5 REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY

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Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 2115REHABILITATIONENGINEERING ANDASSISTIVE TECHNOLOGYAndrew Szeto, PhD, PEChapter Contents5.1 Introduction5.1.1 History5.1.2 Sources of Information5.1.3 Major Activities in Rehabilitation Engineering5.2 The Human Component5.3 Principles of Assistive Technology Assessment5.4 Principles of Rehabilitation Engineering5.4.1 Key Engineering Principles5.4.2 Key Ergonomic Principles5.5 Practice of Rehabilitation Engineering and Assistive Technology5.5.1 Career Opportunities5.5.2 Rehabilitation Engineering OutlookExercisesSuggested ReadingAt the conclusion of this chapter, students will:&Understand the role played by rehabilitation engineers and assistive technologists in therehabilitation process.&Be aware of the major activities in rehabilitation engineering.&Be familiar with the physical and psychological consequences of disability.211

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 2122125.1CHAPTER 5REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY&Know the principles of assistive technology assessment and its objectives and pitfalls.&Discuss key engineering and ergonomic principles of the field.&Describe career opportunities and information sources.INTRODUCTIONSince the late 1970s, there has been major growth in the application of technology toameliorate the problems faced by people with disabilities. Various terms have beenused to describe this sphere of activity, including prosthetics/orthotics, rehabilitationengineering, assistive technology, assistive device design, rehabilitation technology,and even biomedical engineering applied to disability. With the gradual maturation ofthis field, several terms have become more widely used, bolstered by their use in somefederal legislation.The two most frequently used terms today are assistive technology and rehabilitation engineering. Although they are used somewhat interchangeably, they are notidentical. In the words of James Reswick (1982), a pioneer in this field, ‘‘rehabilitationengineering is the application of science and technology to ameliorate the handicapsof individuals with disabilities.’’ In contrast, assistive technology can be viewed as aproduct of rehabilitation engineering activities. Such a relationship is analogous tohealth care being the product of the practice of medicine.One widely used definition for assistive technology is found in Public Law 100-407.It defines assistive technology as ‘‘any item, piece of equipment or product systemwhether acquired commercially off the shelf, modified, or customized that is used toincrease or improve functional capabilities of individuals with disabilities.’’ Notice thatthis definition views assistive technology as a broad range of devices, strategies, and/orservices that help an individual to better carry out a functional activity. Such devices canrange from low-technology devices that are inexpensive and simple to make to hightechnology devices that are complex and expensive to fabricate. Examples of low-techdevices include dual-handled utensils and mouth sticks for reaching. High-techexamples include computer-based communication devices, reading machines withartificial intelligence, and externally powered artificial arms (Fig. 5.1).Several other terms often used in this field include rehabilitation technology andorthotics and prosthetics. Rehabilitation technology is that segment of assistive technology that is designed specifically to rehabilitate an individual from his or her present set oflimitations due to some disabling condition, permanent or otherwise. In a classical sense,orthotics are devices that augment the function of an extremity, whereas prostheticsreplace a body part both structurally and functionally. These two terms now broadlyrepresent all devices that provide some sort of functional replacement. For example, anaugmentative communication system is sometimes referred to as a speech prosthesis.5.1.1 HistoryA brief discussion of the history of this field will explain how and why so manydifferent yet similar terms have been used to denote the field of assistive technology

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 2135.1INTRODUCTIONFigure 5.1213Augmentative communication classification system (from Church and Glennen, 1992).and rehabilitation. Throughout history, people have sought to ameliorate the impactof disabilities by using technology. This effort became more pronounced and concerted in the United States after World War II. The Veterans Administration (VA)realized that something had to be done for the soldiers who returned from war withnumerous and serious handicapping conditions. There were too few well-trainedartificial limb and brace technicians to meet the needs of the returning soldiers. Totrain these much-needed providers, the federal government supported the establishment of a number of prosthetic and orthotic schools in the 1950s.

