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Rehabilitation Engineering Rehabilitation Science in Practice Series Series Editors Marcia J. Scherer Institute for Matching Person & Technology, Webster, New York, USA Dave Muller University of Suffolk, UK Everyday Technologies in Healthcare Christopher M. Hayre, Dave Muller, Marcia Scherer Enhancing Healthcare and Rehabilitation: The Impact of Qualitative Research Christopher M. Hayre and Dave Muller Neurological Rehabilitation: Spasticity and Contractures in Clinical Practice and Research Anand D. Pandyan, Hermie J. Hermens, Bernard A. Conway Quality of Life Technology Handbook Richard Schulz Computer Systems Experiences of Users with and Without Disabilities: An Evaluation Guide for Professionals Simone Borsci, Masaaki Kurosu, Stefano Federici, Maria Laura Mele Assistive Technology Assessment Handbook – 2nd Edition Stefano Federici, Marcia Scherer Ambient Assisted Living Nuno M. Garcia, Joel Jose P.C. Rodrigues Rehabilitation Engineering: Principles and Practice Alex Mihailidis and Roger Smith Principles and Practice For more information about this series, please visit: https:// www.crcpress.com/Rehabilitation-Science-in-Practice-Series/book-series/ CRCPRESERIN https://www.crcpress.com/Rehabilitation-Science-in-Practice-Series/book-series/CRCPRESERIN https://www.crcpress.com/Rehabilitation-Science-in-Practice-Series/book-series/CRCPRESERIN https://www.crcpress.com/Rehabilitation-Science-in-Practice-Series/book-series/CRCPRESERIN Rehabilitation Engineering Principles and Practice Edited by Alex Mihailidis and Roger Smith MATLAB® is a trademark of The MathWorks, Inc. and is used with permission. The MathWorks does not war- rant the accuracy of the text or exercises in this book. This book’s use or discussion of MATLAB® software or related products does not constitute endorsement or sponsorship by The MathWorks of a particular pedagogi- cal approach or particular use of the MATLAB® software. First edition published 2023 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN CRC Press is an imprint of Taylor & Francis Group, LLC © 2023 selection and editorial matter, Alex Mihailidis and Roger Smith; individual chapters, the contributors The right of Alex Mihailidis and Roger Smith to be identifed as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. 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ISBN: 978-1-138-19826-5 (hbk) ISBN: 978-1-032-35482-8 (pbk) ISBN: 978-1-315-27048-7 (ebk) DOI: 10.1201/b21964 Typeset in Times by Deanta Global Publishing Services, Chennai, India Access the companion website: www.routledge.com/9781138198265 http://www.copyright.com http://www.mpkbookspermissions@tandf.co.uk http://www.routledge.com/9781138198265 https://doi.org/10.1201/b21964 Contents Preface ix Editors xiii SECTION I INTRODUCTION AND OVERVIEW 1 History of rehabilitation engineering 3 Gerald Weisman and Gerry Dickerson 2 Assistive technology 45 L. Alvarez, A. Cook and J. Polgar 3 Key human anatomy and physiology principles as they relate to rehabilitation engineering 63 Qussai Obiedat, Bhagwant S. Sindhu, and Ying-Chih Wang 4 Psychosocial and cultural aspects of rehabilitation engineering interventions 87 Marcia Scherer and Malcolm MacLachlan 5 Overview of disease, disability, and impairment 111 L.-J. Elsaesser v Contents 6 Rehabilitation engineering across the lifespan 129 R. H. Wang and L. K. Kenyon SECTION II KEY TOPICS IN REHABILITATION ENGINEERING 7 Policy and regulations in rehabilitation engineering 155 L. Walker and E. L. Friesen 8 Ethical issues in rehabilitation engineering 171 Mary Ellen Buning 9 Rehabilitation engineering in the assistive technology industry 193 Joseph P. Lane 10 Understanding the end user 221 Jennifer Boger, Tony Gentry, Suzanne Martin, and Johnny Kelley 11 Rehabilitation engineering in less resourced settings 235 Jamie H. Noon, Stefan Constantinescu, Matthew McCambridge, and Jon Pearlman SECTION III REHABILITATION ENGINEERING AND AREAS OF APPLICATION 12 Rehabilitation engineering seating and mobility 261 Saleh A. Alqahtani, Cheng-shui Chung, Theresa M. Crytzer, Carmen P. DiGiovine, Eliana C. Ferretti, Sara Múnera Orozco, S. Andrea Sundaram, Brandon Daveler, María L. Toro-Hernández, Amy Lane, Tamra Pelleschi, Rosemarie Cooper, and Rory A. Cooper vi Contents 13 Universal design and the built environment 295 J. Maisel and E. Steinfeld 14 Wireless technologies 319 John Morris and Mike Jones 15 Transportation access 343 A. Steinfeld and C. D’Souza 16 Rehabilitation robotics 361 Michelle J. Johnson and Rochelle Mendonca 17 Universal interfaces and information technology 393 Gregg Vanderheiden and Jutta Treviranus 18 AAC in the 21st century: The outcome of technology: Advancements and amended societal attitudes 429 H. Shane, J. Costello, J. Seale, K. Fulcher-Rood, K. Caves, J. Buxton, E. Rose, R. McCarthy, and J. Higginbotham 19 Cognitive technologies 461 C. Bodine and V. Haggett 20 Technology for sensory impairments (vision and hearing) 493 J. A. Brabyn, H. Levitt, and J.A. Miele 21 Prosthetic and orthotic devices 525 Joel Kempfer, Renee Lewis, Goeran Fiedler, and Barbara Silver-Thorn vii Contents 22 Neural engineering 561 Kei Masani and Paul Yoo SECTION IV OUTCOMES AND ASSESSMENTS 23 Assessment approaches in rehabilitation engineering 587 M. Donahue and P. Schwartz 24 Product usability testing and outcomes: What works? for whom? and why? 619 Jon A. Sanford Index 657 viii Preface Rehabilitation engineering is an interdisciplinary specialty that relies on a thor- ough understanding of the human mind and body, technology, design principles, and technicalresearch and develop- ment, standards for services and standardization of parts and components, testing and evaluation, production and distribution, prescriptions, service and repair, and rehabilitation engineers. It was noted during the workshop, There is a confusion regarding who is the clinical engineer and who is the research engineer. The problem, as the group saw it, is primarily from the clinical side. The research problems seem to be pretty well in hand, but there are not enough clinical engineers and enough knowledge regarding them. The technology is available, but it does not get to the patients. (State of California, Health and Welfare Agency, Department of Rehabilitation 1977) A series of projects were conducted during the 1970s and early 1980s to dem- onstrate the feasibility and effcacy of delivering rehabilitation engineering ser- vices within a medical model (The University of Tennessee Crippled Children’s Hospital School, Rehabilitation Engineering Program 1976) as well as a voca- tional rehabilitation model (University of Tennessee Rehabilitation Engineering Program 1978). 32 History of rehabilitation engineering Rehabilitation engineering service delivery took a signifcant leap forward with the passage of the 1986 amendments to the Rehabilitation Act. The amendments required state vocational rehabilitation agencies to “describe how rehabilitation engineering services will be provided to assist an increasing number of individu- als with handicaps.” This required the state agencies to modify their state plans to include rehabilitation engineering services. Additionally, the amendments defned rehabilitation engineering by including, The term rehabilitation engineering means the systematic application of tech- nologies, engineering technologies, or scientifc principles to meet the needs and address the barriers confronted by individuals with handicaps in areas which include education, rehabilitation, employment, transportation, independent living, and recreation. (GovTrack.us 1986) Recognizing the increasing importance of addressing the delivery of services, RESNA (see Section 1.6 below) coordinated an invitational symposium at Petit Jean State Park, Arkansas, on September 19–23, 1987 resulting in a book entitled Rehabilitation Technology Service Delivery: A Practical Guide. Gerry Warren, the President of RESNA at the time wrote in the forward of the book, This publication represents the cornerstone of a new era in rehab engineering and technology. We have surpassed the eras that focused on producing new technology, defning consumer needs, and technology transfer. We are coming to grips with what we know now to be a pivotal aspect of using technology to meet the needs of disabled people. We have solidly entered the era of service delivery. (Perlman and Enders 1987) Seven models of service delivery were identifed in the RESNA guide (Perlman and Enders 1987): • Durable medical equipment (DME) supplier. • Department within a comprehensive rehabilitation program. • Technology service delivery center in a university. • State agency-based program. • The private rehabilitation engineering/technology frm. • Local affliate of a national nonproft disability organization. • Miscellaneous types of programs, including volunteer groups and infor- mation/resource centers. Through the middle and end of the 1980s, discussions were held regarding the terminology of rehabilitation engineering. As described above, the beginnings of the feld involved a large number of engineers. It soon became apparent there 33 Rehabilitation Engineering were many more individuals involved in providing technology to people with disabilities. It seemed the use of the term, engineering, was limiting. The pas- sage of the “Technology-Related Assistance for Individuals with Disabilities Act of 1988” (Tech Act) contributed to the discussions of how to defne the technol- ogy devices and services used by people with disabilities. The Tech Act recog- nized a “substantial number of assistive technology devices” existed, however people “do not have access to the assistive technology devices and assistive tech- nology services that such individuals need to allow such individuals to function in society commensurate with their abilities.” The Tech Act was designed as a systems-change act to develop “consumer-responsive state-wide program(s) of technology-related assistance for individuals of all ages with disabilities.” The state-wide programs were meant to provide information about assistive tech- nology devices and services, funding, increased capacity, and increased coor- dination. Most importantly, the Tech Act legally defned the terms “assistive technology device” and “assistive technology service” for the frst time. The defnitions in the Tech Act include: (1) ASSISTIVE TECHNOLOGY DEVICE—The term “assistive technol- ogy device” means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modifed, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. (2) ASSISTIVE TECHNOLOGY SERVICE—The term “assistive technol- ogy service” means any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device. Such term includes— (A) the evaluation of the needs of an individual with a disability, includ- ing a functional evaluation of the individual in the individual’s cus- tomary environment; (B) purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by individuals with disabilities; (C) selecting, designing, ftting, customizing, adapting, applying, main- taining, repairing, or replacing assistive technology devices; (D) coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs; (E) training or technical assistance for an individual with disabilities, or, where appropriate, the family of an individual with disabilities; and (F) training or technical assistance for professionals (including individu- als providing education and rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of individuals with disabilities. (GovTrack.us 1988) 34 http://www.GovTrack.us History of rehabilitation engineering 1 5 Rehabilitation engineering affects the complex rehabilitation technology market The impact of rehabilitation engineering, on the commercial complex rehabilita- tion technology (CRT) marketplace, will probably never be fully appreciated for its impact. There are countless instances where rehabilitation engineering changed the CRT landscape and the lives of persons with disabilities. Described below are a few of the frst instances of technology transfer to the commercial CRT market from both research and clinical rehabilitation engineering programs. Starting back in the mid-1960s, before the term rehabilitation engineering had been coined, physicians, clinicians, and engineers at Goldwater Hospital, located on Roosevelt Island in New York City, removed the cross brace of an E&J manual wheelchair with recline, rigidized the frame, and added a rack to support a venti- lator and a battery (Figure 1.27). This gave consumers residing at Goldwater the ability not only for movement within the hospital, but also excursions into “Island Town.” Following the success of this intervention, the frame rigidizing was done to an E&J powered wheelchair frame which, along with new drive control interventions, allowed ventilator-dependent residents of GoldwaterHospital independent mobil- ity within the community. Around the same time, The Rehabilitation Institute Figure 1.27 View of Goldwater frame (Dickerson). 