.⁹

Electronic Voice Output Systems: Digital Speech

A variation in low-tech communication systems has developed as a result of the manufacture of low-cost microprocessors capable of storing digitized speech. These low-tech, digital voice output devices work like a tape recorder, allowing recording and storing of simple phrases into memory within the device. When users want to speak, they simply press a button and the device speaks the prerecorded message.

Devices such as One Step, Step by Step, and Big Mac (Figure 23-3) are simple and relatively inexpensive, and are designed to communicate quick, simple messages such as “hi,” “let’s play,” or “leave me alone.” These technologies are often used by very young children who are beginning communicators, or by those who have significant cognitive impairments. They are not appropriate for individuals needing or wanting to communicate complex thoughts and feelings.¹²

FIGURE 23-3 The Big Mac electronic voice output system.

Complex digitized devices store several minutes of recorded voice that is usually associated with representative pictures or icons on a keyboard. These devices are often used by people who are not yet literate, have developmental disabilities, or simply wish to have a simple device to use when going to the store or out to eat. Examples are the SuperTalker, the ChatBox (Figure 23-4), and the Springboard.

FIGURE 23-4 The ChatBox electronic voice output system.

Synthesized speech is created by software that uses rules of phonics and pronunciation to translate alphanumeric text into spoken output through speech synthesizer hardware. Voice output systems such as Tango, VMax, and ECO2 are examples of high-tech text-to-speech devices with built-in speech synthesis that speak words and phrases that have been typed or previously stored in the device, or both. The advantage of these systems is that they allow users to speak on any topic and use any words they wish to use. These systems, which can encode several thousand words, phrases, and sentences, are expensive ($6000 to $9000). They form, however, an essential link to the world for people with severe expressive communication disabilities.

All of these voice output systems, whether digital or text-to-speech, can be activated by direct selection (e.g., using a finger or a pointing device such as a mouth stick or head pointer). They can also be activated using indirect selection (e.g., using a scanning strategy or an infrared or wireless switch). In AAC device use, individuals will most commonly use a scanning strategy called row-column scanning, in which they activate a switch to begin the scan. When the row containing the desired key or icon is highlighted, the user hits the switch again to scan by column. The process is repeated until the desired word or phrase is assembled. Although the process can be slow and tedious, indirect selection often provides the only means many people have to communicate with others.

Among the latest developments for persons who are completely locked in are speech-generating devices that can be activated by a simple eye blink, or by visually gazing or “dwelling” on the desired area of the screen. The DynaVox EyeMax System is one example of this new, advanced access method for communicators who use the DynaVox Vmax. It comprises two parts: a DynaVox VMax and a DynaVox EyeMax Accessory.

AAC devices differ in the mapping and encoding strategies used to represent language, and in the storing and retrieving methods used for vocabulary. However, all systems use either orthographic or pictographic symbols, which vary in ease of learning. When selecting a set of symbols for an individual as part of the user interface, it is important to consider these factors and compare them with the individual’s cognitive and perceptual abilities.

Portable Amplification Systems

For people who speak quietly because of low breath support or other difficulties with phonation, portable amplification systems that function like a sound system in a large lecture hall are available. The Speech Enhancer processes speech sounds for people with dysarthria and enables improved recognition by others. Users wear a headset with a microphone attached to a portable device, and their clarified voice is projected via speakers attached to the unit.

Assistive Technology for Mobility Impairments

Motor impairments greatly affect the ability of individuals to interact with their environment. Infants are compelled to roll, then crawl and toddle, to explore their surroundings. Any motor impairment can greatly affect overall development. This is often the situation with cerebral palsy, spina bifida, arthogryposis, and other diagnoses that affect motor skills. Early intervention, and having supportive families able to create modifications and incorporate AT devices into activities, can help children achieve developmental milestones.

The loss of acquired motor abilities through trauma or disease is experienced as a severe loss for children and adults and occurs with spinal cord injury, stroke, multiple sclerosis, and amputation. There are many forms of AT that help compensate for impaired motor skills, and they should be introduced as early as possible in rehabilitation to ensure the best outcome possible.

Upper Body Mobility Devices

Given the importance of computer use in education, training, and employment, many AT devices have been developed to provide access to computers for individuals with upper body mobility impairment, such as poor hand control or paralysis. For individuals who are unable to use a standard mouse and keyboard, multiple AT options are available.

Alternate computer keyboards come in many shapes and sizes. Expanded keyboards such as the Intellikeys (Figure 23-5) provide a larger target or key surrounded by inactive space than is found in a standard keyboard. Options such as delayed activation response help individuals who have difficulty with pointing accuracy or removing a finger after activating a key. Individuals unfamiliar with a standard QWERTY keyboard layout have the option for alphabetical layout. This is often helpful for young children who are developing literacy skills, as well as for adults with cognitive or visual impairments.

