Looking at Adaptive Devices through the Eyes of Occupational Therapy Dawn Baker Jennifer Haas Dan Hammond Graeleigh Huffman Students Department oj Occupational Therapy Sargent College of Allied Health Professions Boston University Boston, Massachusetts
The concept of adaptive devices, as suggested by Schwartz during his keynote address at the 1992 Massachusetts Association of Occupational Therapy conference, is perhaps one of the greatest ideas in occupational therapy. Adaptive devices play an integral role in the philosophy and process of occupational therapy; as they modify and assist in an individual's environment, adaptive devices promote the greatest amount of independence and an optimal level offunctioning. Present in home, school, worksite, and community recreational settings, adaptive devices are found everywhere in our environment, in both simple and complex
forms. They run the gamut of possibilities, from everyday drinking straws to more global, architectural features such as wheelchair-accessible ramps and parking spots; from prostheses to aid in mobility to dressing sticks to aid in activities of daily living; from computers to assist with cognitive disabilities to body positioning alarms to maintain good body mechanics (e.g., Pedretti, 1981; Hopkins and Smith, 1983). As a practice, adaptive devices were once unique to the field of occupational therapy, at its inception nearly 76 years ago, but it was not until 1951 that the term officially made its way into print in an occupational therapy manual published by the U.S. Army (Dept. of the Army, 1951). The rise of this recognition coincided with the growing rehabilitative movement after World Wars I and II. With the medical advances occurring at that time, more soldiers were able to survive traumatic injuries, including the loss of limbs. Some sort of adaptation was needed to increase their independence and level of functioning.
DEVICES OF OLD The authors thank Karen Jacobs, MS, OTR/L, FAOTA, for her support and encouragement in this project. We also thank Anna Deane Scott, MEd, OTR/L, for making her personal occupational therapy library available to us. We acknowledge the following individuals for their contributions to the initial framework of this article: Larry Aaronowitz, Rob Drake, Jennifer Min, Jill St. Jacques, and Kerry Sullivan, with special thanks to Cathy Gallagher for her efforts in researching this article.
The adaptive devices first mentioned in 1951 included prostheses, splints, and braces. Three years later, a book by Willard (1954) referred to equipment involving "self-help activities," such as eating and toileting. At that time, the market for prefabricated devices had yet to be developed; therefore, most adaptive equipment consisted of WORK 1993; 3(4):42-48 Copyright © 1993 by Andover Medical
Occupational Therapy Views Adaptive Devices
fairly simple handmade devices, such as built-up spoons to aid in eating and extra long zippers to assist in dressing (Willard, 1954). In addition to these self-help adaptations, a number of other devices were mentioned in association with work and recreational activities. A bicycle jigsaw, for instance, could be powered by a client to cut out wood projects and a paintbrush attachment could be used by an amputee before prosthetic fitting. Moreover, an occupational therapist could teach a recently blinded client a modified method of smoking, a currently taboo recreational activity that was once considered an aspect of daily living. All of these self-care and work-related adaptations formed the foundation of adaptive devices in occupational therapy, an area that has rapidly expanded with the rise in technology to meet the needs of individuals with disabilities. The function that these adaptive devices perform in encouraging independence is invaluable to the individual with a disability; surveys taken in 1969 and 1977 document such a need (Koln et aI., 1983). In 1969, 6.2 million people required 7.2 million adaptive devices in order to function independently at a maximal level. By 1977, that number had increased to 6.5 million people needing up to 8 million devices. This overwhelming demand is clearly reflected in the development and production of adaptive devices. Between 1959 and 1967, >2,500 adaptive devices were developed, including improvements on established devices as well as the introduction of more technological items, such as telephone adaptations (Lowman and Rusk, 1967). Many of today's adaptive devices capitalize on technological advances; they have gone beyond the home and expanded further into the workplace. As technology continues to advance the field of adaptive devices, the functionallevel of individuals may improve, thus reinforcing the role of adaptive devices in the future.
OF CLIENT AND DEVICE Virtually every occupational setting, from the rehabilitation hospital to the workplace, from the home to the site of recreational pursuits, can incorporate an adaptive device. In applying and select-
43
ing an adaptive device, a therapist must simultaneously evaluate the person, the environment, and the tasks at hand. The client is observed and assessed in terms of motor, sensory, and cognitive performance, which includes motivation and memory abilities. Contributing to this comprehensive approach, the therapist must consider the client's rate of "change" over time, for many people show gains or losses in functional ability depending on their condition (Mann and Lane, 1991). The home, work or school, and community environments are fundamental. The therapist assesses how the client interacts with each environment and incorporates the client's personal and functional goals into the evaluation. This insight into the individual's sociocultural, psychodynamic, and behavioral components allows the therapist and client to set realistic goals and construct a comprehensive, constructive treatment program. In this initial evaluation and screening, the therapist determines which adaptive device(s) will promote the client's needs for independence. A major requirement in prescribing an adaptive device is to educate the client on the proper use of the device. Practice and reinforcement contribute to its acceptance, but other issues, such as the client's psychological opinion of the adaptive device, are important considerations. Through rehabilitation, the client is encouraged to accept his or her new lifestyle, which will ease the transition back to the home and work environments.
