E-18 Assistive Technology

Technology “concerns itself with understanding how knowledge is creatively applied to organised tasks involving people and machines that meet sustainable goals.” This is usually manifest as a physical object used to help a person or group achieve a task more efficiently. Almost everything we use daily represents a technological product – taps, remote controls, iPads, trains, handrails on stairs etc. They all assist us. So it is no surprise that there are challenges in deciding what constitutes assistive technology as a specific health-related device, as is well illustrated in national guidance on medical devices. The World Health Organisations International Classification of Functioning defines Assistive Technology as “any product, instrument, equipment, or technology adapted or specially designed for improving the functioning of a disabled person.” [Chapter one, page 180, in WHO ICF] While this common sense definition covers many situations, rehabilitation professionals must be aware of commonly available technology not explicitly designed for people with health conditions, such as smartphones which can significantly improve independence, especially with specific apps to support their needs.

Table of Contents

The Assistive Technology competency

The rehabilitation professional must be “Able to assess the suitability of and a patient’s ability to benefit from assistive technology either during rehabilitation or as a long-term support (or both)”. This means the aid must usually be tailored to the patient, considering their motor, sensory, and cognitive skills, environment, and needs. A supporting document can be downloaded here.

Introduction

One defining characteristic of humans is their development and use of objects to perform functional tasks.  This is not unique to our species, as it has been observed in other primates and corvids (birds such as the New Caledonian crow), but humans excel at devising and using tools. Some tools were undoubtedly developed early in human development for people with health problems, such as traumatic damage to limbs (e.g. walking sticks, a wooden leg). The use of assistive technology cannot be considered a new phenomenon.

The increasing prevalence of people living with difficulties in performing activities dues to the effects of ageing or long-term health conditions has led to the development of a slightly more supportive general environment and a wide range of commonly available aids that can be bought without healthcare input – glasses, hearing aids, walking sticks, incontinence pads, non-slip bath mats etc.

The boundary between defined assistive technology and technology used by anyone is indistinct. However, anything classified as assistive technology may be available at reduced or no cost to the user, and some equipment and adaptations are expensive.

We face many challenges:

  1. Help people to select and buy appropriate and safe aids if they wish to do so. Patients may purchase unsuitable equipment because they do not seek advice or because the vendor does not evaluate the device’s suitability for the patient.
  2. Negotiating financial support for equipment that will help the patients when:
    1. It is expensive.
    2. It is not identified as specifically designed for people with a disability, even if it is undoubtedly effective.
  3. Providing evidence of benefit without trying the equipment. For example, some limb prostheses may be effective for selected individuals, but there is no evidence that they will help the particular patient unless tried.

Range of assistive technology.

Assistive technology covers a great range in cost, purpose, complexity, how it is used etc. Classifying the technologies into helpful categories takes time and effort. Stephen Bauer and colleagues proposed a system based on the WHO International Classification of Functioning.

First, they subdivided technologies into those related to WHO-defined health states (Annex 1, page 220), defined as “the level of functioning within a given health domain of ICF” where the health need is considered as “the primary responsibility of the health system”, and those related to a health-related state which is defined thus, “while they have a strong relationship to a health condition, are not likely to be the primary responsibility of the health system, but rather of other systems contributing to overall wellbeing”. The WHO ICF recognised this as not a secure distinction, “There may be a grey zone depending on differing conceptualisations of health and health-related elements …”

Second, they divided them into intrinsic, located within the body, and extrinsic. Third, they divided them into Disability-specific and Cross-disability technologies. These were mapped to the categories within the ICF.

This classification illustrates three points. First, assistive technology covers a vast range and includes implanted technologies. Second, classification will be challenging given this range. Third, the distinction between technologies that are healthcare responsibilities and not is impossible on a coherent and logically consistent basis and will vary between countries dependent upon healthcare policies. Stephen Bauer and colleagues considered other classification systems.

Use of assistive technology.