FIGURE 23-5 The Intellikeys expanded keyboard.

There are also smaller keyboards (e.g., Tash Mini Keyboard) designed for persons with limited range of motion and endurance. They are also helpful for individuals who type with one hand, or use a head pointer or mouth stick to type. These keyboards use a “frequency of occurrence” layout. The home or middle row in the center of the keyboard holds the space bar and the letters in English words that occur most frequently (e.g., “a” and “e”). All other characters, numbers, and functions (including mouse control) fan out from the center of the keyboard based on how frequently they are used in common computer tasks.

Voice recognition (VR) is a mass-market technology that has become essential for computer access for many persons with motor impairment. Instead of writing via the keyboard, VR users write by speaking words into a microphone. The computer processor uses information from the user’s individual voice file, compares it with digital models of words and phrases, and produces computer text. If the words are accurate, the user proceeds; if not, the user corrects the words to match what was said. As the process continues, the computer updates its voice file and VR accuracy improves. This software is cognitively demanding yet can offer “hands-free” or greatly reduced keyboarding to many individuals with motor impairment.

Another group of computer input methods includes devices that rely on an onscreen keyboard visible on the computer monitor, such as the Head Mouse Extreme and TrackerPro. The user wears a head-mounted signaling device or a reflective dot on the forehead to select keys on the onscreen keyboard, choose commands from pull-down menus, or direct mouse movement. Onscreen keyboards are typically paired with rate enhancement options like word prediction or abbreviation expansion to increase a user’s word-per-minute rate. Because so many tasks can be accomplished through computers, individuals with disabilities—even those with the most severe motor impairments—can fully participate in life. They can perform education- and work-related tasks, and monitor and control an unlimited array of devices and appliances at home, work, and school.

Lower Body Mobility Devices

Individuals with spinal cord injury, spina bifida or cerebral palsy often have lower body mobility impairments. AT solutions can include crutches, a rolling walker, a powered scooter, or a manual or powered wheelchair (see Chapter 17). Simple environmental modifications or adaptations, such as installing a ramp instead of stairs, raising the height of a desk, or widening doorways, can be critical facilitators for these individuals and might be all that is needed. For other activities or to increase participation, adding automobile hand controls, adapting saddles for horseback riding, or using sit-down forms of downhill skiing is possible (Figure 23-6).

FIGURE 23-6 The hand bike, an example of a low-tech recreation aid.

Literally thousands of low-tech assistive devices are available for persons with motor impairments. Commonly referred to as aids or adaptive devices for completing activities of daily living, these devices include weighted spoons and scoop plates to facilitate eating, aids for personal hygiene such as bath chairs and long-handled hairbrushes, items for dressing such as sock aides and one-handed buttoners, adapted toys for play, built-up pencil grips for writing and drawing, and many others. Many low-tech mobility aids can be handmade for just a few dollars, whereas others, such as an adult rolling bath chair, can cost several hundred dollars. All share the common goal of reducing barriers and increasing participation in daily life.

Assistive Technology for Ergonomics and Prevention of Secondary Injuries

A rapidly growing area of concern for AT practitioners is the development of repetitive strain injuries (RSIs) among both able-bodied and disabled individuals. Although specialized keyboards and mouse control have provided computer access for many individuals, the pervasiveness of computer technology has also increased the possibility of RSIs. During the past few years, an entire industry of AT has developed to deal with repetitive motion disorders.

Computer desks, tables, and chairs used in computer laboratories, classrooms, and offices do not always match the physical needs of users. When people with and without disabilities spend hours repetitively performing the same motor movement, they can and do develop RSIs. Potential solutions include properly supporting seated posture, raising or lowering a chair or desk for optimal fit, implementing routine breaks, and using ergonomically designed keyboards and other assistive technologies.

Many of the AT devices described in this chapter (i.e., alternate and specially designed ergonomic keyboards, VR software, and other technologies designed to minimize keystrokes) can also provide useful solutions for individuals with RSIs. There are also Internet-based resources that target ergonomic issues, such as those found in Table 23-1.

