Clin Rheumatol (1998) 17:3-5 �9 1998 Clinical Rheumatology Clinical

Rheumatology

Editorial

Assistive Devices: Integral to the Daily Lives of Human Beings

M. A. H. van Kuyk-Minis

Occupational Therapy Department, Sint Radboud Ziekenhuis, University of Nijmegen, The Netherlands

The use of assistive devices is normal in the everyday lives of human beings. Almost everything that is used to perform activities of daily living are devices - from a fork to a bicycle. At the beginning of this century, employers were interested in how to increase their workers' output by applying alternative working methods. An ergonomic approach has been one way to increase industrial output. Over the past few decades, this notion has expanded such that an ergonomic way of working and the use of assistive devices has increased performance not only in the work environment, but in all activities of daily life (productivity, self-care and leisure). Today, ergonomics in the workplace, including adaptation of environments, using alternative working methods and assistive devices, is increasingly focused on the prevention of injuries. This approach is also designed to increase employees' performance. Ergonomics has also become integrated into occupational behaviour settings such as the home, neighbourhood and work- place, and communal/recreation/resource sites such as theatres, churches, temples and libraries [1]. Ergonomics has become an important science in today's life. It is generally accepted that a dishwasher cleans quicker and cleaner, and that a bigger light switch at hand level is more energy efficient than a switch that requires lifting the arm. An oven at eye level is also more convenient to use than one hidden under a hob. It is evident that a drawer under the kitchen counter is more efficient than a shelf in a cupboard for which one has to kneel, bend and reach to find what we are looking for. At the beginning of the century, clerks used to stand and write all day, and cooking still occurs while standing. Habits are often indestructible, having been adopted over several

Correspondence and offprint requests to: M. A. H. van Kuyk-Minis, Occupational Therapy Department, Sint Radboud Ziekenhuis, University of Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands.

generations, and we do not question why certain activities are performed in a specific way. An ergonomic way of thinking includes consideration for who is doing the activity, why this person is doing the activity and how it is being completed. Sometimes we have to ask ourselves these questions, especially when making choices after developing a chronic disease such as rheumatoid arthritis. For example, does motherhood always imply that the mother cleans the house, shops for food and does the ironing?

Over the past 15 years, technologies have resulted in speciatised technical aids, such as electronic commu- nication devices, computer input devices, and environ- mental control systems [2]. Many of these devices were first invented for disabled people (e.g. remote controls) and later commonly used in society, or were invented for the various purposes commonly found in industry, technology, or science and later used by the disabled (e.g. Temper Foam pillows).

Rheumatoid arthritis is a disease that causes problems in performing activities of daily life [3], because of painful inflammation in the joints, muscle weakness, stiffness, fatigue [4] and a reduced grip force [5]. The impact of a chronic disease on an individual depends on more than the severity of the disease. A different way of thinking about health [6] has clarified the need not only to look at survival rates, but also the quality of life in coping with disease. Many patients with arthritic problems enjoy greater functional independence within the home, school, workplace and community by using altered working methods or assistive devices [2]. In a century in which technological development is increas- ing, the devices available have increased significantly too. Although in the past, both patients and healthcare providers considered that they had failed when devices were needed, many former assistive devices are now part of our regular environment. Taps with a lever arm are common, kitchen pans are lighter and tumble dryers

M. A. H. van Kuyk-Minis

have replaced hanging clothes up to dry. A shift of acceptance has taken place, since devices invented for the disabled have become common in the healthy population, and vice versa. Although it has never been proven that the use of assistive devices prevents deformities, we now believe that assistive devices or using an altered working method can make the difference between being able to perform a task and being unable to perform a task. This is not only true for the arthritic population, but also for people working in industry and other work environments. The design of the most modern keyboard already differs in shape from that of the first keyboard: it has been redeveloped to a more ergonomically sound design. Fortunately, in the twen- tieth century, more emphasis is put on the design of assistive devices, a belief that is essential to ensure the acceptance of future users.