The World Health Organisation has recently published a fact sheet on assistive technology, emphasising its importance, the wide range of patients and disabilities that it can help,  and the vast number of people who could benefit. It also notes that few countries have national policies; most countries need to pay more attention and give more resources.

The situation in the UK is a clear example. In two reports in 2000 and 2002, the Audit Commission found evidence of grossly inadequate resources and poorly organised services despite proof of the benefits. This still applies across all extrinsic aids such as wheelchairs, hearing aids, aids to communication, and housing adaptations.

Effectiveness.

Research into the effectiveness of assistive technology is limited, and much needs to be of better quality. Toby Smith and colleagues evaluated equipment to reduce dislocation and hip arthroplasty, found few trials, and could not draw firm conclusions. Elsbeth de Joode and colleagues reviewed the evidence concerning technologies to help people with cognitive deficits. Only one randomised trial was found. Alex Gillespie and colleagues also investigated its use with people with cognitive losses. There were many studies but little strong evidence. Ji-Hye Nam and Hee Kim used data from 385 people in published studies. They suggested that technology could improve the performance of activities of daily living in people with brain injury.

The first challenge in proving effectiveness concerns the practicality of the usually accepted principles. For example, a credible non-assistive-technology control is difficult to conceive; how would you control for providing a prosthetic leg? One can compare two similar pieces of equipment, though probably not masked. The number of available patients may be limited. Gaining informed consent when one arm will not receive a credible alternative would be difficult; indeed, proposing that might be ethically challenging.

The second challenge is funding. Most equipment is produced by a commercial company, which already must cover the costs of gaining regulatory approval. Most equipment is expensive, and much is not reusable. Research funders and commercial organisations will be reluctant to spend large sums on research projects.

The third challenge is that many technological devices are self-evidently effective; who would question whether a prosthetic leg will assist someone whose leg has been amputated? There is a reasonable case for researching areas of uncertainty. For example, would a person with a below-knee amputation secondary to vascular disease and diabetes who is obese, cognitively impaired, and only walked short distances before amputation benefit from a prosthesis?

In most circumstances, critical analysis and, if necessary, a trial of the equipment will be the best way to determine effectiveness. Before providing the equipment, the likely benefits and risks should be discussed and agreed on, and simple clinical measures should be defined to be used at an agreed time. A period of learning and adaptation must be built-in to the evaluation.

Clinical training

The range of equipment that may be needed is so extensive that it is unrealistic to expect anyone to be an expert in every area of practice. Instead, it is a matter of being aware and able to consider the situation holistically, focussing on the patient’s needs, preferences, and ability to use whatever is being considered in their circumstances.

Further, just as drugs can have adverse effects, one must always consider whether the proposed intervention may cause harm and whether any existing aspect of the environment is adding to their difficulties or causing damage. For example, providing a falls-alarm is a poor response if the environment is littered with trip hazards causing falls.

 

Thus, the essential skill is always to ask, “Could a piece of equipment of any kind give this person more autonomy or safety?” with, as a subsidiary question, “Could altering this person’s physical or social environment increase their autonomy or safety?” This is similar to the approach to other issues, such as mood disturbance (“Could depression or anxiety be causing or exacerbating this person’s difficulties?”)

At the same time, whenever you come across something new, you should ask the patient and any involved professional about it, exploring what it does, how it works, what its risks are etc.

Conclusion

The crucial first step in being competent in using assistive technology is to ask whether equipment or other environment changes might help your patient and, when doing so, not to be constrained to equipment or changes that are defined as being health-related. The second step is always to be curious and learn from your patients about their experience of any equipment they use or have tried and found unhelpful or harmful. Third, always consider your own experience of using technological aids. Many services have considerable expertise in a restricted range of technology, and your role is to be the intermediary between the patient and the experts. The experts are naturally and appropriately in the technology and need your input to ensure it is clinically feasible. The patient may have unrealistic expectations or need help understanding the technology, and your role is to provide additional information and support after any expert assessment or intervention.

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