Running Head: ASSISTIVE TECHNOLOGY DEVICE PAPER

Assistive Technology Device Paper Kristina Harvey Touro University Nevada

ASSISTIVE TECHNOLOGY DEVICE PAPER Introduction Each year in the United States, about 50,000 individuals suffer the loss of a limb. There are two different types of amputations. Acquired amputation is an amputation which is often medically recommended and can be due to disease such as; diabetes or peripheral vascular

disease (Martin, 2013). Traumatic amputation results from an accidental or nonsurgical injury. In this case the limb may be partially or completely detached and medical professionals determine that limb cannot be saved. This type of amputation can be a result of a motor vehicle accident, machinery accident, gunshot wound, etc. (Martin, 2013). The loss of a limb affects many aspects of an individuals life. Whether the amputation was acquired or traumatic, the implications can permanently alter the individuals engagement in occupation. If the amputation is accompanied by other comorbities such as a traumatic brain injury (TBI), the recovery may be more difficult and prolonged. Learning how to reengage in daily occupations will be challenging for an individual who has just lost a limb. If this individual is also suffering from a TBI, the recovery will be that much more challenging. This paper will focus on upper extremity, unilateral amputations as well as TBI, and the affect they have on individuals engaging in occupations. Review of the Literature Individuals who have sustained an amputation will require a variety of services to aid in their recovery and promote independence in daily occupations. The ratio of upper extremity amputations to lower extremity is about 1:2.2 with upper extremity amputations accounting for the smaller proportion (Jang et al., 2011). The upper extremity is responsible for more finely calculated movements, while the lower extremity is responsible primarily for gait. Therefore,

ASSISTIVE TECHNOLOGY DEVICE PAPER loss of an upper extremity can inhibit the individuals ability to perform finely calculated movements bilaterally. One survey assessed activities of daily living and occupations for upper extremity amputees, as well as their struggles with prosthetic usage (Jang et al., 2011). Upper extremity prosthetics have a difficult time replicating the precise movements and tactile sensory functions of the hand and upper extremity. Therefore, amputees experience a great deal of difficulty and frustration during rehabilitation. This study noted that many upper extremity amputees wear a prosthetic for mostly cosmetic reasons. Many choose to forgo a prosthetic because it lacks functionality (Jang et al., 2011).

The survey mailed questionnaires to 968 amputees who had received a prosthetic device. 344 questionnaires were returned. The questionnaire included 17 examples of activities of daily living and the participants were asked to rate their level of satisfaction with each. The questionnaire also included a section about driving to determine whether or not the amputee drove a vehicle before and after the amputation, as well as whether or not his/her vehicle had been modified. Lastly, the questionnaire asked about pain and discomfort at the stump site. If pain or discomfort was present, the questionnaire asked what the pain or discomfort felt like (Jang et al., 2011). The results concluded that 2.6 percent of subjects were highly satisfied with their performance in activities of daily living. 20.9 percent of participants were somewhat satisfied, 44.3 percent were moderately satisfied, 13.2 percent were somewhat dissatisfied, and 19 percent were highly dissatisfied in their performance of activities of daily living (Jang et al., 2011). In regards to driving, all participants reported they drove before the amputation. After the amputation, 41 percent stated they still drove, and 26.9 percent of this group said their vehicle

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had been modified (Jang et al., 2011). When assessing the results regarding pain and discomfort, 27 percent reported experiencing some pain or discomfort all the time. 43 percent of the participants reported feeling pain or discomfort occasionally, and 12.4 percent reported pain occurring with the use of the prosthetic limb (Jang et al., 2011). The study concludes by stating that upper extremity prosthetics appear to have more of a cosmetic purpose rather than a functional one. The study notes a need for more functional prosthetics, changes in social awareness regarding amputees, and establishing policies to help improve occupational rehabilitation for amputees (Jang et al., 2011). Providing adequate and appropriate services for amputees is very important for promoting independence and reengagement in occupations. An interdisciplinary team approach can be beneficial in helping the individual receive a holistic approach to rehabilitation services. One study aimed at assessing amputation-related health services in adult acquired upper limb amputations. The study explored the utilization of health services, unmet needs, and the association between demographic and amputation-related factors (Ostlie, Garfelt, Skjeldal & Magnus, 2012). The study participants included 224 upper limb amputees. These individuals completed a mailed questionnaire. The results of the questionnaires concluded that 55 percent of the participants were satisfied with health services, 23 percent were very-satisfied, and nine percent were dissatisfied (Ostlie, Garfelt, Skjeldal & Magnus, 2012). Some important factors to be noted were current prosthetic users found physical therapy more beneficial than nonprosthetic users. Women over the age of 40 found community-based occupational therapy more helpful than men ages 18-39. While the study reported these findings, no reasoning for these responses was provided.

