Representations of disability and normality in rehabilitation technology promotional materials

Development and Preliminary Validation of Scales to Measure Enacted, Perceived, and Experienced Hearing Loss Stigma in Health Care Settings

OBJECTIVES

Qualitative evidence suggests that stigma experienced by people who are d/Deaf and hard of hearing (d/DHH) can reduce willingness to engage with health services. Quantitative evidence remains lacking, however, about how health care providers (HCPs) perceive societal stigma toward people who are d/DHH, how HCPs might enact d/DHH stigma within provider-patient encounters, and what patients who are d/DHH share with providers about those patients' perceptions and experiences of stigma. Such quantitative evidence would allow HCPs to understand if and how stigma influences hearing health decisions made by people who are d/DHH. It could also shape practices to reduce d/DHH stigma within clinical encounters and guide providers in considering stigma as a driving force in their patients' hearing health care decisions. Building that evidence base requires validated quantitative measures. In response, the present study initiated an iterative process toward developing and preliminarily validating HCP self-report measures for different forms of d/DHH stigma. These measures draw upon HCPs' own perspectives, as well as their reports of secondhand information about stigma shared during clinical conversations. We developed and preliminary validated four measures: (1) provider-perceived stigma (HCPs' perceptions of the existence of negative attitudes and stereotypes toward d/DHH individuals in society), (2) provider-enacted stigma (self-reported subtle or indirect acts of stigma HCPs might commit during clinical encounters), (3) secondhand patient-experienced stigma (external acts of stigma reported to HCPs by patients who are d/DHH during clinical encounters), and (4) secondhand patient-perceived stigma (perceptions of negative attitudes and stereotypes reported to HCPs by patients who are d/DHH during clinical encounters).

DESIGN

Scale items were extracted from a comprehensive literature review of stigma measures. Question stems and individual items were adapted for HCPs, cognitively tested on 5 HCPs, and pretested with 30 HCPs. The 4 scales were then validated on a sample of primary care providers and hearing care specialists (N = 204) recruited through an online survey. All data were collected in the United States.

RESULTS

We conducted an exploratory factor analysis of the four proposed d/DHH stigma HCP stigma scales. Scale items loaded satisfactorily with ordinal alphas ranging between 0.854 and 0.944.

CONCLUSIONS

The four measures developed and preliminarily validated in this study can provide opportunities for HCPs to develop a more nuanced understanding of stigma experienced and perceived by their patients who are d/DHH and how that stigma manifests across social contexts, including health care settings. Further, the ability to assess forms of d/DHH stigma in clinical encounters, as well as their association with patient disengagement and resistance to advanced hearing care, could lead to innovative stigma-reduction interventions. Such interventions could then be evaluated using the measures from this article and then applied to clinical practice. We envision these measures being further refined, adapted, and tested for a variety of health care contexts, including primary care settings where hearing difficulties may first be identified and in hearing health care settings where audiologic rehabilitation is initiated.

Physiotherapy, movement, and action

Movement has always been central to physiotherapy practice and theory. But physiotherapists have largely focused on forms of human bodily movement governed by the neuro-mechanical body system in illness or injury. Many other forms of movement exist though, and we argue here that the exploration of these other movements might give physiotherapists new language, concepts, and tools, to guide its adaptation to forms of healthcare that are becoming increasingly complex, diverse, and inclusive. Drawing on Hannah Arendt's concept of vita activa (or "active life"), we examine how physiotherapists have traditionally captured and defined movement. Critiquing past practices for over-emphasizing what Arendt called labor, and work, we suggest that an approach governed by her concept of action, might offer physiotherapists a way to give movement greater significance. We explore what active life might mean for a revised approach to movement, and highlight examples of vita activa already emerging in physiotherapy. We close the paper by calling for a reevaluation of what movement means for the profession and its clients.

Exoskeleton use in acute rehabilitation post spinal cord injury: A qualitative study exploring patients' experiences

CONTEXT/OBJECTIVE

Spinal cord injury (SCI) is intensely life altering, affecting multiple body systems and functions, including the ability to walk. Exoskeleton assisted walking (EAW) is a rehabilitation tool that aims to support locomotor training, yet little is known about the patient experience. The purpose of this qualitative study, part of a prospective observational case series, was to increase our understanding of SCI patient experience using a robotic exoskeleton in this acute post-injury period.