Table 23-1 Internet-Based Resources for Ergonomics

Organization	Website Address
Government Sites
NASA Ergo Resources	http://ohp.ksc.nasa.gov/topics/ergo/
NIOSH Web	http://www.cdc.gov/niosh/topics/ergonomics/
OSHA Web	http://www.osha.gov/SLTC/ergonomics/index.html
Military Sites
Department of Defense Design Criteria MIL-1472F	http://safetycenter.navy.mil/instructions/osh/MILSTD1472F.pdf
Educational Institution Sites
Cornell University Ergonomics	http://ergo.human.cornell.edu/
Ergonomic Design Standard—University of Melbourne	http://www.unimelb.edu.au/ehsm/Ergonomic_design.pdf
Ergonomic Guidelines for Video Display Terminal	http://www.fiu.edu/~ehs/general_safety/general_ergonomics_video.htm
Ergonomic Standard and Guidelines—University of Maryland	http://www.otal.umd.edu/guse/standards.html
Ergonomic Workstation Guidelines—NC State University	http://www.ncsu.edu/ehs/www99/right/handsMan/office/ergonomic.html
Loughborough University Ergonomics	http://www.lboro.ac.uk/research/esri/
Louisville University Ergonomics	http://louisville.edu/speed/ergonomics/
Office Ergo Guidelines—University of Sydney	http://www.usyd.edu.au/ohs/ohs_manual/ergonomics/ergoguide.shtml
Office Ergonomic Standard—University of Toronto	http://www.ehs.utoronto.ca/services/Ergonomics.htm
Ohio State University Ergonomics	http://ergonomics.osu.edu/#
University of California, Berkeley, San Francisco Ergonomics	http://ergo.berkeley.edu/
University of California Los Angeles Ergonomics	http://ergonomics.ucla.edu/
University of Michigan Ergonomics	http://www.engin.umich.edu/dept/ioe/C4E/
University of Nebraska Ergonomics	http://eeshop.unl.edu/rsi.html
Additional Ergonomic Resources
ANSI BHMA Search	http://www.buildershardware.com/20.html
Ergonomics for Notebooks	http://www.ergoindemand.com/laptop-workstation-ergonomics.htm
Human Factors Standards	http://www.12207.com/human_factors.htm
Ergonomic Edge	http://www.ergonomicedge.com/
Ergonomic Product Guidelines	http://www.cccd.edu/facultystaff/riskservices/erg_resource_center.aspx
Ergonomic Resources	http://www.ergoweb.com/
Ergonomics for Teacher and Student	http://www.ergonomics4schools.com/
Next Gen Ergo	http://www.nexgenergo.com/
Stress Ergonomics	http://www.spineuniverse.com/displayarticle.php/article1484.html
Industry Sites
3MErgo	http://solutions.3m.com/wps/portal/3M/en_US/ergonomics/home/advice/workspacecomfortguide/
American Ergonomics Corporation	http://americanergonomics.com/
Basic Ergo Standard	http://www.ergoweb.com/resources/reference/guidelines/
Ergonomic for Writers and Editors	http://www.sfwa.org/ergonomics/
Hewlett Packard Ergo Guidelines-Working in Comfort	http://www.hp.com/ergo/and http://www.hp.com/ergo/pdfs/297660-002.pdf
IBM Ergo Guide-Healthy Computing	http://www.pc.ibm.com/ww/healthycomputing/
Office Ergonomics Training	http://www.office-ergo.com/
Office Ergonomics	http://www.healthycomputing.com/office/
Repetitive Strain Injury FAQs by CTD Resource Network, Inc	http://www.tifaq.org/information.html
Work-Related Musculoskeletal Disorders	http://www.nsc.org/osh/Training/ergonomics.aspx

ANSI, Almerican National Standards Institute; BHMA, Builders Hardware Manufacturers Association; FAQs, frequently asked questions; NASA, National Aeronautics and Space Administration; NIOSH, National Institute for Occupational Safety and Health; OSHA, Occupational Safety and Health Administration.

Electronic Aids to Daily Living

Electronic aids to daily living (EADLs) provide alternative control of electrical devices within the environment and increase independence in tasks of daily living. This technology is also referred to as environmental control units (ECUs). Within the home, EADLs can control audiovisual equipment (e.g., television, video players and recorders, cable, digital satellite systems, stereo), communication equipment (e.g., telephone, intercom, and call bells), doors, electric beds, security equipment, lights, and appliances (e.g., fan, wave machine). EADLs are controlled directly by pressing a button with a finger or pointer or by voice command, or indirectly by scanning and switch activation. Some AAC devices or computer systems also provide EADL control of devices within the environment.

Almost anyone with limited control over his or her environment can benefit from this technology. Children and adults with developmental delays often benefit from low-tech EADLs that increase independence in play through intermittent switch control of battery-operated toys or electrical devices, such as a disco light. For those unable to operate a television remote control, switches or voice commands to an EADL device allow access to devices they would otherwise be unable to control. Many EADLs also accommodate cognitive and visual deficits. For example, an AAC device can display an icon instead of text for a client without literacy or who cannot read English. The same device can also use auditory scanning so that choices can be heard if the client has impaired vision.

EADLs are primarily used in the home, but can also be used in a work or school setting. An individual can use EADL technology to turn on the lights at a workstation and use the telephone. A child who uses a switch can participate more fully in the classroom by advancing slides for a presentation or by activating a tape player with a story on cassette for the class.

