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Assistive Technology through the Progression of a Degenerative Neurologic
Disease: An Exploration of Best Practice.
Purpose:
Certified Assistive Technology Training Course 2012 Assistive Technology and Specialised Seating Department, Central Remedial Clinic, Clontarf, Dublin 3. Contents
2. Overview of Assistive Technology and Specialised Seating Service in the 3. Overview of Degenerative Neurologic Diseases 4. Research in Assistive Technology and Degenerative Neurologic Diseases 5. Computer access & Degenerative Neurologic Diseases 6. Powered mobility & Degenerative Neurologic Diseases 7. Environmental Controls & Degenerative Neurologic Diseases 8. Communication Devices & Degenerative Neurologic Diseases 9. Key Considerations for Best Practice in Equipment Prescription Acknowledgements
I would like to acknowledge all the help and support of the wonderful and inspirational staff of Assistive Technology & Specialised Seating Department in the Introduction
As a recent employee in the Assistive Technology & Specialised Seating Department (ATSS) in the Central Remedial Clinic (CRC) I have chosen a project that is linked to my previous role as an occupational therapist in elderly care including progressive I chose to investigate current research and identify current practice including commonly prescribed devices in the area of adults with a progressive neurological disease. In this assignment I will outline the service offered by the ATSS Department. I will briefly discuss the conditions commonly seen along with their symptoms. I will summarise the findings of a literature search and finally discuss the devices that are commonly prescribed and the key considerations for equipment Overview of the ATSS Department.
The Assistive Technology and Specialised Seating Department in the Central Remedial Clinic provides a quality assessment service to people with physical disabilities in the area of Assistive Technology (AT). In addition it offers a service to adults with a diagnosis of a degenerative neurological disease. These diseases can include Motor Neuron Disease (or amytrophic lateral sclerosis), Multiple Sclerosis, Huntington’s Disease and Parkinson’s Disease (Progressive Supranuclear Palsy). AT consists of a broad range of devices, technical aids and strategies, which can help solve problems faced by people with disabilities in every day life. The department strives to offer people alternatives and options to facilitate their personal independence in everyday living. Today there is a wide range of technology devices that have become smarter, smaller, lighter and more affordable and it is often simply a lack of understanding of how our environment can be adapted and modified that is the greatest barrier for people with disabilities in our society. A multidisciplinary team of assistive technology advisors brings experience from a variety of backgrounds including, engineering, occupational therapy, speech and language therapy, ICT and education. The team operates both a centre based and national outreach service. Nationally, their work is complemented by a network of regionally based clinical technicians who are available to offer support and follow up to people in their local environments. As far as possible, the team work in partnership with local agencies to provide person centred responses. Overview of the types of Degenerative Neurologic Diseases
For the purpose of this assignment I will focus of the clients with a diagnosis of a degenerative neurological disease. I will outline the key characteristics of a number of degenerative progressive neurological disorders that I have been involved in their Motor Neuron Disease (MND) is an incurable neurological condition that selectively affects the motor neurons, the cells that control voluntary movement activity; walking, talking and swallowing. MND presents its self in various ways depending upon the muscle fibers which degenerate initially. There are two types; limb onset and bulbar onset. Limb onset involves progressive muscle weakness and wasting, and can also include fasciculation and changes in muscle tone. The Bulbar or brainstem type, involves symptoms including speech and swallowing difficulties. Wasting of muscles in the upper limbs, stiffness of the lower limbs and wasting of the tongue muscles affecting speech and swallowing. There are approximately 300 people living in Ireland at any one time with a diagnosis of MND. (IMNDA 2012) Multiple Sclerosis (MS) is also a progressive neurological condition that affects the central nervous system (CNS). This is the switch board responsible for sending electrical messages along the nerve fibers to various parts of the body. Healthy nerve fibers are insulated with myelin, in MS the myelin breaks down and distorts or blocks the message flow. There are four different types of MS, relapsing remitting MS, secondary progressive, benign and primary progressive. The symptoms typically are muscle spasm and stiffness, low mood and depression, memory and other cognitive impairments, fatigue and tremors. There are approximately 7,000 people in Ireland with a diagnosis of MS. (MS Ireland 2012) Huntingtons Disease (HD) is a hereditary incurable neurological disorder that causes brain cell degeneration leading to physical cognitive and emotional deterioration. Symptoms can vary and may include involuntary jerky movements of the limbs, face and trunk, increasing difficulty with communication and swallowing, mental turmoil (depression and apathy) and finally problems with planning, organising, initiation as well as personality changes. As for all degenerative neurological disorders interventions must be timely and responsive to the changing needs of the individual and to the challenges faced by family and others. It is essential to implement internventions while there is still motivation and learning capacity. There are approximately 500 people living in Ireland with HD. (HDA 2012) Progressive Supranuclear Palsy (PSP) is a progressive brain disorder that causes serious progressive deterioration with gait and balance along with complex eye movements and thinking problems. One of the classic symptoms is the inability to aim the eyes properly. Symptoms may also include personality change, memory impairment and blurred vision. The cause is a gradual deterioration in the brain cells in a specific area of the brain known as the brain stem. (parkinsons.ie) Research in Assistive Technology and Degenerative Neurological Diseases
