From the Drawing Board

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October 2003

By Pascal Malassigné, MID, FIDSA; Jon Sanford, MArch; Mark Cors, MDes; Sue Kartes, RN, MSN, LPN; Kathy La Favor, RN; and Jim Bostrom, MArch

Difficulties in bathing and toileting independently are common among ambulatory, semiambulatory, and nonambulatory individuals. For toileting, this is due to problems accessing or transferring to a toilet, including those with raised seats. Similarly, many users have difficulty transferring into, accessing, and using fixtures in bathtub and shower stalls.

In response to these problems, a team sponsored by the Rehabilitation R&D Service of the Department of Veterans Affairs designed and evaluated new toilet inserts to ease access, transfer and independent usage. An attempt to provide solutions to the shower and bathtub problem was also proposed with the design of new bathing inserts and roll-in showers.

EARLY TOILET TRANSFER STUDIES

To develop design criteria, several studies of transfer and access to a toilet were conducted. These studies provided a substantial amount of data indicating that standard accessible toilets (ie, 17" to 19" or 43 to 48 cm high) and wall-mounted grab bars beside and behind the toilet did not adequately meet the needs of many older adults and individuals with disabilities.1-2 In fact, even the best conventional toilet and grab bar configurations were not adequate to accommodate all the positional changes necessary for many people to get on or off a toilet safely and independently.

Most important, these studies indicated that wall-mounted grab bars alone did not provide assistance in the appropriate locations either for many nonambulatory individuals to pull onto and correctly position themselves on a toilet or for ambulatory and semiambulatory individuals to easily sit and stand while getting on and off a toilet. For example, nonambulatory individuals who transferred from their wheelchair to a toilet used the toilet seat for support and did not use the grab bars to assist in transferring. This suggests that the seat was easier to reach and was in a more appropriate location than the grab bars for transferring.3

Based on these findings, the team decided to design two new toilet insert prototypes with built-in handles to assist in transfers instead of relying on wall-mounted grab bars.4

PROTOTYPE DESIGNS

Two prototypes were designed to fit over a standard toilet and to be secured to the existing floor and seat bolts. In addition, both fixtures have optional footrests for added stability when the client is seated. Toilet insert with horizontal side handles: Intended for ambulatory and non-ambulatory individuals who transfer from a wheelchair either at an angle or perpendicularly, this fixture was 70 cm or 24.5" wide and 48 cm or 19" high, which complies with the Americans with Disabilities Act (ADA) Accessibility Guidelines.5 In addition, side openings were designed to provide underseat hand access.

Toilet insert with vertical handles: Intended for ambulatory and semiambulatory individuals, the toilet was the same ADA-compliant height, but its 44.5-cm or 17.5" width was much narrower to accommodate sit-to-stand transfers.

EVALUATION AND RESULTS

A toilet room mock-up was used for the evaluation. All participants used a standard accessible toilet with raised seat and grab bars as a baseline for comparison. All participants also used the inserts with horizontal handles, while only ambulatory participants used the insert with vertical handles. Demographic, cognitive, and medical information was collected during a pretrial interview. During test trials, participants approached and transferred to a toilet, remained seated for a short time, and transferred off the toilet. Post-trial interviews consisted of questions related to safety, ease of use, and the helpfulness of the handles. Of the 68 individuals who participated in the study, 10 (14%) were ambulatory, 29 (43%) were nonambulatory wheelchair users, and 29 (43%) were semiambulatory wheelchair users. The sample was equally divided between those under (49%) and those over (51%) 60 years old. The mean age of the sample was 58 years, with a range of 20 to 102 years old. The mean age of the ambulatory and semiambulatory group was 60+ years, while that of the nonambulatory group was 43 years. There was almost a 9:1 ratio of male (89%) to female participants. Within subgroups, males accounted for 78% of the ambulatory group, 86% of the nonambulatory group, and 96% of the semiambulatory group.

The ambulatory group rated the insert with vertical handles as the safest (50%) and best (57%), as did the semiambulatory group (47% and 50%, respectively). The nonambulatory group rated the insert with horizontal handles as the safest (52%).

All three groups rated the existing toilet with a raised toilet seat as the most difficult to use: ambulatory 57%, semiambulatory 67%, and nonambulatory 82%.