The term EADL was chosen over ECU for two primary reasons. First, the term more accurately defines this area of AT by emphasizing the task (e.g., communication is a daily living activity) rather than the item being controlled (e.g., the telephone). Second, the term was chosen to improve reimbursement by third-party providers because the category of ECUs has been poorly funded in the past. In contrast, aids to daily living (ADL) equipment is traditionally funded very well. ADL equipment, which is designed to make the client more independent in a specific daily living task, includes bath seats, toileting aids, built-up spoon handles, and zipper pulls. This equipment is defined by the “daily living” task it “aids.”

ECU devices had the same general goal, but the name failed to reflect the goal, particularly to funding agencies. EADLs expand ADL equipment to include equipment that happens to use batteries or plug into the wall, but still shares the same goal—increasing independence in tasks of daily living.

Assistive Technology for Hearing Impairments

Hearing impairment and deafness affect the feedback loop in the human environment interaction. Because most individuals can hear, it is commonly recognized as a significant barrier in communication and can compromise safety in situations where sound is used to warn of danger.

Hearing Aids

Individuals who are deaf or hard of hearing deal with two major issues: lack of auditory input and compromised ability to monitor speech output and environmental sound. AT devices such as hearing aids and frequency modulation (or radio wave) systems can be used to facilitate both auditory input and speech output. Other types of AT devices provide a visual representation of the auditory signal. These include flashing lights as an alternative emergency alarm (e.g., for fire or tornado) or the ring of a phone or doorbell.

Cochlear Implants

When the hearing system is impaired at the level of the middle ear or the cochlea, a highly specialized form of AT is used to create an alternate means of stimulating the auditory nerve. This technology is implanted surgically with an electrode array placed within or around the cochlear structure. The external portion, a microphone, relays speech and environmental sound to the implanted portion, which is programmed to process, synchronize, and stimulate electrodes appropriately. This system requires a battery pack worn on the body or behind the ear.⁸ It also requires an experienced audiologist to teach the individual to use the acoustic cues produced by the cochlear implant as a substitute for natural hearing.

Other Hearing Technologies

Another recent adaptation for persons with significant hearing impairments is computer-assisted real-time translation. This AT solution involves a specially trained typist or stenographer who captures what is being spoken on a computer. The text is then projected onto a display, resulting in close to “real-time” translation. The advantage of this technology is that it can be used by hearing-impaired individuals who are not fluent in sign language, as well as others who might need listening help, such as those who use English as a second language. In addition to use in group environments like conferences or meetings, a variation of this technology can be used to assist a single student or employee in a small setting.

Environmental Adaptations

For individuals who wear hearing aids, additional technologies are available that can facilitate hearing in large rooms or in noisy, crowded environments such as a restaurant. The Conference Mate and Whisper Voice are especially designed for these environments. In the case of the Conference Mate, the person with the hearing loss wears a “neck loop,” which acts as an antenna and is capable of broadcasting directly to a hearing aid. A microphone placed near the speaker transmits directly to the neck loop, eliminating background sound. This is also an excellent solution for office and school environments. The Whisper Voice is similar, except it uses a smaller microphone and is more portable. It can be passed from speaker to speaker with sound transmitted to the neck loop and then to the hearing aid for amplification.

Environmental adaptations can frequently support individuals who are deaf or hard of hearing. For example, a person speaking to someone who has difficulty hearing can take care not to stand in front of a light source (windows, lamps, etc.) and not to overexaggerate or hide lip movements. Gestures can also be helpful.

Assistive Technology for Visual Impairments

The term visual impairment technically encompasses all types of permanent vision loss, including total blindness. Low vision refers to a vision loss that is severe enough to impede performing everyday tasks, but still provides some useable visual information. Low vision cannot be corrected to normal by eyeglasses or contact lenses.

Low-Tech Visual Aids

A variety of AT devices and strategies can help individuals with visual impairments become more mobile; perform daily activities, such as reading, writing, and personal care; and participate in recreational activities. Among low-tech solutions are simple handheld magnifiers, the use of large print, and mobility devices for safe and efficient travel (e.g., a white cane; Figure 23-7). High-contrast tape or markers can also be used to indicate hazards, what an item is, or where it is located.

FIGURE 23-7 Use of a cane by a person with visual impairment.

Other low-tech solutions include using wind chimes to help with direction finding, using easily legible type fonts such as Verdana (16 point or larger), and using beige paper rather than white to improve the visibility of text. In recreational activities, solutions include beeper balls, three-dimensional puzzles, and outdoor trails with signage (called “Braille trails”) designed to improve access to wilderness and other outdoor activities.

Braille text is still the first choice of many individuals for reading, although it is less used than in the past because of the advances in computer and other technologies. Many restaurants now provide large-print, Braille, and picture-based menus for customers with a variety of abilities.

Books on tape are another resource for individuals with severe visual impairments. In addition to commercially available tapes for sale and at public libraries, special libraries provide print materials in alternate formats for persons with visual, physical, and learning impairments. Borrowers can arrange to have textbooks and other materials translated into alternate formats. For more information, contact the American Federation for the Blind or the National Library Service for the Blind and Physically Handicapped (http://www.loc.gov/nls/) (Box 23-2).