ASSISTIVE TECHNOLOGY DEVICE PAPER The study concluded that there was a relatively low utilization of health services among amputees. This may be in part due to amputees lacking information about available services and their potential benefit. Some contributing factors included; individuals initiative to seek services, referrals being needed for physical and occupational therapy, and communication barriers regarding services (Ostlie, Garfelt, Skjeldal & Magnus, 2012). The previous studies explore some of the common challenges associated with an upper extremity amputation. The next study explores difficulties individuals have reengaging in occupations while transitioning from a hospital to home setting after TBI. This particular study

does not focus on other comorbidities like an upper extremity amputation, but challenges in daily activities would be compounded for individuals suffering from both events. One study focused on difficulties of transitioning from a hospital setting to a home setting, and reengaging in daily occupations. Community reintegration has been an important aspect to measure to reflect the experiences of individuals with TBI post hospital discharge (Nalder, Hons, Fleming, Cornwell, Foster & Haines, 2012). Research has been consistent in showing individuals with TBI have lower levels of community reintegration compared to the general population. This population often has lower employment levels, more social isolation, increased dependency on informal caregivers, and emotional distress (Nalder, Hons, Fleming, Cornwell, Foster & Haines, 2012). This study uses sentinel events to better understand experiences and challenges faced by individuals with TBI. A sentinel even is defined as an important event, either positive or negative, which arises in the life of an individual and requires investigation to assess its timing, precursors, and impact on aspects of the life course (Nalder, Hons, Fleming, Cornwell,

ASSISTIVE TECHNOLOGY DEVICE PAPER Foster & Haines, 2012, p. 838). There are several factors that can influence community reintegration and include; severity of injury, age, gender, education, occupation, living arrangements, cognitive and emotional status, and functional performance (Nalder, Hons, Fleming, Cornwell, Foster & Haines, 2012). The study analyzed the transition from a hospital to home setting for 127 participants. The results of this study concluded that in general, younger, higher educated individuals with good employment and less emotional distress achieve better community reintegration. Positive

sentinel events such as returning to work and gaining independence helped contribute to positive community reintegration. Individuals, who experience more negative sentinel events such as financial strain, had less success with community reintegration (Nalder, Hons, Fleming, Cornwell, Foster & Haines, 2012). Limitations in the Literature Each study previously described, provided salient points regarding upper extremity amputation challenges and community reintegration challenges following TBI. One limitation to all three of the studies is that they were conducted outside the United States. The physiological response across the human population may present similarly regardless of the country the study is taking place in. However, each country has different health policies and different access to health care services. Therefore, the results of these studies may present differently, had they been conducted in the United States. Another limitation noted was population size. The study evaluating sentinel events explicitly stated that population size was a limitation to the study. Each study would have benefited from a larger sample size to increase the validity. Each of the three studies

ASSISTIVE TECHNOLOGY DEVICE PAPER obtained their participants from one site. It would have been beneficial for each study to obtain participants from multiple sites to again increase the validity of the study. Lastly, after extensively researching a variety of journals and search engines, no studies were found regarding challenges faced by amputees with other comorbities such as TBI. Both acquired and traumatic amputees may often have other comorbid conditions depending on the nature of the disease or injury. Understanding specific challenges faced by that population would be beneficial for healthcare practitioners to provide specialized care in those situations. Description of the client Kate is a 35 year old woman who works as an administrative assistant for a publishing

company in Chicago. While on vacation, Kate was involved in a motor vehicle accident resulting in a traumatic, transhumeral amputation of her left arm. She also sustained two broken ribs and traumatic brain injury (TBI). Kate lives alone, and has recently been discharged home from an inpatient rehabilitation hospital. Kate is having difficulty performing ADLs independently due to her loss of a limb. She often has difficulty sequencing steps. If items are placed in front of Kate, such as makeup and other items to complete her morning routine, she often becomes confused with what she should do first. The effects of her TBI along with her upper extremity amputation have caused Kate to take two or three times as long to complete tasks. Her family is concerned her excess time and confusion with sequencing steps will affect her ability to get to work on time. Kate would like to resume working part time as soon as possible. Kate and her family met with her doctor and a prosthetist, and decided for the time being it would be best for Kate to learn compensatory and adaptive techniques to complete her occupations. They concluded that right now would not be an opportune time for Kate to obtain a