FINAL DESIGN

Refinements were made to the prototype designs based on results of the research, and a manufacturer of assistive products and devices worked with the project team model under a Collaborative Research and Development Agreement (CRADA) with the Department of Veterans Affairs to develop a commercially viable fixture. The final design for the universal toilet transfer seat is 53 cm or 21" high, 61 cm or 24" wide, and 51 cm or 20" deep. It incorporates the functional attributes of the two prototypes and includes the following features:

Swing-away vertical grab bar on each side
Horizontal handles molded into the seat on each side
Right and left cutouts to provide underseat hand access
A splash guard that lines the inner area and fits inside an existing toilet bowl
Openings on each side to facilitate floor installation

Nonambulatory users are able to access and transfer onto the toilet by swinging the vertical grab bar on the transfer side out away from the toilet, holding the horizontal handle and grab bar on the opposite side, and pulling themselves across the toilet for positioning.

Semiambulatory and ambulatory users are able to perform stand-to-sit and sit-to-stand transfers by holding onto the vertical handles to help lower and raise themselves.

EVALUATION AND RESULTS

The toilet transfer seat was evaluated by 18 nonambulatory persons at the SCI Center of the Medical College of Wisconsin and by 11 elderly veterans at the Milwaukee VA Nursing Home.

The 13 male and five female participants had a combined mean age of 28 years. The mean height measurement of the subjects was 1.75 m or 5’10" and the mean weight was 75 kg or 166 pounds. Seventy percent had paraplegia, 20% had tetraplegia, and 10% had hemiplegia. Respondents had been injured on average for 5 years.

The eleven male participants had a combined mean age of 75 years. The participants’ mean height measurement was 1.72 m or 5’8" and mean weight was 74 kg or 163 pounds. Forty-five percent were reported to be ambulatory, 45% were reported to be semiambulatory, and 10% were nonambulatory.

All individuals with spinal cord injuries reported:

Transfer onto toilet: 90% reported that getting on the insert was safe.
Use of handles to transfer onto toilet: 87% reported helpful to a little helpful, while 23% reported they were unnecessary.
Transfer back to the wheelchair: 94% reported that was safe.
Use of handles to transfer back to the wheelchair: 76% reported that they were helpful to a little helpful, while 22% indicated that they were unnecessary.
Openings for underseat hand access: 94% reported that they were just right.
Width: 100% reported that it was just right for their needs.
Height: 80% reported it to be just right while 20% reported it to be somewhat high.
Older adults reported that:
Transfer onto toilet: 65% reported that transfer was safe, and 18% somewhat safe.
Use of handles to transfer onto toilet: 90% reported that they were helpful to a little helpful, and 10% indicated that they were unnecessary.
Transfer back: 82% reported that getting off the insert was safe, and 8% somewhat safe.
Use of handles to stand or transfer back to the wheelchair: 83% reported that they were helpful to a little helpful, while 17% reported they were unnecessary.
Width: 75% reported that it was just right, while 25% said that it was too wide.
Height: 30% reported that it was just right, 20% somewhat high, and 50% too high without a footrest.

TRANSFER SEAT CONCLUSIONS

Evaluation of the toilet transfer seat was successful with both older adults and individuals with spinal cord injuries. Participants in both groups reported that transfer on and off the transfer seat was safe and that the handles were helpful when needed. Participants in both groups reported that the dimensions (height, width, depth) of the insert were appropriate and that the side openings for underseat hand access were just right for their needs.

BATHING INSERTS AND ROLL-IN SHOWERS

Bathtubs or showers found in most American homes can be safety hazards according to a study by ABT Associates commissioned by the US Consumer Products Safety Commission.6 This study documented more than 110,000 accidents annually in the bathroom, and although the study did not identify use by older people or individuals with disabilities, it is reasonable to assume people with limited mobility, balance, or dexterity would be more likely to be injured while bathing. An attempt to provide solutions to this problem was proposed with the design of new bathing inserts and roll-in showers.

EARLY SHOWER STALL STUDIES

To develop design criteria for the new prototypical designs, the team evaluated bathtubs and showers with semi- and nonambulatory individuals and gathered static anthropometry (body measurement) and dynamic (lifting and transfer) data to supplement the available information about individuals with disabilities.