BOX 23-2 Resources for Persons With Low Vision or Blindness

• American Academy of Ophthalmology

PO Box 7424

San Francisco, CA 94120

Tel 415 561-8500

http://www.eyenet.org

• American Council of the Blind

2200 Wilson Boulevard, Suite 650

Arlington, VA 22201

Tel 202 467-5081

http://www.acb.org

• American Council of the Blind in Colorado

1536 Wynkoop Street, Suite 201

Denver, CO 80202

Tel 888 775-2221

http://www.acbco.org

• American Foundation for the Blind

11 Penn Plaza, Suite 300

New York, NY 10001 Tel 800 232-5463

http://www.afb.org

• American Printing House for the Blind

1839 Frankfort Avenue

Louisville, KY 40206

Tel 502 895-2405

http://www.aph.org

• National Association for Visually Handicapped

22 West 21st Street, 6th Floor

New York, NY 10010

Tel 212 889-3141

http://www.navh.org

• National Braille Association, Inc

95 Allen Creek Road, Building 1, Suite 202

Rochester, NY 14618

Tel 585 427-8260

http://www.nationalbraille.org

• National Braille Press, Inc.

88 St. Stephen Street

Boston, MA 02115

Tel 617 266-6160

http://www.nbp.org

• Recordings for the Blind and Dyslexic

• Rehabilitation Engineering and Assistive Technology Society of North America State Technology Projects

1700 N Moore Street, Suite 1540

Arlington, VA 22209-1903

Tel 703 524-6866

http://www.resna.org

• Aspen Braille Nature Trail

White River National Forest

Aspen, CO 81611

Tel 970 945-2521

http://www.fs.fed.us/r2/whiteriver

• Assistive Technology Partners

601 East 18th Avenue, Suite 130

Denver, CO 80203

Tel 303-315-1280

http://www.uchsc.edu/atp

• Guide Dogs for the Blind, Inc.

PO Box 151200

San Rafael, CA 94915-1200

Tel 415 499-4000

http://www.guidedogs.com

• Guide Dogs for the Blind, Inc.

32901 Southeast Kelso Road

Boring, OR 97009

Tel 503 668-2100

http://www.guidedogs.com

• Helen Keller National Center for Deaf-Blind Youth and Adults

141 Middle Neck Road

Sand Point, NY 11050

Tel 516 944-8900

http://www.helenkeller.org

• National Federation of the Blind

• National Library Services for the Blind–Physically Handicapped

Library of Congress

1291 Taylor Street, Northwest

Washington, DC 20011

Tel 888 657-7323

www.loc.gov/nls

High-Tech Visual Aids

Numerous high-tech solutions exist for persons with visual impairments. Computers outfitted with a speech synthesizer and specialized software, such as Jaws or WindowEyes, allow navigation of the desktop, operating system, applications, and documents, as well as the entire Internet. Any digital text can be heard aloud by the person using this software. For text that is printed, such as menus, memos, and letters, using a technology called optical character recognition allows a page scanner and software to convert print into digital form. It can then be listened to through the computer’s speech synthesizer or converted to Braille or large print.

Another category of high-tech aids is portable note takers with either Braille or speech synthesizer feedback for the user. These devices are specialized personal digital assistants with calendars, contacts, and memo and document capabilities, and can be purchased with either a QWERTY or Braille keyboard.

For individuals with some degree of visual ability, screen magnification software such as Zoomtext (Figure 23-8) or MAGic enables the user to choose the amount (2 to 20 times) and type of magnification preferred for optimal computer access. Many magnification applications combine enlargement with speech synthesis or text to speech.

FIGURE 23-8 Zoomtext screen magnification software for the visually impaired.

A recent addition to the list of screen magnification software is called Bigshot. This software is less expensive ($99) and provides fewer features than some other programs. However, it appears to be a highly affordable alternative for users who do not need access to the more sophisticated computer functions.

Environmental Adaptations

Persons with visual impairments usually keep the setup of their home and work environments constant because this helps in locating items. However, they usually need specialized training for mobility in the community. They learn to use environmental cues such as traffic sounds, echoes, or texture of the sidewalk in combination with mobility aids such as a white cane or a guide dog.

To supplement these less technical aids, some individuals use electron ic travel aids that have the capability of detecting obstacles missed by a cane, such as overhanging branches or objects that have fallen. This technology (Talking Signs) uses ultrasound or information embedded in the environment expressly for users who have limited vision. The demands for independence in community mobility by persons with significant visual impairments are huge because of the high cognitive demand for remembering routes and because environments constantly change. Many individuals use these types of technologies to increase their independent mobility in both familiar areas and the larger community.