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prosthetic. When she has recovered from her TBI and restored some normalcy to her life, she can pursue obtaining a prosthetic if she chooses to do so. Therefore, with the help of her occupational therapist, Kate has been learning compensatory and adaptive ways to perform her daily activities. Currently, Kates main goals are to return to work, care for herself independently, and restore as much normalcy to her life as possible. The Routine Remedy Purpose The Routine Remedy is a simple device that takes many of the products Kate already uses, and organizes and stabilizes them in an easy and convenient manner. The device is designed to organize items Kate utilizes as part of her morning routine such as; toothbrush, contacts, makeup, and lotion. These items are secured with Velcro to a board which can be set on Kates bathroom counter. These items can be easily removed, but the Velcro provides stability for Kate to utilize each item with only one hand. The items are labeled with a color corresponding to a step. Kate has a printed sheet with steps one through four as well as the colors each step corresponds to. This way she can sequence her steps in a timely manner. Also, if the items were to be removed, she can look at the color on the item and know which step it is according to the sheet. This device is very important for Kate to perform her ADLs independently, as well as restore some normalcy to her life. She feels confident when she wears makeup. That confidence is going to be especially important when dealing with the psychosocial components of losing a limb and looking different.

ASSISTIVE TECHNOLOGY DEVICE PAPER Current Products

After extensive online and store research, there are no devices that organize and sequence items used for a morning routine like the Routine Remedy. No devices were found to help stabilize items for an amputee, or sequence items for someone with a TBI. This device is unique in that it is very low cost to the client. It utilizes very few materials, is portable, and uses many of the items the client already has. Aside from being portable and low cost, all items can easily be removed, replaced, or changed out, depending on the clients wants and needs in regards to his/her morning routine. Cost analysis As previously mentioned, this device is very inexpensive to fabricate. The materials needed include a piece of plywood (about one foot by two feet), Velcro, spray paint, and color labels. The piece of plywood was purchased at Lowes for $6.03. The Velcro, spray paint, and color labels were purchased at Wal-Mart for $5.63 total. This device requires a timer to help Kate stay on task and perform her morning routine within a certain time frame. In this case, she is going to use the timer on her iPhone because she is familiar with using this timer. If she were not familiar with how to use the timer on her phone, a digital or egg timer could be purchased. Each timer costs about $10 at Wal-Mart. Practical Utility This device will be beneficial for Kate because it will allow her to complete her morning routine in a timely and independent manner. It will help her work on sequencing steps and being independent with use of only one hand. This may be a device Kate uses indefinitely, or rather something she only uses for a short time depending on her path of rehabilitation. The easy

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fabrication and low cost of this device make it a practical option for someone like Kate, trying to regain independence in ADLs. This device is small enough that it can easily be transported anywhere Kate goes. Conclusion In conclusion, the literature does not assess clients with both an upper extremity amputation and TBI. However, the studies explored difficulties clients encounter having just one ailment. In Kates case, she is dealing with two profound deficits. It is important that she receive as much support and resources as possible to promote independence and help her regain a sense of normalcy. The Routine Remedy will help Kate be independent in her ADLs, prepare her for a timely morning routine when she resumes work, and enhance her self-efficacy. Ultimately, this device will help Kate on her road to recovery by increasing her participation in meaningful occupations.

ASSISTIVE TECHNOLOGY DEVICE PAPER Reference: Jang, C., Yang, H., Yang, H., Lee, S., Kwon, J., Yun, B., Jeong, H. (2011). A survey on activities of daily living and occupations of upper extremity amputees. Annals of Rehabilitative Medicine, 35, 907-921. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22506221 Martin, S. (2013) Amputations & prosthetics [PowerPoint Slides]. Retrieved from Touro University Nevada website: https://bb-

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tun.touro.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_3_1&url=%2Fwebapps% 2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_741574_1%26u rl%3D Nalder, E., Hons, B., Fleming, J., Cornwell, P., Foster, M., & Haines, T. (2012). Factors associated with the occurrence of sentinel events during transition from hospital to home for individuals with traumatic brain injury. J Rehabil Med, 44, 837-844. doi: 10.2340/16501977-1033 Ostlie, K., Garfelt, B., Skjeldal, O., & Magnus, P. (2012). Health services utilization in adult acquired major upper-limb amputees: A population-based survey. J Rehabil Med, 44, 593-600. doi: 10.2340/16501977-0985