THE HOME PERSPECTIVE In the home, adaptive devices center around activities of daily living, including self care, cooking, feeding, and toileting. Depending on the individual's abilities, adaptations may encompass the architecture of the home as well as specific tools for accomplishing tasks. For example, an individual with limited mobility would ideally live in a onelevel, accessible home, free of stairs and narrow passages. For the client in a wheelchair, countertops and kitchen facilities would be at wheelchair height; the lavatory would incorporate a higher toilet seat for easy transfers and grab bars
44
WORK / FALL 1993
and hand-held shower nozzles for easy bathing. More specific adaptive devices in the home could include a dressing stick and a sock aid for ease in dressing, rubber mats, plate guards, and swivel utensils for ease in feeding, and jar openers and one-handed egg beaters for ease in cooking. All of these devices apply to an array of disabilities, from rheumatoid arthritis to the effects of a stroke. According to an occupational therapy stroke support group at Braintree Hospital, the most popular adaptive devices are sock aids, reachers, book stands, adaptive cutting boards, utensils/equipment with handles, and dressing sticks (Blake, V.S., unpublished observation, 1992). One of the more unique applications of "adaptive devices" is the use of trained animals to assist individuals with disabilities. Since the early 1980s, specially trained capuchin monkeys have been used as helpers and companions for individuals with quadriplegia and other high-level spinal cord injuries (Haldane, 1991). In this setting, the occupational therapist functions in the exciting and challenging role of coordinating placements and helping the owner and the monkey adjust to their new adaptive environment. Taught to obey simple word commands and follow a red laser light controlled by the individual with quadriplegia, a capuchin monkey can perform simple manual tasks, such as retrieving objects, getting drinks, and feeding the owner, as well as putting tapes into a video machine. Although these simple tasks may be required a dozen times a day, the capuchin monkey performs them readily, receiving praise and a reward in return. In addition to this physical assistance, however, the capuchin monkey also provides a very beneficial and rewarding psychological contribution to the owner. These affectionate, responsive, and entertaining monkeys can be a very welcome addition to the unstimulating environment that a person with quadriplegia often experiences. The capuchin monkeys also increase the degree of control the individual with quadriplegia feels over the environment; many owners refer to their capuchin monkeys as their "children" (St. Jacques, J., unpublished observation, 1992). The independence the individual gains over the physical environment as well as psychological rewards of companionship make
the use of capuchin monkeys an invaluable and unique adaptive approach.
EMPLOYMENT IN A
NONDISABLED WORLD Independence through adaptive devices In the home often corresponds to independence in the workplace. Due to the development of adaptive devices, employment has become a viable option for people with disabilities. Work, paid or unpaid, provides the individual with a purpose in life. Individuals with disabilities are frequently segregated from society because of limited mobility as well as society's prejudices. Employment helps break this barrier and makes life more fulfilling. In a 1985 poll, two thirds of working-age unemployed adults with disabilities expressed an interest in working (Zeitzer, 1991). Adaptive devices play an important role in enabling people with disabilities to work in almost any field; the implementation of adaptive equipment in the workplace makes this more possible. Adaptive devices are often specific to a certain job, but generally they can be divided into aides for blue collar or white collar work settings; some devices are suitable for both. Many devices already present in everyday workplaces are beneficial to people with disabilities. Electric staplers, automatic pencil sharpeners, and motion-detecting lights may be helpful for people with low energy levels or limited mobility. The blue collar work setting involves manual labor and the use of the full body in work. New advances in biomechanics, kinesiology, and work hardening have contributed greatly to this area of adaptive devices. Many adaptive devices relate to good body mechanics, which reduces the risk of back injuries and fatigue. A back brace and a body alarm may be used as adaptive devices to encourage proper lifting. Whereas the back brace provides physical support to the lower back and abdomen, the body alarm trains the individual to be more conscious of body positioning. Should an individual fail to maintain proper posture, the body alarm will sound, reminding the user to adjust to correct body mechanics.
Occupational Therapy Views Adaptive Devices
Many tools have been adapted for the manual laborer, including flexed saws and hammers. Designed to maintain the wrist in a neutral position, these tools absorb the impact of vibration and pounding. The Farmer's hook, a prosthetic terminal device, allows a person sustaining an amputation to perform several functions, including holding a hammer; nail, bailing twine, and various other tools. Other prosthetic terminal devices, such as pediatric and adult hooks, meet the everyday needs of the individual. The cosmetic hand is yet another option for a terminal device; its cumbersome design, however, renders it less functional (Trombly, 1989). Adaptive equipment for the white collar worker primarily concerns office situations, with particular emphasis on ergonomics. Derived from the Greek words "ergo" meaning to work and "nomics" meaning knowledge, ergonomics is the science of correct body positioning. Several specially fabricated devices promote an ergonomically correct environment. The wrist rest, a padded rectangular bar, is used at a typewriter or key board. This adaptive device may assist an individual at risk of carpal tunnel syndrome by maintaining the wrist in a neutral position. In 1973, one of the first versions ofthe wrist rest was constructed from wood (Robinault, 1973); currently, it is mass produced and prevalent in almost every office setting. To prevent fatigue and improve one's sitting posture, a footrest may be installed. Specially designed chairs are other adaptive devices, which properly support the lower back by keeping the spine and pelvis in a neutral position. There are many ways an office environment can be modified to fit the needs of a person with a disability. Many of these modifications are inexpensive and easy to install. For example, simply rearranging files or shelves so that they are accessible to a person in a wheelchair is a valuable adjustment. The installation of handles on desks and benches provides stability for individuals with poor balance. An extension arm or gooseneck to hold phone receivers is of great use to a person with poor grip (Grossman, 1978). Several other devices are adaptable to a wide range of work environments. One important adaptation is a motorized cart. With a basket for
45
carrying objects, this highly portable adaptive device provides mobility and functional ability. An individual who is susceptible to fatigue or instability is at risk of slipping and falling; a skid-resistant rubber surface can be installed to decrease this risk. Scissors with adapted handles are beneficial to many people with different disabilities. They require half the energy required to use regular scissors; therefore, they are ideal for the client with rheumatoid arthritis or weak motor control. Padded shoes evenly distribute body weight on the entire foot, reducing the risk of body stress and fatigue, thus increasing the person's efficiency. Simple devices such as mouthsticks and head/chin pointers enable a person with quadriplegia to type, turn pages, or push various types of buttons (Robinault, 1973). The advancement of technology has contributed to the development of adaptive equipment. Interactive robotic aids are helpful to people with severe physical disabilities. In Fu's (1986) analysis, Boeing Computer Services developed a small, voice-activated robotic arm that allows a person with quadriplegia to independently access office equipment, including a keyboard, telephone, manuals, floppy disks, and filing cabinet. The robotic arm is specialized to handle individual sheets of paper and take notes.