35 Rehabilitation Engineering of Chicago (RIC; Illinois, United States) was developing “Quad Systems” that included power-independent recline and sip-and-puff interfaces that allowed peo- ple with high-level spinal cord injuries, including those requiring respiratory sup- port, full, independent control of their powered chairs’ direction and the added beneft of postural change utilizing the power recline. The MED Group (a group of independent equipment suppliers) was located in Chicago and members of that group realized the impact of these technologies and successfully executed a technology transfer of the sip-and-puff control, power- recline E&J wheelchair (Figure 1.28). The MED Group also brought to the commercial marketplace what became known as the MED Micro-Dec, which was also developed at RIC. The Micro- Dec was a compact, portable Environmental Control Unit that was one of the frst to utilize X-10 control modules. Other signifcant contributions to the seating and wheeled mobility world came from a technology transfer agreement between the MED Group and the University of Tennessee-Rehabilitation Engineering Program (UT-REP). The Molded Plastic Inserts (MPI) pediatric seating system and the Spherical Thoracic Supports were developed at UT-REP under the leadership of Doug Hobson and Elaine Trefer. Figure 1.28 MED catalogue circa 1980 (Dickerson). 36 History of rehabilitation engineering Figure 1.29 MPI circa 1980 (Dickerson). The MPI was a modular component seating system that consisted of four sizes of seats and fve sizes of backs, along with accessories including armrests, head- rests, trays, and footrests. The seats and backs were constructed using acryloni- trile butadiene styrene (ABS) plastic with only a moderate polyethylene seat pad. While successful at UT-REP, the commercial launch was problematic at frst as parents and clinicians struggled to embrace the solid plastic shells. The modular- ity and ease of cleaning and growth, combined with the success of the early adap- tors, made the MPI a very successful commercial product that was developed by rehabilitation engineers (Figure 1.29). Also developed at UT-REP around the same time, were the spherical thoracic support pads. These unique supports were also technology transferred to the MED Group and remain a product today, available from Otto Bock. 1 6 Rehabilitation engineering fnds a home In addition to the conference on “Delivery of Rehabilitation Engineering Services in the State of California” held in Pomona, California, another meeting was held on 37 Rehabilitation Engineering November 3–5, 1977 at the University of Tennessee in Knoxville, on “Rehabilitation Engineering Education” (The University of Tennessee, Knoxville 1977). Recommendations from these conferences foreshadowed a number of important activities in the growth and development of the rehabilitation engineering feld. A recommendation at the California meeting suggested, “There should be a meeting of rehabilitation engineers scheduled in the near future, so that the feld could begin to interchange information and also start a self-policing and regulating effort” (State of California, Health and Welfare Agency, Department of Rehabilitation 1977). Joe Traub of the Rehabilitation Services Administration and Tony Staros of the VA organized just such meetings called the Interagency Conferences on Rehabilitation Engineering. The frst meeting was held in Washington, DC in 1978. Additionally, recommendations at the California and Tennessee meetings sug- gested an organization of rehabilitation engineers be formed. The recommenda- tion from the California meeting suggested, “An organization for rehabilitation engineers should be established—for the exchange of information and ideas” (State of California, Health and Welfare Agency, Department of Rehabilitation 1977). As Doug Hobson recollected, At the 1978 (Interagency) meeting, Staros, Traub, McLaurin, Reswick, and Hobson met to formulate a concept for a multidisciplinary society on rehabilitation engi- neering that would function independently from government. It was to provide the forum for information sharing and rehabilitation technology development and application that had been so effective within the CPRD model. In 1979, the concept of a new society, along with founding bylaws, was presented to a multi- disciplinary forum (at the Interagency conference) of about 250 people. The con- cept was accepted, and the Rehabilitation Engineering Society of North America (RESNA) was born, with Jim Reswick as its founding President. Colin McClaurin was RESNA’s second president, and the rest is recorded history. (Hobson 2002, 17) Figures 1.30 and 1.31 illustrate the founding documents of RESNA. RESNA, now known as the Rehabilitation Engineering and Assistive Technology Society of North America, became the professional home for professionals and con- sumers with an interest in rehabilitation engineering and assistive technology, primarily in North America. RESNA is a worldwide leader in the development and maintenance of assistive technology device standards, the certifcation of assistive technology pro- fessionals and the accreditation of education programs for assistive technology. 1 7 Summary and conclusions Technology extends abilities and allows people to accomplish what they would not otherwise be able to do. Assistive technology enhances the abilities and 38 History of rehabilitation engineering Figure 1.30 RESNA founding document. 39 Rehabilitation Engineering Figure 1.31 RESNA founding document. 40 History of rehabilitation engineering opportunities for people with disabilities to lead more independent lives. The his- tory of assistive technology and rehabilitation engineering provides lessons in the invention and development of devices and technology that aid people with disabil- ities. A central tenet of the development of assistive technology is the involvement of people with disabilities in defning the needs and problems and substantially being involved in the design process. Many devices and technologies frst developed for use by people with disabili- ties have evolved to become mainstream consumer products. Conversely, many consumer goods have become important assistive technologies for people with functional limitations. The history of assistive technology describes the many kinds of devices that have been developed and used by people with disabilities. Prosthetics, technologies for visual impairment, hearing impairments, and communication, as well as mobil- ity and computer technologies, are only some of the categories of devices that enhance the abilities of people with disabilities. Public policies, including the passage of laws, have contributed to the advance- ment of the development and provision of assistive technology. These laws include the funding for research, development, and delivery of assistive technology. The need for assistive technology and advances in engineering have led to the development of the professional practice of biomedical engineering and, specif- cally, rehabilitation engineering. In addition to the creation of university-based academic programs, professional organizations have been established in order to provide information, training, and networking for assistive technology and reha- bilitation engineering professionals. 1 8 Discussion questions 1. How would you explain the growth of biomedical and rehabilitation engineering? 2. Considering the evolution of prosthetic development, discuss what you see as the future of prosthetics. 3. Discuss the importance of consumer-centereddesign and its role in the development of assistive technology. 4. Discuss how certain current mainstream technologies can beneft people with disabilities. 5. Discuss how professional organizations such as RESNA can advance the feld of rehabilitation engineering and assistive technology. 41 Rehabilitation Engineering Bibliography American Chemical Society. “Discovery and Development of Penicillin.” https://www.acs.org/ content/acs/en/education/whatischemistry/landmarks/femingpenicillin.html. Amputee-coalition.org. “A Brief History of Prosthetics.” https://www.amputee-coalition.org/ resources/a-brief-history-of-prosthetics/. 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Polgar Contents 2.1 Chapter overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.2 Theoretical models and frameworks: Structuring assistive technology reasoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2.2.1 Informing research and development . . . . . . . . . . . . . . . . . . . . . . 47 2.2.2 Informing practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 2.2.3 Informing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 2.3 Assistive technology: Models and frameworks . . . . . . . . . . . . . . . . . . . . 49 2.3.1 The HAAT model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2.3.1.1 Human.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 2.3.1.2 Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 2.3.1.3 Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 2.3.1.4 Assistive technology . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 2.3.2 The SETT framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 2.3.3 The CAT model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 2.3.4 The MPT model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 2.3.5 Theoretical career path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 2.3.6 The HETI model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 2.4 Assistive technology: The human. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 2.4.1 Needs and wants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 2.4.2 Body structures and functions . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 2.4.3 Habits and roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 2.4.4 Technology acceptance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 2.5 Assistive technology: The activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 2.5.1 Mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 2.5.2 Manipulation and control of the environment . . . . . . . . . . . . . . . 56 2.5.3 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 2.5.4 Cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 2.6 Ethical tensions in assistive technology: Challenges and opportunities . . . . 58 2.6.1 Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 2.6.2 Fidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 2.6.3 Benefcence and non-malefcence. . . . . . . . . . . . . . . . . . . . . . . . . 59 DOI: 10.1201/b21964-3 45 https://doi.org/10.1201/b21964-3 Rehabilitation Engineering 2.6.4 Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 2.6.5 Stigma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 2.7 Future vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 2.8 Discussion questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 2 1 Chapter overview Assistive technology (AT) can be broadly defned as including a range of “devices, services, strategies, and practices that are conceived and applied to ameliorate the problems faced by individuals who have disabilities” (Cook and Polgar 2014). By thinking about AT as extending beyond a device, rehabilitation engineers will be ideally positioned to consider the range of factors, needs and solutions that can most beneft AT users. This chapter provides an overview of the conceptual underpinnings of AT development, research, services (practice) and education. In addition, the chapter will expose students to a range of factors that impact the relation between human, activity, AT and environment. The chapter will explore AT that supports different functions and the participation of individuals in differ- ent activities including (Figure 2.1) mobility (e.g., using a wheelchair to navigate Figure 2.1 Examples of assistive technology devices that support activities such as mobility, control of the environment, communication and cognition (Courtesy of Janice Polgar). 46 Assistive technology the environment), manipulation and control of the environment (e.g., using a switch or adapted keyboard to access a computer), communication and cognition (e.g., using a picture-based augmentative and alternative communication device that supplements speech). Finally, the chapter invites readers to refect upon the ethical tensions facing AT as a feld of practice, and to consider the implications of their role in the design, development and implementation of AT. 2 2 Theoretical models and frameworks: Structuring assistive technology reasoning Theoretical models allow members of a discipline to establish a common ground upon which to further develop inquiry, practice and refection. Historically, mod- els and frameworks have been developed to simplify and explain a phenomenon (Duncan 2006). This can be seen in several engineering disciplines where abstrac- tion and approximation of the most relevant properties of an object can serve the design, modeling and development processes (Seeler 2014). However, AT livesin the intersection between engineering and the health sciences and humanities. AT seeks to reduce the disabling infuence that environments can have on an indi- vidual (Cook and Polgar 2014). Thus, the complex nature of this human activity– environment–technology interaction requires models and frameworks that can comprehensively address the different factors that infuence such interaction. The following section provides a description of how such models can serve the needs of AT practitioners, including rehabilitation engineers, in research and develop- ment, practice and education. 