RESNA 28th Annual Conference - Atlanta, Georgia
Rebecca I Estes, PhD, OTR
Disuse of assistive technology devices is an area of concern among professionals. Matching the correct assistive device with the consumer is a complex and challenging task that would be aided by increased understanding of the components of user preference and continued device use. This case study, of a consumer with Muscular Dystrophy, explored three aspects of satisfaction, attainment of user-established goals and device selection after ten-day trials on three hands-free computer access devices.
computer access, assistive technology, satisfaction
The reasons for disuse (abandonment) of assistive technology devices acquired by individuals with disabilities have been reviewed in the literature as relating to personal factors (age, gender, diagnosis, expectations, severity of disability, etc.), quality and appearance of the device, the user’s environment (barriers and support), and intervention (user involvement, training, follow-up, etc.) (1). Additionally, the psychosocial aspect of quality of life has also been shown to impact device use (2). Matching the correct assistive technology device to the consumer is a daunting task for the professional who has a focused contact and knowledge of the consumer in a limited timeframe. Numerous strategies have been suggested to effect this: relating equipment use to meaningful tasks, involving clients and caregivers, considering client preferences, in general, having a client-centered approach (3). A review of assessments revealed a variety of outcome measures available to professionals: psychosocial (quality of life, social participation, psychosocial impact & user satisfaction), functional performance, and costs (4). We do not yet have an adequate understanding of all of the components involved in (dis-) use of assistive technology devices, and continued research in this area is needed (2,3,4)
This case study explores user satisfaction, level of attainment of user-established goals and device selection for hands-free computer access. Three assessments looking at different components of satisfaction were used. The Matching Persons and Technology Assistive Technology Device Predisposition Assessment (MPT ATD-PA) includes ten questions eliciting information about how the consumer feels about using the device or their ‘satisfaction’ associated with feelings about using a device (5). The Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) includes questions on consumer satisfaction with the physical characteristics of the device, use of the device and services (6). The Occupational Adaptation frame of reference for occupational therapy treatment recommends use of a self-rating scale of consumers’ occupational performance based on three elements: satisfaction, efficiency and effectiveness (7) (satisfaction with occupational performance while using the device). The rating of occupational performance is done on user-established goals.
RAM was a pleasant, outgoing 35-year-old male diagnosed with Muscular Dystrophy with onset at birth. He had been a university professor but resigned due to physical decline and was currently employed, from home, as a private tutor, computer programmer, and internet entrepreneur. He had interests in music, reading, computers and chess. He desired to explore options in hands-free computer access due to continuing physical decline.
Initial evaluation revealed significant limitations in range of motion (see Table 1). He had limited head movement and limited right forearm and hand movement. He had no other functional upper or lower extremity movements available. He was able to speak, chew soft foods and swallow; however, his oral motor skills were deteriorating and he was also becoming increasingly ventilator dependent. His current computer access methods were Dragon Dictate and a touch pad that he controlled with his right index finger. The MPT Survey of Technology Use indicated that he was very familiar, comfortable and satisfied with a variety of technologies he currently used. The MPT Assistive Technology Predisposition Assessment indicated that he was realistically able to identify his areas of strengths and weaknesses, he had a good support system, and that he was positively predisposed toward new technology. Due to continuing decline, his voice quality was not remaining consistent enough for voice-activated control, and his increasing dependence on the ventilator prevented prolonged computer use. He was also experiencing reduced endurance and movement control of his remaining hand motions resulting in poor mouse control.