Assistive Technology for Cognitive and Learning Disabilities

Cognitive disabilities include disorders such as traumatic brain injury, mental retardation, developmental disabilities, autism, Alzheimer disease, learning disability, fragile X syndrome, and other disorders, both developmental and acquired. Most individuals in this group have not had the benefit of using AT devices because relatively few products have been specifically developed for intellectual impairments. In addition, families, teachers, and others providing support services for individuals with cognitive impairments have generally not been aware of the potential usefulness of AT.⁴⁰

Most have looked to simple solutions for persons with learning impairments, cognitive impairments, or both, using strategies such as colored highlighter tape, pencil grips, enlarged text, reminder lists, and calendars. Others try low-tech adaptations such as using a copyholder to hold print materials for easy viewing, and making cardboard windows to help the eyes follow text when reading.

In 2004 the U.S. Department of Education, National Institute on Disability Research and Rehabilitation, recognizing the need to increase AT development for persons with cognitive disabilities by funding, funded the nation’s first Rehabilitation Engineering Research Center for the Advancement of Cognitive Technologies (RERC-ACT; www.rerc-act.org). The RERC-ACT is developing a wide range of new ATs designed to facilitate vocational and literacy skills, service provision, and enhanced caregiving supports for persons with significant cognitive impairments.

One of the newer developments from the RERC-ACT is the use of intelligent agents to interactively help people with everyday tasks in education, health care, and workforce training. The systems are designed to assess, instruct, or assist new readers and learners, as well as people who have speech, language, reading, or cognitive difficulties. The intelligent or “animated” agent is available on desktop or mobile computing devices. It is being used to assist persons with cognitive disabilities to learn new job tasks or to prompt them through various steps within a task, or both (Figure 23-9).

FIGURE 23-9 An example of a handheld intelligent animated agent. These devices are used to help persons with cognitive disabilities to learn new job tasks or to prompt them through various steps within a task, or both.

(Courtesy Sarel Van Vuuren, PhD, University of Colorado.)

Other RERC-ACT work includes the development of “batteryless” micropower sensors. Access to low levels of power and the elimination of batteries in sensor technologies for persons with cognitive and physical disabilities enable additional prompts or inputs based on time, weight, location awareness, and other context-aware sensoring capabilities. This technology enables developers to use context-aware sensors in a multitude of environments and other ATs to facilitate the safety, capacity, and well-being of persons with cognitive disabilities. This new field of “cognitive technologies” promises numerous advances during the next decade.

Literacy Technologies

A number of both low- and high-technology solutions are available to assist literacy development. Individuals who are unable to read print materials often use books on tape or some of the text-to-speech software solutions mentioned earlier, such as Jaws. Co:Writer is an example of a specially designed application that predicts the word or phrase an individual is trying to spell as he or she begins to type a word. Other applications (e.g., Write Outloud and Kurzweil 3000) provide multisensory feedback by both visually highlighting and speaking the text an individual is generating on the computer.

In addition to helping persons with mobility impairment, VR software can sometimes be helpful for persons with learning disabilities so significant they are unable to develop writing skills. VR software enables such individuals to speak words, phrases, or sentences into a standard computer word-processing program such as Microsoft Word. A review or playback feature in the application allows writers to hear the text they have written.

Although VR software is a rapidly developing technology, the user must currently have a fifth grade reading ability to read the text used to generate a voice file, which hinders its usability by those with significant learning disabilities. Dragon Naturally Speaking has developed a VR version for children 9 years and older, but its success rate for children with learning and other cognitive disabilities has not yet been published.

Other limitations of VR include reduced accuracy in the presence of ambient noise, such as that found in a typical classroom, and fluctuating vocal abilities related to fatigue or some types of disabilities. In general, it takes more than 20 hours to train the software to an acceptable level of accuracy (greater than 90%). Caution is currently in order when prescribing this type of software, but the rapid pace of development bodes well for future use of this type of software for persons with disabilities.

Other applications for persons with cognitive impairment focus on a range of topics, including academics, money management, personal skills development, behavior training, development of cognitive skills, memory improvement, problem solving, time concepts, safety awareness, speech and language therapy, telephone usage, and recreation and games.

Prompting Technologies

Recent mainstream technology developments include handheld personal digital assistants. AbleLink Technologies, Inc. have used this technology and developed software applications (PocketCoach; Figure 23-10) that provide auditory prompts for individuals with cognitive disabilities. This software can be set up to prompt an individual through each step of a task as simple as mopping a floor, or a task as complex as solving a math problem. The latest version of this software combines both voice prompts with visual prompts (Visual Assistant). The individual setting up the system for a user can simply take digital pictures with the accompanying camera and combine them with digitally recorded voice prompts to further facilitate memory and cognition.

FIGURE 23-10 Prompting technology: the Pocket Coach.