DESIGN

A qualitative descriptive approach was implemented in this study, with the aim to explore and understand participants' experience with EAW training.

PARTICIPANTS/SETTING

Nine of the 11 participants enrolled in the observational study agreed to participate in an interview. All participants had suffered a SCI, and had received their trauma care and inpatient rehabilitation at a tertiary center in Calgary, Alberta, Canada.

RESULTS

The benefits to EAW use described by participants were primarily psychological and included the joy of eye level contact, excitement at being able to walk with assistance, improvement in mood, and hope for the future. Potential physiological benefits include increased strength, decreased spasticity and reduced pain. Challenges to EAW use include weakness and fatigue, and a fear of incontinence.

CONCLUSION

Qualitative research will continue to be an important component in future research on the use of EAW training as part of the rehabilitation process. Increasing understanding of the participants experience with this novel therapeutic modality and technology will be fundamental to improve its implementation in clinical practice.

A call to resist occupational therapy's promotion of ableism

BACKGROUND

Critical occupational therapists have exhorted their profession to engage with disability studies' scholarship, curtail occupational therapy's promotion of ableism and amend its disabling practices. These appeals have largely been ignored despite their importance for a profession that researches, theorizes, assesses, and intervenes in the lives of disabled people.

AIMS AND OBJECTIVES

To interrogate occupational therapy's collusion with an ableist neoliberal agenda; and call for occupational therapists to resist their profession's disabling practices.

MATERIAL AND METHODS

This paper draws from critical disability scholarship to expose, critique and contest the ableist ideology underpinning occupational therapy.

RESULTS

Interlinked with racism, heteronormativity and gender binarism, ableism upholds certain bodies as normal and appropriate. Ableist values shape occupational therapy, with clients classified according to their proximity to 'normality', and exhorted to minimize their occupational performance deviations from dominant norms.

CONCLUSIONS

Collusion with colonialism's binary classificatory systems and neoliberal ableist norms, and avowed aspirations to improve bodies, 'normalize' performances, promote individualism, self-reliance, independence, self-care, and productivity contribute to the perception that ours is a disabling profession.

SIGNIFICANCE

This paper calls for occupational therapists to resist their profession's promotion of ableism, and refuse to collude with colonial practices that contribute to the oppression of disabled people.

"Your double-blind RCT needs feminism": an argument for engaging critical theory in quantitative rehabilitation research

PURPOSE

Rehabilitation science has, for years, endorsed a connection between quantitative research and the philosophical assumptions of positivism. These assumptions can limit the scope of rehabilitation research, particularly in relation to matters of equity, diversity, and inclusivity. As our field moves toward a greater focus on inclusivity in research design and patient-centred care, it is imperative that we reconsider the theoretical foundations of rehabilitation research and practice.

METHODS

We provide an analysis of positivism on equity, diversity, and inclusivity within quantitative rehabilitation research, using the Participant Intervention Comparison Outcome (PICO) model to provide structure for the resultant discussion and recommendations.

RESULTS

Our analysis reveals that there are significant limitations and ethical concerns to engaging in positivism as the primary paradigm for quantitative rehabilitation research. We argue that decoupling of positivism and quantitative research methods may be warranted.

CONCLUSIONS

Equitable and inclusive rehabilitation research requires the researcher to consider variables which are neglected in the positivist paradigm. We argue that critical theory can equip researchers with a lens to better address injustices within rehabilitation research. We provide a series of recommendations for researchers to engage critical theory at each stage of the PICO model of clinical trials.IMPLICATIONS FOR REHABILITATIONCommon assumptions in quantitative rehabilitation research (i.e., positivism) can limit the utility of research findings to rehabilitation patients.Equitable, diverse, and inclusive participant samples in research better reflect the diversity of real world rehabilitation patients, helping us better serve these populations.Critical theory can help researchers and clinicians identify and avoid interventions that may cause harm to rehabilitation patients.Research and practice that prioritize concepts of "normalcy" (i.e., "normal gait," "normal behaviours") may perpetuate negative concepts of disability and further marginalize the individuals that our interventions aim to serve.

Impact of Occupational Therapy Education on Students' Disability Attitudes: A Longitudinal Study

IMPORTANCE

Discrimination based on disability-ableism-is pervasive and affects the opportunities of people with disabilities to fully engage in society.

OBJECTIVE

The aim of this study was to explore the impact of occupational therapy graduate education on students' explicit and implicit disability attitudes throughout their graduate education.