A literature review was carried out using CINAHL. The key words were AT, Motor Neuron Disease/Amyotrophic Lateral Sclerosis, Multiple Sclerosis and degenerative neurological conditions. The searches yielded little results, indicating a vast need for From the research, assistive technology is described as a means to help persons with a degenerative condition continue to fulfil meaningful life roles. A study by Casey (2012) discussed AT and Amyotrophic Lateral Sclerosis (ALS). It reported that AT may be used to help improve mobility, communicate, perform activities of daily living and maintain social and professional relationships (Casey 2012). The study showed, while there is limited evidence specifically supporting the usefulness of an AT clinic for persons with ALS, there is evidence that supports attendance at a multidisciplinary clinic positively impacting the lives of persons with ALS, as well as evidence supporting access to AT for persons with ALS. Other studies showed that if AT is available for persons with ALS, they will use it to stay connected with family and friends and to discuss important issues (Doyle 2001 & An article by Souza (2010) investigated powered mobility in the MS population. Mobility impairments frequently restrict participation in work, family, social, vocational, and leisure activities. Furthermore, persons with MS often experience difficulties adapting to the changing and progressive nature of mobility loss, frequently marked by exacerbations and remissions. This article cites one of the biggest challenges for professionals and persons with MS is finding a mobility device that meets the users’ needs and maintains or increases community participation. Being able to remain active in the community and also keep their jobs are some of the biggest challenges for persons with MS. In an overview of AT and MS Blake provides us with practical examples of low tech and high tech solutions for this client group. In this article they highlight the importance of selecting the optimal device from the beginning that can . For individuals with MS, having a single device with which they can learn to use and become comfortable and that adjusts with the continuum of their disability it a high In all the research the timing of intervention in noted, it is essential to consider AT early on in the systematic care of persons in order to maximize the benefits of the technology. If technology is not thoroughly addressed in the early stages of the disease process, the person is more likely to have more impairments leading to more advanced technology needs resulting in delays in recommendations for the AT evaluation, procurement of, and education with the device. Considering the rapidly progressive loss in overall function experienced by persons with progressive neurological disorders, it is essential to provide comprehensive multidisciplinary care, including AT services in an effective and efficient manner. (Casey 2012) Computer Access and Degenerative Neurological Diseases
Access to the computer can be one of the first reasons an individual losing motor function in upper limbs is referred to the ATSS Dept in the CRC. There are many solutions that can be implemented for the impairments the client report but it is important to anticipate the deterioration in motor function. It is necessary to remember that direct access may need to be replaced by switch or other alternatives within a short period of time. I have a number of MND clients who required one of the solutions below, but I have educated them on the devices available as the disease The following are examples of short term solutions for computer access listed in Key-guards: The addition of a keyguard can be very useful for people with reduced
strength in their hands, tremor, or difficulties with fine motor control. A guard is placed above the keyboard, with holes to allow access to the individual keys. The user must insert their finger into the hole to press the keys, thereby avoiding accidentally hitting nearby keys. This physical separation of the individual keys can allow a user to be more accurate in their selections. Many people find it difficult to hold their hands above the keyboard for long periods of time. Keyguards also allow the user to rest their hands on the keyboard without making any selections. This helps in managing fatigue when typing. It can be difficult to get a keyguard for an existing keyboard - most users will purchase a new keyboard supplied with a custom Mini-keyboards: These small keyboards come in a range of sizes. They are most