It is important, however, that individuals are taught how to change former lifestyles. People need to learn new ways of carrying out activities and new strategies to perform activities that we are not able to do in an ordinary way, by using assistive devices. Advice on assistive devices is part of the service provided by occupational therapists. First of all, an accurate holistic assessment is needed to detect the needs of the patient in his or her lifestyle and to assess daily activities for the level of disability and handicap. A disability in one patient may require a different solution from another person with the same disability. Different solutions depend on many factors, such as volition, habituation, performance and environmental factors [7]. Active involvement of the patient in his or her own treatment is a prerequisite to reach occupational treatment goals. Occupational therapy uses a holistic view of the individual; the occupational therapist will therefore include the influence of the disease on the performance of the individual in their assessment.

The first step in therapy is to identify the occupational role in which the person wishes to engage and then facilitate the means to fulfil those identified roles to a person's satisfaction [8]. Occupational therapists have a role in supporting peformance components, maintaining functional mobility, facilitating functional performance and engaging in meaningful activities [9]. Kielhofner [7] explains in his Model Of Human Occupation (MOHO) that occupational roles consist of three levels of functioning: (1) organisation of routines; (2) life roles: achievement of balance in work, play and daily living tasks; and (3) interests, values and goals. Although there is no linear relationship between impairment, disability and handicap, assistive devices and altered working methods can make the difference between experiencing or not experiencing a handicap. In the arthritic population the progression from being healthy without any impairment or disability to being disabled may take several years. On the other hand a severely disabled patient does not have to have a handicap per se. As professionals know, the ability of their patients to function in society varies widely, even among people with very similar disabilities and impairments [10].

According to Geiger [1 1], the role of the occupational therapist in developing a recommendation for assfstive devices and the reasons for this decision have not been studied. An important part of prescribing equipment is the follow-up phase. In the present climate of cost containment in health care, one has to consider the economic aspect of prescribing equipment when evalu- ating a person's need for devices. In most countries, assistive devices are covered or subsidised by health insurance Or the government. Regardless of the source of payment, the cost is not justified if it proves to be useless to the consumer [11]. Findings have revealed that some subjects have inadequate information on assistive devices, suggesting the importance of more involvement of occupational therapists in selecting devices [12,13] and the need for instruction [3]. The strength of occupational therapy is that the patient can use the device first during a training period, before having to decide whether to buy or adopt the device. These days, more and more assistive devices are available in numerous shops, though the patient may not have an opportunity to test them. It is debatable whether training is always needed. Occupational therapists must be certain of the need of a device when advising an individual. In western countries; it is not always possible to teach the patients how to use assistive devices in their own environment for a variety of reasons. When training the patient in the artificial environment of the occupa- tional therapy department, the therapist will not always be able to predict whether the patient will use the device and whether the advice given to the patient is suitable for his or her own home environment. The therapist needs feedback from the patient after a reasonable period of time to make sure that the advice has been appropriate.

Rogers and Holm [14] found that little theoretical or empirical research has been done on the prescription, provision or evaluation of assistive technology devices. They designed a model to attempt to predict those patients who will use, and those who will not use, assistive devices. According to Rogers and Holm [14], use of the model would foster an understanding of the factors that contribute to use of devices and hence would benefit patients with arthritis (users) and the therapists (prescribers).

It is only since the last decade that occupational therapists have started to build a research tradition. Trial and error was often the only way to find out what was best for the patient. Not all departments of rheumatology have the option of teaching patients in group sessions, such as described by Nordenski61d et al. [15]. Not all patients Who need advice from an occupational therapist have the opportunity to meet an occupational therapist. The optimal way to reach the patient is via extensive information sessions. The judgement of the patient is then relied upon to choose a device that may assist in the performance of daily activities. Therapists use pro- cedural, interactive and conditional reasoning to make decisions within each step, and also individualised training [16]. Gitlin and Burgh [16] suggest six steps to follow when issuing an assistive device: device

Assistive Devices 5

selection, an activity to introduce the device, a site for instruction, a method of instruction, the time to introduce a device during hospitalisation and reinforcement of its use. There are several articles on assistive devices for the arthritic population [17-19]. A critical assessment of the extent of use or non-use by patients of assistive devices is needed along with an understanding of the reasons for non-use from the perspective of the user. Haworth [20] stated that the most frequent reasons for non-use of dressing aids were the ability to function without the aid or because assistance was received from another person. In 1995, Mann et al. [13] demonstrated in a study of the use of assistive devices at home for elderly persons with arthritis that a relationship exists between the level o f disease and the amount of assistive devices used. Generally, there was a high rate of satisfaction. In comparing these two articles, it can be seen that progress has been made over the past decade in the ways that we prescribe assistive devices.

