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December 2002


Patient Aids Get Creative

By Liz Finch

Assistive devices play a crucial role in helping disabled people regain their independence. An array of such equipment, ranging from grab bars to wheelchairs, is used within the home once patients have returned from receiving medical or therapeutic care. But assistive devices are also increasingly being used within a medical or therapeutic setting as tools in the process of rehabilitation. Often, off-the-shelf aids must be modified to suit individual needs, which gives those with reduced capabilities a further lesson in how to adapt to living on their own again.

“Patient aids are an integral part of my therapeutic approach,” says Noelle Ward, OTR-L, who has worked as a spinal cord injury therapy supervisor at the Atlanta-based Shepherd Center for 2 years. “We rehabilitate those with spinal cord injuries, and once they come into therapy, they start working on functional goals such as self-care, transferring into a wheelchair from their bed, and just getting around. We use aids right off the bat, within the first week of treatment, depending on the patient’s injury level.”

Aids play an immediate and central role at Bloorview MacMillan Children’s Centre, Toronto, as well. The rehabilitation center caters to children and youth, and focuses on giving the patients the skills they need to live independently. Often, this means they need a range of devices to assist them with their activities. “We want to see a return to participation in home, school, and community activities,” says Yani Hamdani, OT, a therapist in community-based services at Bloorview. In a transition clinic, she compares the current level of each patient’s abilities to where they want to be in the future.

“We look a lot at life skills, and the different ways our clients can learn to do basic things independently,” Hamdani says. “For instance, a young person can learn to cook by utilizing special adaptive devices such as a pot stabilizer on a stove. They can use a dressing stick to pull their pants up, and they can use a reacher or a grasp device to get things off a shelf that may be too high for them.”


Sandra Villante, CTRS

Assistive devices can play a pivotal role even when the focus is not on acquiring skills of daily living. Sandra Villante, CTRS, has been involved in therapeutic recreation for 20 years, and currently works in the brain injury program at Spalding Rehab Hospital in Boston. Villante looks at each patient’s previous leisure lifestyle, with the ultimate goal being to get them participating in those activities again.

“When they leave the rehabilitation setting, we want them to be aware of what sports, games, and crafts they can still do, either in an adaptive way or using a compensation strategy,” she says. “We work on mobility skills like a physical therapist would, because active recreation has an impact on standing balance and coordination. Recreational therapy encompasses a little of everything because you need to have a lot of skills to engage in recreational activities.”

TYPES OF ASSISTIVE DEVICES

A wealth of equipment options exist that assist rehabilitation patients in regaining life skills. Many of these items are for self-care, a priority for those who wish to live independently again.

“Someone with a diagnosis of severe rheumatoid arthritis may have a limited range of motion, making it challenging to bend down to pull on their pants or put on their shoes,” Hamdani says. “An OT might do a dressing assessment and determine what adaptive device is suitable. A person using a dressing stick can pull things off the floor, or put a jacket on, and those types of things allow a person to become more independent. Long-handled sponges allow clients to reach their legs in the shower, and feature a place to slip the hand in so that gripping the handle is not necessary. With such items, patients don’t have to rely on the parents or the caregiver to assist them with basic routines, which leads to increased self-confidence and self-esteem.”

At Shepherd Center, most of those who use adaptive equipment lack trunk and hand function, though they may have some function in their wrists and shoulders. Thus, adaptive equipment known as universal cuffs are often used among patients with spinal cord injuries or limited movement in their arms. Ward says that various types of adaptive equipment can be applied to items from telephones to shower nozzles, making these items easier to hold. “Patients who come in with a C5 or C6 injury level have no hand function but some arm function,” Ward says. “In order to feed themselves, they need a brace called a universal cuff that wraps around their hand. The fork fits into the cuff and they can manipulate the fork to pick up their food. We also use a plate guard so that when they are pushing the food onto their fork, they don’t push it off the plate.”

The Shepherd Center often employs a mobile arm support to help patients brush their teeth, feed themselves, and write, and reachers and rigid leg lifters help paraplegics learn how to move from point A to point B, according to Ward.

“On a few occasions, we have equipped patients who do not have bladder control with a catheter inserter,” Ward says. “This is a pretty important device for patients who need to catheterize themselves every 4 hours.”

Once personal hygiene and other basic self-care needs are met, Hamdani says clients express a great desire to learn how to cook on their own. Aids specific to the kitchen include adapted cutting boards with a spike in the middle to hold the food still, and rocker knives so the patient does not have to use a back-and-forth motion.

“One of our young cerebral palsy clients loved to cook, and she learned to [fix her meals] using a pot stabilizer, which is affixed to the top of a stove with suction cups,” Hamdani says. “The handle fits into the device, which keeps the pot from spinning off the stove. Learning to work with that allowed the girl a degree of independence because she didn’t have to wait for [her mother] to come home to prepare her meals. Now she is living independently and able to prepare meals for herself.”

And, of course, not all patient aids focus on work. There is a crucial need for play when considering an independent life. The young patient population at Bloorview frequently uses card holders, puzzles, or game pieces with larger handles, and adapted joysticks so they can play video games. The patients at Spalding have access to a lot of assistive devices for passive leisure activities as well. Adaptive book holders are among the pieces used most frequently, and prism glasses help those who cannot flex their neck to read again. Devices for more active diversions are also available.

