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A team approach to evaluating the need for assistive technology reduces equipment abandonment

R Verza, Occupational Therapist, Italian Multiple Sclerosis Society Rehabilitation Centre, Padua, Italy
M Messmer Uccelli, BA, MSCS, Department of Research and Development, Italian Multiple Sclerosis Society, Genoa, Italy

Way Ahead 2007;11(2):4-5


Introduction

People with MS requiring assistive technology for mobility, or due to being restricted to a wheelchair or bed, comprise around one-third of the MS population[1]. Since reduced mobility has been associated with diminished quality of life, the potential benefits of assistive technology reach far beyond the impact on mobility itself, influencing employment, social interaction and family role.

The aims of assistive technologies are to improve functioning, to allow a person to remain in their home, to successfully control his or her environment and to enhance independence. However, improved functioning alone is no guarantee that assistive technology will be utilised. The term 'abandonment' refers to the disuse of a previously obtained device, for any reason. Although the term is widely accepted in the field of assistive technology, it may be misleading, particularly when applying it to the non-use of a device due to worsening in physical functioning or status. In some cases abandonment occurs even before the device is ever put to use. Lack of consideration of user opinion in device selection, poor device performance, change in the needs of the user, lack of training, inappropriateness of the device and other factors, all influence assistive device abandonment in various disability groups.

The abandonment of assistive equipment has a negative impact in economic terms and means that the user's needs continue to be unmet and that his or her autonomy and quality of life are threatened. In addition, when equipment that has been prescribed by a healthcare team is abandoned, this can be seen as a failure for the team, as well as have a potentially negative impact on the healthcare team-patient relationship.

An interdisciplinary approach for evaluating and following patients requiring assistive technologies may reduce abandonment of the equipment, particularly when the person with MS is an active participant in the process. Based on this, we performed a study comparing two distinct methods of prescribing assistive technology: a single professional approach (Rehabilitation Physician), which included devices prescribed between January 1997 and December 1999, versus an interdisciplinary team approach (Assistive Device Evaluation and Prescription Protocol), which included devices prescribed between January 2000 and December 2002. (See figure 1)


Figure 1. Assistive Device Evaluation and Prescription Protocol

Patient presents/identified with problem

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Form team:
patient, family, rehabilitation professionals

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Perform assessments:
functional, environmental, lifestyle

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Team develops list of needs to be addressed

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Rehabilitation specialists perform market search and present options to team

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Team assesses equipment for personalisation possibilities

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Decision made

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Training period

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Activation period:
patient applies device in home/work environment

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Monitoring period:
device appropriateness for meeting needs


Method

54 subjects, 35 females (65%) and 19 males (35%), were followed at the Italian Multiple Sclerosis Society Rehabilitation Centre of Padua during the study period. The subjects obtained 151 assistive devices during the study period, 67 during the pre-intervention period and 84 during the intervention period, of which 33 were subsequently abandoned, 25 (37.3%) during the pre-intervention period and eight (9.5%) during the intervention period.

Manual wheelchairs and pressure cushions were the types of assistive technology most frequently obtained in the preintervention period compared to manual wheelchairs and electric wheelchairs during the intervention period. Out of 15 different types of devices, six had a 50% or greater abandonment rate, with braces, standing frames and walkers being the most frequently abandoned assistive devices during pre-intervention (100%, 100%, 75%, respectively). During the intervention period, canes/sticks, transfer lifts and braces were the devices most frequently abandoned (50%, 50%, 40%, respectively).

With the application of the Assistive Device Evaluation and Prescription Protocol, the number of assistive device prescriptions increased from 67 to 84, while there was a significant reduction in the rate of device abandonment (37.3% vs. 9.5%, respectively). Out of eight devices obtained during the intervention period and subsequently abandoned, two were abandoned due to worsening of subjects' physical functioning and six out of eight (75%) were never used by subjects.


Reasons for abandoning assistive devices

The majority of assistive devices were abandoned due to worsening in physical status (36.4%), followed by nonacceptance of the device on the part of the user (30.3%), inappropriateness (24.2%) and insufficient/lack of information and training (9%). During the intervention period, no device was abandoned due to inappropriateness, or due to a lack of information and training.


Timing of assistive device abandonment

Most devices were never actually put to use by subjects (pre-intervention, 13/25 and intervention, 6/8). During the intervention period, 8/25 devices were abandoned after two years of use.

A decline in medical condition and functional abilities is a strong factor influencing abandonment of assistive devices. It is obvious that, unlike for other disability groups, assistive devices for MS-related deficits may not be long-term solutions, given the progressive nature of the disease. The rate of abandonment for canes, braces and walkers (33%, 67%, 46%, respectively) attests to the fact that as functioning worsens, invariably these types of devices become obsolete.

There appears to be a relatively high overall rate of non-use of equipment within a short period of obtaining it (61% within the first year). While an individual may want to appear agreeable to the healthcare team, whether or not he or she actually puts the device to use is a personal choice. Assistive technology is a symbol of disability, which although promoted as a means for increasing functional autonomy, may be seen by the individual as a validation of being "ill", a loss of independence and a diminished self-image. Non-acceptance of the device was frequently reported as the reason why subjects never actually used the devices they obtained. Predisposition to technology use depends, in part, on one's adjustment to disability[2].

A small number of assistive devices (6/84) were still abandoned due to non-acceptance on the part of the user, even though these devices were chosen and implemented following the protocol. Since predisposition to technology use is multifaceted and includes the needs, abilities and preferences of the individual, previous contact or experience with technologies, personality, expectations and many other variables, it may be that an even more comprehensive assessment of the individual needs to be performed before making any decision as to assistive technologies.


Future directions

The Assistive Device Evaluation and Prescription Protocol did not have a 100% success rate, which is important in terms of satisfying the needs of each user as well as assuring appropriate investment of monetary resources. The Matching Persons and Technology (MPT) model is a tool based on a partnership approach between the client and the professional that complements the assistive technology assessment process[3]. The MPT assesses the individual's predisposition to the use of assistive technologies and attempts to estimate to what extent the device is likely to be accepted and used. The MPT, through a series of worksheets compiled by the user and the professional, analyses factors related to the individual's environment, technology and personality. The information gained with the MPT allows the professional to identify critical factors that will influence acceptance and use of assistive technologies, thus, avoiding device abandonment. The MPT utilised as a precursor to the Assistive Device Evaluation and Prescription Protocol would provide the team with valuable insight into possible effective interventions, the user's way of thinking and incentives and disincentives to acceptance and use.


Conclusions

An interdisciplinary approach to evaluation and prescription of assistive technology that directly involves the patient and family decreases the rate of device abandonment by people with MS. Although a small number of individuals will still abandon equipment even when a thorough assessment is performed, a comprehensive tool, such as the Matching Persons and Technology model, utilised prior to initiating a specific device evaluation and prescription protocol could likely decrease the risk for abandonment of assistive devices.

Since all devices were abandoned within the first three years following obtainment, the follow-up period by the healthcare team should include these "at risk" years. Also, the assessment process must be on-going given the progressive nature of the disease, changing needs of the individual and the rapid evolution of technology.


References

  1. Pittock SJ, Mayr WT, McClelland RL, et al.
    Change in MS-related disability in a population-based cohort: a 10-year follow-up study.
    Neurology 2004; 62(1): 51-9.
  2. Scherer MJ, Galvin JC.
    Matching people with technology.
    Rehabilitation Management 1994; 9: 128-30.
  3. Scherer MJ.
    Living in the state of stuck: how technology impacts the lives of people with disabilities. 3rd ed.
    Cambridge (MA): Brookline Books; 2000.

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