Employment issues and assistive technology use for persons with spinal cord injury

Employment, health outcomes, and life satisfaction after spinal cord injury: comparison of veterans and nonveterans

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To explore differences between veterans and nonveterans with spinal cord injury (SCI) for employment, health, and satisfaction with life outcomes after controlling for demographic and injury characteristics.

SETTING

Hospitals in the Spinal Cord Injury Model System of care.

METHODS

A total of 9754 (85% nonveterans and 15% veterans) adults with traumatic SCI interviewed from 2000 and 2015 and completed follow-up years 1, 5, and 10 were included in this study. Employment status and the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) measured employment. The SF-36 for self-perceived health status, CHART-SF, and rehospitalization determined health outcomes. Satisfaction with life was measured by the Satisfaction with Life Scale (SWLS). Secondary data analyses using χ2, t-tests, and generalized estimating equations (GEEs) model to determine group differences with control of demographic and injury characteristics.

RESULTS

There were no significant differences for employment and SWL between nonveterans and veterans. There were some differences in health outcomes; whereas, veterans had better physical independence and mobility compared with nonveterans.

CONCLUSION

Interventions for both groups should target adults with a disability from SCI, be customized for varying levels of injury that address differences in healthcare systems, demographic backgrounds, economic resources, disincentives, and motivation.

Evidence Review-Social Determinants of Health for Veterans

BACKGROUND

Veterans Health Administration (VHA) is committed to providing high-quality care and addressing health disparities for vulnerable Veterans. To meet these goals, VA policymakers need guidance on how to address social determinants in operations planning and day-to-day clinical care for Veterans.

METHOD

MEDLINE (OVID), CINAHL, PsycINFO, and Sociological Abstracts were searched from inception to January 2017. Additional articles were suggested by peer reviewers and/or found through search of work associated with US and VA cohorts. Eligible articles compared Veterans vs non-Veterans, and/or Veterans engaged with those not engaged in VA healthcare. Our evidence maps summarized study characteristics, social determinant(s) addressed, and whether health behaviors, health services utilization, and/or health outcomes were examined. Qualitative syntheses and quality assessment were performed for articles on rurality, trauma exposure, and sexual orientation.

RESULTS

We screened 7242 citations and found 131 eligible articles-99 compared Veterans vs non-Veterans, and 40 included engaged vs non-engaged Veterans. Most articles were cross-sectional and addressed socioeconomic factors (e.g., education and income). Fewer articles addressed rurality (N = 20), trauma exposure (N = 17), or sexual orientation (N = 2); none examined gender identity. We found no differences in rural residence between Veterans and non-Veterans, nor between engaged and non-engaged Veterans (moderate strength evidence). There was insufficient evidence for role of rurality in health behaviors, health services utilization, or health outcomes. Trauma exposures, including from events preceding military service, were more prevalent for Veterans vs non-Veterans and for engaged vs non-engaged Veterans (low-strength evidence); exposures were associated with smoking (low-strength evidence).

DISCUSSION

Little published literature exists on some emerging social determinants. We found no differences in rural residence between our groups of interest, but trauma exposure was higher in Veterans (vs non-Veterans) and engaged (vs non-engaged). We recommend consistent measures for social determinants, clear conceptual frameworks, and analytic strategies that account for the complex relationships between social determinants and health.

Need and availability of assistive devices to compensate for impaired hand function of individuals with tetraplegia