DESIGN

Longitudinal observational study, measuring occupational therapy students' attitudes on an annual basis.

SETTING

Three Midwestern graduate occupational therapy programs.

PARTICIPANTS

Occupational therapy students (N = 67). Outcomes and Measures: Participants completed the Symbolic Ableism Scale (to measure their explicit disability attitudes) and the Disability Attitude Implicit Association Test (to measure their implicit disability attitudes) on an annual basis, from when they entered their occupational therapy program to when they graduated.

RESULTS

The students' explicit attitudes decreased (i.e., became more favorable) throughout their education; however, their implicit attitudes did not change. In fact, most students (68%) were implicitly ableist at graduation.

CONCLUSIONS AND RELEVANCE

Occupational therapy education programs have an important role to play in terms of intervening with students' beliefs and preconceived assumptions about disability. Our finding suggests that occupational therapy programs may fail to intervene with students' ableist attitudes. What This Article Adds: Little longitudinal research has examined how students' implicit disability bias may be affected by their academic experience. Our findings about ableism among occupational therapy students should open the door for further dialogue on the existence of ableism in program content, its potential impact on future client interactions, and the development of approaches to address it.

HabITec: A Sociotechnical Space for Promoting the Application of Technology to Rehabilitation

Society is currently facing unprecedented technological advances that simultaneously create opportunities and risks. Technology has the potential to revolutionize rehabilitation and redefine the way we think about disability. As more advanced technology becomes available, impairments and the environmental barriers that engender disability can be significantly mitigated. The opportunity to apply technology to rehabilitation following serious injuries or illnesses is becoming more evident. However, the translation of these innovations into practice remains limited and often inequitable. This situation is exacerbated by the fact that not all relevant parties are involved in the decision-making process. Our solution was to create a sociotechnical system, known as HabITec, where people with disabilities, practitioners, funders, researchers, designers and developers can work together and co-create new solutions. Sociotechnical thinking is collaborative, interdisciplinary, adaptive, problem-solving and focused on a shared set of goals. By applying a sociotechnical approach to the healthcare sector, we aimed to minimize the lag in translating new technologies into rehabilitation practice. This collaborative co-design process supports innovation and ensures that technological solutions are practical and meaningful, ethical, sustainable and contextualized. In this conceptual paper, we presented the HabITec model along with the empirical evidence and theories on which it has been built.

The Divergence and Convergence of Critical Reflection and Critical Reflexivity: Implications for Health Professions Education

As a field, health professions education (HPE) has begun to answer calls to draw on social sciences and humanities (SS&H) knowledge and approaches for curricular content, design, and pedagogy. Two commonly used SS&H concepts in HPE are critical reflection and critical reflexivity. But these are often conflated, misunderstood, and misapplied. Improved clarity of these concepts may positively affect both the education and practice of health professionals. Thus, the authors seek to clarify the origins of each, identify the similarities and differences between them, and delineate the types of teaching and assessment methods that fit with critical reflection and/or critical reflexivity. Common to both concepts is an ultimate goal of social improvement. Key differences include the material emphasis of critical reflection and the discursive emphasis of critical reflexivity. These similarities and differences result in some different and some similar teaching and assessment approaches, which are highlighted through examples. The authors stress that all scientific and social scientific concepts and methods imported into HPE must be subject to continued scrutiny both from within their originating disciplines and in HPE. This continued questioning is core to the ongoing development of the HPE field and also to health professionals' thinking and practice.

Perspectives of people with spinal cord injury learning to walk using a powered exoskeleton

BACKGROUND

Powered exoskeletons for over ground walking were designed to help people with neurological impairments to walk again. Extended training in powered exoskeletons has led to changes in walking and physiological functions. Few studies have considered the perspective of the participants. The users' perspective is vital for adoption of assistive devices. We explored the expectations and experiences of persons with spinal cord injury, training with the ReWalk exoskeleton.

METHODS

A qualitative research design with individual interviews was used. Eleven participants with spinal cord injury, taking part in 12 weeks of 4 times weekly training using the ReWalk, were interviewed before, immediately after, and 2 months after training. Interviews were audio recorded and transcribed verbatim. A six stage approach to thematic analysis was used.