Getting From Here to There Using adaptive equipment, many people with disabilities have successfully set up work environments in their homes. Whereas cottage industries allowed a person to avoid mobility problems in earlier times, public awareness and recent legislation such as the American's with Disabilities Act (ADA) of 1992 are opening up the outside job market to people with disabilities. Adaptive transportation, therefore, is in greater demand; work outside the home cannot be discussed without mentioning transportation. The history of automotive adaptive devices extends as far back as the post-World War I period, with the introduction of the Model T Ford. Equipped with a hand throttle and one pedal, this design was ideal for veterans returning with disabilities. In 1935, the Ford Phaeton was the first car introduced with complete hand controls, offering people with disabilities
46
WORK / FALL 1993
more independence. With the establishment of the fully automatic transmission and the surging use of private transportation, the research on adaptive automotive equipment began to boom (Koppa, 1990). Today, many adaptations once considered revolutionary are commonplace in private vehicles. Ramps, lifts, hand controls, and standard features such as power windows and seat adjustments are vital to the transportation of people with disabilities.
The Interdisciplinary Approach Typically, individuals with disabilities are expected to adjust to the requirements of a particular job. In many instances, however, itis more advantageous to adapt the job to the specific abilities of the individual. When prescribing adaptive devices, it is imperative to consider the person's unique situation, including the employer, the job description, and any extraneous needs. Adaptive devices and technology in particular must be considered at any time during the rehabilitation process (Langton, 1991). In a specific case study, a veteran with a prosthetic terminal hook was employed by a hotel to unload hot glassware from steam sterilizers. Previously, other employees found the glasses too hot to handle and protective gloves too cumbersome to use, causing excessive breakage (Arthur, 1967). In this example, the job was more skillfully and efficiently performed by a person with a disability, thus benefiting both the employer and the employee. Providing adaptive equipment for people with disabilities may require an interdisciplinary approach. The interdisciplinary team may incorporate an occupational therapist, vocational rehabilitation counselor, the employer, and the prospective employee. Whereas an occupational therapist identifies and suggests appropriate adaptive devices, the vocational rehabilitation counselor acts as a liaison between the employer and employee (Rubin and Roessler, 1987). The Vocational Rehabilitation Act Amendments of 1954 (Public Law 565, passed August 3, 1954) provided strong financial support for vocational rehabilitation, a benefit that contributes to a comfortable transition into the work world (Neuschutz, 1959).
ADAPTIVE DEVICES The ADA has comprehensively and formally provided protection for individuals with disabilities. Adaptive equipment plays an integral role in this landmark act of legislation, for without these devices, many people would not be able to foster their abilities. In guaranteeing fair employment, the ADA has provided the groundwork for people with disabilities to access adaptive equipment. Employers are given recommendations of appropriate work environments, including architectural accessibility regulations. As the ADA is more fully incorported into public life, adaptive devices will continue to playa crucial role in its implementation.
Rest and Relaxation As well as contributing to one's independence in home and work environments, adaptive devices are also of great benefit in leisure pursuits and recreation. Promoting an individual's ability to pursue recreational activities is a vital component of the holistic approach of occupational therapy. The ability of an individual with a disability to participate offers many therapeutic rewards, as well as building the client's self-esteem and acceptance of disability. Evaluating the recreational task environment involves understanding a client's past and present interests and determining how an adaptive device might support independence in a recreational activity. The application of adaptive devices to recreation spans all generations and disabilities. For the child, adaptive devices center around the activities of play, such as the extended handle for manipulating pull-push toys. For the visually impaired child, adaptive devices focus on auditory or tactile stimulation, such as playing jump rope with bells attached, or playing a version of texturized "Twister" (Dixon, 1981). For adults, adaptive devices may be geared toward focused hobbies, for example, devices used to assist one with bowling or fishing. Participation in recreational activities offers the client a number of emotional benefits. Occupational therapists should encourage recreational involvement and provide the appropriate adaptive
Occupational Therapy Views Adaptive Devices
devices for the client to meet this goal. Through the use of adaptive devices, recreational activities can be made accessible, thus fostering the client's independence in his or her environment and exercising the client's motivation and potential; this also limits the level of professional intervention. The wheelchair stands out as perhaps one of the most revolutionary adaptive devices, and in the area of recreation its contribution is invaluable. Competitive sports such as track, football, and basketball, which were once limited to ambulatory individuals, are completely possible for wheelchair users. The internationally prominent Special Olympics emphasize this point and showcase the abilities and potential of individuals with disabilities.