Context/Objective: To evaluate the availability and self-declared unmet need of assistive devices to compensate for impaired hand function of individuals with tetraplegia in Switzerland.Design: Cross-sectional survey.Setting: Community.Participants: Individuals with tetraplegia, aged 16 years or older, living in Switzerland.Interventions: not applicable.Outcome Measures: The self-report availability and unmet need of 18 assistive devices for impaired hand function was analyzed descriptively. The availability of devices was further evaluated stratified by sex, age, SCI severity, independence in grooming, time since injury, living situation, working status, and income. Associations between availability of devices and person characteristics were investigated using logistic regression analysis.Results: Overall 32.7% of participants had any assistive device for impaired hand function at their disposal. The most frequent devices were adapted cutlery (14.8%), type supports (14.1%), environmental control systems (11.4%), and writing orthosis (10.6%). In the bivariate analysis several factors showed significant associations with at least one assistive device. Nevertheless, when controlling for potential confounding in multivariate analysis only independence in grooming (adapted cutlery, environmental control systems, type support, speech recognition software), SCI severity (writing orthosis, type support), and sex (adapted kitchenware) remained significantly associated with the availability of the mentioned assistive devices. The self-declared unmet need was generally low (0.7% - 4.3%), except for adapted kitchenware with a moderate unmet need (8.9%).Conclusion: This study indicates that most individuals with tetraplegia in Switzerland are adequately supplied with assistive devices to compensate for impaired hand function. The availability depends mainly on SCI severity and independence in grooming.

Research progress from the SCI Model Systems (SCIMS): An interactive discussion on future directions

CONTEXT/OBJECTIVE

To describe current and future directions in spinal cord injury (SCI) research.

DESIGN

The SCI Model Systems (SCIMS) programs funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) during the 2011 to 2016 cycle provided abstracts describing findings from current research projects. Discussion among session participants generated ideas for research opportunities.

SETTING/PARTICIPANTS

Pre-conference workshop before the 2016 American Spinal Injury Association (ASIA) annual meeting. A steering committee selected by the SCIMS directors that included the moderators of the sessions at the ASIA pre-conference workshop, researchers presenting abstracts during the session, and the audience of over 100 attending participants in the pre-conference workshop.

METHODS/RESULTS

Group discussion followed presentations in 5 thematic areas of (1) Demographics and Measurement; (2) Functional Training; (3) Psychosocial Considerations; (4) Assistive Technology; and (5) Secondary Conditions. The steering committee reviewed and summarized discussion points on future directions for research and made recommendations for research based on the discussion in each of the five areas.

CONCLUSION

Significant areas in need of research in SCI remain, the goal of which is continued improvement in the quality of life of individuals with SCI.

The Health Economics of the spinal cord injury or disease among veterans of war: A systematic review

CONTEXT

Information on health-care utilization and the economic burden of disease are essential to understanding service demands, service accessibility, and practice patterns. This information may also be used to enhance the quality of care through altered resource allocation. Thus, a systematic review of literature on the economic impact of caring for SCI/D veterans would be of great value.

OBJECTIVE

To systematically review and critically appraise the literature on the economics of the management of veterans with SCI/D.

METHODS

Medline, EMBASE and PsycINFO databases were searched for articles on economic impact of management of SCI/D veterans, published from 1946 to September/2016. The STROBE statement was used to determine publication quality.

RESULTS

The search identified 1,573 publications of which 13 articles fulfilled the inclusion/exclusion criteria with 12 articles focused on costs of management of SCI/D veterans; and, one cost-effectiveness analysis. Overall, the health care costs for the management of SCI/D veterans are substantial ($30,770 to $62,563 in 2016 USD per year) and, generally, greater than the costs of caring for patients with other chronic diseases. The most significant determinants of the higher total health-care costs are cervical level injury, complete injury, time period (i.e. first year post-injury and end-of-life year), and presence of pressure ulcers.

CONCLUSIONS

There is growing evidence for the economic burden of SCI/D and its determinants among veterans, whereas there is a paucity of comparative studies on interventions including cost-effectiveness analyses. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for veterans with SCI/D.

Operationalizing workplace accommodations for individuals with disabilities: A scoping review

BACKGROUND

The provision of workplace accommodations is a proven strategy in supporting individuals with disabilities at work. Accommodations include a wide range of supports and strategies that are not very well defined beyond the Americans with Disabilities Act in the United States. Understanding the landscape of accommodations is important to measure the impact of programs that support employment of individuals with disabilities.