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 214214CHAPTER 5REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGYThe VA also realized that the state of the art in limbs and braces was primitive andineffectual. The orthoses and prostheses available in the 1940s were uncomfortable,heavy, and offered limited function. As a result, the federal government establishedthe Veterans Administration Prosthetics Research Board, whose mission was to improve the orthotics and prosthetic appliances that were available. Scientists andengineers formerly engaged in defeating the Axis powers now turned their energiestoward helping people, especially veterans with disabilities. As a result of their efforts,artificial limbs, electronic travel guides, and wheelchairs that were more rugged,lighter, cosmetically appealing, and effective were developed.The field of assistive technology and rehabilitation engineering was nurtured by atwo-pronged approach in the federal government. One approach directly fundedresearch and development efforts that would utilize the technological advancescreated by the war effort toward improving the functioning and independence ofinjured veterans. The other approach helped to establish centers for the training ofprosthetists and orthotists, forerunners of today’s assistive technologists.In the early 1960s, another impetus to rehabilitation engineering came from birthdefects in infants born to expectant European women who took thalidomide tocombat ‘‘morning sickness.’’ The societal need to enable children with severe deformities to lead productive lives broadened the target population of assistive technologyand rehabilitation engineering to encompass children as well as adult men. Subsequent medical and technical collaboration in research and development producedexternally powered limbs for people of all sizes and genders, automobiles that couldbe driven by persons with no arms, sensory aids for the blind and deaf, and variousassistive devices for controlling a person’s environment.Rehabilitation engineering received formal governmental recognition as an engineering discipline with the landmark passage of the federal Rehabilitation Act of 1973.The act specifically authorized the establishment of several centers of excellence inrehabilitation engineering. The formation and supervision of these centers were putunder the jurisdiction of the National Institute for Handicapped Research, which laterbecame the National Institute on Disability and Rehabilitation Research (NIDRR). By1976, about 15 Rehabilitation Engineering Centers (RECs), each focusing on adifferent set of problems, were supported by grant funds totaling about 9 millionper year. As the key federal agency in the field of rehabilitation, NIDRR also supportsrehabilitation engineering and assistive technology through its Rehabilitation Research and Training Centers, Field Initiated Research grants, Research and Demonstration program, and Rehabilitation Fellowships (NIDRR, 1999).The REC grants initially supported university-based rehabilitation engineeringresearch and provided advanced training for graduate students. Beginning in themid-1980s, the mandate of the RECs was broadened to include technology transferand service delivery to persons with disabilities. During this period, the VA alsoestablished three of its own RECs to focus on some unique rehabilitation needs ofveterans. Areas of investigation by VA and non-VA RECs include prosthetics andorthotics, spinal cord injury, lower and upper limb functional electrical stimulation,sensory aids for the blind and deaf, effects of pressure on tissue, rehabilitationrobotics, technology transfer, personal licensed vehicles, accessible telecommunica-