In this issue of Clinical Rheumatology, a paper describes the development and use of a way to assess the effects of assistive devices and altered working methods in women with rheumatoid arthritis. By examining the patients with the Evaluation of Daily Activities Questionnaire (EDAQ) [15], pat ients-can inform us using their own judgement and their own level of satisfaction, with the use of assistive devices and altered working methods suggested by the occupational therapist. The research therapist can start making inferences and use this feedback to improve occupational therapy treatment.

Not long ago a rheumatologist gave his old computer to a patient who could not get one funded. The patient wanted to use the computer as an alternative leisure activity because he was no longer able to continue his role as a clockmaker. Devices are sometimes even better than medication! We live in a century of assistive devices. If we could create an optimal, ergonomically justified world, patients with a chronic disease would not experience disabilities to the extent that they do now. What we cannot do is take away fatigue, pain, stiffness and reduced range of motion. With assistive devices and altered working methods, however, we can try to compensate.

R e f e r e n c e s

1. Kielhofner G. A model of human occupation. In: Environmental influences on occupational behavior, 2nd edn. Baltimore: Williams & Wilkins, 1995:105.

2. Dickey R, Shealy SH. Using technology to control the environment. Am J Ocup Ther 1987;41:717-21.

3. Nordenski61d U, Grimby G, Hedberg M, Wright B, Linacre ML. The structure of an instrument for assessing the effects of assistive devices and altered working methods in women with rheumatoid arthritis. Arthritis Care Res 1996;9:358-67.

4. Schumacher HR, Klippel JH, Koopman WJ. Primer on the rheumatic diseases. Atlanta, Georgia: The Arthritis Foundation, 1993.

5. Nordenski61d U, Grimby G. Grip force in patients with rheumatoid arthritis and fibromyalgia and in healthy subjects: a study with the Grippit instrument. Scand J Rheumatol 1993;22:14-19.

6. World Health Organization. International classification of impairments, disabilities, and handicaps. Geneva: WHO, 1980: 1993.

7. Kielhofner G. Current concepts and clinical applications of the model of human occupation: theoretical overview. Edmonton: University of Alberta, 1992.

8. Dickerson AE, Oakley F. Comparing the roles of community- living persons and patient populations. Am J Occup Ther 1995;49:1-15.

9. Bowbly-Sifton C. The dementia story: challenging the art of occupational therapy. Can J Occup Ther 1997;64:3-6.

10. Whiteneck GG, Charifue SW, Gerhart KA, Drew Overholser J, Richardson GN. Quantifying handicap: a new measure of long- term rehabilitation outcomes. Arch Phys Med Rehabil 1992; 73:519-26.

11. Geiger CM. The utilization of assistive devices by patients discharged from an acute rehabilitation setting. Phys Occup Ther Geriatr 1990;9:3-25

12. Gitlin LN, Birgh D, Dodsen C, Freda M. Strategies to recruit older adults for participation in rehabilitation research. Topics Geriatr Rehabil 1995; 11 : 10-19.

13. Mann WC, Hurren D, Tomita M. Assistive devices used by home- based elderly persons with arthritis. Am J Occup Ther 1995; 49:810-20.

14. Rogers JC, Holm MB. Assistive technology device use in patients, with rheumatic disease: a literature review. Am J Occup Ther 1992;46:120-7.

15. Nordenski61d U, Grimby G, DahlimIvanoff S. Questionnaire to evaluate the effects of assistive devices and altered working methods in women with rheumatoid arthritis. Clin Rheumatol 1998;17:6-16.

16. Gitlin LN, Burgh D. Issuing devices to older patients in rehabilitation: an exploratory study. Am J Occup Ther 1995; 49:994-1000.

17. Sweeney GM, Catchpool N, Clarke AK. Choosing lever taps for people with rheumatoid arthritis. Br J Occup Ther 1994;57:263- 5.

18. Dallas MJ. Clothing fasteners for women with arthritis. Am J Occup Ther 1982;36:515-8.

19. Dickey R, Shealy SH. Using technology to control the environment. Am J Occup Ther 1987;41:717-21.

20. Haworth RJ. Use of aids during the first three months after total hip replacement. Br J Rheumatol t983;22:29-35.