OBJECTIVE

To conduct a scoping review and thematic analysis of research literature to identify how workplace accommodations are operationalized and to identify knowledge gaps in its conceptualization.

METHODS

Keywords searches were conducted in seven electronic databases. Title, abstract, and full text screening was conducted followed by a thematic analysis of the content to identify how workplace accommodations are operationalized.

RESULTS

Overall, 47 studies were selected for review. 433 different types of accommodations were identified, of which assistive technology and specialized equipment represented the most frequently reported type of accommodation (40%). A very small percentage of studies included policy changes (9%) and human assistance (5%) as an accommodation strategy.

CONCLUSIONS

This scoping review aims to clarify how accommodations are operationalized in the research literature. Key knowledge gaps identified include the systematic exclusion of certain types of supports or disability types.

Predicting prosthetic prescription after major lower-limb amputation

We describe prosthetic limb prescription in the first year following lower-limb amputation and examine the relationship between amputation level, geographic region, and prosthetic prescription. We analyzed 2005 to 2010 Department of Veterans Affairs (VA) Inpatient and Medical Encounters SAS data sets, Vital Status death data, and National Prosthetic Patient Database data for 9,994 Veterans who underwent lower-limb amputation at a VA hospital. Descriptive statistics and bivariates were examined. Cox proportional hazard models identified factors associated with prosthetic prescription. Analyses showed that amputation level was associated with prosthetic prescription. The hazard ratios (HRs) were 1.41 for ankle amputation and 0.46 for transfemoral amputation compared with transtibial amputation. HRs for geographic region were Northeast = 1.49, Upper Midwest = 1.26, and West = 1.39 compared with the South (p < 0.001). African American race, longer length of hospital stay, older age, congestive heart failure, paralysis, other neurological disease, renal failure, and admission from a nursing facility were negatively associated with prosthetic prescription. Being married was positively associated. After adjusting for patient characteristics, people with ankle amputation were most likely to be prescribed a prosthesis and people with transfemoral amputation were least likely. Geographic variation in prosthetic prescription exists in the VA and further research is needed to explain why.

Assistive technology use by disability type and race: exploration of a population-based health survey

PURPOSE

To examine the relationships among Assistive Technology (AT) use, race, type of disability and selected other demographic characteristics.

METHOD

Using 2009 National Health Interview Survey, descriptive statistics, statistical interactions and binary logistic regression were performed to identify, contrast and predict the likelihood of using AT based on the type of disability among African Americans (AAs) and European Americans (EAs).

RESULTS

We found that more AAs (10% within group proportion of total AAs) used AT compared to EAs (7.5% within group proportion of total EAs). Physical (p < 0.001), auditory (p = 0.028) and emotional (p = 0.008) impairments were statistically significant predictors of AT use. However, physical impairment as a predictor of AT use was greater among AAs (OR = 222.49, CI: 64.04-773.04, p < 0.001) than EAs (OR = 50.77, CI: 31.78-81.12, p < 0.001). EAs had a greater number of disabling conditions that predict the use of AT than AAs, whereas AAs had more demographic characteristics beyond race that predict AT use than EAs.

CONCLUSIONS

Disparities were observed in AT usage by disability types and demographic characteristics between AAs and EAs. Moreover, the predictive strength of AT usage based on disability types and other demographic variables differed by races. Overall, the findings about the different relationships among race, disability type, and AT use are found. Implications for Rehabilitation The finding may inform the development of initiatives by rehabilitation leaders to encourage the use of AT by AAs and EAs according to their type of impairment. Having identified physical impairment as statistically significant predictor of AT use greater among AAs, rehabilitation leaders should ensure that people living with those types of disability have access to the corresponding type of AT and can use them effectively.

