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Clinical Consultation: Therapeutic Use of Assistive Technology: A Clinical Perspective
Healthcare providers involved in patient handling activities are at risk for injury. One solution to minimize this risk is the use of assistive equipment. However, concern exists that use of assistive equipment may minimize the rehabilitation potential of patients compared to using manual handling skills and other traditional techniques. Practical examples are provided of how typical assistive equipment can actually enhance patient rehabilitation while also preventing caregiver injury.
Over the past few decades a dichotomy of paradigms has developed regarding the use of assistive technology and its place in rehabilitation settings. In some instances, a culture of safety and protection of the healthcare provider is the dominant focus. This culture often includes the use of assistive devices and decreased manual patient handling (Barr & Cunneen, 2001; Beyea, 2002). In other instances, focus on the patient and his or her rehabilitation potential is the main priority. This emphasizes the patient practicing motor skills and providing maximum effort with rehabilitation activities (Graf, 2006; Schofferman, 2006).
In a practical sense, the priority of safety and the priority of rehabilitation are not equally shared by all stakeholders and can even conflict. For example, if a lift device is used, it can send the message that the patient is incapacitated or unable to perform rehabilitation activities. Conversely, it can be assumed that if a patient is able to assist with movement, no assistive technology should be used at all to encourage further rehabilitation. In addition, the use of the assistive equipment often can be cumbersome, time consuming, or otherwise inconvenient, which can also further limit efforts toward safe practices (Bell, 1987).
These positions have collided in recent years as discussions formed around the excessive injury rates to healthcare providers (Nelson, Fagala, & Menzel, 2003). The need to increase the use of assistive technology was identified, yet resistance grew from those who thought assistive technology limits rehabilitation potential. In 2003, a task force was formed, consisting of members of the Association of Rehabilitation Nurses, the American Physical Therapy Association, and the Veterans Administration (VA) to determine whether a consensus could be developed on minimizing injuries to healthcare providers while maximizing patient rehabilitation.
The result of the task force was a consensus white paper published on December 1, 2004 (Nelson et al., 2004). This document demonstrates that each of these organizations agrees that safety and rehabilitation potential are not exclusionary goals. In fact, it was agreed that regardless of the practice setting, patients and caregivers can both benefit from the use of assistive equipment to encourage rehabilitation while minimizing the risk of injury.
Many tasks can be redesigned to accomplish the goal of maximizing rehabilitation potential along with patient and caregiver safety (Nelson, Lloyd, Menzel, & Gross, 2003).To illustrate how rehabilitation potential can be maximized without compromising caregiver safety, a few examples will be given of recent patient cases at the Salt Lake City VA Hospital.
Example 1: Rehabilitation Setting
Mr. Z is an older man with Parkinson’s disease. In addition, he has severe stenosis throughout the lumbar spine, causing him to bend forward at the waist to almost a 60-degree angle. Previous treatment consisted of using a four-wheeled walker, gym exercises, and a home exercise program to improve strength and endurance, improve posture, increase stride length with gait, and other functional goals. However, treatment options in the gym were limited by his excessive forward posture. Unsteadiness of gait from advanced Parkinson’s disease made most gait training and functional training hazardous for the therapist, who was providing manual support. This manual support also minimized other cueing and activities by the therapist because his hands were otherwise occupied.
Although Mr. Z improved somewhat with these activities over several weeks, his overall functional progress was very slow, and it often placed the treating therapist at risk for injury. Physical therapy changed to focus on ambulation using an unweighting harness while walking on a treadmill. The harness allowed the patient to ambulate without fear of falling and also freed the hands of the treating therapist. The patient was able to exercise longer, safer, and eventually with better rehabilitation gains (see Figure 1).