useful for people who will be typing with one hand only (e.g. in the case of hemiplegia, or reduced control in one hand). They reduce the area that the typist needs to cover, helping to conserve energy and reduce finger stretch. They look very similar to the keyboards seen on laptops. The main difference between a mini- and standard keyboard is the absence of a number pad. The keys on these small keyboards are generally the same size as a standard keyboard but are in closer proximity to each other. They can be easier to position on a desktop, and are portable if the user needs to bring them from place to place. Alternative Mouse Options: Many people can have difficulties with the fine motor
control needed to operate a standard mouse. Additionally it can be difficult for people to isolate finger movement to use the left- and right-click mouse buttons. The mouse can be altered to suit a left-handed person via the ‘Control Panel’ on a computer. Using the Windows ‘Accessibility Features’ it is possible to make the keyboard perform all of the mouse functions. This can be useful for people who have reliable typing skills but specific difficulties using the standard. Touch-Pad Mouse: Many people are familiar with a touch pad mouse from their use
on laptops. These small, touch-sensitive pads are used by moving your finger across the surface of the mouse. They are available as separate plug-in devices. Touchpad mice are useful for people with a limited range of physical movement. Joystick Mouse: This type of mouse is considered a static mouse, in that the mouse
stays in a static position, involving less movement of the user’s hand. A joystick mouse isolates the mouse movement from the selections made (left click, right click, double click etc.), as the person needs to release the joystick and then press buttons for those functions. The ‘Point It Joystick’ has a low profile base with 5 programmable buttons for these functions. The ‘Penny & Giles Joystick Plus’, has a keyguard for the main buttons, and a useful speed button, allowing the user to quickly change the mouse movement from fast to slow. This can be useful for people who use their mouse for fine detail work, or who need to land on small targets on the For people who drive their chair with a joystick, and who also use a joystick to control the computer, or even a communication aid, these can be integrated into a single joystick, mounted on the client’s chair, which can be used for all of these functions. An example of this is the ‘Genie Joystick’. This can help increase a user’s independence as they can drive up to their computer, switch the joystick to control the computer, and then switch back when they are finished. (see below for powered Head Mouse: Many people do not have adequate hand function to operate a
standard mouse or indeed an alternative mouse which requires a level of hand function. A head mouse may be a suitable option for these people. A head mouse can be a difficult piece of equipment to master. By their very nature progressive neurological diseases cause a rapid deterioration in a multitude of motor functions. Therefore it is essential we consider the disease progression and the likely requirement of high tech devices. It is possible to build more facilities into a device if you start off with a high tech device. This eliminates the need to learn to use a whole new device, in addition failure with one device may lead Selection of devices such as a Dynavox or a Tobii can be used via direct access but as the disease progresses switches and eyegaze can be activated. (See section on Alternative and Augmentative Communication Devices for further)
Switch Use: Many switch options for computer control are available. For many
users, accessing a physical keyboard is either not possible, or inadvisable. Many software packages will allow a keyboard to be displayed on the screen, removing the need for a separate keyboard on the desk. The user accesses the keyboard using Eye-Gaze Control: Options for controlling computers via eye-gaze are considered
for people whose hand movements are extremely limited. Powered Mobility and Progressive Neurologic Diseases
As we know, mobility impairments frequently restrict participation in work, family, social, vocational, and leisure activities, therefore it is essential that clients with a progressive neurological disease are enabled to optimise their quality of life. Similarly to access methods for computers it is necessary to pre-empt the issues that are almost guaranteed to arise around standard joystick use due to loss of motor function in degenerative neurological diseases. The rapid deterioration of motor function it is a key consideration in ordering the type of joystick. I have experienced difficulty in getting joysticks retro-fitted to older models powered wheelchairs. If the therapist had anticipated the need for alternative access when initially prescribing the powered chair it would have eliminated the issue from arising later in the disease progression. Therefore when prescribing powered mobility with a joystick I feel it is necessary to ensure it will have the potential to accommodate one or all of the R-Net Chin Joystick (P&G Technology): This device is designed for use with the
R-net Compact Joystick. This versatile kit provides a discrete, lightweight chin solution. Two ‘Gooseneck’ switches may be fixed to the base of the joystick using the plates provided or mounted discreetly for optimum positioning. Each switch can be assigned different functions depending on the requirements of the user, e.g. for use as a horn, power, profile or mode button. The brightly coloured ‘softball’ offers a comfortable alternative to the traditional, rigid chin knob. Head Array: This consists of a set of three Egg Switches mounted on a Stealth