Assessment of brain-machine interfaces from the perspective of people with paralysis

OBJECTIVE

One of the main goals of brain-machine interface (BMI) research is to restore function to people with paralysis. Currently, multiple BMI design features are being investigated, based on various input modalities (externally applied and surgically implantable sensors) and output modalities (e.g. control of computer systems, prosthetic arms, and functional electrical stimulation systems). While these technologies may eventually provide some level of benefit, they each carry associated burdens for end-users. We sought to assess the attitudes of people with paralysis toward using various technologies to achieve particular benefits, given the burdens currently associated with the use of each system.

APPROACH

We designed and distributed a technology survey to determine the level of benefit necessary for people with tetraplegia due to spinal cord injury to consider using different technologies, given the burdens currently associated with them. The survey queried user preferences for 8 BMI technologies including electroencephalography, electrocorticography, and intracortical microelectrode arrays, as well as a commercially available eye tracking system for comparison. Participants used a 5-point scale to rate their likelihood to adopt these technologies for 13 potential control capabilities.

MAIN RESULTS

Survey respondents were most likely to adopt BMI technology to restore some of their natural upper extremity function, including restoration of hand grasp and/or some degree of natural arm movement. High speed typing and control of a fast robot arm were also of interest to this population. Surgically implanted wireless technologies were twice as 'likely' to be adopted as their wired equivalents.

SIGNIFICANCE

Assessing end-user preferences is an essential prerequisite to the design and implementation of any assistive technology. The results of this survey suggest that people with tetraplegia would adopt an unobtrusive, autonomous BMI system for both restoration of upper extremity function and control of external devices such as communication interfaces.

Assistive technology and veterans with severe disabilities: examining the relationships among race, personal factors, medical support, income support, and use

PURPOSE

Examine the relationship among assistive technology (AT), race, and other demographic characteristics (eg, sex, educational attainment, and employment status), medical coverage, as well as government support for veterans with severe disabilities.

METHODS

Data were analyzed from the Rehabilitation Services Administration-911 dataset collected in the United States in 2012. Descriptive and multivariate analyses were performed.

RESULTS

Among veterans with severe disabilities, factors that increased AT usage for European Americans (EAs) and African Americans (AAs) were employment, medical coverage (eg, access to private insurance and Medicare), government support (eg, Supplemental Security Income or Social Security Disability Income), and having a sensory type of disability. Having a mental disability was associated with decreased use of AT for EAs and AAs. Whereas EAs) had more factors associated with a decreased likelihood of using AT, AAs had more factors associated with an increased likelihood. For EA veterans with severe disabilities, receiving Medicaid, veteran benefits, and Workers' Compensation were associated with a decreased likelihood of using AT. AA veterans with severe disabilities were 60% less likely to use AT compared with EAs.

CONCLUSIONS

Racial differences between AAs and EAs were observed in the use of AT by veterans with severe disabilities based on sex, education, employment status, medical coverage, and government support. AAs were generally less likely to use AT; however, greater exposure to resources such as employment, insurance, and government income support partially explained the differential AT use between EAs and AAs. Future policies and research should address these racial disparities in veterans with severe disabilities to promote equitable AT use and healthy functioning.

Assisting people with multiple disabilities to improve computer typing efficiency through a mouse wheel and on-screen keyboard software

The main purpose of this study was to find out whether three students with multiple disabilities could increase their keyboard typing performance by poking the standard mouse scroll wheel with the newly developed Dynamic Typing Assistive Program (DTAP) and the built-in On-Screen Keyboard (OSK) computer software. The DTAP is a software solution that allows users to complete typing tasks with OSK software easily, quickly, and accurately by poking the mouse wheel. This study was performed according to a multiple baseline design across participants, and the experimental data showed that all of the participants significantly increased their typing efficiency in the intervention phase. Moreover, this improved performance was maintained during the maintenance phase. Practical and developmental implications of the findings were discussed.

Software wizards to adjust keyboard and mouse settings for people with physical impairments

CONTEXT/OBJECTIVE

This study describes research behind two software wizards that help users with physical impairments adjust their keyboard and mouse settings to meet their specific needs. The Keyboard Wizard and Pointing Wizard programs help ensure that keyboard and pointing devices are properly configured for an individual, and reconfigured as the user's needs change. We summarize four effectiveness studies and six usability studies.