“If a patient wants to play pool, we have a device that can help those who have a weak grasp,” Villante says. “The cuff straps around the patient’s hand and the pool cue straps onto that so the patient doesn’t have to worry about grasping the stick. All they need is a flex movement, either an extension or from side to side—just enough to hit the pool balls.”

AVAILABILITY AND COST CONCERNS

While each facility makes an array of assistive devices available to its patients, the policy on whether patients can take those items home varies. At the Shepherd Center, patient aids are included in the per diem charge, which varies depending on the level of injury. Patients are issued a limited amount of equipment that is theirs to take home at the end of their treatment. Most often, that includes basic, inexpensive devices such as a plate guard and a universal cuff. Spalding owns most of its patient aids, which do not go home with the patients when they leave the program, and Bloorview loans out some items but does not allow clients to keep them permanently.

“Unfortunately, we can’t send things home,” Villante says. “We can lend items to patients while they are here, and educate them about what they can purchase once they leave. Most patients are willing to purchase the equipment if we have the information for them about where they can find it.”

Because assistive devices tend to be costly, and because insurance coverage for them is minimal, facilities are proactive in helping patients afford the aids they need. Shepherd Center gears part of its donation campaign toward funding the more expensive assistive devices for their patients, and Bloorview and Spalding work with patients prior to their discharge on finding appropriate resources.

“Some patient aids are very expensive,” Ward says. “For instance, a mouthstick can run up to $80. For those items, we have something our patients can use while they are here, but when they leave, they have to find their own funding if insurance denies our request for equipment.”


Yani Hamdani, OT

Even though the majority of aids are denied by insurance, rehabilitation facilities tend to be good about processing the paperwork for its patients.

“Unfortunately, DME coverage is only up to a certain amount, and because our patients have such high needs, that amount is usually not even enough to cover their wheelchair,” Ward says. “Workers’ compensation always covers aids, but private insurance denies them, even with justification and letters from the physician, depending on the patient’s specific policy.”

FINDING SOLUTIONS

The high cost of many assistive devices has led facilities such as Bloorview, Spalding, and Shepherd Center to get creative. At Spalding, in addition to identifying the items a patient needs, the staff also focuses on finding the cheapest route to get those items.

“For instance, you can take a 2x4 and slice a line down the middle to make a card holder,” Villante says. Hamdani agrees that there are lots of ways to problem-solve, and many of them do not require buying a special device.

“Sometimes a device isn’t the answer, it’s problem solving a different way to do an occupation or activity,” Hamdani says.

Ward says that although much of what Shepherd Center uses is on the market, there have been a few occasions where the facility has created its own versions of devices in catalogs.

“There is a lot of making our own things around here,” Ward says. “Our patients come up with ideas based on their needs, and we try to work with them on the design and testing. . . and we have been very active with a manufacturer in building new models of items based on problems we have noted with what is already on the market.”

THE IMPACT OF PATIENT AIDS

In spite of best efforts, however, sometimes equipment simply does not work to meet patient needs. Villante says she tries to go over each device carefully and explain to patients that the goal is really to come up with a compensation strategy, not to have a one-size-fits-all answer in patient aids. Even with modification, certain tasks may simply be out of reach.

“For our patients who wanted to do needlepoint again, we used a hoop that would attach to a wheelchair or a table for stability. That ostensibly allowed people with the use of only one hand to continue that activity,” Villante says. “I have talked with those who do knit, and it’s very difficult to do it even with the device. You really need the movement in both wrists. In fact, our occupational therapists have tried different ways to use this item, and there is no great way to use it. So sometimes we have to talk to patients about giving up an old activity and looking at a new one, which can be hard.”

Then again, sometimes patients thrive thanks to the incorporation of special devices in their rehabilitation process. Villante cites one case from 6 years ago, when an 18-year-old spinal cord patient entered Spalding as an incomplete quadriplegic.

“I approached her with the idea of using assistive devices to paint, which would improve her fine motor coordination,” Villante says.

Villante used a cuff that strapped around the girl’s hand and included a piece of rubber with a hole in it that sat on her palm. By sticking a paintbrush in the hole, the patient could paint by using either side-to-side or up-and-down movements.

“Each time she painted, her strength improved,” Villante says. “As her function improved, we changed the devices, building up the handle so she could grasp it. She was able to paint more detail, and she downsized the handle until she could use a regular paintbrush.

“That patient ended up walking out of the hospital, and going to school at Georgetown,” she says. “The use of the patient aids was so progressive for her, and caused her to feel better about her abilities. To change assistive devices each week is pretty progressive, then to go to none and essentially become functional is phenomenal.” Even without such a dramatic change, the goal of the patient aids is to give each patient a level of independence and empower them to go on with their lives.

“The whole point is that, even though patients will not do the activity exactly the same as before, they will be doing it again in some way,” Villante says. “And that alone gives them such a feeling of accomplishment.”

Liz Finch is a contributing writer for Rehab Management.

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