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 2155.1INTRODUCTION215tions, applications of wireless technology, and vocational rehabilitation. Anothermilestone, the formation of the Rehabilitation Engineering Society of North America(RESNA) in 1979, gave greater focus and visibility to rehabilitation engineering.Despite its name, RESNA is an inclusive professional society that welcomes everyoneinvolved with the development, manufacturing, provision, and usage of technologyfor persons with disabilities. Members of RESNA include occupational and physicaltherapists, allied health professionals, special educators, and users of assistive technology. RESNA has become an adviser to the government, a developer of standardsand credentials, and, via its annual conferences and its journal, a forum for exchangeof information and a showcase for state-of-the art rehabilitation technology. Inrecognition of its expanding role and members who were not engineers, RESNAmodified its name in 1995 to the Rehabilitation Engineering and Assistive TechnologySociety of North America.Despite the need for and the benefits of providing rehabilitation engineeringservices, reimbursement for such services by third-party payers (e.g., insurance companies, social service agencies, and government programs) remained very difficult toobtain during much of the 1980s. Reimbursements for rehabilitation engineeringservices often had to be subsumed under more accepted categories of care such asclient assessment, prosthetic/orthotic services, or miscellaneous evaluation. For thisreason, the number of practicing rehabilitation engineers remained relatively staticdespite a steadily growing demand for their services.The shortage of rehabilitation engineers with suitable training and experience wasspecifically addressed in the Rehab Act of 1986 and the Technology-Related Assistance Act of 1988. These laws mandated that rehabilitation engineering services hadto be available and funded for disabled persons. They also required an individualizedwork and rehabilitation plan (IWRP) for each vocational rehabilitation client. Thesetwo laws were preceded by the original Rehab Act of 1973 which mandated reasonable accommodations in employment and secondary education as defined by a leastrestrictive environment (LRE). Public Law 95-142 in 1975 extended the reasonableaccommodation requirement to children 5–21 years of age and mandated an individual educational plan (IEP) for each eligible child. Table 5.1 summarizes the majorUnited Stated Federal legislation that has affected the field of assistive technology andrehabilitation engineering.In concert with federal legislation, several federal research programs have attempted to increase the availablity of rehabilitation engineering services for personswith disabilities. The National Science Foundation (NSA), for example, initiated aprogram called Bioengineering and Research to Aid the Disabled. The program’s goalswere (1) to provide student-engineered devices or software to disabled individualsthat would improve their quality of life and degree of independence, (2) to enhancethe education of student engineers through real-world design experiences, and (3) toallow the university an opportunity to serve the local community. The Office ofSpecial Education and Rehabilitation Services in the U.S. Department of Educationfunded special projects and demonstration programs that addressed identified needssuch as model assessment programs in assistive technology, the application of technology for deaf–blind children, interdisciplinary training for students of communicative

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 216216TABLE 5.1CHAPTER 5REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGYRecent Major U.S. Federal Legislation Affecting Assistive TechnologiesLegislationMajor Assistive Technology ImpactRehabilitation Act of 1973, asamendedMandates reasonable accommodation and least restricted environment in federallyfunded employment and higher education; requires both assistive technology devicesand services be included in state plans and Individualized Written RehabilitationPlans (IWRP) for each client; Section 508 mandates equal access to electronic officeequipment for all federal employees; defines rehabilitation technology asrehabilitation engineering and assistive technology devices and services; mandatesrehabilitation technology as primary benefit to be included in IWRPIndividuals with DisabilitiesEducation Act Amendments of1997Recognizes the right of every child to a free and appropriate education; includesconcept that children with disabilities are to be educated with their peers; extendsreasonable accommodation, least restrictive environment (LRE), and assistivetechnology devices and services to age 3–21 education; mandates IndividualizedEducational Plan for each child, to include consideration of assistive technologies;also includes mandated services for children from birth to 2 and expanded emphasison educationally related assistive technologiesAssistive Technology Act of 1998(replaced Technology RelatedAssistance for Individuals withDisabilities Act of 1998)First legislation to specifically address expansion of assistive technology devices andservices; mandates consumer-driven assistive technology services, capacitybuilding, advocacy activities, and statewide system change; supports grants toexpand and administer alternative financing of assistive technology systemsDevelopmental DisabilitiesAssistance and Bill of Rights ActProvides grants to states for developmental disabilities councils, university-affiliatedprograms, and protection and advocacy activities for persons with developmentaldisabilities; provides training and technical assistance to improve access to assistivetechnology services for individuals with developmental disabilitiesAmericans with Disabilities Act(ADA) of 1990Prohibits discrimination on the basis of disability in employment, state and localgovernment, public accommodations, commercial facilities, transportation, andtelecommunications, all of which affect the application of assistive technology; useof assistive technology impacts requirement that Title II entities must communicateeffectively with people who have hearing, vision, or speech disabilities; addressestelephone and television access for people with hearing and speech disabilitiesMedicaidIncome-based (‘‘means-tested’’) program; eligibility and services differ from state tostate; federal government sets general program requirements and provides financialassistance to the states by matching state expenditures; assistive technology benefitsdiffer for adults and children from birth to age 21; assistive technology for adultsmust be included in state’s Medicaid plan or waiver programEarly Periodic Screening,Diagnosis, and TreatmentProgramMandatory service for children from birth through age 21; includes any required oroptional service listed in the Medicaid Act; service need not be included in thestate’s Medicaid planMedicareMajor funding source for assistive technology (durable medical equipment); includesindividuals 65 or over and those who are permanently and totally disabled;federally administered with consistent rules for all statesFrom Cook and Hussey (2002).disorders (speech pathologists), special education, and engineering. In 1993, NIDRRcommitted 38.6 million to support Rehabilitation Engineering Centers that wouldfocus on the following areas: adaptive computers and information systems, augmentative and alternative communication devices, employability for persons with lowback pain, hearing enhancement and assistive devices, prosthetics and orthotics,