2.2.1 Informing research and development Models have served science for generations. From the Hodgkin–Huxley model of the neuron that led to our understanding of nerve condition and intracellular inter- action, to the physical models used by Watson and Crick to untangle the mystery of DNA, models have informed research. Now they are also informing research and development in AT. Models inform the AT research and development process in several ways. One of the most important is the use of models to characterize the assistive device system in terms of the intended use, the contexts of use, the characteristics of the user and the characteristics of the technology used. One such model is the human activity assistive technology (HAAT) model. Models like HAAT describe the interrelationships that exist in the application of ATs. They are useful at various stages of the research and development cycle. Models can help place raw data from surveys, focus groups and other data collection activities into a meaningful 47 Rehabilitation Engineering relationship, enabling development of device characteristics. This in turn can help defne specifcations for development of innovative technology-based approaches to user needs. Comprehensive models like the HAAT can also provide a framework for the evaluation of prototype devices to determine their ability to meet the needs of people with disabilities. Factors relating to user characteristics can be separated from those related to environmental, social, cultural and institutional contexts that infuence successful device use. AT models also support the evaluation of competing technologies for effectiveness, effciency and effcacy. 2.2.2 Informing practice Evidence-based practice (EBP) has become a paramount element of healthcare policy, funding and implementation, including rehabilitation settings. In its most fundamental form, EBP seeks to elicit conscious, explicit and judicious use of current best evidence to guide decision making regarding the care and strate- gies around an individual’s health (Sackett et al. 1996). AT practitioners, includ- ing rehabilitation engineers, face an important commitment to advance EBP in AT. By doing so, practitioners can integrate rigorous evidence into practice and demonstrate the impact of AT use and improve funding. Models and frameworks can also allow AT practitioners to develop a practice that is client-centered, and that systematically assesses and considers the match between human, technology, activity and context. Client-centered AT is one that recognizes the client, not as a recipient of AT, but as an active partner and primary stakeholder in the AT process (Cook and Polgar 2014). AT practitioners must utilize an AT model or framework that refects the primary role of the user, and that supports the considerations regarding the client’s needs and skills. By using a model that emphasizes the individual and not just the technology capabilities or potential, practitioners can ensure that the resulting match serves the client’s priorities and is sustainable over time. Moreover, client- centered models allow users, practitioners and other stakeholders, to plan for, explain and predict successful outcomes (Giesbrecht 2013). 2.2.3 Informing education Application of AT models in education prioritizes acquisition of reasoning pro- cesses that develop technology most likely to enable function over acquisition of knowledge of technology alone. Comprehensive models such as HAAT (Section 2.3.1) and comprehensive assistive technology (CAT) (Section 2.3.3) inform cur- ricular content in terms of depth and breadth of knowledge, professional rea- soning and research (as described in Section 2.2.1). The rapid pace of complex 48 Assistive technology technology development requires students to gain competence in professional rea- soning, using a process that guides thinking in the development and application of technology. As students become more competent reasoners, they make increas- ingly complex connections among ideas and use these in sophisticated ways to inform thinking and practice in AT design and application. AT models provide a systematic approach to increase professional reasoning and expand the depth and breadth of knowledge related to AT. Similar to practice above, development of technology that is benefcial to the user requires knowledge about the person, their needs, preferences and abilities, the activities in which they need and want to engage and the contexts in which they will be engaging in these activities. Models like HAAT, matching person and technology (MPT) and CAT provide a systematic way of learning and reasoning around these aspects, infuencing the likelihood that new and existing technology will be accepted and used. 2 3 Assistive technology: Models and frameworks 2.3.1 The HAAT model The HAAT model describes a person (human) doing something (activity) in a context with the use of AT (see Figure 2.2) (Cook and Polgar 2014; Cook and Polgar 2012). The elements of the person, the activity, context and AT comprise a system that is transactional in nature and that enables performance and participa- tion in needed and desired daily activities. Figure 2.2 The HAAT model. This fgure was published in Cook and Polgar (2015, 41). 49 Rehabilitation Engineering 2.3.1.1 Human Understanding the person guides AT development and selec- tion by clarifying what the client can do and what personal skills and abilities the technology needs to augment or replace. In service delivery, consideration is given to the client’s cognitive, sensory and physical abilities, as well as to the meaning that the activity holds, including whether it is important for them to per- form the activity on their own or with assistance (Cook and Polgar 2014). 2.3.1.2 Activity Activity (or occupation) includes areas of self-care, instru- mental activities of daily living, productivity and leisure as well as manipula- tion, cognition, mobility and communication that support these daily activities. Further, when understanding the activity, considerations of timing (how long, how frequent), location (where the activity occurs) and whether it is a solitary or joint activity, provide a greater depth of understanding of how the occupation is performed and thus, what the technology needs to do in order to support it (Cook and Polgar 2014). 2.3.1.3 Context The context in which the person engages in activities is com- prised of physical, social, cultural and institutional elements. Physical aspects include the built or natural environment as well as physical aspects of heat, light and sound that affect the performance or use of technology (e.g., LED screens are diffcult to see in high light situations). The presence of others in the context in which the technology is used, and their knowledge of and/or willingness to support the use of the technology infuence the possibilities for its use to support activity engagement. Cultural aspects of inclusion of persons with disabilities or others (e.g., older adults, women) in community activities and the degree to which independence and autonomy are valued will affect access and use of technology. Finally, institutional aspects of funding, regulations and legislation affect whohas access to technology and the conditions under which technology is accessed and used (Cook and Polgar 2014). 2.3.1.4 Assistive technology AT includes devices and strategies in the contin- uum of low to high complexity. Low technology is simple, often easy to obtain, like a mouth stick or head pointer. High technology is more complex and more diffcult to obtain, such as an alternative and augmentative communication device. The HAAT model differentiates between hard and soft technologies. Hard tech- nologies include the physical device, whereas soft technologies incorporate deci- sion-making around device selection and different means of instruction on device use (Cook and Polgar 2014). The human/technology interface (HTI) is another necessary consideration in device design and selection. HTI infuences how the user inputs and receives information from the device. Understanding the user’s sensory, physical and cognitive abilities is important to determine what HTI they will be able to use. 50 Assistive technology 2.3.2 The SETT framework The student, environments, tasks, tools (SETT) framework (Zabala 2002) is a tool designed to help collaborative teams create student-centered, environmentally use- ful, task-focused systems that foster educational success for students with disabili- ties. The SETT framework gathers information about the student, the customary environments in which the student spends time and the required tasks the students need to carry out to be successful participants in the teaching/learning process. SETT guides practitioners through a series of questions associated with students, environments, tasks and tools intended to guide the development of an AT plan for a specifc student. The following are some of the questions in each category that guide AT decision-making: (1) Student questions: What does the student need to do? What are the student’s special needs? What are the student’s current abili- ties? (2) Environment questions: What materials and devices are available? What resources are available? (3) Task questions: How can activities be modifed to meet student needs? How can tech support the student’s participation in the activi- ties? (4) Tools questions: What strategies might be used to increase student per- formance? What no-tech, low-tech and high-tech options should be considered? How might tools be tried with students in environments where they will be used? 2.3.3 The CAT model The CAT model (Hersh and Johnson 2008a; Hersh and Johnson 2008b) was developed to (1) identify accessibility barriers, (2) analyze existing AT systems, (3) design and develop new AT systems and (4) evaluate outcomes (Hersh and Johnson 2008b). The model is described as an extension of an earlier HAAT model (Cook and Hussey 2002) and draws on aspects of the International Classifcation of Functioning, Disability and Health (ICF) (WHO 2001) and the Matching Person and Technology model (Scherer and Glueckauf 2005). The model is hierarchical, involving three levels (attributes, components and factors). The highest level (attributes) comprises the elements of an AT system, including person (characteristics, social aspects and attitudes), context (social and cultural), activity and AT (Hersh and Johnson 2008a). Activity includes funda- mental activities (e.g., communication, mobility, etc.) and contextual activities (e.g., activities of daily living, employment, leisure/recreational and educational activities). Finally, AT is divided into activity specifcation, design issues, system technology issues and end-user issues (Hersh and Johnson 2008b). 2.3.4 The MPT model The MPT model (Scherer 2002) involves the AT user in a collaborative process to identify technology that can best support the user’s needs, health and wellness. 51 Rehabilitation Engineering This ecological model incorporates three primary elements: the milieu (or con- text), the person and the AT. Like the HAAT and the CAT, each of these elements is comprised of several different variables. The milieu includes social, cultural, physical and attitudinal aspects of the context in which the individual will use the AT. Person aspects include temperament, personality and preferences for tech- nology as well as experience and predisposition to technology use (inclusive of all technology, not just assistive technology). Salient aspects of the technology include a blend of practical aspects such as cost and availability, device perfor- mance and aesthetic aspects of comfort and appearance (Corradi, Scherer and Lo Presti 2012). This model has been operationalized through several evidence-based assessments, most of which involve a comparison of self and collaborator reports on device attri- butes, use, need and contextual aspects. This comparison yields a technology rec- ommendation that balances the client needs and preferences with the contextual support/constraints. A key premise is that this user-driven process will result in technology that is accepted and used for maximum beneft across key settings. An application process is described that begins with understanding the person and their needs, incorporates the assessment and its analysis, includes device recommenda- tion and concludes with follow-up and re-assessment with MPT measures to evalu- ate the process outcome (Corradi, Scherer and Lo Presti 2012). More details on the MPT are provided in Chapter 4. 2.3.5 Theoretical career path Developed by Gitlin (1998), the theoretical career path describes the AT user as involved in a “user career.” As such, the user progresses through a path involv- ing four stages of expertise in AT use including novice, early, experienced and expert user. At each step, the path considers the needs and factors that may infu- ence the individual’s mastering of the AT device. For example, a novice user is described as an individual likely to be in hospital who has a need for a device, device instruction and for determining environmental ft. An expert user, on the other hand, is an individual who has been at home for one or more years and has mastered the use of the device. The theoretical career path has been used as a model to inform decision mak- ing and research (Fok 2011). The model provides a structured way of outlining the trajectory of use of an AT device considering the infuential factors and the needs of the user at each stage. However, the complexity of AT use (e.g., multiple device use), as well as the personal factors (e.g., cultural background) may limit the scope of the model (Demers et al. 2008). As such, engineers and other prac- titioners are encouraged to use complementary perspectives that account for the complex interactions between human, activity, technology and environment. 