RESULTS

The theme consistently expressed was the exoskeleton allowed participants to do everyday activities, like everyone else, such as looking people in the eye or walking outside. Their experiences were captured in three categories: 1) learning, a description of both expectations for learning and perspectives on how learning occurred; 2) changing, perspectives on perceived changes with training; and 3) contributing, which captured participant perspectives on contributing to research, including the giving of direct feedback regarding the exoskeleton (i.e., what worked and what could be changed).

CONCLUSIONS

Incorporating the view of the user in the design and refinement of exoskeletons will help ensure that the devices are appropriate for future users. Availability and support for the use of exoskeleton devices in community settings is an interim step to home use as the devices continue to improve.

TRIAL REGISTRATION

www.clinicaltrials.gov ( NCT02322125 ). Registered Dec 22, 2014 - Retrospectively registered after the first 4 participants had enrolled in the study.

Clinician, student and faculty perspectives on the audiology-industry interface: implications for ethics education

Objective: Supporting audiologists to work ethically with industry requires theory-building research. This study sought to answer: How do audiologists view their relationship with industry in terms of ethical implications? What do audiologists do when faced with ethical tensions? How do social and systemic structures influence these views and actions? Design: A constructivist grounded theory study was conducted using semi-structured interviews of clinicians, students and faculty. Study sample: A purposive sample of 19 Canadian and American audiologists was recruited with representation across clinical, academic, educational and industry work settings. Theoretical sampling of grey literature occurred alongside audiologist sampling. Interpretations were informed by the concepts of ethical tensions as ethical uncertainty, dilemmas and distress. Results: Findings identified the audiology-industry relationship as symbiotic but not wholly positive. A range of responses included denying ethical tensions to avoiding any industry interactions altogether. Several of our participants who had experienced ethical distress quit their jobs to resolve the distress. Systemic influences included the economy, professional autonomy and the hidden curriculum. Conclusions: In direct response to our findings, the authors suggest a move to include virtues-based practice, an explicit curriculum for learning ethical industry relations, theoretically-aligned ethics education approaches and systemic and structural change.

Rehabilitation culture and its impact on technology: unpacking practical conditions for ultrabilitation

Purpose: It has been proposed that rehabilitation practice expand its aims beyond recovery to "ultrabilitation," but only if certain biological, technological, and psychosocial conditions are met. There is thus an opportunity to connect ultrabilitation, as a concept, to adjacent literature on assistive technology and sociotechnical systems.Method: We draw on insights from sociology of technology and responsible innovation, as well as concrete examples of neural devices and the culture of rehabilitation practice, to further refine our understanding of the conditions of possibility for ultrabilitation.Results: "Assistive" technologies can indeed be re-imagined as "ultrabilitative," but this shift is both psychosocial and technological in nature, such that rehabilitation professionals will likely play a key role in this shift. There is not, however, sufficient evidence to suggest whether they will support or hinder ultrabilitative uses of technology.Conclusion: Advancing the idea and project of ultrabilitation must be grounded in a nuanced understanding of actual rehabilitation practice and the norms of broader society, which can be gained from engaging with adjacent literatures and by conducting further research on technology use in rehabilitation contexts.Implications for rehabilitation"Assistive" technologies can be conceptually re-imagined as "ultrabilitative" technologies, expanding their utility from recovery to enhancement and flourishing.Actual development and use of ultrabilitative technology is both a technical and psychosocial challenge, and its success depends on the cultural context in which technology is situated.Further empirical research is needed on the ways in which rehabilitation culture and the norms of broader society might impact or even inhibit the use of ultrabilitative technology.

'You want to show you're a valuable employee': A critical discourse analysis of multi-perspective portrayals of employed women with fibromyalgia

Background Advice on fibromyalgia, a chronic illness primarily affecting women, often presents it as incompatible with work and rarely covers how to remain employed. Yet many women do. Objectives We aimed to understand how these women, their family members, and workmates portrayed employees with fibromyalgia, and how these portrayals helped women retain employment. Methods We interviewed 22 participants, comprising five triads and three dyads of people who knew each other. Using the methodology of critical discourse analysis, we analysed the interview data within and across the triads/dyads through coding, narrative summaries, and relational mapping. Results Participants reported stereotypes that employees with fibromyalgia are lazy, malingering, and less productive than healthy workers. Countering these assumptions, participants portrayed the women as normal, valuable employees who did not 'give in' to their illness. The portrayals drew on two discourses, normalcy and mind-controlling-the-body, and a related narrative, overcoming disability. We propose that participants' portrayals helped women manage their identities in competitive workplaces and thereby remain employed. Discussion Our findings augment the very sparse literature on employment with fibromyalgia. Using a new approach, critical discourse analysis, we expand on known job-retention strategies and add the perspectives of two key stakeholders: family members and workmates.