Selecting Appropriate Assistive Technologies

Abandonment

Practitioners are sometimes surprised to learn that not everyone with a disability enjoys using technology, however useful it might appear. Depending on the type of technology, nonuse or abandonment can be as low as 8% or as high as 75%. On average, one third of more optional assistive technologies are abandoned, most within the first 3 months.²³

Research has not yet been done to determine the number of individuals who are unhappy with their devices, but who must continue to use them because they cannot abandon them without severe consequences.^22,²⁹^–³¹ For example, an individual who has just received a new wheelchair that does not meet expectations simply cannot stop using the chair, but must wait until third-party funding becomes available again (typically several years). Alternatively, the individual must engage in potentially difficult and unproductive discussions with the vendor, who has more than likely provided the chair as it was prescribed by the assessment team.

Research does tell us that the main reason individuals with disabilities choose not to use assistive devices is because practitioners failed to consider their opinions and preferences during the process of selecting the device. In other words, the person with a disability was not included as an active member of the team during the evaluation process.^10,^11,^22,²⁷

Principles of Clinical Assessment

The goal of an AT evaluation is to determine whether AT devices and services have the potential to help an individual meet his or her activity or participation goals at home, school, work, or play. Other goals include (1) providing a safe and supportive environment for the person with a disability and his or her family to learn about and review available assistive devices; (2) identifying the need for AT services, such as training support staff or integrating an AT device into daily activities; (3) determining the modification or customization needed to make the equipment effective; and (4) developing a potential list of recommended devices for trial usage before a final selection of technology is made. In addition, the individual and family, as well as the AT team, should specify exactly what they hope to achieve as a result of the evaluation (e.g., equipment ideas, potential success with vocational or educational objectives).

When selecting team members to conduct an AT evaluation, professional disciplines should be chosen based on the identified needs of the person with the disability. For example, if the individual has both severe motor and communication impairments, team members should include an occupational or physical therapist with expertise in human-technology interface, as well as a speech-language pathologist with a background in working with persons with severe communication impairments and alternative forms of communication. If a cognitive impairment has been identified, someone versed in learning processes, such as a psychologist, neurolinguist, teacher, or special educator, would be an appropriate member of the team. If there is an ergonomic issue (e.g., repetitive stress injury), an evaluator with training in ergonomic assessment or a background in physical or occupational therapy is a necessary component for a successful experience.

It is not appropriate for an AT vendor to be called in to perform an AT evaluation. Although vendors can and should be members of the evaluation team, it must be recognized that they have a conflict of interest because they earn a living by selling products. When working with a manufacturer or vendor, it is important to work with a credentialed provider. When requested by the team, vendors demonstrate their products, discuss pertinent features, and assist in setting up the equipment for evaluation and trial usage. However, other team members, including the end user and family, should perform the evaluation and make the final recommendations.

Phase 1 of the Assessment Process

Knowledge within the field of AT continues to expand and change, sometimes on a daily basis. This directly affects whether the AT device recommended by the assessment team will be used or abandoned by the consumer.^15,¹⁹ As a result of rapidly changing information, the evaluation process continues to be refined. Many researchers are working to develop standardized AT measurement tools,^∗ but the fact remains that few resources are available to guide practitioners who have not received formalized training in AT assessment.

As mentioned earlier in this chapter, the most common reason AT is abandoned is because the needs and preferences of the consumer are not taken into account during the evaluation process. Other reasons cited for abandonment of devices include the following ²²:

• Changes in consumer functional abilities or activities

• Lack of consumer motivation to use the device or do the task

• Lack of meaningful training on how to use the device

• Ineffective device performance or frequent breakdown of the device

• Environmental obstacles to use, such as narrow doorways

• Lack of access to and information about repair and maintenance

• Lack of sufficient need for the device functions

• Device aesthetics: Device’s weight, size, and appearance

Given the relationship that must develop between individuals and AT devices, it is common sense that these factors be considered during the evaluation process. The AT assessment process has evolved from a random process of trying out any number of devices with the individual, to a team process that begins with the technology out of sight.

Phase 1 of the assessment process begins when a referral is received. Standard demographic and impairment-related information is collected, usually over the phone. In most cases, cognitive, motor, vision, and other standard clinical assessments have already been performed, and a release of information is requested from the individual or caregiver so information can be forwarded to the team. If appropriate assessments have not been conducted, they are scheduled as a component of phase 2 of the assessment process.

Based on the preliminary information, an appropriate team of professionals is assembled, and a date is chosen for the evaluation. The team leader takes responsibility for ensuring that the individual with the disability, the family, and any other significant individuals are invited to the evaluation.

At the initial meeting, team members spend some time getting to know the individual. Using methods described by Cook and Hussey ⁸ and Galvin and Scherer,¹⁰ the team identifies the life roles of the consumer (e.g., student, brother, or musician) and the specific activities engaged in by the individual to fulfill that life role. For example, if a young man is a “brother,” that means he might play hide and seek with a sibling, squabble over toys, or otherwise engage in brotherly activities. If he is a musician, then he might want or need to have access to musical instruments, sheet music, or simply a radio.