52 Assistive technology 2.3.6 The HETI model Developed by Smith (Smith 1991), the human environment/technology (HETI) model focuses on the relationship between the human and the technology. Using an engineering framework, the model considers the input, processing and output elements required for successful use. The AT user receives an input from the environment, which is then processed and used to inform the appropriate motor output. This, in turn, results in an input to the AT device, which must be capable of processing the information and subsequently producing an output which is appropriate for the user. The HETI model has been applied to inform the assessment and intervention approach to various types of assistive technologies, including computer access (Hoppestad 2004) and powered mobility (Field 1999). By considering the in-depth interaction between the person and technology, this model provides rehabilitation engineers with tools to consider, develop, design and implement client-centered assistive technology solutions. 2 4 Assistive technology: The human Development of successfulAT solutions requires an understanding of the user’s needs, preferences and cultural, social and other environmental backgrounds (Mihailidis and Polgar 2016). Use of a client-centered process by rehabilitation engineers supports acquisition of this understanding. But what exactly does it mean to practice in a client-centered manner? This section provides an overview of the important factors that rehabilitation engineers must consider when design- ing or developing AT. 2.4.1 Needs and wants At the center of the AT process are the needs and preferences of the user. Guiding questions that can help identify such needs and wants include: • What does the user want to do? • How is that activity meaningful/important to the user? • What are the demands of that activity that AT may be able to bridge? • How can AT enable participation in what the client wants and needs to do? • What characteristics or features of the AT would suit the clients’ preferences? The user’s need to perform a meaningful activity determines whether an AT device is the best approach, and that drives the selection and implementation of 53 Rehabilitation Engineering the device. For example, a client may wish to access their computer to engage in work-related activities, or to communicate with family and friends. The demands of these two scenarios may require two different AT solutions, which are informed by the meaning the client ascribes to each activity. Personal meaning is derived from a user’s previous experiences, the sense of competence, accomplishment, challenge and emotional engagement with a cer- tain activity (Cook and Polgar 2014). Thus, personal meaning is fuid, dynamic and may change over time. As part of an interdisciplinary team, rehabilitation engineers ensure timely engagement of the user in the service or development processes and consider the meaning the user attributes to certain activities. User involvement informs the selection of AT, or the design and customization of avail- able options that can be useful in the desired context. By partnering with users as primary stakeholders of the AT process, practitioners can ensure that the AT solutions are satisfactory to the user, increasing the likelihood of long-term use. 2.4.2 Body structures and functions In order to perform an activity and participate in a meaningful occupation, the activity and environmental demands must match the person’s skills (Townsend and Polatajko 2013). AT provides one means by which a match between the user’s skills and activity engagement can be achieved. Critical to that process is the identifcation of the different motor, cognitive and sensory functions and emo- tional state of the user as they affect activity performance. The ICF (WHO 2001) provides a standardized framework that describes human functioning in the con- text of health and disability. Used across multiple settings and populations by both healthcare professionals and government agencies, the ICF can assist reha- bilitation engineers in considering the body functions that infuence activity per- formance and AT use. The ICF defnes body functions as “physiological functions of body systems (including psychological functions)” (WHO 2001). These include: mental func- tions (i.e., functions that allow an individual to be alert and responsive to the environment, to communicate with others, to process and analyze information, to learn, reason and organize their behavior); sensory (i.e., those pertaining to all forms of sensation, such as seeing, hearing, tasting, touching or pain); voice and speech (functions that involve the production of sounds and speech); respira- tory functions (i.e., respiration and exercise tolerance); neuromusculoskeletal and movement-related functions (i.e., movement and mobility), among others (WHO 2001). Evaluation of the user’s function (existing and future) in relevant categories of the ICF is necessary to determine implications for AT use. For example, an individual who has experienced a change in voice functions may not beneft from voice-activated technologies. Alternately, identifcation of reliable movements is useful for determination of how the user will access/control the AT. 54design methods. Additionally, one key content area that makes this technical design feld unique is its understanding of aging and disability. Much like a human factors engineer or ergonomist, a rehabilitation engineering professional focuses on improving the functional interaction between the human being and technology. Much like a biomedical engineer, technology that helps a human improve their health, safety, function, and quality of life through life sci- ences is the goal. Much like core engineering specialties like electrical and elec- tronics, mechanical, civil, industrial, and software engineering, the rehabilitation engineering professional must be technically competent. However, unique to this rehabilitation engineering specialty, the professional must also be able to effec- tively understand and relate to other rehabilitation professionals such as occupa- tional and physical therapists, recreation therapists, speech language pathologists, social workers, psychologists, physiatrists, nurses, and educators. A good rehabilitation engineering practitioner integrates these areas of skill and knowledge and participates as part of the rehabilitation, health, and educational team seamlessly and effciently. Rehabilitation engineering, however, is an elusive area of study and practice. It is relatively a young profession and area of study. Only a few universities have spe- cifc instructional programs specifc to rehabilitation engineering practice. While there are many reasons for the sparse distribution of rehabilitation engineering training programs, three reasons jump out: (1) rehabilitation engineering practice is not directly funded by major third-party funding sources in healthcare or edu- cation; (2) in recent years, related specialty areas have emerged that have devel- oped their own conferences and communities, which include specialties such as software accessibility and rehabilitation robotics; and (3) perhaps the main ix Preface challenge of rehabilitation engineering education is that it is daunting. Because rehabilitation engineering depends heavily on so many underlying disciplines in the physical, biological, social, health, educational, and technical sciences, broad- based instruction is required. Coalescing a competent highly interdisciplinary instructional team is a challenge. This textbook has accepted this challenge and is intended to facilitate the education of the rehabilitation engineer. The purpose of this textbook is to bridge the reader from their core technical training and closer to the specialty of rehabilitation engineering. As editors of this textbook, we think that this resource can serve as a core textbook in rehabilitation engineering elective courses in biomedical engineering and human factors pro- grams, or even in architecture, art and design programs, or other design-oriented programs. Rehabilitation engineering may be seen as an “add-on” to the design professions. Biomedical engineers, human factors engineers, architects, software developers, medical device designers, and health-related device inventors of all types will beneft from the information in this text. The timing is right with the current emphasis on entrepreneurial programming throughout North America, Europe, Asia, and the rest of the world. As healthy aging is becoming more dominant worldwide, as the launch of the WHO assistive technology initiative in 2018 increases globally and entrepreneurial competition grows across nations and regions, the need for competent rehabilitation engineers becomes more pressing each day. The chapters in this text prepare learners to understand the scope of rehabilita- tion engineering and the depth of the many specialties related to rehabilitation engineering. These chapters highlight the breadth of disability, the scope of func- tional areas rehabilitation engineers address, and the foundational underpinnings of rehabilitation and technology. The chapters in the text can be read in order as the textbook was designed as a single document with a sequence of concepts. However, the chapters are not interdependent. Each is prepared to stand alone and can be taken as an individual treatise of its respective core content in rehabilitation engineering. The learning objectives of each chapter aim to orient the reader and the instructor. Additional readings are also available and listed with most chapters. Importantly, the text not only teaches core concepts of accessibility and universal design but also serves as a model. Each of the more than 125 illustrations has accompanying equivalent text descriptions (EqTDs). These are for readers who use screen readers and cannot see illustrations as sighted people do, or for other readers who may be challenged to understand the content of an illustration. These x Preface EqTDs have multiple levels of descriptions and exemplify how one modality of information is insuffcient for readers that may bring an impairment or impair- ments to the reading task. Please note where the EqTDs are located that describe each illustration. The editors of this textbook bring not only their interdisciplinary scholarly wis- dom and rehabilitation and technology perspectives on practice through their engineering and rehabilitation work backgrounds, but they are also both past presidents of RESNA, the globally recognized Rehabilitation Engineering and Assistive Technology Society of North America. They tapped the extraordinary wisdom of some of their premier colleagues in assistive technology and engineer- ing. We heartily thank each of them for helping to create a textbook to represent the feld. We would be remiss if we did not point out the key historical context of the release of this textbook. Globally, the World Health Organization launched a major assis- tive technology initiative in 2018 to bring technology and disability together— not just for highly resourced countries. Also, the manufacturing powerhouse of China launched the Belt and Road Initiative to address the technology supply for people with disabilities, starting with the large population of China and then globally. In 2019, assistive technology and rehabilitation organizations worldwide pulled together and created GAATO, the Global Alliance of Assistive Technology Organizations. These major international efforts indicate more robust attention to assistive technology and rehabilitation engineering for the future. We hope that this textbook can be part of the educational solution for bringing technology to all the people in the world who need it. Alex Mihailidis, Ph.D., P.Eng, RESNA Fellow Professor Department of Occupational Science and Occupational Therapy Barbara G. Stymiest Research Chair in Rehabilitation Technology – KITE Research Institute and University of Toronto Scientifc Director of the AGE-WELL Network of Centres of Excellence University of Toronto Roger Smith, Ph.D., OT, FAOTA, RESNA Fellow Professor Programs in Occupational Therapy, Science, and Technology Department of Rehabilitation Sciences and Technology Director, Rehabilitation Research Design and Disability (R2D2) Center University of Wisconsin-Milwaukee xi Preface MATLAB® is a registered trademark of The MathWorks, Inc. For product infor- mation, please contact: The MathWorks, Inc. 3 Apple Hill Drive Natick, MA 01760-2098 USA Tel: 508 647 7000 Fax: 508-647-7001 E-mail: info@mathworks.com Web: www.mathworks.com xii http://www.info@mathworks.com http://www.mathworks.com Editors Alex Mihailidis, Ph.D., P.Eng, is the Barbara G. Stymiest Research Chair in Rehabilitation Technology at the University of Toronto (U of T) and Toronto Rehabilitation Institute. He is also the Scientifc Director for the AGE-WELL Network for Centres of Excellence, which focuses on the development of new technologies and services for older adults. He is an Associate Professor in the Department ofOccupational Science and Occupational Therapy (U of T) and the Institute of Biomaterials and Biomedical Engineering (U of T), with a cross appointment in the Department of Computer Science (U of T). He has been con- ducting research in the feld of pervasive computing and intelligent systems in health for the past 15 years. He has published over 150 journal papers, confer- ence papers, and abstracts in the feld. He is also highly active in the rehabilita- tion engineering profession, currently as Immediate Past-President for RESNA (Rehabilitation Engineering and Assistive Technology Society of North America). He was named a Fellow of RESNA in 2014. Roger Smith, MD, Ph.D., is Director of the Rehabilitation Research Design and Disability Center at the University of Wisconsin-Milwaukee. His research has focused on the measurement of interventions for people with disabilities and populations of all ages, particularly in the domains and outcomes of assistive technologies and training and accessible environments. Dr. Smith has also taught courses at the graduate level in assistive technologies and rehabilitation. Contributor biographies are included in the online supplementary material of this book. xiii http://taylorandfrancis.com Section I Introduction and overview http://taylorandfrancis.com Chapter 1 History of rehabilitation engineering Gerald Weisman and Gerry Dickerson Contents 1.1 Chapter overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.1.1 History of engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.1.2 Biomedical engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.2 Assistive technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.2.1 Prosthetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.2.2 Technology for vision impairments . . . . . . . . . . . . . . . . . . . . . . . 