What's to Come . Adapted devices will continue to enhance home, work, and recreational pursuits. With advances in technology, the future of adaptive equipment is focused on computers and electronic devices. For example, computer programs have been designed to work with people with cognitive and physical limitations. A head pointer harness, for example, may be used in place of the mouth-held pointer, thus allowing for a clearer visual field and more adjustment flexibility. An environmental control system has been developed that allows an individual to control appliances with a remote transmitter. Finally, an electronic self-feeder has been invented, making it possible for a person
47
with disabilities to feed him- or herself. Although these modern adaptive devices are revolutionary, they can also be very costly. One must keep in mind, however, that despite inflated prices, people with disabilities may benefit from technology. Many legislative acts, including Public Law 99506 of the 1986 Amendments to the Rehabilitation Act and Public Law 100-407 of the TechnologyRelated Assistance for Individuals with Disabilities Act of 1988, have legally asserted the need for and availability of assistive technology and rehabilitation engineering for people with disabilities (Langton, 1991). The adaptive devices of yesterday were the basis for what is used today and today's devices will be changed to keep up with tomorrow's advances. As occupational therapists, we must keep abreast of the developments in adaptive equipment, particularly for the sake of our clients. Furthermore, we must be aware of the potential drawbacks of advanced technology. Undoubtedly, one detrimental factor is increasing medical costs. Other drawbacks include the possible depersonalization of the practice of occupational therapy. Although advanced technology may sacrifice the interaction between the therapist and the client, a human component will always be needed to give the client a support system. Occupational therapists must encourage creativity and think of every client as an individual with his or her own adaptive needs. With this sensitivity in mind, adaptive devices will be successfully integrated into the holistic view of the client.
REFERENCES Arthur, J. K. (1967). Employmentfor the handicapped: A guide for the disabled, their families, and their counselors. New York: Abingdon Press. Department of the Army. (1951). Occupational Therapy (DHHS Publication no. TM8-291). Washington, DC: US Government Printing Office. Dixon, J. T. (1981). Adapting activitiesfor therapeutic recreation service: Concepts and applications. San Diego, CA: Campanile Press. Fu, C. (1986). An independent vocational workstation for a quadriplegic. In R. Foulds (Ed.), Interactive robotic aids - One option for independent living: An interactive perspective (pp. 42-44). New York: World Rehabilitation Fund.
Grossman, V. (1978). Employing handicapped persons: Meeting EEO obligations. Washington, DC: The Bureau of National Affairs. Haldane, S. (1991). Helping hands. New York: Dutton Children's Books. Hopkins, H. L., and Smith, H. D. (Eds.). (1983). Willard and Spackman's Occupational Therapy (7th ed.). Philadelphia, PA: J. B. Lippincott. Kohn, J., Enders, S., Preston, J., Jr., and Modoch, W. (1983). Provision of assistive equipment for handicapped persons. Arch Phys Med Rehabil, 64, 378-38l. Koppa, R. J. (1990). State of the art automotive adaptive equipment. Hum Factors, 32, 439-455.
48
WORK / FALL 1993
Langton, A.] . (1991). Utilizing technology in the rehabilitation process. In Issues and applications in assistive technology. West Columbia: Center for Rehabilitation Technology Services, SC Vocational Rehabilitation Department. Lowman, E. W., and Rusk, H. A. (1967). Self-help devices (2nd ed.). New York: Institute of Rehabilitation Medicine. Mann, W. C., and Lane,]. P. (1991). Assistivetechnology for persons with disabilities: the role of occupational therapy. Rockville, MD: American Occupational Therapy Association, Inc. Neuschutz, L. M. (1959). The orthopedically handicapped and the cerebral palsied. In L. M. N euschutz (Ed.), Vocational rehabilitation for the physically handicapped (pp. 11-20). Springfield, IL: Charles C. Thomas. Pedretti, L. W. (1981). Occupational therapy: Practice skills for physical dysfunction. St. Louis, MO: Mosby.
Pratt, P. N., and Allen, A. S. (1989). Occupational therapy for children (2nd edition). St. Louis, MO: Mosby. Resources for Rehabilitation. (1991). Meeting the needs of employees with disabilities. Lexington, MA: Author. Robinault, I. P. (1973). Functional aids for the multiply handicapped. Hagerstown, MD: Harper and Row. Rubin, S. E., and Roessler, R. T. (Eds.). (1987). Foundations of the vocational rehabilitation process (3rd ed.). Austin, TX: Pro-Ed. Trombly, C. A. (Ed.). (1989). Occupational therapy for physical dysfunction (3rd ed.). Baltimore, MD: Williams and Wilkins. Willard, H. S. (1954). Occupational therapy (2nd ed.). Philadelphia, PA:]. B. Lippincott. Willard, H. S. (1963). Occupational therapy (3rd ed.). Philadelphia, PA:]. B. Lippincott. Zeitzer, I. R. (1991). The role of assistive technology in promoting return to work for people with disabilities: The U.S. and Swedish systems. Soc Secur Bull, 54, 24-29.