Swing Away Headrest that connects to the ClickToGo wheelchair control operating in Head Array mode. The right hand switch turns on the wheelchair and drives the chair to the right. It can also optionally be used to change modes between Driving, Seat function, Lights and External device. The left hand switch drives the chair to the left. It can also optionally be used to switch off the wheelchair. The “behind the head” switch is used to drive the chair forwards or backwards. Pressing and holding it will drive the chair forwards but clicking it once and then pressing and holding it will drive the chair backwards. The Head Array compensates for accidental switch presses or releases automatically as a user drives over bumpy pavements. The Heading Lock ensures that when driving forward the chair does not veer to one side or the other ClickToGo: This provides effective Powered Wheelchair control using switches. It
gives independent control of mobility to individuals who do not have the requisite strength, control or co-ordination to use a standard joystick control. The ClickToGo is operated by single or multiple switches via a scanning interface. The eight direction indicators are illuminated by ultra-bright LEDs and can be scanned in many different ways. When a direction is chosen, pressing a switch drives the chair. Sip/Puff Controls: Sip and puff drives are the solution for those users who aren't
able to use any part of their body to operate a control device on their power wheelchair. Sip and puff systems are digital non-proportional drives and require quite a bit of practice by the user to get good at driving. In order to drive with a sip and puff system the user will either blow into a tube or suck on the tube. Not only do the wheelchair electronics distinguish between a sip and a puff it, can also recognize the strength of the sip and puff. A hard sip or puff will mean one thing to the wheelchair and a soft sip or puff will mean something else. The trick for the user is to get used to how hard to sip or puff and be consistent with those actions. Single Switch Controls: This consists of one switch mounted on a Stealth Swing
Away Headrest that connects to the ClickToGo wheelchair control (as described above) operating in Head Array mode. It can also optionally be used to change modes between Driving and Seat functions. Environmental Control Units & Progressive Neurological Diseases
Environmental control is a way of enabling a person to live more independently and safely in their house or apartment using technology. Environmental control systems can bring huge benefits to a person with a disability in terms of access, safety and Depending on what the needs and requirements are environmental control systems can be simple or advanced. As with all the other areas of AT discussed it is advisable to ensure the ECU device is switch accessible. For example, a person who as difficulty using their hall door key can be given an electronic key, which will release an electric lock when they press it. Similarly a wheelchair user may require the above solution with the addition of an electric door opener. Another example is the person who cannot get to the phone quickly. They can be given a hands-free phone with a remote control so that they can make and receive callas from the There are a number of infrared transmitters on the market that enable people with a degenerative condition maintain independent living. Again these devices will require The following are a list of devices and summary of their uses; Senior Pilot: This is a remote control with large illuminated keys and a
comprehensive set of transparent symbols which can be placed underneath the key caps. The unit consist of 14 keys which can be freely assigned and programmed to control most devices. A large red key at the top of the unit is reserved for the most frequently used function, such as a service call. A similar key at the bottom turns on a back light. The Senior Pilot is also switch accessible. A single switch can be used to activate a scan of the buttons and make selections. HouseMate Lite: This is a stand-alone switch accessible Infra-red remote control
with auditory feedback using recorded speech. Practical and easy to use HouseMate can be operated by external switches or directly by pressing the keypad. It records up to 20 Infra-red commands from other remote controls. It can be programmed to different scanning options. It is single or two level switch operation. GEWA Control Prog: This is the most popular Infra-Red transmitter, highly versatile,
simple to use and easy to program. For people who require more than 18 functions, up to 10 pages or levels can be defined giving access to a maximum of 161 functions. Using levels, each key has a different function depending on what level is selected. For example you can have one level for the phone, one for the television control and another for house functions such as lights, window openers etc. Pressing the level key changes the level. The Control Prog contains a large number of scanning options and is ideal for people who cannot access keys directly but who can have the ability to press one or more switches. It is less ideal for those people with cognitive impairment, but can be stripped back to a simplified format to allow tv InfraRed mains socket: This is ideal for a person who wishes to be able to turn on
and off an electric heater, table lamp or other device by pressing a key on an InfraRed transmitter. During installation the socket learns what key to respond to by pressing the program button on the side of the socket and a key on the remote control at the same time. Then, whenever that key is pressed the socket will either switch power on or off to the appliance. Compatible only with GEWA infrared controls but or those that have been pre-programmed with GEWA codes. Electric Door Openers: These can be fitted to timber, metal or PVC doors and