13 1.2.3 Technology for hearing impairments . . . . . . . . . . . . . . . . . . . . . . 16 1.2.4 Technology for mobility impairments . . . . . . . . . . . . . . . . . . . . . 17 1.2.5 Technology for communication impairments. . . . . . . . . . . . . . . . 21 1.2.6 Computer technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.3 The beginning of modern rehabilitation engineering. . . . . . . . . . . . . . . . 25 1.4 Rehabilitation engineering service delivery . . . . . . . . . . . . . . . . . . . . . . . 30 1.5 Rehabilitation engineering affects the complex rehabilitation technology market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.6 Rehabilitation engineering fnds a home . . . . . . . . . . . . . . . . . . . . . . . . . 37 1.7 Summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.8 Discussion questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1 1 Chapter overview The term “rehabilitation engineering” was frst defned as “To improve the qual- ity of life of the physically handicapped through a total approach to rehabilitation, combining medicine, engineering, and related sciences” (Reswick 2002, 11–16). “Assistive technology” is the product of rehabilitation engineering. First legally defned in 1988, (ATRC 2018) in the Technology-Related Assistance Act of 1988, “assistive technology device” means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modifed, or customized, DOI: 10.1201/b21964-2 3 https://doi.org/10.1201/b21964-2 Rehabilitation Engineering that is used to increase, maintain, or improve functional capabilities of individu- als with disabilities.” Assistive technology distinguishes us from the rest of the animal kingdom. It is one factor that makes us uniquely human. There are several obvious anatomical dif- ferences between us and other mammals, such as our large brain and our unusual ability to walk on our hind legs, freeing our forelimbs to develop a high degree of manipulative ability. The most apparent product of our brains and hands is tech- nology. While the technology of our ancestors changed very little for more than two million years, there has been tremendous growth during the last 200 thousand years. Technology, in modern terms, is only a few hundred years old. The growth of technology is consistent with the growth of scientifc discoveries. Humans have created assistive technology to feed themselves, to provide shelter, to get around, to communicate with one another, and to fnd recreation in the world around them. Assistive technology has extended the abilities of humans in all these pursuits, and new technologies continue to expand our abilities, opportunities, and horizons. There is no difference between these uses of assistive technology and its use by people with disabilities. In either case, technology extends abilities and allows people to accomplish what they would not otherwise be able to do. We could not fy without airplanes, and someone with quadriplegia couldn’t go down the road without a wheelchair. Telephones allow us to speak to people halfway around the world, while a telecommunications device for the deaf (TDD) enables a person who is deaf or hearing-impaired to use the telephone. Tractors and plows enable a farmer to till 40 acres in a single day and if that farmer is paraplegic a lift will allow them to get onto the tractor. This chapter will explore the history of the feld of rehabilitation engineering and the fruits of those efforts in the development of assistive technology devices. The earliest examples of devices to aid in the independence of people with disabili- ties and functional limitations will be explored, as well as the evolution of these devices. Many devices and technologies frst developed for use by people with disabilities have evolved to become mainstream consumer products. Conversely, many consumer goods have become important assistive technologies for people with functional limitations. The social and environmental factors that have contributed to the development and growth of the feld will be identifed. The professionalism of the feld, and the political and legal frameworks that have contributed to building the feld, will be explored. 1.1.1 History of engineering Necessity is the mother of invention is a well-known proverb that best describes the fundamental nature of engineering. The practice of engineering originated in 4 History of rehabilitation engineering ancient times. The history of engineering has been described as composed of four eras by Auyang (2006): • Prescientifc revolution: The prehistory of modern engineering features ancient master builders and Renaissance engineers such as Leonardo da Vinci. • Industrial revolution: From the 18th through early 19th century, civil and mechanical engineers changed from practical artists to scientifc professionals. • Second industrial revolution: In the century before World War II, chemical, electrical, and other science-based engineering branches developed electricity, telecommunications, cars, airplanes, and mass production. • Information revolution: As engineering science matured after the war, microelectronics, computers, and telecommunications jointly produced information technology. The origin of the word “engineering” comes from medieval Latin ingeniator, from ingeniare, to “contrive, devise” and “engine” from Latin ingenium “talent, device.” The engineer thus creates new and clever devices. Imhotep, the engineer and architectof the Pyramid of Djoser, a step pyramid at Saqqara in Egypt during the time period of 2630–2611 BC, is considered one of the frst engineers. At the time, and before the industrial revolution, engineering was primarily a craft in which trial and error was the predominant practice. While some record- ing of practice took place, it was not until the Renaissance that technical drawings became common. The notebooks of Leonardo da Vinci are excellent examples of the recording of his inventions. The Industrial Revolution, from the 18th through the early 19th centuries, brought the adoption of the scientifc approach to solving practical problems and design- ing products. Universities were established to teach the new scientifc methods augmenting and replacing the traditional apprenticeship. Information about new inventions and practices was more readily available and more widely shared through publications and professional organizations. Engineering also benefted from the creation of a method to record the devel- opment and design of inventions. Gaspard Monge of Mezieres (En.wikipedia. org 2018b) invented descriptive geometry and thus created a way to represent three-dimensional objects in two dimensions. He developed his orthographic pro- jection drawing techniques while working as a draftsman for French military for- tifcations around 1765. Because his work involved military fortifcations, it was kept secret until 1794. Technical drawing was further advanced around 1799 by Marc Isambard Brunel (En.wikipedia.org 2018d). Brunel designed and developed metal machines to mass produce blocks or pulleys for the British navy. While 5 http://www.En.wikipedia.org http://www.En.wikipedia.org http://www.En.wikipedia.org Rehabilitation Engineering the processes for mass producing the blocks were a signifcant contribution to the practice of engineering, his greater contribution was the development of the drawings of the machines. Technology and the practice of engineering progressed from the Industrial Revolution through the Second Industrial Revolution and most recently through the Information Revolution. The development and use of electricity and mass pro- duction characterized the Second Industrial Revolution. Advances in physics and chemistry spurred the growth of electrical and chemical engineering. Engineering schools and curricula became well established and graduate programs were cre- ated. World War II and the subsequent Cold War and Space Race created an envi- ronment where research and development expanded, creating all kinds of new technologies and thus establishing the Information Revolution. Graduate engi- neering schools became well established (Creatingtechnology.org 2018). 1.1.2 Biomedical engineering Biomedical engineering has been an interdisciplinary activity among the medi- cal, biological, and engineering felds for hundreds of years. It was not until the 1960s that biomedical engineering became a feld in its own right. The Biomedical Engineering Society was incorporated in 1968 and had 171 founding members. By 2018, the society had more than 7000 members. According to the Biomedical Engineering Society (Bmes.org 2018), “A biomedi- cal engineer uses traditional engineering expertise to analyze and solve problems in biology and medicine providing an overall enhancement of health care.” The feld of biomedical engineering has grown signifcantly since the 1960s. Many engineering disciplines have become involved with biomedical technology. Figure 1.1 illustrates the many specialties that have come to defne the breadth of biomedical engineering (Enderle and Bronzino 2012). Figure 1.2 illustrates a classifcation of engineering in medicine presented by James B. Reswick (The University of Tennessee, Knoxville 1977). Reswick describes the “bioengineer” as someone who is typically trained to teach, perform, and lead research in the medical and biological felds emphasizing the engineering aspects. Except in the context of the research being performed, the bioengineer is rarely concerned with the direct care of patients. According to Reswick, the medical engineer applies “engineering in a direct way which improves patient care in the long run and often is directed to the specifc prob- lem of a particular patient.” The medical engineer works closely with physicians and other medical and healthcare professionals. The clinical engineer focuses primarily on the equipment and technology used for therapy and diagnosis in the healthcare environment. 6 History of rehabilitation engineering Figure 1.1 The world of biomedical engineering (after Enderle and Bronzino 2012). It was primarily in the 1960s that the problems of medical technology causing injuries to patients were identifed as an issue to be addressed. Of particular con- cern was the electrical safety of patients in hospitals. Activists such as Ralph Nader raised the issue of patient safety. Nader stated, “at least 1,200 Americans are electrocuted annually during routine diagnostic and therapeutic procedures” (Nader 1971, 98). Questions of legal rights and responsibilities were raised if a hospital patient was injured as a result of equipment failure. Which healthcare professional should bear the responsibility—the physician, the nurse, or the clini- cal engineer? Issues of training in the use of sophisticated medical equipment were also raised. The issues around medical technology and equipment led to the develop- ment of certifcation programs for clinical engineers. The Association for the Advancement of Medical Instrumentation (AAMI) formed the International Certifcation Commission for Clinical Engineers. The frst certifcations for clinical engineers were awarded at the AAMI meeting in Atlanta in 1976. The certifcation process has gone through a number of changes over the years since. The AAMI suspended its program in 1999. Starting in 2002, clinical engineers can be certifed under the Clinical Engineering Certifcation under 7 Rehabilitation Engineering Figure 1.2 Engineering in medicine classifcation (after Reswick, The University of Tennessee, Knoxville 1977). the sponsorship of the American College of Clinical Engineering under the administration of the Healthcare Technology Certifcation Commission and the United States and Canadian Board of Examiners for Certifcation in Clinical Engineering. Reswick (The University of Tennessee, Knoxville 1977) goes on to describe the rehabilitation engineer as, “involved with patients on a continuing and active basis. He is concerned both with the development of new devices and the advancement of science as it relates to the rehabilitation of disabled persons.” It is important to note Reswick’s description is primarily concerned with those working within a medical model. However, his description also applies to those rehabilitation engineers working in various other models, i.e., vocational or inde- pendent living. 