Community-Based Rehab and AT

Reprinted from PN January 2010

A workshop offers presentations from experts with extensive experience in developing technologies and providing services to impoverished regions.

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Several times each year, with support by the Paralyzed Veterans of America (PVA), the University of Pittsburgh’s Schools of Medicine and Health and Rehabilitation Sciences, Departments of Physical Medicine and Rehabilitation and Rehabilitation Science and Technology, the Human Engineering Research Laboratories (HERL), and Walter Reed Army Medical Center’s Department of Physical Medicine and Rehabilitation unite to host state-of-the-science workshops on varying topics.

On September 25–26, 2009, approximately 100 physicians, therapists, counselors, social workers, and rehabilitation engineers gathered to learn about the state of the science on Assistive Technology (AT) and Community-Based Rehabilitation, with some of the world’s foremost experts highlighting the intricacies of providing effective interventions to areas with limited resources. Throughout the symposium, the audience was stimulated by discussions of common problems encountered when providing care and services to different geographic areas and the novel practices that have been developed to overcome them, as well as future directions of treatment.

While the U.S. healthcare system with its complexities and shortcomings is far from perfect, imagine living in an area that has sparsely qualified providers, no money, limited materials, and hardly any resources. The workshop offered presentations from experts with extensive experience in developing technologies and providing services to impoverished regions.

The day began with an interesting lecture by Dr. Yeongchi Wu of the Center for International Rehabilitation (CIR). Dr. Wu began his talk with a brief history of prosthetic-socket technology and current fabrication techniques. He presented CIR casting and alignment—a simple and effective low-cost system used with great success in a number of regions. It is rare to see a system that produces a well-fitting functional socket that can also be rapidly manufactured. In his lecture’s “trash to treasure” section, Dr. Wu described some novel materials and methods to make low-cost orthoses and prostheses, such as using empty plastic soda bottles for upper-extremity sockets.

Special Recognition

Attendees next witnessed a Purple Heart ceremony for two of the many wounded warriors from Operation Iraqi Freedom. Those who had never observed a Purple Heart ceremony were moved and humbled by the presentation of the award and had an opportunity to thank two of America’s finest for their service to this great nation.

The symposium continued with a lesson on cultural competency from Mary Matteliano, MS, ORT/L, clinical assistant professor at the State University of New York (SUNY)–Buffalo. She began by reviewing the challenges of providing healthcare to an increasing multicultural patient population. She discussed a number of health risks that plague minority populations, such as earlier onset of morbid conditions, lack of access to consistent medical care, crime-ridden neighborhoods, and inherited social hierarchy.

Matteliano attested that one of the largest barriers for healthcare providers is lack of appreciation for various cultural customs and its accompanying stereotyping and biasing, which leads to patients’ mistrust of providers, decreased compliance with treatments, and lack of self-efficacy. She said a number of these issues could be alleviated by using a cultural brokering model, which “is the act of bridging groups or persons of differing cultural systems for the purpose of reducing conflict.”

Statistical Disparity

Katherine Seelman, PhD, associate dean, Disability Programs, University of Pittsburgh School of Health and Rehab Sciences, provided a spirited and informative lecture on World Health Organization (WHO) and United Nations (UN) initiatives. She began with an overview of recent participation and community integration initiatives by the UN and WHO. She then moved into the disparity among disability statistics around the world, highlighting the problems that can occur with data collection based on how questions are posed to different populations.

Mary Matteliano, MS, ORT/L, tells the audience that one of the largest barriers for healthcare providers is lack of appreciation for various cultural customs.

Dr. Seelman then conducted an elaborate dissection of the initiatives, thoroughly discussing adoption and implementation of the WHO International Classification of Functioning (ICF) Framework, changing attitudes and updating disability-related policies and practices, and identification and implementation of good practices and policies by countries and regions. She concluded with a few examples of good practices and good policies worldwide. Her philosophy of “participation for all” was heard far beyond Joel Auditorium’s confines.