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 2175.1INTRODUCTION217quantification of physical performance, rehabilitation robotics, technology transferand evaluation, improving wheelchair mobility, work site modifications and accommodations, geriatric assistive technology, personal licensed vehicles for disabledpersons, rehabilitation technology services in vocational rehabilitation, technologicalaids for blindness and low vision, and technology for children with orthopedicdisabilities. In fiscal year 1996, NIDRR funded 16 Rehabilitation Engineering Research Centers at a total cost of 11 million dollars and 45 Rehabilitation Researchand Training Centers at a cost of 23 million dollars (NIDRR, 1999).5.1.2Sources of InformationLike any other emerging discipline, the knowledge base for rehabilitation engineering was scattered in disparate publications in the early years. Owing to its interdisciplinary nature, rehabilitation engineering research papers appeared in such diversepublications as the Archives of Physical Medicine & Rehabilitation, Human Factors,Annals of Biomedical Engineering, IEEE Transactions on Biomedical Engineering,and Biomechanics. Some of the papers were very practical and application specific,whereas others were fundamental and philosophical. In the early 1970s, manyimportant papers were published by the Veterans Administration in its Bulletin ofProsthetic Research, a highly respected and widely disseminated peer-reviewed periodical. This journal was renamed the Journal of Rehabilitation R&D in 1983. In1989, RESNA began Assistive Technology, a quarterly journal that focused on theinterests of practitioners engaged in technological service delivery rather than theconcerns of engineers engaged in research and development. The IEEE Engineeringin Medicine and Biology Society founded the IEEE Transactions on RehabilitationEngineering in 1993 to give scientifically based rehabilitation engineering researchpapers a much-needed home. This journal, which was renamed IEEE Transactions onNeural Systems and Rehabilitation Engineering, is published quarterly and covers themedical aspects of rehabilitation (rehabilitation medicine), its practical design concepts (rehabilitation technology), its scientific aspects (rehabilitation science), andneural systems.5.1.3Major Activities in Rehabilitation EngineeringThe major activities in this field can be categorized in many ways. Perhaps the simplestway to grasp its breadth and depth is to categorize the main types of assistivetechnology that rehabilitation engineering has produced (Table 5.2). The development of these technological products required the contributions of mechanical,material, and electrical engineers, orthopedic surgeons, prosthetists and orthotists,allied health professionals, and computer professionals. For example, the use of voicein many assistive devices, as both inputs and outputs, depends on digital signalprocessing chips, memory chips, and sophisticated software developed by electricaland computer engineers. Figures 5.2 through 5.4 illustrate some of the assistivetechnologies currently available. As explained in subsequent sections of this chapter,the proper design, development, and application of assistive technology devices

Enderle / Introduction to Biomedical Engineering 2nd ed. Final Proof 5.2.2005 6:17am page 218218CHAPTER 5TABL

artificial limbs, electronic travel guides, and wheelchairs that were more rugged, lighter, cosmetically appealing, and effective were developed. The field of assistive technology and rehabilitation engineering was nurtured by a two-pronged approach in the federal government. One approach directly funded

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