1 2 Assistive technology The development of devices to aid people with disabilities is clearly one of the results of rehabilitation engineering practice. Assistive technology devices have been made since ancient times. The simplest and oldest assistive technologies are the walking stick and under-arm crutch. Illustrations of such devices appear in Egyptian hieroglyphs as early as 3000 BC. 8 History of rehabilitation engineering 1.2.1 Prosthetics Prostheses are devices used to primarily replace missing or non-functional body parts. The earliest known prosthesis is suspected to be an artifcial toe made of wood and leather found on an Egyptian mummy (Figure 1.3). Found on a mummy of a 50–60-year-old woman in 2000 near the ancient city of Thebes, the prosthe- sis dates from 950–710 BC. While the Egyptians were known to replace certain body parts of corpses in order to make them viablein the afterlife, a biomechani- cal study by Finch et al. (2012) suggests the toe prosthesis was probably func- tional during the woman’s life. An artifcial lower leg, known as the “Roman Capua Leg” was found in a grave attached to a skeleton in Capua, Italy. The prosthesis was made of bronze and is dated to 300 BC (Broughttolife.sciencemuseum.org.uk 2018). German mercenary knight Götz von Berlichingen was known as a Robin Hood in 16th-century Bavaria. It was during a battle around 1504 that a cannonball took Berlichingen’s hand. He commissioned an artist to fabricate an iron hand. The iron prostheses (Figure 1.4) sported hinged fngers to enable Berlichingen to continue battling with his sword (Atlas Obscura 2018). Modern amputation surgery and prosthetics probably began with Ambroise Paré, a French army barber/surgeon. He advanced the techniques of amputation and prosthetics. His contributions to prosthetics include “an above-knee device that was a kneeling peg leg and foot prosthesis that had a fxed position, adjustable harness, knee lock control and other engineering features that are used in today’s devices” (Amputee-coalition.org 2018). Figure 1.3 Egyptian toe (Choi, 2007). 9 Rehabilitation Engineering Figure 1.4 Iron hand prostheses (Atlas Obscura, 2018). The frst non-locking below-knee prosthesis was introduced in 1696 by Pieter Andriaanszoon Verduyn (Figure 1.5), which allowed for knee movement (Nya mcenterforhistory.org 2018). Upper-limb prosthetics were signifcantly advanced by Peter Baliff in 1818 when he invented a prosthesis that was powered by the user’s opposite shoulder (Figure 1.6). Through a series of leather straps, the device enabled the user to power and control the fngers of the prosthesis. Powered prostheses continued to evolve with electric motors and control mechanisms using myoelectric signals (Zuo and Olson 2014). Advances in prosthetics, particularly lower-limb prosthetics, followed advances in the surgical techniques of amputation. Gaseous anesthesia developed in the 1840s enabled doctors to perform longer and more detailed amputation surgeries, allowing for better preparation of the stump for interfacing with the prostheses (Garden 2018). Upper- and lower-limb prosthetics continued to advance, particularly in response to the needs of soldiers disabled through wars in the 19th and 20th centuries. The latest developments in lower-extremity prosthetics include inventions by amputees themselves. The Cheetah Flex-Foot was developed by Van Phillips in 1984 after a waterskiing accident. The Cheetah Flex-Foot is a radical design that provides fexibility and the ability to store energy. The prosthesis (Figure 1.7) has become a favorite of athletes (Vlaskamp, Soede, and Gelderblom 2011). Hugh Herr, a double amputee, developed the frst commercially available prosthetic foot to mimic the function of the real human foot. According to the Medical Center Orthotics and Prosthetics website, the distributor of the iWalk BiOM (Figure 1.8), 10 History of rehabilitation engineering Figure 1.5 Verduyn prosthesis (Nyamcenterforhistory.org 2018). Figure 1.6 Body-powered prosthesis (Upperlimbprosthetics.info 2018). 11 http://www.Upperlimbprosthetics.info Rehabilitation Engineering Figure 1.7 Cheetah Flex-Foot (Ossur.com 2018). Figure 1.8 iWalk BiOM (Business Insider 2018). 12 http://www.Ossur.com History of rehabilitation engineering By using robotics to replicate the calf muscles and Achilles tendon, the iWalk BiOM feels and functions like no other foot/ankle prosthesis. With each step, the iWalk BiOM provides a powered push-off which propels the wearer forward. It is the only prosthesis in the world that does not depend on the wearer’s energy. With the iWalk BiOM, users will experience natural walking mechanics and increased stability, mobility, and confdence. (MCOP Prosthetics 2018) 1.2.2 Technology for vision impairments Eyeglasses, specifcally reading glasses, frst appeared in Italy between 1268 and 1300 AD. According to the Zenni Optical website (Surrence 2013), The frst illustrations of someone wearing this style of eyeglasses are in a series of mid-14th-century paintings by Tommaso da Modena, who featured monks using monocles and wearing these early pince-nez (French for “pinch nose”) style eye- glasses to read and copy manuscripts. Before personal computers became available, typewriters were ubiquitous. The typewriter was one of the frst examples of advances in technology frst inspired by the needs of people with disabilities that ultimately became generally use- ful and available to the general population. Pellegrino Turri built the frst type- writer around 1808 in order to help his blind friend, Countess Carolina Fantoni da Fivizzono, to write legibly. In response to a request by Napoleon for a code that soldiers could use to com- municate silently and without light, Army Captain Charles Barbier de la Sierra developed a system, known as “night writing,” that used 12 raised dots (Vlaskamp, Soede, and Gelderblom 2011). Barbier taught his system to blind students at the Royal Institution for Blind Youth in Paris, France. One of those students, Louis Braille, was interested in the method. Braille, born January 4, 1809, was blinded by an accident in his father’s shop in 1812. He was 10 years old when he met Barbier and then modifed the code by reducing the number of dots to six. Braille published his frst book in Braille in 1829. An example of a Braille page is pre- sented in Figure 1.9. Braille’s system of writing required a slate and stylus to punch holes in the paper in order to raise the dots. The writer punches each dot one at a time. Needless to say, this process was slow and ineffcient. The frst successful mechanical Braille writer was invented by Frank H. Hall, the superintendent of the Illinois Institution for the Education of the Blind (see Figure 1.10). From a Brief History of the Illinois Institution for the Education of the Blind 1849–1893: Under the direction of the Superintendent, a machine for writing Braille has been constructed by which a pupil can write many times as fast as he could write with 13 Rehabilitation Engineering a “stylus and tablet,” with the further advantage of having what he has written in a convenient position to be read. With these machines, the pupils solve their problems in algebra and write their letters and school exercises. (Antiquetypewriters 2018) While Braille signifcantly increased the literacy of blind individuals, those with visual impairments are challenged by printed materials. Samuel Genensky became visually impaired soon after birth. He was determined to live his life as Figure 1.9 Braille page (Blind Foundation 2018). Figure 1.10 Hall Braille writer (Antiquetypewriters.com 2018). 14 History of rehabilitation engineering a partially sighted person and not as a blind person. While at Perkins School for the Blind, one teacher told him, “Why don’t you act like a well-behaved blind child?” to which he replied, “Because I am not blind.” He remarked later that this retort had signif- cant importance in his life because by it he permanently placed himself in the camp of the sighted and not in the camp of the blind, and at that point, he determined to make it in life “using everything [he] had going for [him] including [his] none-too impressive residual vision.” (En.wikipedia.org 2018e) While working at the RAND corporation in 1968, Genensky and colleague Paul Baran developed the first practical and user-friendly closed-circuit TV (CCTV) magnifier system (see Figure 1.11) (Vlaskamp, Soede, and Gelderblom 2011). Reading printed materials by blind and visually impaired people was signifcantly advanced by Ray Kurzweil who invented the frst machine to read printedmate- rial using computer-generated speech in 1977. The Kurzweil reading machine was revolutionary in advancing three new technologies that have since become commonplace. The machine included “omni-font character recognition (OCR), the CCD (Charge Coupled Device) fat-bed scanner, and text-to-speech synthesis” (Figure 1.12) (Vlaskamp, Soede, and Gelderblom 2011). Figure 1.11 Genensky CCTV (Cclvi.org 2018). 15 http://www.En.wikipedia.org http://www.Cclvi.org Rehabilitation Engineering Figure 1.12 Kurzweil reading machine (https://www.gettyimages.com/detail/news- photo/raymond-kurzweil-of-cambridge-massachusetts-is-shown-with-news-photo/ 515406792?#raymond-kurzweil-of-cambridge-massachusetts-is-shown-with-the- he-picture-id515406792). 1.2.3 Technology for hearing impairments Assistive technology for the hearing-impaired began in the 13th century with animal horns being used to amplify sounds. Man-made trumpets, primarily made from tin, were frst developed in the 17th century. While Alexander Graham Bell is best known for inventing the telephone, it was his interest in helping deaf and hearing-impaired people that contributed signifcantly to the development of assistive technology. Bell’s mother was profoundly deaf, and Bell was a teacher of the deaf in Boston. In 1874, Bell began to formulate the design of his device. He stated, “If I could make a current of electricity vary in intensity precisely as the air varies in density during the production of sound, I should be able to transmit speech telegraphically” (Bell 2018). He hoped this device would help people with hearing impairments to speak. His telephone was patented in 1876 and 1877. Vacuum tubes used in the fabrication of microphones and amplifers contrib- uted to the development of wearable hearing aids. Probably the earliest wear- able vacuum tube hearing aid made in the United States was Arthur Wengel’s “Stanleyphone,” available in 1937 and 1938 (Sandlin 2000). The Aurex hearing aid (Figure 1.13) developed by Walter Huth was the frst to use American-made vacuum tubes. Around 1952, hearing aids became smaller and more energy eff- cient with the advent of the transistor. The microelectronic/digital era, beginning in the late 1960s, resulted in size reductions and the increased performance of 16 https://www.gettyimages.com https://www.gettyimages.com https://www.gettyimages.com https://www.gettyimages.com History of rehabilitation engineering Figure 1.13 Aurex vacuum tube hearing aid (Sandlin, 2000). Figure 1.14 Belltone hearing aids (Beltone.com 2018). hearing aids. Starting around 1988, the programming of hearing aids became available, making the device better tuned to the specifc audiogram of the user (Sandlin 2000) (Figure 1.14). 1.2.4 Technology for mobility impairments For those people with mobility impairments, wheeled chairs became a solution for transporting the individual and ultimately for the person to have indepen- dent mobility. Wheeled furniture and wheeled carts, common in the 4th and 5th centuries BC, were used for people with disabilities. Self-propelled chairs were 17 http://www.Beltone.com Rehabilitation Engineering frst reported in the 17th century. German mechanic and inventor Johann Hautsch made rolling chairs in Nürnberg (Encyclopedia Britannica 2018). Wheelchair use became prominent in the United States after the Civil War, when chairs were typically made of wood (Figure 1.15). In fact, the frst US patent for a wheelchair was awarded to Sarah Potter on December 25, 1894. The wooden chair had a fxed frame, and push-rims for self-propulsion. The modern era of manual wheelchairs began in 1932 when mechanical engi- neer Harry Jennings built the frst tubular steel wheelchair for his disabled friend Herbert Everest (Figure 1.16). The wheelchair was capable of folding by using a cross frame. The folding wheelchair was capable of being transported in a vehi- cle, making the outside community more readily available to the person with a disability. They founded the Everest & Jennings (E&J) wheelchair company, which dominated the wheelchair market through the 1980s. The typical E&J steel manual wheelchair weighed approximately 55 pounds. Modifcations to these wheelchairs, particularly for sports, e.g., wheelchair bas- ketball, generally involved reducing weight and modifying the wheels by mount- ing them at an angle and installing wheel guards to protect the spokes. Figure 1.15 Civil War wheelchair (https://www.bing.com/images/search?view =detailV2&ccid=suMAcA5L&id=9FDAAA26E2BB497B1E7B91F35C797E4 CD3374DD0&thid=OIP.suMAcA5LFmZ9jFrGUIxCmwHaKO&mediaurl=https %3a%2f%2fs-media-cache-ak0.pinimg.com%2f236x%2f12%2ff1%2f70%2f1 2f170412a810cb02ad4d9064e56c840.jpg&exph=276&expw=200&q=Old +Wheelchairs+From+the+1800&simid=608018877235528118&selectedIndex =15&ajaxhist=0). 