mortise locks, rim locks and multi-point locks can be made to open electrically. The type of door opener and lock required can have a big impact on the cost. Other important factors include the depth of the reveal around the door, the type of material used in the wall above the door, location of electric power and the orientation of the door in relation to the prevailing wind. Window Opener: This is a small compact chain drive which can be used to open a
bottom hung, top hung or side hung window. The drive is fitted parallel to the window frame and the chain is connected to the window itself with a bracket and pin. When the window is closed the chain is rolled up inside the housing and is completely sealed. When the unit is operated the chain pushes the window open to a maximum of 10 inches. The window can be manually opened further for cleaning purposes by removing the bracket pin. The unit requires a 24v power supply, an IR2ML infra-red receiver and can be operated from any GEWA transmitter. Videx Door-Entry System: This uses a person’s existing telephone to speak to a
caller at the front door and open it. The system consists of a front door unit and an interface to the telephone line. When a caller rings the door bell the telephone rings twice as fast as normal. This allows the occupant to distinguish between a call to the front door and a normal incoming telephone call. When they answer the phone they can speak directly with the caller at the door. To let the caller in they press button 9 on the phone. This releases an electric lock and the caller can push open the door. DuoCom: This is a door-entry system with advanced features. The system consists
of a front door unit and one or more room units. When a person rings the door bell the occupant answers by pressing the “Answer” button. After speaking with the caller the occupant can open the door by pressing the “Door Open” button. The electric lock is released and the caller can push open the door. If an electric door opener is fitted the door will open and close automatically. For people who have difficulty speaking three recorded phrases can be used, one for “hello who is it…”, a second for “please come in.” and a third for “call back later…”. For people who have difficulty pressing buttons, the DuoCom can be operated by any GEWA transmitter. The GewaTel 200 is a hands-free telephone that allows a person to make and receive calls without ever having to pick up the handset. In addition the phone can be operated by any GEWA transmitter. This feature can be used in a simple way to allow a person to answer a call quickly by pressing a pendant or it can be used to its maximum potential and allow a switch user to operate their phone using a PROG 3 or Progress. Other features include being able to build up a telephone number before making a call, 8 direct dial numbers and battery backup in case of power Alternative and Augmentative Communication Devices
Degenerative neurological diseases can lead to weakness or loss the muscle strength involved in production of speech it is necessary to provide clients with the ability to communicate with family, friends and others on a daily basis. The following are a list of devices that are suitable for direct access, most of which can also be adapted to allow switch access or eyegaze access to accommodate loss Lightwriters: These are small, robust, portable text-to-speech communication aids
specially designed to meet the particular and changing needs of people with speech loss. Lightwriters are designed to accommodate the wide range of physical disabilities which may accompany loss of speech, such as poor control, tremor, weak muscles, spasticity, slow reactions, cognitive limitations, impaired vision and deafness. Lightwriters have high legibility dual displays, one facing the user and a second out-facing display allowing natural face-to-face communication. This gives the user the opportunity to maintain eye contact, facial expression, and body language with their conversational partner. Unfortunately the new modles of Lightwriter being manufactured, I discovered, does not offer the option of switch scanning. The older models do have that option and are still being used within the Dynawrite: This is a 'type and talk' communication aid for people with strong
literacy skills, motor control and dexterity. It features a standard-size keyboard and writing enhancement features including word prediction (the wordlist can sit at various positions around the screen) and flexible abbreviation expansion, where any letters contained in an abbreviated phrase will trigger the expansion. The DynaWrite is a dedicated communication aid, ie you can't run any of your own software on it. There's also a built-in recorded speech facility where you can store over an hour of your own words or phrases into word banks. The DynaWrite can be used with its keyboard, or via single and dual-switch scanning. The scanning overlay clips onto the top of the unit and is available in three key configurations - scanning optimised, QWERTY or ABC. This is useful because it can accommodate the functional deterioration without changing device. If a client has a negative experience of failure with the first device it can create a psychological barrier to trialing and learning to ECO2: This is an integrated communication aid and computer with a large colour