Anthropometry study: While anthropometry data of able-bodied individuals were available when the project began, data about individuals with disabilities were almost non-existent. To compensate for this lack of data, 82 individuals with disabilities participated in an anthropometry study. With established measurement techniques, semiambulatory individuals were measured in five standing and 29 seated positions and nonambulatory individuals were measured in 29 seated positions.7 The data were analyzed to determine the relative variation of body size by disability and gender in order to compare participants’ data to that of the able-bodied population. The analysis indicated that the general body size of participants was smaller than that of the ablebodied population, especially in the torso measurements.

While these findings were inconclusive due to the limited subject sample size, they nevertheless demonstrated that using anthropometry data on able-bodied individuals was inappropriate when designing products for individuals with disabilities.

Lifting and transfer study: This study involved observing the lifting and transferring abilities of 25 individuals with paraplegia, tetraplegia, hemiplegia, and cerebral palsy. Using a bathtub-shaped lift simulator, we observed the hand and body placement of participants and recorded lifting distances off the simulator platform. The results showed that for individuals with hemiplegia, the lifting distance was between 0 and 15 cm; with paraplegia, the lifting distance was between 6 and 18 cm; with tetraplegia, between 0 and 3 cm; and with cerebral palsy, between 0 and 10 cm. The results of this study indicated that due to the vertical lifting limitation of these individuals, any new fixture design should require no or a minimal amount of vertical motion.

EVALUATION OF BATHTUBS AND STALLS

To add to the anthropometry studies results, a transfer and access study of bathtubs and shower stalls was conducted with 45 semiambulatory and nonambulatory individuals and led to the following findings: Bathtubs: Semiambulatory and nonambulatory individuals searched for holding areas on surrounding walls and bathtub edges for transferring into or stepping in and out of the bathtubs because the grab bars, mounted according to prevalent accessibility standards in the late ’70s and early ’80s,8 were found to be located either too high or too far away for assistance.

Shower stalls: Semiambulatory individuals searched for grasping areas to assist in stepping in because the built-in grab bars could not be reached. Likewise, the grab bars were not helpful in sitting and standing up despite being installed according to the prevalent accessibility standards. Nonambulatory individuals experienced greater difficulties transferring to the shower stall seats because they were located away from the thresholds, and because of a lack of grasping areas on the shower stall walls, and reachable grab bars. Based on the findings of the preliminary studies, the team established as a goal to design fixtures that could be easily accessed, transferred, or rolled into. The team iterated and evaluated numerous prototypes with individuals who have disabilities and finalized development by designing seat inserts for existing bathtubs and showers as well as roll-in showers.

NEW DESIGNS

Long insert for bathtub. Intended for ambulatory, semi-, and non-ambulatory individuals who transfer from a wheelchair, this insert is 140 cm or 55" long and 68 cm or 27" wide. In use, the long insert is placed over a bathtub. The insert has a seat and a backrest to support the user and a recessed area to soak the feet. The insert is covered with cushioning material for greater comfort and to limit skin pressure.

Short insert for bathtub. Intended for ambulatory, semi-, and non-ambulatory individuals who transfer from a wheelchair, this insert is 83 cm or 32" long and 63 cm or 25" wide. In use, the insert is placed over a bathtub. The insert has a seat and backrest to support the user, whose feet hang down in the bathtub.

Wall-mounted seat for shower stall. Intended for ambulatory, semi-, and nonambulatory individuals who transfer from a wheelchair, this seat is 83 cm or 32" long and 63 cm or 25" wide and offers the same features as the other inserts.

Roll-in shower for independent bathing. Intended for nonambulatory individuals, this shower was 124 cm or 49" long, 81 cm or 32" wide, and 149 cm or 58" high. Built in two sections to allow installation in existing homes or medical facilities, this shower can be recessed into the floor for direct wheelchair access or installed above the floor and is accessible with a small ramp. It is equipped with a push-button faucet, a handheld shower spray, and a shower curtain.

Roll-in shower for assisted bathing. Intended for nonambulatory individuals who require bathing assistance by a caregiver, this shower is 124 cm or 49" long, 81 cm or 32" wide, and 87 cm or 34" high and offers the same usage features as the other roll-in shower.

