Mobility – Today, Tomorrow & Everywhere. Lloyd Walker1 Regency Park Rehabilitation Engineering, CCA of SA Inc, Adelaide, SA, Australia . Keywords: Assistive Technology, Mobility, Seating, Emerging Issues Introduction Mobility technology has developed rapidly in the last few centuries and in the last 70 years developments seem to be occurring exponentially. The number of wheelchair users has been doubling every decade since 1940 (Cooper, 2003), and mobility technologies that mimic upright mobility (albeit through balancing on two wheels) are now a clinical reality. This presentation will explore some of the current issues and possible emerging trends in mobility and related technologies for people with disabilities. Mobility Today Despite the desire by many with a significant mobility disability to “just be able to walk” the current reality involves either orthotic assistance (which may include electronic muscle stimulation) or more commonly a wheeled mobility system (technically a prosthetic). Over the years changes have occurred in a number of facets of these mobility items. Different solutions and choice In the early days of wheeled mobility the choice was limited to a chair or bed strong enough to both support weight and have wheels fitted. Over the years we have seen the experiment (in nearly all parts of the world) with the “one chair fits all” approach to wheelchair delivery, through to the vast array of materials, configurations and 1 Address correspondence to Lloyd.Walker@cca.org.au features that exist in the current wheelchair market. One large manufacturer has commented that for one model of chair alone, there are potentially thousands of combinations possible. This all forms part of the recognition that this technology is a key part of achieving “community (re)integration” (Scherer, 2002. p4) for a user2, and as such the user will require choice to meet their individual needs. User control Although this may seem obvious to many practitioners today, the concept that a mobility device user should control their technology (through self propulsion or deciding when and where they went) has only become routine as disability has moved away from the medical model to the social model. This change is emphasised through the release of the International Classification of Functioning, Disability and Health (WHO, 2003). It will strengthen further as the developed world’s population ages and people acquire mobility disabilities, yet refuse to be sidelined from activities they take for granted. For some the transfer of control has been unsettling. Families have been upset when a teenager has “run away from home” when given their first chance of independent powered mobility. Funders have expressed exasperation that users in remote communities continue to catch fish from their equipment leading to premature failure. Although it may be tempting to restrict use of equipment to the “right place,” mostly the problems are being acknowledged as limitations on valued roles for the individual that require addressing. Increasing expectations of technology Current users of assistive technology (and particularly mobility technology) refuse to accept that “near enough is good enough” for disability equipment. Although the 2 The change over the decades from “patients” to “clients” or even “customers” reflects the changing status of the users of assistive technologies. In this paper I will refer to all such people as technology “users”. technology is often not as expensive as some medical devices or treatments, there is a considerable investment both in time and finance into achieving good solutions. Users (and funders) are increasingly demanding standards of manufacture, design, information disclosure and so forth that only twenty years ago would have been unthinkable. Current work on International Standards (ISO) seeks to ensure that equipment is both fit for purpose, and continues to deliver consistent service over a reasonable lifetime. Similar aspects of service delivery development (eg outcomes measures etc) are growing in prominence as this facet of the mobility solution is refined and improved. Advances in Technology generally Most agree that developments in technology are occurring at a rapid pace. The growing assuredness of both users and professionals of assistive technologies is resulting in a relatively swift adoption of new technologies (including materials, electronics and software) into technology for people with disabilities. The first solid state power wheelchair controller was released only 15 years or so ago, yet current controller technology is capable of performing complex self diagnostics, correcting for user limitations and even interfacing with a range of commercial devices for environmental control. Indeed some technologies pioneered by people with disabilities, have spin-offs that assist others (eg the DEKA research for a balancing wheelchair, now realised in the IBOT3000, has resulted in the production of the Segway Personal Transporter). Issues Today and Tomorrow Although mobility technologies have come a long way, and users have greater options than ever before, there are some issues that remain to be resolved, and some that are only now being recognised. The aging, and increasingly obese population In case you had been hiding for the last five years, Australia (and much of the developed world) is aging and generally fatter (thus heavier). As mobility device users are part of the population, they are also aging and in some cases, becoming obese. As we get heavier, the wheelchairs, orthotics and other support devices required have to be adjusted to make them stronger and often wider or longer – in other words bigger – to carry the user. ISO test dummies now include a 150kg user and provision for scaling for bigger dummies. This “growing” problem has health and infrastructure impacts, which will be discussed a little later. The aging population includes people with disabilities. Disability no longer means a markedly shorter life expectancy. People born with some quite severe disabilities are now reaching retirement age. We have little understanding of the effect of aging on those with disabilities and sometimes, conditions which we believed were an acute disease or condition (eg polio myelitis) are generating new challenges for those people with “stable” disabilities as they age. These changes with age have traditionally been ignored in an adult population. It is quite likely that we will have to review and consider technology changes for older users just as we do for children now as they grow (age). Long-term harm from equipment use. A further but to date poorly defined, and even dismissed factor for the aging population with disabilities, is the impact of