touchscreen. The user can switch between standard computer mode and communication aid mode by pressing a single button. In fact, the vocabulary software can serve as an onscreen keyboard for accessing standard Windows software. An eye-pointing or eye gaze version of the ECO is also available, called the ECO point. The ECO point is an eye-gaze access module that 'bolts-on' to the bottom of Liberator's ECO2 and older Lib 14 communication aids. It enables these aids to be accessed using eye movement, useful for when direct selection or head tracking may be difficult. Individuals who use eye-gaze control may have conditions such as (but not limited too) ALS, Multiple sclerosis. The module itself is purpose built by Tobii Technology and has two high-definition cameras and over 100 LEDs to track the user’s eyes. A relatively large 'operational' area that accommodates a reasonable range of head and body movement. Tobii C12: This is a computer-based touchscreen communication aid that's suitable
for for a wide range of communication abilities and access methods. It features Tobii's Communicator software that gives both text and symbol-based communication, along with email, internet, mobile phone and environmental capabilities. The Tobii C12 enables text and symbol-based communication. The SymbolStix symbols set is included, although other symbol sets can be used. An optional upgrade to Tobii Communicator Premium will provide email, text messaging and environmental control options. The C12 can also run other Windows compatible communication software. The C12 is designed for operation via the 12.1 inch (31cm) resistive touchscreen directly or with a stylus. It's also accessible with one or two external switches, joystick, trackerball, mouse, headpointer, and eye-gaze via the optional Tobii CEye unit. Auditory scanning is also possible. The C12 has built-in infrared environmental controls for controlling a TV, DVD and other household appliances (with additional equipment required). The two slim batteries that are supplied can be swapped without turning the device off, and these give about four hours of continuous use. High capacity batteries are available that give six hours of use. The device also has a moisture resistant construction. The C12 can be mounted and used on a wheelchair. An integrated desk stand is included along with a mounting bracket for Daessy mounting systems. Optional brackets for Vesa and Rehadapt are available, along with a soft carrying case and a shoulder strap. A built- in camera enables users to capture images and use them in their communication Dynavox V and VMAX: The multilingual and durable DynaVox V and Vmax are
designed to meet a broad range of needs based on one’s age and ability. The functional framework of the V and Vmax and comprehensive features of Series 5 Software make them the solution for individuals of all ages and abilities. It facilitates communicate with increased audio clarity, voice projection and intelligibility using enhanced voices that are natural-sounding and easy to understand. It accelerates communication using rate enhancement techniques like concept-based Phrase Prediction. It allows customization of the device to suit varying needs, abilities and access methods, including “eye tracking” or eyegaze. In summary, these devices give a voice to those who’s disease has left them without one. It enables them to fulfil the basic need of communication and enhances their Key Considerations for Best Practice in Equipment Prescription
Following an investigation into practice in the area both clinically and theoretically I have found there are multiple factors to consider when introducing assistive technology to an individual with a diagnosis of a degenerative neurological disease. Many of these are psychosocial, emotional and require a high degree of sensitivity on the behalf of the AT assessor. Some observations from my own experience and from the literature highlight the following as key considerations; 1. The timing of intervention is essential in order to maximize the benefits of the
technology. If technology is not thoroughly addressed in the early stages of the disease process, the person is more likely to have more impairments leading to more advanced technology needs resulting in delays in recommendations for the AT evaluation, procurement of, and education with the device. 2. Always ensure any type of AT device can be adapted to meet the deteriorating
functional ability of the individual is essential to maintain interest and participation in AT. For example, when prescribing powered mobility with a joystick it is necessary to ensure it will have the potential to accommodate alternative access drives. In addition, for the prescription of AAC or ECU devices always ensure the device can The Enable Ireland Certified Assistive Technology Training Course has given me the opportunity to reflect on my clinical experiences and research in the area of AT and degenerative neurological conditions. I feel it has allowed me to develop my skills of assessment and prompted me to think more thoroughly about equipment prescription for this client group. As a result I will be far more mindful of the key considerations I identified for any equipment I prescribe to clients with degenerative References
Souza A, Kelleher A, Cooper R, Cooper RA, Iezzoni LI and Colins DM. Multiple sclerosis and mobility-relater assistive technology: Sysematic review of literature. Journal of Rehabilitation Research & Development. Volume 47, Number 3, 2010 Krantz O. Assistive devices utilisation in activities of everyday life – a proposed framework of understanding a user perspective. Disability and Rehabilitation: Assistive Technology, 2012; 7(3): 189–198 Showalter Casey K, Creating an assistive technology clinic: The experience of the Johns Hopkins AT Clinic for patients with ALS. NeuroRehabilitation 28 (2011) 281– Blake JB & Bodine C. An overview of assistive technology for persons with multiple sclerosis. Journal of Rehabilitation Research and Developmen. Vol 39 No.2

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