18 https://www.bing.com/ https://www.bing.com/ History of rehabilitation engineering Figure 1.16 E&J 1932 wheelchair. The wheelchair was revolutionized with the introduction of the Quickie wheel- chair in 1979. Marilyn Hamilton was an avid hang glider enthusiast when in 1978 an accident left her with paraplegia. Using her knowledge of hang-gliding tech- nology Hamilton, along with Jim Okamoto and Don Helsman, created an ultra- lightweight wheelchair. Their chair featured adjustability, high performance, and bolt-on accessories (Marilynhamilton.com 2018). At a time when almost all wheelchairs were manufactured with chrome-plated steel, the Quickie signif- cantly changed the aesthetics of wheelchairs by introducing colors to their materi- als (Figure 1.17). In response to a request from Canadian World War II disabled veteran, John Counsell, the Canadian National Research Council (NRC) created a project to create the frst electric wheelchair to be mass produced. George Klein, a mechani- cal engineer at the NRC, developed an electric wheelchair with “a unique package of technologies including the joystick, tighter turning systems and separate wheel drives that are still features of electric wheelchairs today” (U of T Engineering News 2018). Klein and the NRC shared the design of the wheelchair, patent free, with manufacturers in order to facilitate the manufacture and distribution of the wheelchair. Klein was a pioneer in what has come to be known as participatory action research, wherein consumers and end-users of the technology are collabo- rators in the process of its development. Electric or powered wheelchairs evolved with the separation of the drive com- ponents and the seating systems frst developed by Fortress in the early 1980s (Figure 1.18). 19 Rehabilitation Engineering Figure 1.17 Hamilton and Quickie (Stimdesigns.com 2018). Figure 1.18 Fortress-powered wheelchair. 20 http://www.Stimdesigns.com History of rehabilitation engineering Figure 1.19 Amigo mobility scooter (Myamigo.com 2018). The form factor of the powered wheelchair changed with the design and develop- ment of the mobility scooter by Allan Thieme. Thieme, a plumber, invented the frst mobility scooter in 1968 for a family member with mobility impairments due to multiple sclerosis. The “Amigo,” or “friendly wheelchair” became the frst product of Amigo Mobility International, Inc. in Bridgeport, Michigan, and the beginnings of the “scooter” industry (Figure 1.19). 1.2.5 Technology for communication impairments Communication is a fundamental and critical human need. Augmentative and alternative communication (AAC) technology meets the needs of people with dis- abilities with communication impairments. Simple language boards with displays of pictures, icons, or traditional orthography serve as an effective means of com- munication. Communication technology and language boards in particularwere advanced with the use of Bliss Symbols. Charles Bliss, a survivor of Dachau and Buchenwald concentration camps became a refugee in Shanghai and Sydney from 1942 to 1949. Inspired by Chinese characters, he “wanted to create an easy- to-learn international auxiliary language to allow communication between dif- ferent linguistic communities” (En.wikipedia.org 2018a). Bliss Symbols “consists 21 http://www.En.wikipedia.org http://www.Myamigo.com Rehabilitation Engineering of several hundred basic symbols, each representing a concept, which can be composed together to generate new symbols” and concepts (Vlaskamp, Soede, and Gelderblom 2011). The application of Bliss Symbols (Figure 1.20) to aug- mentative communication was pioneered by Shirley McNaughton in 1971 at the Ontario Crippled Children’s Centre, Ontario, Canada (now Holland Bloorview Kids Rehabilitation Hospital). It was at about the same time, in 1971, that AAC systems progressed from simple language boards to electronic devices. Rick Foulds, a student at Tufts University in Massachusetts, and Gregg Vanderheiden at the University of Wisconsin devel- oped electronic communication devices to respond to the needs of children with communication limitations. Foulds developed the Tufts Interactive Communicator (TIC; Figure 1.21), a device that used scanning input to display letters on a screen and on a printer. The letters on the TIC were arranged in order of frequency of use, so the most frequently used letters could be selected in the least amount of time. Subsequent devices incorporated letter prediction by dynamically changing the display of letters to be scanned. The Auto Monitoring Communication Board (AutoCom; Figure 1.22) was a direct selection device developed by Vanderheiden at the Trace Center at the University of Wisconsin. The AutoCom was a user- programmable device, where the user could develop their own vocabulary. The AutoCom was commercialized by Telesensory Systems and the Prentke Romich Company (Vanderheiden 2003). Notable augmentative communication devices developed and available in the 1970s include the Handivoice (Figure 1.23) and the Canon Communicator (Figure 1.24). The Canon Communicator was a small portable device that was printed out on a small paper tape. It was notable for being the frst device developed and commer- cialized by a major manufacturer. The Handivoice was one of the frst available devices that utilized computer-generated speech (Vanderheiden 2003). Figure 1.20 Bliss Symbols (Idsgn.org 2018). 22 http://www.Idsgn.org History of rehabilitation engineering Figure 1.21 Tufts Interactive Communicator (TIC) (Rehab.research.va.gov 2018). Figure 1.22 Auto monitoring communication board (AutoCom) (Rehab.research.va. gov 2018). 1.2.6 Computer technology The introduction of the Apple II personal computer (see Figure 1.25) to the world by Steve Wozniak and Steve Jobs in 1977 promised a level playing feld for people with disabilities. People with disabilities would have the ability to use the computer to compensate for functional limitations in communication and 23 http://www.Rehab.research.va.gov http://www.Rehab.research.va. gov http://www.Rehab.research.va. gov Rehabilitation Engineering Figure 1.23 Handivoice (Rehab.research.va.gov 2018). Figure 1.24 Canon Communicator (Rehab.research.va.gov 2018). access to tools that would enhance their productivity. While the graphic display and user-friendly design of the Apple II were touted as a revolution in computer design, it also presented challenges to people with certain functional limitations. Specialized programs were being developed for people with disabilities to run on the Apple II. Many of these programs could be accessed by adaptive con- trol systems, i.e., scanning, coding, etc. However, people with disabilities could not access the standard programs being used to increase productivity, such as word processors and Visicalc, an interactive visible calculator. Unlike present-day 24 http://www.Rehab.research.va.gov http://www.Rehab.research.va.gov History of rehabilitation engineering Figure 1.25 Apple II computer (http://americanhistory.si.edu/collections/search/ object/nmah_334638). computers, the Apple II computer could only run one program at a time. Access to the Apple II took a signifcant leap with the introduction of the adaptive frm- ware card (AFC) (Figure 1.26) by Paul Schwejda and Judy McDonald. The AFC enabled transparent access to the computer. It was a keyboard emulator that gen- erated text as if it was coming from the keyboard with one or two switches. The AFC could be accessed by scanning or coded input (e.g., Morse Code). Schwejda and Vanderheiden published an article in Byte magazine in September 1982 (Schwejda and Vanderheiden 1982) describing the AFC, including all the techni- cal details of the AFC and a schematic. 1 3 The beginning of modern rehabilitation engineering The development of assistive technologies and devices for people with disabili- ties have mostly come as a result of disease, injury, and warfare. Ancient and medieval societies saw disabilities as a consequence of hunting and war, and in some cases, occupational accidents. Through the middle of the 20th century, disabled soldiers were primarily as a result of amputations. The US Civil War between the Union northern states and the southern Confederate states produced as many as 30,000 amputations on the Union side alone. James Edward Hanger, a Confederate soldier, became the frst amputee of the Civil War when a cannonball 25 http://americanhistory.si.edu http://americanhistory.si.edu Rehabilitation Engineering Figure 1.26 Adaptive Firmware Card tore through his leg at the Battle of Philippi. In 1861, Hanger fashioned an artif- cial leg and was granted patents from the Confederate government. He was later granted a US patent in 1891. The prosthetics company Hanger started in 1861 is now a US$1 Billion+ company providing prosthetics and orthotics around the world (Hanger.com 2018). Amputations continued to be a predominant cause of disability in warfare through World War II. The development of penicillin by Alexander Fleming in 1928 signifcantly increased the survivability of battlefeld injuries, particu- larly amputations (American Chemical Society 2018). In 1945, at about the same time the Battle of the Bulge was being waged in the Ardennes, Surgeon General Norman T. Kirk, an orthopedic surgeon, asked the United States National Research Council of the National Academy of Sciences to convene of meeting of experts at Northwestern University in Chicago with the aim of recommend- ing the best artifcial limbs for veterans. The attendees of the meeting included doctors, engineers, and prosthetists. The consensus of those in attendance was that the design of prosthetics required further research and development. Dudley Childress described this meeting as the beginning of modern research on pros- thetics and the beginnings of the feld of rehabilitation engineering (Childress 2003). Soon after the meeting a Committee on Prosthetic Devices was formed under the National Research Council. The Committee ultimately evolved into the Committee on Prosthetics Research and Development (CPRD) initially directed by Brig. General F. S. Strong Jr and ultimately by A. Bennet Wilson Jr (Childress 2003). According to Hays (2010), “NRC committees reviewed pro- posals for contracts in support of prosthetics research, held meetings to review state-of-the-art prosthetics and advise on new directions, and interacted directly 26 History of rehabilitation engineering with contractors.” Funds supporting contracts came from the Offce of Scientifc Research and Development (OSRD) and the War Department from 1945 to 1947; after that, the US Veterans’ Administration(VA, now known as the Department of Veterans Affairs) provided the funding. Public Law 729, 80th Congress, June 19, 1948, formally authorized VA research in the felds of prosthetics and sensory devices and provided a budget of US$1 million per year. The law required VA to “make available the results of such research so as to beneft all disabled people.” The budget remained fat until 1962, when the US$1 million funding ceiling was lifted by Public Law 87–572, which authorized “such funds as were necessary” for the program. Soon after the passage of Public Law 729 and the initial funding of research for prosthetics and sensory aids, the VA created the Prosthetics and Sensory Aids Service. The Service, based at the VA Central Offce in Washington, DC, admin- istered contracts for research as well as intramural research. Augustus Thorndike was the initial director, followed in 1955, by Robert E. Stewart who served as director until 1973. Stewart directed the establishment of the VA Prosthetics Center (VAPC) in 1956. The VAPC combined clinical services and research in prosthetics and sensory aids. At the time, Eugene Murphy was Assistant Director of Research operating out of the VA Regional Offce in New York. Murphy supervised the intramural research program at the VAPC and was responsible for coordinating the contract research program. Anthony Staros soon became the director of the VAPC. As described by Hays (2010), While the VAPC carried out a variety of practical projects, primarily to improve upper and lower limb prostheses, it became increasingly involved in the evaluation of devices developed by others. It established a network of VA Prosthetics Service units at VA hospitals willing and able to evaluate new devices. In some cases, when the new device was clearly benefcial, it would be adopted in VA for general