Comparison of a robotic-assisted gait training program with a program of functional gait training for children with cerebral palsy: design and methods of a two group randomized controlled cross-over trial

Background

Enhancement of functional ambulation is a key goal of rehabilitation for children with cerebral palsy (CP) who experience gross motor impairment. Physiotherapy (PT) approaches often involve overground and treadmill-based gait training to promote motor learning, typically as free walking or with body-weight support. Robotic-assisted gait training (RAGT), using a device such as the Lokomat^®Pro, may permit longer training duration, faster and more variable gait speeds, and support walking pattern guidance more than overground/treadmill training to further capitalize on motor learning principles. Single group pre-/post-test studies have demonstrated an association between RAGT and moderate to large improvements in gross motor skills, gait velocity and endurance. A single published randomized controlled trial (RCT) comparing RAGT to a PT-only intervention showed no difference in gait kinematics. However, gross motor function and walking endurance were not evaluated and conclusions were limited by a large PT group drop-out rate.

Methods/design

In this two-group cross-over RCT, children are randomly allocated to the RAGT or PT arm (each with twice weekly sessions for eight weeks), with cross-over to the other intervention arm following a six-week break. Both interventions are grounded in motor learning principles with incorporation of individualized mobility-based goals. Sessions are fully operationalized through manualized, menu-based protocols and post-session documentation to enhance internal and external validity. Assessments occur pre/post each intervention arm (four time points total) by an independent assessor. The co-primary outcomes are gross motor functional ability (Gross Motor Function Measure (GMFM-66) and 6-minute walk test), with secondary outcome measures assessing: (a) individualized goals; (b) gait variables and daily walking amounts; and (c) functional abilities, participation and quality of life. Investigators and statisticians are blinded to study group allocation in the analyses, and assessors are blinded to treatment group. The primary analysis will be the pre- to post-test differences (change scores) of the GMFM-66 and 6MWT between RAGT and PT groups.

Discussion

This study is the first RCT comparing RAGT to an active gait-related PT intervention in paediatric CP that addresses gait-related gross motor, participation and individualized outcomes, and as such, is expected to provide comprehensive information as to the potential role of RAGT in clinical practice.

Trial registration ClinicalTrials.gov NCT02196298

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3535-0) contains supplementary material, which is available to authorized users.

Living Labs: overview of ecological approaches for health promotion and rehabilitation

PURPOSE

The term "Living Lab" was coined to reflect the use of sensors to monitor human behavior in real life environments. Until recently such measurements had been feasible only within experimental laboratory settings. The objective of this paper is to highlight research on health care sensing and monitoring devices that enable direct, objective and accurate capture of real-world functioning.

METHOD

Selected articles exemplifying the key technologies that allow monitoring of the motor-cognitive activity of persons with disabilities during naturally occurring daily experiences in real-life settings are discussed in terms of (1) the ways in which the Living Lab approach has been used to date, (2) limitations related to clinical assessment in rehabilitation settings and (3) three categories of the instruments most commonly used for this purpose: personal technologies, ambient technologies and external assistive systems.

RESULTS

Technology's most important influences on clinical practice and rehabilitation are in a shift from laboratory-based to field-centered research and a transition between in-clinic performance to daily life activities. Numerous applications show its potential for real-time clinical assessment.

CONCLUSIONS

Current technological solutions that may provide clinicians with objective, unobtrusive measurements of health and function, as well as tools that support rehabilitation on an individual basis in natural environments provide an important asset to standard clinical measures.

IMPLICATIONS FOR REHABILITATION

Until recently objective clinical assessment could not be readily performed in a client's daily functional environment. Novel technologies enable health care sensing and monitoring devices that enable direct, objective and accurate capture of real-world functioning. Such technologies are referred to as a "Living Lab" approach since they enable the capture of objective and non-obtrusive data that clinicians can use to assess performance. Research and development in this field help clinicians support maintain independence and quality of life for people who have disabilities or who are aging, and to promote more effective methods of long-term rehabilitation and maintenance of a healthy life style.