The concept of adaptive devices, as suggested by Schwartz during his keynote address at the 1992 Massachusetts Association of Occupational Therapy conference, is perhaps one of the greatest ideas in occupational therapy. Adaptive devices play an integral role in the philosophy and process of occupational therapy; as they modify and assist in an individual's environment, adaptive devices promote the greatest amount of independence and an optimal level offunctioning. Present in home, school, worksite, and community recreational settings, adaptive devices are found everywhere in our environment, in both simple and complex
forms. They run the gamut of possibilities, from everyday drinking straws to more global, architectural features such as wheelchair-accessible ramps and parking spots; from prostheses to aid in mobility to dressing sticks to aid in activities of daily living; from computers to assist with cognitive disabilities to body positioning alarms to maintain good body mechanics (e.g., Pedretti, 1981; Hopkins and Smith, 1983). As a practice, adaptive devices were once unique to the field of occupational therapy, at its inception nearly 76 years ago, but it was not until 1951 that the term officially made its way into print in an occupational therapy manual published by the U.S. Army (Dept. of the Army, 1951). The rise of this recognition coincided with the growing rehabilitative movement after World Wars I and II. With the medical advances occurring at that time, more soldiers were able to survive traumatic injuries, including the loss of limbs. Some sort of adaptation was needed to increase their independence and level of functioning.
DEVICES OF OLD The authors thank Karen Jacobs, MS, OTR/L, FAOTA, for her support and encouragement in this project. We also thank Anna Deane Scott, MEd, OTR/L, for making her personal occupational therapy library available to us. We acknowledge the following individuals for their contributions to the initial framework of this article: Larry Aaronowitz, Rob Drake, Jennifer Min, Jill St. Jacques, and Kerry Sullivan, with special thanks to Cathy Gallagher for her efforts in researching this article.
The adaptive devices first mentioned in 1951 included prostheses, splints, and braces. Three years later, a book by Willard (1954) referred to equipment involving "self-help activities," such as eating and toileting. At that time, the market for prefabricated devices had yet to be developed; therefore, most adaptive equipment consisted of WORK 1993; 3(4):42-48 Copyright © 1993 by Andover Medical
Occupational Therapy Views Adaptive Devices
fairly simple handmade devices, such as built-up spoons to aid in eating and extra long zippers to assist in dressing (Willard, 1954). In addition to these self-help adaptations, a number of other devices were mentioned in association with work and recreational activities. A bicycle jigsaw, for instance, could be powered by a client to cut out wood projects and a paintbrush attachment could be used by an amputee before prosthetic fitting. Moreover, an occupational therapist could teach a recently blinded client a modified method of smoking, a currently taboo recreational activity that was once considered an aspect of daily living. All of these self-care and work-related adaptations formed the foundation of adaptive devices in occupational therapy, an area that has rapidly expanded with the rise in technology to meet the needs of individuals with disabilities. The function that these adaptive devices perform in encouraging independence is invaluable to the individual with a disability; surveys taken in 1969 and 1977 document such a need (Koln et aI., 1983). In 1969, 6.2 million people required 7.2 million adaptive devices in order to function independently at a maximal level. By 1977, that number had increased to 6.5 million people needing up to 8 million devices. This overwhelming demand is clearly reflected in the development and production of adaptive devices. Between 1959 and 1967, >2,500 adaptive devices were developed, including improvements on established devices as well as the introduction of more technological items, such as telephone adaptations (Lowman and Rusk, 1967). Many of today's adaptive devices capitalize on technological advances; they have gone beyond the home and expanded further into the workplace. As technology continues to advance the field of adaptive devices, the functionallevel of individuals may improve, thus reinforcing the role of adaptive devices in the future.
OF CLIENT AND DEVICE Virtually every occupational setting, from the rehabilitation hospital to the workplace, from the home to the site of recreational pursuits, can incorporate an adaptive device. In applying and select-
43
ing an adaptive device, a therapist must simultaneously evaluate the person, the environment, and the tasks at hand. The client is observed and assessed in terms of motor, sensory, and cognitive performance, which includes motivation and memory abilities. Contributing to this comprehensive approach, the therapist must consider the client's rate of "change" over time, for many people show gains or losses in functional ability depending on their condition (Mann and Lane, 1991). The home, work or school, and community environments are fundamental. The therapist assesses how the client interacts with each environment and incorporates the client's personal and functional goals into the evaluation. This insight into the individual's sociocultural, psychodynamic, and behavioral components allows the therapist and client to set realistic goals and construct a comprehensive, constructive treatment program. In this initial evaluation and screening, the therapist determines which adaptive device(s) will promote the client's needs for independence. A major requirement in prescribing an adaptive device is to educate the client on the proper use of the device. Practice and reinforcement contribute to its acceptance, but other issues, such as the client's psychological opinion of the adaptive device, are important considerations. Through rehabilitation, the client is encouraged to accept his or her new lifestyle, which will ease the transition back to the home and work environments.