clinical use. The VAPC also played an active role in prosthetics education. Disease was a major contributor to the development of assistive technology devices and rehabilitation engineering. Poliomyelitis (polio) infections were known as far back as ancient times. However, it was the outbreak of 1952, the worst in the his- tory of the United States, that contributed most signifcantly to the development of rehabilitation engineering. There were approximately 57,628 cases of polio reported, of which 3145 died and 21,269 were left with mild to disabling paralysis (En.wikipedia.org 2018c). The vaccine developed by Jonas Salk in 1955 and mod- ifed to an oral vaccine by Albert Sabin put an end to the polio epidemic. Many people who survived polio in the 1950s matured to become strong advocates and were at the leading edge of the disability rights and universal design movements of the late 1960s and 1970s. 27 http://www.En.wikipedia.org Rehabilitation Engineering The late 1950s and early 1960s saw another outbreak of disabling conditions caused by the use of thalidomide. Prescribed primarily as a sedative or hypnotic, thalidomide was also prescribed to pregnant women to combat nausea and morn- ing sickness. The drug caused malformations of the eyes, ears, and deafness, defects of the heart and kidneys, and most signifcantly, phocomelia (malforma- tion of the limbs) in the unborn children of the pregnant women. There were approximately 10,000 cases of phocomelia throughout the world. Only 50% of the children survived, mostly in Europe and Canada. The US Food and Drug Administration (FDA) refused to approve the drug, thus limiting the impact in the United States (En.wikipedia.org 2018f). Canada responded to the needs of the children affected by thalidomide by creating centers that would provide tech- nology to meet the needs of the children affected by thalidomide. These centers included: • Manitoba Rehabilitation Hospital, Winnipeg, Manitoba. • Ontario Crippled Children’s Centre (now called the Holland Bloorview Kids Rehabilitation Hospital), Toronto, Ontario. • Rehabilitation Institute of Montreal, Montreal, Quebec. These centers recruited teams of prosthetists, orthotists, and technicians to pro- vide clinical services and conduct research and development. Engineers were recruited to lead the research and development activities at these centers, includ- ing James Foorte, Colin McLaurin, and Andre Lippay respectively. The centers contributed to the development of assistive technologies by creating new prosthe- ses, seating systems, and manual and powered mobility devices (Hobson 2002). The CPRD, as described above, coordinated projects researching prosthet- ics and sensory aids throughout the 1960s. In a report entitled “Rehabilitation Engineering: A Plan for Continued Progress,” published in 1971 the CPRD listed research the committee was coordinating along with other projects in sensory aids totaling 103 projects. The term “rehabilitation engineering” was frst identi- fed in this report. The preface of the report stated: In 1966, at the request of the then Vocational Rehabilitation Administration, CPRD developed a set of recommendations for research in orthotics and prosthetics for the next fve-year period or so. This report seems to have been useful to the sponsors of research and to those planning work during the past four years. Most of the recom- mendations made in the report have been acted upon. Thus, it seems appropriate at this time to develop a new set of recommendations for the next fve to ten years. Sensory aids for the blind and deaf are included as a logical extension to prosthet- ics and orthotics, and, with the addition of structural internal prostheses, the whole area can be known as rehabilitation engineering. The CPRD was chaired at the time by Colin McLaurin with A. Bennet Wilson acting as the Executive Director. 28 http://www.En.wikipedia.org History of rehabilitation engineering It was in this 1971 report the CPRD determined their program and the feld had matured to such a degree that “certain centers of excellence could and should be established to carry out integrated programs of research, development, evaluation, and education in rehabilitation engineering” (National Research Council (US) Committee on Prosthetics Research and Development and National Academy 1971). Their recommendation for centers included having “strong teaching affl- iations with medical and engineering schools and have available a substantial patient load.” They suggested, At least half-a-dozen rehabilitation engineering centers are needed in the near future and they probably should be spread across the country on some sort of a geographical basis. The objectives of rehabilitation engineering centers should be: 1. To improve the quality of life of the physically handicapped through a total approach to rehabilitation, combining medicine, engineering, and related science. (This thus becomes the frst defnition of the term “reha- bilitation engineering.”) 2. To perform research and development in pioneering areas wherein a cen- ter has developed unique capabilities. 3. To collaborate with laboratories and industry to carry new devices and techniques through all phases of research, development, and clinical evaluation to active production and patient use. 4. To make available new devices and techniques to all patients referred to the center. 5. To educate others to provide these devices and techniques to patients throughout the nation. 6. To cooperate with other centers in ftting and evaluating their develop- ments whenever the need is indicated. 7. To provide an environment for education of physicians, engineers, and other technical persons in related life and physical sciences. 8. To communicate effectively with other centers through recognized means and cooperative effort. Soon after this report was released, the US Department of Health, Education, and Welfare funded the frst two Rehabilitation Engineering Centers in 1971. Thetwo centers were at Rancho Los Amigos Medical Center in Downey, California, and Moss Rehabilitation Hospital in Philadelphia, Pennsylvania. Three more centers were established the following year at Texas Institute for Rehabilitation and Research in Houston, Texas, Northwestern University and the Rehabilitation Institute of Chicago in Chicago, Illinois, and Children’s Hospital Center in Boston, Massachusetts (Hobson 2002). The passage of the Rehabilitation Act of 1973 (PL93–112) was a watershed moment for the civil rights of people with disabilities in the United States, as well as the advancement of rehabilitation engineering. Section 504 of the Rehabilitation Act was the frst time the law extended civil rights to people with disabilities. It 29 Rehabilitation Engineering prohibited discrimination against people with disabilities in programs that were funded by the federal government. The law became a model for the Americans with Disabilities Act passed in 1990. The Rehabilitation Act of 1973 also contributed signifcantly to ensuring elec- tronic and information technology would be accessible and useable by people with disabilities. Instead of simply regulating the design of the technology, the law stated that the federal government would only purchase technology that was accessible. Market pressures and the desire to sell their products to the federal government ensured manufacturers would make their products accessible to peo- ple with disabilities. Section 508 of the Rehabilitation Act of 1973 establishes requirements for electronic and information technology developed, maintained, procured, or used by the federal government. It requires federal electronic and information technology to be accessible to people with disabilities, including employees and members of the public. Most importantly in the context of rehabilitation engineering, the Rehabilitation Act of 1973 established the Rehabilitation Engineering Research Centers. Section 202(b)2 states: Establishment and support of rehabilitation engineering research centers to (a) develop innovative methods of applying advanced medical technology, scientifc achievement, and psychological and social knowledge to solve rehabilitation prob- lems through, planning and conducting research, including cooperative research with public and private agencies and organizations, designed to produce new scien- tifc knowledge, equipment, and devices suitable for solving problems in the reha- bilitation of handicapped individuals and for reducing environmental barriers and to (b) cooperate with state agencies designated pursuant to Section 101 in devel- oping systems of information exchange and coordination to promote the prompt utilization of engineering and other scientifc research to assist in solving problems in the rehabilitation of handicapped individuals. (GovTrack.us 1973) Twelve Rehabilitation Engineering Research Centers (RERCs) were soon estab- lished by the Rehabilitation Services Administration of the US Department of Health, Education, and Welfare in response to the requirements of the Rehabilitation Act of 1973 (Rehabilitation Services Administration, US Department of Health, Education, and Welfare, and the Veterans Administration 1978). These centers are included in Table 1.1. 1 4 Rehabilitation engineering service delivery As the Rehabilitation Services Administration (RSA) and the VA took on the respon- sibilities of managing and coordinating the rehabilitation engineering programs, 30 History of rehabilitation engineering Ta bl e 1 .1 R eh ab ili ta ti on E ng in ee ri ng R es ea rc h C en te rs ( R E R C s) O rg an iz at io n Lo ca ti on D ir ec to r C or e A re a Ra nc ho L os A m ig os H os pi ta l Do wn ey , C A Ja m es B . R es wi ck Fu nc tio na l E le ct ric al S tim ul at io n of P ar al yz ed Ne rv es a nd M us cl es Kr us en R es ea rc h Ce nt er , Ph ila de lp hi a, P A A. B en ne tt W ils on , J r Lo co m ot io n an d M ob ili ty M os s Re ha bi lit at io n Ho sp ita l Ch ild re n’ s Ho sp ita l M ed ic al C en te r Bo st on , M A W ill ia m B er en be rg Ne ur om us cu la r C on tro l U si ng S en so ry Fe ed ba ck S ys te m s Te xa s In st itu te fo r R eh ab ili ta tio n an d Re se ar ch Ho us to n, T X W ill ia m A . S pe nc er Ef fe ct s of P re ss ur e on Ti ss ue No rth we st er n Un iv er si ty Ch ic ag o, IL Cl in to n L. C om pe re In te rn al To ta l J oi nt R ep la ce m en t Un iv er si ty o f I ow a, O rth op ed ic s De pa rtm en t, Di ll Ch ild re n’ s Io wa C ity , I A Ca rro ll B. L ar so n Lo w Ba ck P ai n Ho sp ita l Sm ith -K et tle we ll In st itu te o f V is ua l S ci en ce s Sa n Fr an ci sc o, C A La wr en ce A . S ca dd en Se ns or y A id s fo r B lin d an d De af Un iv er si ty o f T en ne ss ee , D ep ar tm en t o f O rth op ed ic S ur ge ry M em ph is , T N Ro be rt E. To om s M ob ili ty S ys te m s fo r S ev er el y D is ab le d Ca se W es te rn R es er ve U ni ve rs ity , Cl ev el an d, O H Ch ar le s H. H er nd on Up pe r E xt re m ity F un ct io na l E le ct ric al S tim ul at io n Sc ho ol o f M ed ic in e Ce re br al P al sy R es ea rc h Fo un da tio n of K an sa s W ic hi ta , K S Jo hn . F . J on as Vo ca tio na l A sp ec ts o f R eh ab ili ta tio n Un iv er si ty o f M ic hi ga n, C ol le ge o f E ng in ee rin g An n Ar bo r, M I J. Ra ym on d Pe ar so n Au to m ot iv e Tr an sp or ta tio n fo r t he H an di ca pp ed Un iv er si ty o f V irg in ia , S ch oo l o f M ed ic in e Ch ar lo tte sv ill e, V A W ar re n G. S ta m p Sp in al C or d In ju ry 31 Rehabilitation Engineering including the Rehabilitation Engineering Research Centers established by the Rehabilitation Act of 1973, the Committee on Prosthetics Research and Development was disbanded in 1976. It was between 1973 and 1977 that a series of 12 state-of-the- art workshops in rehabilitation engineering were held on various topics. A summary meeting, chaired by Colin McLaurin, was held in Washington, DC on May 12–13, 1977 resulting in a report entitled “Rehabilitation Engineering: A Plan for Continued Progress II” (Rehabilitation Services Administration, US Department of Health, Education, and Welfare, and the Veterans Administration 1978). With the passage of the Rehabilitation Act of 1973 and the establishment of the RERC program and centers, rehabilitation engineering research was matur- ing. The 12 workshops and the May 1977 meeting resulted in recommenda- tions regarding the service delivery of rehabilitation engineering. Additionally, recommendations were made regarding knowledge gaps and recommended research, evaluation of devices, education and information transfer, service delivery, and the formation of a national organization (Rehabilitation Services Administration, US Department of Health, Education, and Welfare, and the Veterans Administration 1978). It was during this time, and at these workshops, that a consensus on the prob- lems of delivering rehabilitation engineering services and the role of the reha- bilitation engineer in service delivery was formulated. During the conference on “Delivery of Rehabilitation Engineering Services in the State of California” held in Pomona, California on January 16–18, 1977 recommendations were made in a number of areas related to delivering rehabilitation engineering services including information, education, costs for services and equipment,
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