RESNA 27th International Annual Confence

Technology & Disability: Research, Design, Practice & Policy

June 18 to June 22, 2004
Orlando, Florida

ASSESSING THE INFLUENCE OF ASSISTIVE TECHNOLOGY ON PEOPLE WITH SPINAL CORD INJURY USING A MEASURE OF PARTICIPATION

Eliana Chaves, B.S., Michael L. Boninger, M.D. Rosemarie Cooper M.P.T., A.T.P,
Shirley G. Fitzgerald, Ph.D., David Gray, Ph.D.,
and Rory A. Cooper, Ph.D
Departments of Rehabilitation Science & Technology, University of Pittsburgh ,
Human Engineering Research Laboratories, VA Pittsburgh Healthcare System
Washington University School of Medicine

ABSTRACT

The purpose of this study was to investigate wheelchair and related factors that affect the participation of individuals with spinal cord injury in activities performed in the home, community and for transportation. A written survey that recorded assistive technology usage in daily activities was distributed among wheelchair users from Pittsburgh and Saint Louis . The wheelchair was the most commonly cited factor limiting participation, followed by physical impairment and physical environment. Differences were also seen among level of injury. I dentifying factors that impact activity performance is essential to encourage further advancement and development of programs that will assist full participation of individuals with SCI in society.

Keywords:

Assistive technology; wheelchair; spinal cord injury; outcomes; participation; activities of daily living.

BACKGROUND

The occurrence of spinal cord injury (SCI) leads to an enormous change in an individual's lifestyle. Limitation related to mobility can become critical affecting ability to participate in nearly all activities of daily living [1]. Quality of life (QOL) and perception of life satisfaction have also been shown to be affected [2]. QOL associated with SCI is affected mainly by health and social factors [2]. Research identified what a person with SCI has to do to avoid deterioration of his health. Initially, the person should be involved in self-care and health care activities. Secondly, he should maintain appropriate participation in productive activities [3]. Participation is defined as the extent of a person's involvement in life situations in relation to impairments, activities, health condition and contextual factors [4]. Assistive technology (AT) has been used by people with disabilities to facilitate the return to as many pre-injury activities as possible [5]. People with SCI rely on AT, especially wheelchairs to engage in many life activities [5]. Wheelchairs are used to enhance function, improve independence and enable a person to successfully live in the home and community [6]. However, little empirical work has been done to assess the effects of AT interventions on the lives of consumers. Most of the literature on AT is focused around issues of design, consumer preferences, use, disuse, abandonment, cost and policy [6]. What is not known is how AT and related factors of a physical disability affect overall participation. Identifying factors that impact activity performance is essential to encourage further advancement and development of programs that will assist full participation of individuals with SCI in society. The overall aim of this study was to investigate the wheelchair and related factors that affect the participation of individuals with SCI in activities performed in the home, community and for transportation. The first specific aim was to d etermine wheelchair and related factors that individuals with SCI rank as the most limiting for participation in the three settings. The second specific aim was to compare the perceived wheelchair and related limiting factors on participation between individuals with tetraplegia and paraplegia for activities in all three settings. It was hypothesized that the participation limiting factors for individuals with paraplegia were less than those with tetraplegia for activities in all three settings.

METHODS

Subjects:

Seventy individuals with SCI who use wheelchairs for mobility provided written informed consent. All participants had to be discharged from rehabilitation for at least one year and had to live in a community setting. The subjects' demographic information is listed in table 1.

Protocol:

A written survey that recorded AT usage in daily activities was distributed among clients from Pittsburgh (Pitt) and Saint Louis (SL). Pitt subjects were recruited through research centers and through an AT clinic. SL subjects were recruited from research centers and rehabilitation centers. In both locations, subjects were recruited via flyer or approached by clinical study coordinators, who asked if they were interested in participating.

Questionnaire:

The questionnaire used in this study was a combination of two surveys: 1) Participation Survey/Mobility (PARTS/M) and, 2) Facilitators and Barriers Survey/Mobility (FABS/M). The PARTS/M is composed of 25 major life activities. The FABS/M consists of 191 items that probe the situational specificity of activity limitations, requests information on the type of assistive technology used in activities, and asks respondents to categorize aspects of their environments as barriers or facilitators to participation. For this study, only activity performance limiting factors in the home, community and for transportation were analyzed. Subjects were asked five questions within each setting related to their perceived reason for functional limitations (Table 2&3). Subject responses were divided into two categories: 1) Participation limitations: defined as health-related factors that interfere with the ability to do activities (e.g. wheelchair, physical impairment, wheelchair seating, pain, fatigue and illness) and 2) Access limitations: defined as non health-related issues that interfere with the opportunity to participate in activities (e.g. wheelchair, physical environment, wheelchair seating, lack of assistance, lack of equipment, social attitudes, self-concept and family attitudes). The wheelchair and wheelchair seating were cited as participation limitations because they are used to compensate for health conditions (i.e. inability to walk). Statistical Analysis : SPSS software (SPSS, Inc.) was used to calculate frequencies of perceived limitations. The frequency of perceived reasons for limitation in activities performed at home, community and transportation were used to calculate the percentage of time that each factor was perceived as a limitation. Differences between perceived reasons for limitations to complete a task for individuals with paraplegia and tetraplegia were analyzed using a chi-square test. The significance level was set a priori at < 0.05.