Next, the team identifies any problems that might occur during the individual’s daily activities. For example, the musician might not have enough hand control to manage recording equipment, or could experience visual or cognitive difficulties with sheet music. The team asks specific questions about where and when these difficulties occur (activity limitations). Perhaps problems occur when the individual is tired or not properly positioned, or when trying to communicate with others. The individual is also asked to describe instances of success with these activities and to discuss what made them successful (prior history with and without technology). By now the team is usually able to recognize patterns of success and failure from the individual’s perspective as common limitations across environments emerge.

Finally, the team prioritizes the order in which to address barriers to participation, and a specific plan of action is developed. This specific plan of action contains “must statements” such as “the device must have a visible display in sunlight,” or “the technology chosen must weigh less than 2 lb.”

It is at this point that the team might be reconfigured. For example, if the individual is not properly seated and positioned, he or she is referred to the occupational or physical therapist for a seating and positioning evaluation before proceeding further. Some members of the team may leave after determining that further assessment from their perspective is not needed. In other situations as additional needs becomes apparent, new members are invited to join the team (e.g., a vision specialist). At all times the assessment team includes the individual and caregivers as the primary members.

Phase 2 of the Assistive Technology Assessment

Once the team has agreed on the specific plan of action and those things that “must” occur, phase 2 of the assessment process begins. The person with the disability, the caregivers, or both, are asked to preview any number of AT devices that might serve to reduce activity limitations and increase participation in chosen environments. These AT devices are tried along with various adaptations, modifications, and placements to ensure an appropriate match of the technology to the individual.

It is at this point that the clinician’s AT skills become critical. If trial devices are not properly configured or if the wrong information is given to the consumer, he or she will be unable to make an appropriate selection. Because many devices require extensive training and follow-up, it is essential that realistic information about training and learning time is provided and appropriate resources within the local community identified. With very few exceptions the wise course of action involves borrowing or renting the AT device before making a final purchase decision. For many individuals the actual use of technologies on a day-to-day basis raises new issues that must be resolved. For instance, there might not be the local supports necessary for the technology that appears to be best for an individual. In these cases it is best to first identify local resources or local AT professionals willing to seek additional training before sending the device home with the user. Consumers and their families should always be informed so they can make the final decision regarding when and where the equipment will be delivered.

Unexpected benefits of trial use occur as a result of improved functioning, including changes in role and status. In some cases these unexpected benefits create an entirely new set of problems. For most individuals these problems can be resolved with time, energy, and patience. Others decide that they either prefer the old way of doing things or that they are interested in adding or changing the technology once they have had a chance to experiment with it in different settings.

AT professionals, in consultation with the physician, should also anticipate future needs (e.g., physical and cognitive maturation), and final decisions should consider both the expected performance and durability of the device.³¹

Writing the Report

The evaluation report documents the AT assessment process and must include several components. It is important to use layman’s terms to help case managers, educators, and others unfamiliar with ATs understand the process.

In cases where medical insurance is being used to purchase technology, it is essential to document the medical need for the device(s) within the report. This information will be included in the “letter of medical necessity” required by medical insurers before funding approval. For example, the evaluation report might state, “Mr. Jones will use this wheelchair to enable safe and independent mobility in the home and community and to meet the functional or activities of daily living goals as listed.” In instances where educational or vocational funding is being requested to purchase the technology, the report should focus on the educational or vocational benefit of the assistive devices and how relevant goals will be met with the recommended equipment.

It is also extremely important that all components of the AT device be included in the list of recommended equipment (e.g., cables, ancillary peripherals, and consumable supplies). In many instances devices are recommended for purchase as a “system.” As a result, acquisition can be delayed for months because an item was not included in the initial list. An estimate of the amount of time, cost, and source of training should also be included at this point. Purchasing AT devices without paying for the AT services needed to learn how to use and integrate the devices into identified life activities will result in low use or abandonment.²⁹^–³¹

Finally, it is also important to include contact information for the vendors who sell the equipment. Many purchasers are unfamiliar with rehabilitation technology supply companies, and acquisition can be delayed if this information is not included in the report.

Physician Responsibilities

Prescribing the Technologies

The American Medical Association ³⁶ recommends the following items be considered when prescribing AT and certifying medical necessity: The physician must provide evidence of individual medical necessity for the specific AT being prescribed and be prepared to talk with insurance company representatives about the medical necessity of complex assistive technologies (e.g., power wheelchairs and AAC devices). Reviewing a comprehensive assessment report from the AT assessment team should supply all the needed information.

Health insurance requires an “appropriate” prescription that includes mention of the comprehensive assessment process, the individual’s motivation, the availability of training, and the potential functional outcomes for the patient, as compared with the cost of the products. Success with reimbursement also includes using the appropriate medical necessity forms and prior authorization procedures.