EVALUATION AND RESULTS

The VA Rehabilitation R&D Service evaluated 70 fixtures with patients in six VA Spinal Cord Injury Centers and/or residential settings for several months.9

The long insert for a bathtub was evaluated by 10 nonambulatory individuals in four SCI centers and in residential settings. The participants had a combined mean age of 55 years. Thirty percent had paraplegia, 30% had tetraplegia, 20% had hemiplegia, and 20% were above-knee amputees. Fifty percent rated the long insert for a bathtub as excellent and 50% from very good to good for their needs. Participants also liked the cushioning, the ability to soak legs, the ease of transfer, and the backrest.

The short insert for a bathtub was evaluated by eight nonambulatory individuals in three SCI centers and in residential settings. The participants had a combined mean age of 47 years. Thirty percent had paraplegia, 20% had tetraplegia, 20% had hemiplegia, 20% were above-knee amputees, and 10% had multiple sclerosis. Forty percent rated the short insert for a bathtub as excellent and 60% as good for their needs. Participants liked the overall appearance, stability, sturdiness, and the ease of transfer of the insert and its spacious seat and backrest.

The wall-mounted seat for a shower stall was evaluated by 11 nonambulatory individuals in two SCI centers. The participants had a combined mean age of 58 years. Fifty percent had paraplegia and tetraplegia, 30% had hemiplegia, and 20% were above-knee amputees. Eighty percent rated the wall-mounted shower seat as excellent and 20% as good for their needs. Participants also liked the stability, sturdiness, comfort, spacious seating area, and overall safe use of the shower seat.

Roll-in showers were evaluated by 17 nonambulatory individuals in three SCI centers and in residential settings. The participants had a combined mean age of 47 years. Sixty-five percent had tetraplegia, 30% had paraplegia, and 5% were above-knee amputees. Forty percent rated the roll-in showers as excellent and 35% as very good for their needs. Participants also reported that they liked the size and appearance of the fixtures, their ease of access, the floor mat, and the push-button faucet.

SHOWER STALL CONCLUSIONS

The evaluation of bathing inserts and roll-in showers was successful and led the Department of Veterans Affairs to recommend that they be made available to disabled-veteran beneficiaries within VA facilities and be prescribed for a veteran’s home use, or to anyone else who could use them.

Pascal Malassigné, MID, FIDSA,* is a professor of industrial design at the Milwaukee Institute of Art & Design and a research industrial designer at the Milwaukee VA Medical Center Jon Sanford, MArch, is a research architect at the Atlanta VA Medical Center Mark Cors, MDes, is an industrial designer in Chicago Sue Kartes, RN, MSN, LPN, is a geriatrics nurse practitioner at the Milwaukee VA Medical Center Kathy La Favor, RN, is a clinical nurse specialist at the SCI Center of Froedtert Hospital, Medical College of Wisconsin, Milwaukee Jim Bostrom, MArch,** is senior accessibility specialist and architect with the Civil Rights Division, Department of Justice, Washington, DC. Contact Malassigné by email at: pmalassi@miad.com. *Co-author of both the bathing and toileting sections. **Co-author of the bathing section.

References

Sanford JA, Megrew MB. An evaluation of grab bars to meet the needs of elderly people. Assist Technol. 1995;7:36-47.
Sanford JA, Echt K, Malassigné P. An E for ADAAG: the case for accessibility guidelines for the elderly based on three studies of toilet transfer. J Phys Occup Ther Geriat. 1999;16(3/4):39-58.
Sanford JA, Malassigné P. Final Report: Evaluation of New Toilet Prototypes for Elderly and Disabled Veterans. Washington, DC: Rehabilitation Research and Development Service, Department of Veterans Affairs; 1995.
Malassigné P, Sanford JA. Final Report: Design of New Toilet Inserts for Disabled and Elderly Veterans. Washington, DC: Rehabilitation Research and Development Service, Department of Veterans Affairs; 2000.
Americans with Disabilities Act Accessibility Guidelines. Washington, DC: US Architectural and Transportation Barriers Compliance Board; 1992.
Executive Summary: A Systematic Program to Reduce the Incidence and Severity of Bathtub and Shower Injuries. Cambridge, Mass: ABT Associates; 1975.
Roebuck JS Jr, Kroemer KHE, Thomas WG. Engineering Anthropometry Methods. New York: John Wiley and Sons Inc; 1975.
American National Standard Institute. Standard A117.1 from 1971 and 1980.
Report on the Clinical Evaluation of Six Bathing Fixtures. Washington, DC: Rehabilitation Research & Development Service, Department of Veterans Affairs; 1990.

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October 2003