RESULTS

The data revealed that the wheelchair most often limited participation in each of the three settings, followed by physical impairment and environment. Table 2 illustrates the relative percentages of the participation limitation for all participants. Table 3 illustrates the relative percentages of access limitations for all respondents. Ninety five percent (N=38) of individuals with paraplegia use manual wheelchairs and 55% (N=29) of individuals with tetraplegia use power wheelchairs. Significant differences were revealed in transportation use between individuals with paraplegia and tetraplegia. Pain was shown as a limiting factor for paraplegia (paraplegia=21% tetraplegia=3%), whereas, lack of equipment was indicated by tetraplegia (tetraplegia=7% paraplegia=3%).

DISCUSSION

The data indicate that the main cause for limited participation inside the home, leaving the home and for transportation was the wheelchair. The wheelchair is not only most likely the user's most important mobility device, but also the one that is most associated with barriers. In a real sense, a wheelchair is an extension of the user's body [7]. Therefore, it is critical that a wheelchair must match the user's current expectations, preferences, physical needs and functional requirements based on his interactions with the environment [7]. The second most limiting cause of decreased participation in the three settings was the physical environment and physical impairment. Individuals with mobility limitations often experience change in participation in major life activities as a result of their physical limitations and the barriers encountered in their environment. Environmental access increases the likelihood that a person with SCI will engage in a variety of meaningful activities [8]. Wheelchair seating was the third main cause for limited participation in the three settings as well as the fourth access limiting factor for leaving the home and transportation use. Forty one percent of wheelchair problems are related to the fit between the user and the wheelchair (e.g. uncomfortable to sit in) [7]. The lack of specific training for wheelchair prescription and fitting by suppliers and clinicians may have caused this finding. Experts indicated that most clinicians do not receive any specific training for prescribing wheelchairs [9]. Only a very small number of therapy or medical residency programs dedicate more than a few hours to training students in the proper selection and use of AT, especially wheelchairs [9]. Also, the type of technology might be appropriate at a given point in time, but later the AT may be obsolete for the individual and his particular needs. In addition, the lack of financial resources, fraud, and denials of prescribed equipment by third-party payers are also among the most frequent reasons why clients receive inadequate equipment [9]. Surprisingly, individuals with paraplegia reported pain as transportation limiting factor when compared with individuals with tetraplegia. This may be explained by the fact that 95% of the individuals with paraplegia were using manual wheelchairs, which require more effort to load and unload in and out of a vehicle. Another possible reason may be related to transfers in and out of the vehicle seat. Pain and injury of the upper extremities are experienced by as much as 70% of manual wheelchair users and represent a form of overuse [10]. Individuals with tetraplegia indicated that the lack of equipment is a limiting factor in transportation use. This may be due to difficulties in transporting a power wheelchair in a vehicle. For future studies finding the cause of the problems of each factor identified in this study would be useful to lead to an understanding of the limitations that individuals with SCI face in daily routines. Consideration of other limiting factors in addition to those found in this study is needed. Measuring the length of time a given technology is appropriate would also be useful. Further studies investigating not only the impact of seating intervention, but also environmental modifications and related factors on changes in daily participation of an individual with SCI are needed. Such studies could be used to advocate for social policy change in support of the provision of AT.

REFERENCES

1. Noreau, L., & Fougeyrollas, P. (2000). Long-term consequences of spinal cord injury on social participation the occurrence of handicap situations. Disability and Rehabilitation, 22(4), 170-180.
2. Putzke, J.D., Richards, S., Hicken, B., & DeVivo, M. (2002). Predictors of life satisfaction: A Spinal cord injury.Cohort study. Arch Phys Med Rehabilitation, 83, 555-561.
3. Treischmann, R. (1988). Spinal Cord Injuries: Psychological, Social and Vocational Rehabilitation (2 nd edition). New York : Demos Publications.
4. World Health Organization (2001). ICIDH-2: International Classification of functioning, Disability and Health. Final draft, full version. Geneva : world Health Organization.
5. Smith, R.O. (1996). Measuring the outcomes of Assistive technology: challenge and innovation. Assistive technology, 8, 71-81.
6. Cushman, L.A. , & Scherer, M.J. (1996). Measuring the relationship of assistive technology use, functional status over time, and consumer/ therapist perceptions of AT. Assistive technology, 8, 103-109.
7. Batavia , M., Batavia , A., & Friendmans, R. (2001). Changing chairs: Anticipating problems in prescribing wheelchair. Disability and Rehabilitation, 23(12), 539-548.
8. Richards, J.S., Bombardier, C.H., Tate, D., Dijkers, M., Gordon, W., Shewchuk, R., & DeVivo, M. (1999). Access to the environment and life satisfaction after spinal cord injury. Arch Phys Med Rehabilitation, 80, 1501-1506.
9. Cooper, R. (2002). Wheelchair users are not necessarily wheelchair bound (Editorial). Journal of American Geriatrics Society, 50(4), 771-772.
10. (10) Davidoff, G., Werner, R., & Warning, W. (1991) Compressive mononeuropathies of the upper extremity in chronic paraplegia. Paraplegia, 29,17-24.

ACKNOWLEDGEMENTS

This study was supported by NIDRR Model Systems for SCI (# B2311-T).

Eliana Chaves,
7180 Highland Drive building 4,
2 nd floor, East Wing, 151R-1
Pittsburgh , PA , 15206 .
Ph: (412) 365-4850
e-mail: esc14@pitt.edu