METHODS

Studies involved participants whose physical impairments affect their ability to use a keyboard and mouse. Effectiveness studies used an A-B-A design, with condition A using default Windows settings and condition B using wizard-recommended settings. Primary data were performance metrics for text entry and target acquisition. Usability studies asked participants to run through each wizard, with no outside guidance. Primary data were completion time, errors made, and user feedback.

RESULTS

The wizards were effective at recommending new settings for users who needed them and not recommending them for users who did not. Sensitivity for StickyKeys, pointer speed, and object size algorithms was 100%. Specificity for StickyKeys and pointer speed was over 80%, and 50% for object size. For those who needed settings changes, the recommendations improved performance, with speed increases ranging from 9 to 59%. Accuracy improved significantly with the wizard recommendations, eliminating up to 100% of errors. Users ran through the current wizard software in less than 6 minutes. Ease-of-use rating averaged over 4.5 on a scale of 1 to 5.

CONCLUSION

The wizards are a simple yet effective way of adjusting Windows to accommodate physical impairments.

Assisting people with disabilities improves their collaborative pointing efficiency through the use of the mouse scroll wheel

This study provided that people with multiple disabilities can have a collaborative working chance in computer operations through an Enhanced Multiple Cursor Dynamic Pointing Assistive Program (EMCDPAP, a new kind of software that replaces the standard mouse driver, changes a mouse wheel into a thumb/finger poke detector, and manages mouse actions). The study used an ABAB design to evaluate whether four people (two pairs) with multiple disabilities, who have very limited voluntary muscle control and cannot use a standard mouse, would be able to improve their collaborative pointing performance using their finger poke ability with a mouse wheel through EMCDPAP software. The data showed that both pairs of participants improved their collaborative pointing efficiency through the use of the EMCDPAP software during the intervention phase. The practical and developmental implications of the findings are discussed.

Unmet need for disability-related health care services and employment status among adults with disabilities in the Massachusetts Medicaid program

BACKGROUND

The employment rate among adults with disabilities is significantly lower than that among adults without disabilities. Ensuring access to rehabilitative and other health care services may help to address health-related barriers to employment for working-age people with disabilities. This study examined the relationship of unmet need for 6 disability-related health care services to current employment status among working-age adults with disabilities enrolled in the Massachusetts Medicaid (MassHealth Standard) program.

METHODS

Study participants included 436 MassHealth Standard members aged 19 to 64 who responded to the 2005/2006 MassHealth Employment and Disability Survey. Variables included members' demographic characteristics; Medicaid health plan and Medicare enrollment; members' self-report of potentially disabling conditions and current health status; access to health care as well as need and unmet need for 6 specific disability-related health care services (medications, mental health services, substance abuse services, medical supplies, durable medical equipment, personal assistance services); and current employment status.

RESULTS

Fifteen percent of members reported currently working. Logistic regression analysis showed that (controlling for demographics, disability, health status, and other factors) members with greater unmet need were significantly less likely to be working (odds ratio = 0.58; 95% confidence interval = 0.33 to 0.99). Members' experience of unmet need was significantly greater for physical health services (supplies, durable medical equipment, personal assistance services) than for behavioral health services (mental health and substance abuse services) or medications. Working members generally rated services as important to work. Approximately 10% to 22% of nonworking members thought they would be able to work if needs were met.

CONCLUSIONS

Meeting unmet needs for disability-related health care services may result in modest increases in employment among certain working-age adults with disabilities enrolled in the Massachusetts Medicaid program.