THE HOME PERSPECTIVE In the home, adaptive devices center around activities of daily living, including self care, cooking, feeding, and toileting. Depending on the individual's abilities, adaptations may encompass the architecture of the home as well as specific tools for accomplishing tasks. For example, an individual with limited mobility would ideally live in a onelevel, accessible home, free of stairs and narrow passages. For the client in a wheelchair, countertops and kitchen facilities would be at wheelchair height; the lavatory would incorporate a higher toilet seat for easy transfers and grab bars
44
WORK / FALL 1993
and hand-held shower nozzles for easy bathing. More specific adaptive devices in the home could include a dressing stick and a sock aid for ease in dressing, rubber mats, plate guards, and swivel utensils for ease in feeding, and jar openers and one-handed egg beaters for ease in cooking. All of these devices apply to an array of disabilities, from rheumatoid arthritis to the effects of a stroke. According to an occupational therapy stroke support group at Braintree Hospital, the most popular adaptive devices are sock aids, reachers, book stands, adaptive cutting boards, utensils/equipment with handles, and dressing sticks (Blake, V.S., unpublished observation, 1992). One of the more unique applications of "adaptive devices" is the use of trained animals to assist individuals with disabilities. Since the early 1980s, specially trained capuchin monkeys have been used as helpers and companions for individuals with quadriplegia and other high-level spinal cord injuries (Haldane, 1991). In this setting, the occupational therapist functions in the exciting and challenging role of coordinating placements and helping the owner and the monkey adjust to their new adaptive environment. Taught to obey simple word commands and follow a red laser light controlled by the individual with quadriplegia, a capuchin monkey can perform simple manual tasks, such as retrieving objects, getting drinks, and feeding the owner, as well as putting tapes into a video machine. Although these simple tasks may be required a dozen times a day, the capuchin monkey performs them readily, receiving praise and a reward in return. In addition to this physical assistance, however, the capuchin monkey also provides a very beneficial and rewarding psychological contribution to the owner. These affectionate, responsive, and entertaining monkeys can be a very welcome addition to the unstimulating environment that a person with quadriplegia often experiences. The capuchin monkeys also increase the degree of control the individual with quadriplegia feels over the environment; many owners refer to their capuchin monkeys as their "children" (St. Jacques, J., unpublished observation, 1992). The independence the individual gains over the physical environment as well as psychological rewards of companionship make
the use of capuchin monkeys an invaluable and unique adaptive approach.
EMPLOYMENT IN A
NONDISABLED WORLD Independence through adaptive devices In the home often corresponds to independence in the workplace. Due to the development of adaptive devices, employment has become a viable option for people with disabilities. Work, paid or unpaid, provides the individual with a purpose in life. Individuals with disabilities are frequently segregated from society because of limited mobility as well as society's prejudices. Employment helps break this barrier and makes life more fulfilling. In a 1985 poll, two thirds of working-age unemployed adults with disabilities expressed an interest in working (Zeitzer, 1991). Adaptive devices play an important role in enabling people with disabilities to work in almost any field; the implementation of adaptive equipment in the workplace makes this more possible. Adaptive devices are often specific to a certain job, but generally they can be divided into aides for blue collar or white collar work settings; some devices are suitable for both. Many devices already present in everyday workplaces are beneficial to people with disabilities. Electric staplers, automatic pencil sharpeners, and motion-detecting lights may be helpful for people with low energy levels or limited mobility. The blue collar work setting involves manual labor and the use of the full body in work. New advances in biomechanics, kinesiology, and work hardening have contributed greatly to this area of adaptive devices. Many adaptive devices relate to good body mechanics, which reduces the risk of back injuries and fatigue. A back brace and a body alarm may be used as adaptive devices to encourage proper lifting. Whereas the back brace provides physical support to the lower back and abdomen, the body alarm trains the individual to be more conscious of body positioning. Should an individual fail to maintain proper posture, the body alarm will sound, reminding the user to adjust to correct body mechanics.
Occupational Therapy Views Adaptive Devices
Many tools have been adapted for the manual laborer, including flexed saws and hammers. Designed to maintain the wrist in a neutral position, these tools absorb the impact of vibration and pounding. The Farmer's hook, a prosthetic terminal device, allows a person sustaining an amputation to perform several functions, including holding a hammer; nail, bailing twine, and various other tools. Other prosthetic terminal devices, such as pediatric and adult hooks, meet the everyday needs of the individual. The cosmetic hand is yet another option for a terminal device; its cumbersome design, however, renders it less functional (Trombly, 1989). Adaptive equipment for the white collar worker primarily concerns office situations, with particular emphasis on ergonomics. Derived from the Greek words "ergo" meaning to work and "nomics" meaning knowledge, ergonomics is the science of correct body positioning. Several specially fabricated devices promote an ergonomically correct environment. The wrist rest, a padded rectangular bar, is used at a typewriter or key board. This adaptive device may assist an individual at risk of carpal tunnel syndrome by maintaining the wrist in a neutral position. In 1973, one of the first versions ofthe wrist rest was constructed from wood (Robinault, 1973); currently, it is mass produced and prevalent in almost every office setting. To prevent fatigue and improve one's sitting posture, a footrest may be installed. Specially designed chairs are other adaptive devices, which properly support the lower back by keeping the spine and pelvis in a neutral position. There are many ways an office environment can be modified to fit the needs of a person with a disability. Many of these modifications are inexpensive and easy to install. For example, simply rearranging files or shelves so that they are accessible to a person in a wheelchair is a valuable adjustment. The installation of handles on desks and benches provides stability for individuals with poor balance. An extension arm or gooseneck to hold phone receivers is of great use to a person with poor grip (Grossman, 1978). Several other devices are adaptable to a wide range of work environments. One important adaptation is a motorized cart. With a basket for
45
carrying objects, this highly portable adaptive device provides mobility and functional ability. An individual who is susceptible to fatigue or instability is at risk of slipping and falling; a skid-resistant rubber surface can be installed to decrease this risk. Scissors with adapted handles are beneficial to many people with different disabilities. They require half the energy required to use regular scissors; therefore, they are ideal for the client with rheumatoid arthritis or weak motor control. Padded shoes evenly distribute body weight on the entire foot, reducing the risk of body stress and fatigue, thus increasing the person's efficiency. Simple devices such as mouthsticks and head/chin pointers enable a person with quadriplegia to type, turn pages, or push various types of buttons (Robinault, 1973). The advancement of technology has contributed to the development of adaptive equipment. Interactive robotic aids are helpful to people with severe physical disabilities. In Fu's (1986) analysis, Boeing Computer Services developed a small, voice-activated robotic arm that allows a person with quadriplegia to independently access office equipment, including a keyboard, telephone, manuals, floppy disks, and filing cabinet. The robotic arm is specialized to handle individual sheets of paper and take notes.