After breaking for lunch, which was provided by PVA, the course resumed with international consultant Jamie Noon presenting “Low-Cost Custom Seating Options” for areas in need. He reviewed several aspects of effective interventions in low-resource regions, such as providing sustainable, repeatable, quality products to trained clinicians. He pointed out that without competent clinical service skills, great products are pointless. He discussed the importance of simple and accurate documentation throughout the design process in order to maximize repeatability of an effective product. Noon continued with the importance of simplicity (we veterans understand this as the KISS principle, or “Keep It Simple, Stupid!”), as he shared his components for his clinician-fitting toolbox, as well as the various forms used by the designer for documentation.

Rough and Tumble

Mark Krizack, executive director, Whirlwind Wheelchair International (WWI), provided a brief history of the organization—a “hybrid nonprofit” that produces and distributes wheelchairs in developing countries. Krizack described the design criteria Whirlwind uses, including the ability to produce a wheelchair that is safe, stable, maneuverable, foldable, comfortable, locally customizable, has no removable parts, is inexpensive and easy to build and repair, and can be used in multiple environments (i.e., indoors, outdoors, and on mud, rocks, dirt, sand, stone, etc.). These design criteria led to the production of their signature chair, the Rough Rider, designed by Ralf Hotchkiss.

Paraplegic as the result of a motor­cycle accident while in high school, Hotchkiss earned an engineering degree at Oberlin College (Oberlin, Ohio). He started the Center for Concerned Engineering, where he invented wheelchair improvements using inexpensive materials and then made them available publicly.

However, Hotchkiss did not want to just hand out wheelchairs to people. He started WWI to teach them how to manufacture their own chairs in small shops.

A rough-and-tumble, rugged chair, the Rough Rider is capable of handling a variety of undeveloped terrain found in developing countries. Based in San Francisco, Whirlwind has been active in the world market for years and has current regional production sites in Vietnam, South Africa, Mexico, Turkey, and the Philippines. Future locations are slated for India, Georgia, and Kazakhstan.

Krizack next discussed various manufacturing and distribution challenges encountered by various organizations and ways Whirlwind has attempted to solve them. Among the manufacturing issues are lack of rehabilitation infrastructure in most places, distance from a factory, and untrained distribution partners.

Solutions include (but are not limited to) developing training materials, working with large purchasers by providing educational and training materials, and insisting on a minimum level of service for screening, measuring, ordering, fitting, and adjusting.

Managing Health Data

Brigadier General (Ret.) Michael Dunn, MD, FACP, addressed a topic near and dear to my heart as a former military healthcare provider: “Information Technology Support for Care of Injured Combat Veterans.” Dr. Dunn covered the importance of electronic health records (EHR) and personal health records (PHR) and reviewed three main approaches to managing them: (1) the big system, where everyone uses the same application/resources, (2) central standards with multiple players, a combination of applications that must be compatible with a central component that is standardized, and (3) personal health storage, where everyone is responsible for his/her own data.

Dr. Dunn said Microsoft and Google already have services to accommodate this approach of personal health-data storage to some degree. Correction of these issues is long overdue and will require the concerted effort of consumers, providers, and information technologies engineers.

The final talk of the day was “Appropriate Mobility and Transportation” by Nahom Beyene, University of Pittsburgh doctoral candidate. He began by defining “appropriate technology” and the damage that can occur when inappropriate technology is instituted in its place. He provided examples of how this technology is incorporated where it’s needed based on the goal, available resources, and the creativity of the providers and consumers.

Beyene expertly deciphered the complex world of AT development from conception to experimental research and thoroughly explained various service-delivery models that have been used for people with disabilities over the years. He concluded by presenting some  research studies on international AT.

Information about this, and future state-of-the-science workshops, is at University of Pittsburgh / Shelly Brown, 412-954-5287. If you would like to receive e-mails announcing future workshops, join HERL’s mailing list.  


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