| Degrees of Motion | |
| Neck | |
| Cervical Flexion | 0-8 |
| Cervical Extension | 0-29 |
| Lateral – Left | 0-5 |
| Lateral – Right | 0-10 |
| Rotation – Left | 0-10 |
| Rotation – Right | 0-8 |
| Forearm | |
| Supination | Unable |
| Pronation | 34-56 |
| Hand | |
| Right Digits able to flex generally | MCP 0 - 24 PIP 0 - 55 DIP 0 - 40 |
| No other functional movements available | |
Client goals for hands-free computer access were to control the mouse and keyboard in order to independently access the Internet, a word processing and computer programming programs and files. Team members included the consumer, caregiver, occupational therapy and an assistive technology supplier. The intervention plan was to: 1. determine preferred options, 2. provide instruction and opportunities for practice, 3. provide extended trial usage, 4. reassess performance – based on goals, and 5. determine preferred solutions. After discussion of options RAM elected to try three alternative computer access methods: Tracker One, EyeGaze and Cyberlink. Instructions and a training session were provided in the use of each device that was then left for a ten day extended trial use. Performance was assessed after training on a computer keyboard skills assessment, the Occupational Adaptation Scales of Relative Mastery (OAS-RM), and a device satisfaction scale on the MPT (ATD-PA). Reassessment at the end of each ten-day trial period included the post training assessments and the QUEST. The final step involved comparing and contrasting the devices to determine the preferred solution.
The data displayed in Table 2 provide an overview of RAM’s assessment results. His preferred solution was Cyberlink, which he rated the lowest in overall occupational performance, satisfaction, efficiency and effectiveness. After 10 days he was only able to type 3 words per minute, although his mouse control was much improved. He rated his feelings about using Cyberlink, on the ATD-PA, the lowest of all three devices. The high QUEST scores begin to indicate why Cyberlink was the preferred choice with the highest device characteristics score. He was, in fact, fascinated with the idea of controlling the computer with brainwaves and requested additional trial time. The low performance and satisfaction scores at the end of the trial period reflected the frustrations of adjusting the device to the electrical output of equipment in the room and the need for extended practice time on Cyberlink to attain skill. Overall, the EyeGaze system received the highest post-trial scores, and it was the second preferred choice of the three; however, he stated he would not want to install one for permanent use due to the bulkiness of the system. Tracker One was the third preferred choice and ratings overall were mid-range. The possibility of having to change to yet another system if he lost head and neck control was also a negative factor for selection of Tracker One. At the end of the study, RAM chose not to pursue the search for hands-free computer access stating, “I think I’ll wait until I really need it.” Follow-up contact revealed continuing decline over the next year and subsequent reduction in ability to use the computer. However, reduced endurance necessitated a reduction in activities overall and his choice for quality of life was to reduce computer use and save his energies for interactions with people through tutoring and visiting garage sales.
| Tracker One | EyeGaze | Cyberlink | |||||
|---|---|---|---|---|---|---|---|
| Post training | Post 10 day trial | Post training | Post 10 day trial | Post training | Post 10 day trial | ||
| Characters per minute | 12.99 | 27.87 | 25.64 | 50.34 | 2.5 | 3 | |
| ATD-PA (out of 5) | 4.4 | 3.9 | 3.8 | 4.2 | 2.7 | 2.7 | |
| QUEST (out of 5) | Characteristics | - | 3.88 | - | 3.75 | - | 4.25 |
| Services | - | 4 | - | 4 | - | 4.2 | |
| Satisfaction (out of 5) | 2.4 | 3 | 3.2 | 4 | 1.8 | 2.4 | |
| Efficiency (out of 5) | 2 | 3.2 | 3.2 | 3.2 | 1 | 1.6 | |
| Effectiveness (out of 5) | 2 | 3 | 3.2 | 3.6 | 1.4 | 1.8 | |
| Occupational Performance (%) | 44.4 | 58.4 | 64 | 65.6 | 28.4 | 38.6 | |
The study results support the complexity of assistive technology service delivery and device recommendation. The psychosocial aspects of quality of life, and satisfaction require further study. Satisfaction appears to be a multidimensional concept that impacts device preference and, among other factors, may relate to occupational performance, device characteristics and services, or feelings associated with using the device. Further research and development is needed to devise an instrument that may begin to assess the multitude of components impacting device choice and continued device use in order to improve assistive technology service delivery and device recommendation; hopefully thereby reducing device abandonment.
The time, energy and thoughtful responses of the participant and his caregiver in this case study are deeply appreciated.
Rebecca I Estes, PhD, OTR
School of Occupational Therapy, TWU
PO Box 425648
Denton, TX 76204-5648
Office Phone (940) 898-2815
EMAIL: restes@mail.twu.edu