a lifetime of poor technique or overuse of otherwise healthy body systems. Manual wheeled mobility for instance, puts considerable load on the upper limbs and shoulders that is often substantial, abnormal and repetitive. Recent studies have shown that overuse injuries are at extraordinary levels in the wheelchair use population. In many cases there are suggestions to reduce significantly the injury, but this is required during the training phase of chair delivery. It is highly likely that, as a result of these injuries, many current manual wheelchair users will be required to transfer to powered mobility as they age. The literature reporting on why people abandon technology is growing. In many cases abandonment is the result of poor user consultation, and a process focused more often on completing documentation than on effectively evaluating, testing and then training in the appropriate mobility device. The evidence (see below) on the cost effectiveness of higher unit cost items for long-term users, calls for greater support during the evaluation and training phases to avoid costly abandonment. Given the long-term cost and social impact identified – shouldn’t we finally spend the appropriate funds on technology delivery and training? Quality of production and variability of use For some time, consumer and government organizations have undertaken durability and usability testing of consumer products (eg washing machines, cars etc). The same approach has only recently been funded for wheeled mobility devices by the Dept of Veteran’s Affairs (DVA) in the USA (Cooper, 2003). This life cycle testing has highlighted two key factors: - the quality control of manufacturers remains patchy, and you tend to get what you pay for. The variability of usage continues to confound manufacturers and those responsible for testing devices. As a result there is more “real-life/time” testing underway, with systems for logging the usage level and patterns of mobility devices, over periods of up to a year, likely to become commonplace. This research is not only permitting the refinement of testing and manufacturing protocols, but also demonstrating the considerable work users give their mobility devices. Issues such as privacy and the purpose of such information gathering remain controversial. Integration Users are increasingly expecting their complex technological devices (from communication devices to power wheelchairs) to work together. At the cutting edge of research, work is underway on implantable biosensors that could transmit signals to pressure relief cushions to alter profile when perfusion in at risk skin areas falls. In mainstream settings, we now expect many of our home entertainment and even computer devices to work together. Manufacturers of complex control systems (eg power wheelchair controllers) face the challenge of seeking to provide the broadest range of integrations, at the cheapest price, while at the same time ensuring the integrity and safety of the primary control system. Pushing technology to its limits Our expectation of modern technology grows by the year. Mobility devices are also expected to do more with each new model release – but usually without an equivalent cost increase. While the ability to increase capability while restraining cost is assisted by spin-offs from the consumer technology industry, the volume of mobility and even other assistive technology devices is rarely sufficient to absorb the extensive development costs required. Many technologies are being pushed to their limit both by manufacturers and sometimes by prescribers and users (eg the range a power wheelchair will travel between charges). As we continue to push, we must understand that technology may fail, sometimes unpredictably. Mobility Technology Everywhere! When we have resolved all our technology problems we still have to consider where we will go. Confinement to a custom built residence is no longer considered acceptable. Increases in the size and weight of users, and thus their mobility technology, have an impact on the built environment. A growing concern for designers is the weight associated with wheeled devices. As users and their associated wheelchairs get heavier (due to obesity, increased battery needs, accessories etc), lifts, buses and vehicle restraints need to be reviewed. The combined weight of an obese user, their large power wheelchair and potentially some shopping could exceed 300kg. Current changes to Australia’s Building Codes and related Australian Standards are seeking to redress a perceived increase in the sizes of wheelchairs in the last decade or so. Our problem is how far we should go? Many standards and dimensions are based on percentiles (typically the 80 th or 90th). In most populations, the distribution of height or weight is a “normal distribution.” Unfortunately there is growing evidence that the distribution of wheelchair dimensions is skewed towards the large sizes (thus more users would be larger than the 90th percentile, than those smaller than the 10th). If doors, corridors, railings and even wheelchair areas on buses exclude 10% or more of those using wheelchairs – is that acceptable? Should we expect users to have a smaller/alternative wheelchair for use at home or work, but a larger “outdoor” chair for other activities? Should a Segway transporter be GST free (as a medical device) for a high-level lower limb amputee to reduce their fatigue and enhance their independence for longer? Conclusion Wheeled mobility and seating has come a long way in the last century and now changes are occurring exponentially. We must recognise that we are now starting to be blessed with a vast array of suitable options for those with disabilities, but also increasing complexity and expectation. Some emerging issues are challenging our “lolly bag” approach to technology delivery over recent decades. If we fail to consider the effects of aging and obesity, as well as the place of mobility technology in an individual’s complex life, in our funding models and approach to service delivery and technology development the next few decades could be very costly, both at a personal and a societal level. If we recognise the integral nature of mobility and do it well – good mobility will take people with disabilities everywhere! References 1. Scherer M (2002) Assistive Technology: Matching Device and Consumer for Successful Rehabilitation. Washington DC: American Psychological Association. 2. Cooper R (2003) An overview of the work of the Pittsburgh University Rehabilitation Engineering Centre. Presentation at the ISO TC173 SC1 Working Party Meeting 27 October 2003. Christchurch, NZ.
Pages to are hidden for
"Good practice or best practice"Please download to view full document