Using an Extended Automatic Target Acquisition Program with Dual Cursor technology to assist people with developmental disabilities in improving their pointing efficiency

The latest research adopting software technology to improve pointing performance is through an Automatic Target Acquisition Program (ATAP), where the user can click on the mouse button when a dashed line is aimed at the desired target, instead of moving the cursor to the target. However, ATAP has one limitation--it cannot benefit from Mouseover effects because they only work when the cursor is over the target. This study evaluated whether two children with developmental disabilities would be able to improve their pointing performance through a Dual Cursor Automatic Target Acquisition Program (DCATAP), which solves the limitation of ATAP. At the beginning, both participants had baseline sessions. Then the first participant began his intervention sessions. New intervention occurred with the second participant when the first participant's performance was consolidated. Finally, both participants were exposed to the maintenance phase, in which their pointing performance improved significantly. With the assistance of DCATAP, participants can significantly improve their pointing performance, and can position targets quickly, easily, and accurately.

Assisting people with developmental disabilities to improve computer pointing efficiency through Multiple Mice and Automatic Pointing Assistive Programs

This study combines multi-mice technology (people with disabilities can use standard mice, instead of specialized alternative computer input devices, to achieve complete mouse operation) with an assistive pointing function (i.e. cursor-capturing, which enables the user to move the cursor to the target center automatically), to assess whether two people with developmental disabilities would be able to improve their pointing performance through a Multiple Mice Automatic Pointing Assistive Program (MMAPAP), where driver technology is adopted to enable people with disabilities to export the remaining ability of each limb to complete the mouse operation. At the beginning of the study, both participants received their baseline sessions. Then the first participant started his intervention session. The second participant had her intervention when the first participant's performance was consolidated. In the end, both participants were exposed to the maintenance phase, in which their pointing performance improved significantly. Data showed that both participants improved their pointing efficiency with the use of MMAPAP and remained highly successful through the maintenance phase. Implications of the findings are discussed.

Vulnerable Groups Living with Spinal Cord Injury

There is considerable variation in rehabilitation outcomes within the population of spinal cord-injured individuals across racial and socioeconomic groups. This suggests that the long-term health following spinal cord injury (SCI) is determined, at least in part, by group differences in exposure to advantages and disadvantages among persons living in the community. This article conceptualizes the nature of vulnerability and how increased vulnerability leads to disparities in SCI outcomes. Demographic, socioeconomic, and geographic determinants of adverse outcomes among vulnerable groups are discussed. Finally, a research model that outlines potential processes that elicit vulnerability following SCI and clinical implications is reviewed.

Review of critical factors related to employment after spinal cord injury: implications for research and vocational services

BACKGROUND/OBJECTIVE

Employment rates after spinal cord injury (SCI) vary widely because of discrepancies in studies' definition of employment and time of measurement. The objective of this study was to provide a comprehensive summary of the literature on employment rates, predictors of employment, and the benefits and barriers involved.

METHODS

A search using the terms spinal cord injury and employment in the databases PubMed, PsycINFO, and MEDLINE. The search included a review of published manuscripts from 1978 through 2008.

RESULTS

A total of 579 articles were found and reviewed to determine the presence of reported employment rates. Of these, 60 articles were found to include a report of employment rates for individuals with SCI. Results indicated that, in studies that examined paid employment, the average rate of any employment after SCI was approximately 35%.

CONCLUSIONS

Characteristics associated with employment after SCI include demographic variables, injury-related factors, employment history, psychosocial issues, and disability benefit status. It is recommended that researchers studying employment after SCI use common outcome measures such as competitive employment rates, duration of employment, and job tenure. Empirical evidence is lacking in regard to the most effective methods of vocational rehabilitation among this population. Evidence-based supported employment practices seem to be the most applicable model for assisting persons with SCI in restoring meaningful employment. Controlled studies are needed to test this assumption.

Return to work following spinal cord injury: a review

PURPOSE

To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work.

METHODS

A systematic review for 2000 - 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords 'spinal cord injuries', 'spinal cord disorder', 'spinal cord lesion' or 'spinal cord disease' were cross-indexed with 'employment', 'return to work', 'occupation' or 'vocational'.

RESULTS

Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 - 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age.

CONCLUSIONS

This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.