Getting From Here to There Using adaptive equipment, many people with disabilities have successfully set up work environments in their homes. Whereas cottage industries allowed a person to avoid mobility problems in earlier times, public awareness and recent legislation such as the American's with Disabilities Act (ADA) of 1992 are opening up the outside job market to people with disabilities. Adaptive transportation, therefore, is in greater demand; work outside the home cannot be discussed without mentioning transportation. The history of automotive adaptive devices extends as far back as the post-World War I period, with the introduction of the Model T Ford. Equipped with a hand throttle and one pedal, this design was ideal for veterans returning with disabilities. In 1935, the Ford Phaeton was the first car introduced with complete hand controls, offering people with disabilities
46
WORK / FALL 1993
more independence. With the establishment of the fully automatic transmission and the surging use of private transportation, the research on adaptive automotive equipment began to boom (Koppa, 1990). Today, many adaptations once considered revolutionary are commonplace in private vehicles. Ramps, lifts, hand controls, and standard features such as power windows and seat adjustments are vital to the transportation of people with disabilities.
The Interdisciplinary Approach Typically, individuals with disabilities are expected to adjust to the requirements of a particular job. In many instances, however, itis more advantageous to adapt the job to the specific abilities of the individual. When prescribing adaptive devices, it is imperative to consider the person's unique situation, including the employer, the job description, and any extraneous needs. Adaptive devices and technology in particular must be considered at any time during the rehabilitation process (Langton, 1991). In a specific case study, a veteran with a prosthetic terminal hook was employed by a hotel to unload hot glassware from steam sterilizers. Previously, other employees found the glasses too hot to handle and protective gloves too cumbersome to use, causing excessive breakage (Arthur, 1967). In this example, the job was more skillfully and efficiently performed by a person with a disability, thus benefiting both the employer and the employee. Providing adaptive equipment for people with disabilities may require an interdisciplinary approach. The interdisciplinary team may incorporate an occupational therapist, vocational rehabilitation counselor, the employer, and the prospective employee. Whereas an occupational therapist identifies and suggests appropriate adaptive devices, the vocational rehabilitation counselor acts as a liaison between the employer and employee (Rubin and Roessler, 1987). The Vocational Rehabilitation Act Amendments of 1954 (Public Law 565, passed August 3, 1954) provided strong financial support for vocational rehabilitation, a benefit that contributes to a comfortable transition into the work world (Neuschutz, 1959).
ADAPTIVE DEVICES The ADA has comprehensively and formally provided protection for individuals with disabilities. Adaptive equipment plays an integral role in this landmark act of legislation, for without these devices, many people would not be able to foster their abilities. In guaranteeing fair employment, the ADA has provided the groundwork for people with disabilities to access adaptive equipment. Employers are given recommendations of appropriate work environments, including architectural accessibility regulations. As the ADA is more fully incorported into public life, adaptive devices will continue to playa crucial role in its implementation.
Rest and Relaxation As well as contributing to one's independence in home and work environments, adaptive devices are also of great benefit in leisure pursuits and recreation. Promoting an individual's ability to pursue recreational activities is a vital component of the holistic approach of occupational therapy. The ability of an individual with a disability to participate offers many therapeutic rewards, as well as building the client's self-esteem and acceptance of disability. Evaluating the recreational task environment involves understanding a client's past and present interests and determining how an adaptive device might support independence in a recreational activity. The application of adaptive devices to recreation spans all generations and disabilities. For the child, adaptive devices center around the activities of play, such as the extended handle for manipulating pull-push toys. For the visually impaired child, adaptive devices focus on auditory or tactile stimulation, such as playing jump rope with bells attached, or playing a version of texturized "Twister" (Dixon, 1981). For adults, adaptive devices may be geared toward focused hobbies, for example, devices used to assist one with bowling or fishing. Participation in recreational activities offers the client a number of emotional benefits. Occupational therapists should encourage recreational involvement and provide the appropriate adaptive
Occupational Therapy Views Adaptive Devices
devices for the client to meet this goal. Through the use of adaptive devices, recreational activities can be made accessible, thus fostering the client's independence in his or her environment and exercising the client's motivation and potential; this also limits the level of professional intervention. The wheelchair stands out as perhaps one of the most revolutionary adaptive devices, and in the area of recreation its contribution is invaluable. Competitive sports such as track, football, and basketball, which were once limited to ambulatory individuals, are completely possible for wheelchair users. The internationally prominent Special Olympics emphasize this point and showcase the abilities and potential of individuals with disabilities.