One of the most challenging problems for nurses is that patients often need different levels of assistance according to their fatigue levels throughout the day. The patient may do well for physical therapy but be fatigued later in the evening or possibly even from the rehabilitation activities. When using a device- assisted approach to ambulation, the patient is still able to provide effort according to his ability at a given time, yet minimize the risk to the healthcare provider if he falls or needs assistance. It also helps to minimize the uncertainty of how much staff is needed at a given time in the day or evening to help with mobility. In the case of Mr. Z, a treadmill and unweighting harness may not always be available to nursing staff. However, portable and in-room harnesses often are available for similar walking activities. Other options include variations in walkers that allow upright posturing and support according to the patient’s needs and abilities.
Example 2: Sit-to-Stand Transfers
Mr. A is a 66-year-old man who was admitted for abdominal surgery. He went home shortly after surgery but was eventually readmitted secondary to complications. Initially, he needed moderate assistance for supine-to-sit activities. After 3–4 days, he progressed to sitting independently but was unable to stand without moderate to maximum assistance. The physical therapist used a standing lift to help train sit-to-stand activities for days 5 and 6 in the hospital. While Mr. A was in the stander, tension was decreased on the sling to allow exercises such as hip and knee extensions and mini-squats in a controlled and safe environment. By day 7, the patient began ambulation activities and progressed to 100 feet of walking.
Had manual cueing and support been used throughout the rehabilitation progression, treatment would have required a minimum of two therapists. Also, the patient’s unsteadiness and unpredictable functional abilities could have placed the therapists at risk for injury. In addition, the patient’s ability to participate in rehabilitation could have been lessened by the fatigue of trying to work with only manual cues and support. The use of an assistive device not only improved his rehabilitation but also minimized the risk of injury to the caregiver.
Rehabilitation and staff nurses can use a sit-to-stand transferring device for this patient for their unique goals. The rehabilitation staff can continue to aid the patient in standing and tolerating prolonged standing. Also, staff nurses can use the device to assist with transfers to a commode, linen changes, and other repositioning needs. Physical therapists can also use the device to maximize gross motor response and work toward functional goals (see Figure 2).
Example 3: Maximum Assistance Lift
Mr. R is a 65-year-old man who suffered a C3–4 complete spinal cord injury, resulting in severe quadriplegia. The goal was for the patient to return home, where family would care for him. However, the patient also had lymphoma, necessitating frequent visits to the local university hospital for treatment.
Because of the patient’s size and severe functional limitations, the prospect of the patient’s spouse providing transfers and other care seemed impossible. In addition, the patient would require needed transfers to chairs and other upright positions to maximize cardiovascular, gastrointestinal, pulmonary, psychological, and other rehabilitation goals. None of these goals could be accomplished safely with manual transfer techniques.
For the several days the patient was in the hospital, the patient’s spouse was educated on the use of a lift device that would be issued for home use. The spouse was able to use this device for the rehabilitation goals and transfers to a wheelchair, allowing the patient to participate in regular treatment for the lymphoma (see Figure 3).
The use of this device benefits nursing staff as they work toward rehabilitation goals throughout the day with the patient. If the patient is fatigued or less able to assist throughout the day or evening, the amount that the device assists can be adjusted accordingly without having to change the amount of staffing or increasing risk of injury to the healthcare providers. Also, when the patient goes home and needs to continue transferring activities, both the family and the healthcare providers are able to assist with the patient’s needs without increasing their risk of injury.
These are only a few examples that occur every day in U.S. hospitals. The important aspect of each is that they show how using assistive technology helps protect the caregiver from potential injury without limiting rehabilitation potential. Of course, it is important to choose the appropriate device for the needs of the patient and encourage the patient to provide as much effort as possible in functional activities. In the end, if these principles are applied to most mobility situations, healthcare providers can be protected in the work setting and patients can still reach their full rehabilitation potential.
About the Author
Kevan Whipple, DPT OCS CEAS, is a doctor of physical therapy at VA Salt Lake City Healthcare System, Salt Lake City. Address correspondence to him at 500 Foothill Boulevard, 117 PT, Salt Lake City, UT 84148, or Kevan.Whipple@va.gov.
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