What's to Come . Adapted devices will continue to enhance home, work, and recreational pursuits. With advances in technology, the future of adaptive equipment is focused on computers and electronic devices. For example, computer programs have been designed to work with people with cognitive and physical limitations. A head pointer harness, for example, may be used in place of the mouth-held pointer, thus allowing for a clearer visual field and more adjustment flexibility. An environmental control system has been developed that allows an individual to control appliances with a remote transmitter. Finally, an electronic self-feeder has been invented, making it possible for a person
47
with disabilities to feed him- or herself. Although these modern adaptive devices are revolutionary, they can also be very costly. One must keep in mind, however, that despite inflated prices, people with disabilities may benefit from technology. Many legislative acts, including Public Law 99506 of the 1986 Amendments to the Rehabilitation Act and Public Law 100-407 of the TechnologyRelated Assistance for Individuals with Disabilities Act of 1988, have legally asserted the need for and availability of assistive technology and rehabilitation engineering for people with disabilities (Langton, 1991). The adaptive devices of yesterday were the basis for what is used today and today's devices will be changed to keep up with tomorrow's advances. As occupational therapists, we must keep abreast of the developments in adaptive equipment, particularly for the sake of our clients. Furthermore, we must be aware of the potential drawbacks of advanced technology. Undoubtedly, one detrimental factor is increasing medical costs. Other drawbacks include the possible depersonalization of the practice of occupational therapy. Although advanced technology may sacrifice the interaction between the therapist and the client, a human component will always be needed to give the client a support system. Occupational therapists must encourage creativity and think of every client as an individual with his or her own adaptive needs. With this sensitivity in mind, adaptive devices will be successfully integrated into the holistic view of the client.
REFERENCES Arthur, J. K. (1967). Employmentfor the handicapped: A guide for the disabled, their families, and their counselors. New York: Abingdon Press. Department of the Army. (1951). Occupational Therapy (DHHS Publication no. TM8-291). Washington, DC: US Government Printing Office. Dixon, J. T. (1981). Adapting activitiesfor therapeutic recreation service: Concepts and applications. San Diego, CA: Campanile Press. Fu, C. (1986). An independent vocational workstation for a quadriplegic. In R. Foulds (Ed.), Interactive robotic aids - One option for independent living: An interactive perspective (pp. 42-44). New York: World Rehabilitation Fund.
Grossman, V. (1978). Employing handicapped persons: Meeting EEO obligations. Washington, DC: The Bureau of National Affairs. Haldane, S. (1991). Helping hands. New York: Dutton Children's Books. Hopkins, H. L., and Smith, H. D. (Eds.). (1983). Willard and Spackman's Occupational Therapy (7th ed.). Philadelphia, PA: J. B. Lippincott. Kohn, J., Enders, S., Preston, J., Jr., and Modoch, W. (1983). Provision of assistive equipment for handicapped persons. Arch Phys Med Rehabil, 64, 378-38l. Koppa, R. J. (1990). State of the art automotive adaptive equipment. Hum Factors, 32, 439-455.
48
WORK / FALL 1993
Langton, A.] . (1991). Utilizing technology in the rehabilitation process. In Issues and applications in assistive technology. West Columbia: Center for Rehabilitation Technology Services, SC Vocational Rehabilitation Department. Lowman, E. W., and Rusk, H. A. (1967). Self-help devices (2nd ed.). New York: Institute of Rehabilitation Medicine. Mann, W. C., and Lane,]. P. (1991). Assistivetechnology for persons with disabilities: the role of occupational therapy. Rockville, MD: American Occupational Therapy Association, Inc. Neuschutz, L. M. (1959). The orthopedically handicapped and the cerebral palsied. In L. M. N euschutz (Ed.), Vocational rehabilitation for the physically handicapped (pp. 11-20). Springfield, IL: Charles C. Thomas. Pedretti, L. W. (1981). Occupational therapy: Practice skills for physical dysfunction. St. Louis, MO: Mosby.
Pratt, P. N., and Allen, A. S. (1989). Occupational therapy for children (2nd edition). St. Louis, MO: Mosby. Resources for Rehabilitation. (1991). Meeting the needs of employees with disabilities. Lexington, MA: Author. Robinault, I. P. (1973). Functional aids for the multiply handicapped. Hagerstown, MD: Harper and Row. Rubin, S. E., and Roessler, R. T. (Eds.). (1987). Foundations of the vocational rehabilitation process (3rd ed.). Austin, TX: Pro-Ed. Trombly, C. A. (Ed.). (1989). Occupational therapy for physical dysfunction (3rd ed.). Baltimore, MD: Williams and Wilkins. Willard, H. S. (1954). Occupational therapy (2nd ed.). Philadelphia, PA:]. B. Lippincott. Willard, H. S. (1963). Occupational therapy (3rd ed.). Philadelphia, PA:]. B. Lippincott. Zeitzer, I. R. (1991). The role of assistive technology in promoting return to work for people with disabilities: The U.S. and Swedish systems. Soc Secur Bull, 54, 24-29.
