Assistive technology enables dreams. Mathew Lee (personal communication) Assistive technology (AT) provides powerful tools used to diminish disability, enable activities of daily living (ADLs), and promote recreational and vocational pursuits (Grott, 2015; Stiens, 1998). Persons with disabilities benefit from AT in a variety of ways: within their own bodies, such as through cochlear transplantation to enhance hearing; within the immediate environment, such as with a scooter to improve mobility; and within an extended environment, such as a wheelchair-adapted van (Boninger et al., 2008). This chapter serves as an introduction to AT tools, patient assessment, person-centered application of AT, and resources for patients and clinicians alike. INTRODUCTION: DEFINITIONS AND VARIETIES OF INTERVENTIONS

Although the terms assistive technology, accessible technology, and adaptive technology are often used synonymously, there are semantic differences (Figure 32.1). Hersh and Johnson (2008) define assistive technology as

. . . a generic or umbrella term that covers technologies, equipment, devices, apparatus, services, systems, processes, and environmental modifications used by disabled and/or elderly people to overcome the social, infrastructural, and other barriers to independence, full participation in society, and carrying out activities safely and easily. (p. 196)

Accessible technology is a general term used to describe "any item, piece of equipment or system, whether acquired commercially, modified or customized, that is utilized to increase, maintain or improve functional capabilities of individuals with disability" (Assistive Technology Act of 1998). Accessible technology may incorporate principles of universal design, and is either directly available and usable by people with a wide range of abilities and disabilities, or is compatible with assistive technology (AccessibleTech.org, 2014). Adaptive technology is a product created specifically to aid those who cannot use a regular version of a product. Adaptive technology is a subset of assistive technology and is almost solely used by persons with disabilities. Nearly 8.5% of the U.S. civilian noninstitutionalized population is considered to have disability status, including hearing difficulty (6.2%), vision difficulty (6.5%), cognitive difficulty (7.0%), ambulatory difficulty (7.1%), self-care difficulty (7.1%), and independent living difficulty (6.9%; U.S. Census Bureau, 2014). AT has emerged as an essential tool in the rehabilitation and functional self-sufficiency in this growing and often underserved population. AT tools can improve cognitive, mental, and physical functioning by allowing persons with disabilities to compensate for impairments. As such, AT has become one of the most powerful tools in assisting persons with disabilities achieve social equality (Santiago-Pintor, Hernndez-Maldonado, Correa-Coln, & Mndez-Fernndez, 2009).

FIGURE 32.1 Hierarchy of technology categorizations from most inclusive to most specific. AT solutions are diverse in form, function, technology, and cost. Not all AT is sophisticated and high cost. Simple, low-tech solutions designed to address a particular impairment are often very effective and accessible to a broad range of consumers. A sticky note may aid a patient with a traumatic brain injury to compensate for memory deficits. A thicker spoon handle may aid a person with a dexterity impairment eat more easily. AT can increase independence, improve quality of life, and aid persons with disabilities in accomplishing educational and vocational pursuits. The physical medicine and rehabilitation (PM&R) and neurorehabilitation fields have seen a dramatic increase in academic attention and scientific activities devoted to AT and innovation promoting equality among persons with disabilities. Many regional and international conferences focus on the expanding role of AT solutions. A recent learning colloquium focused on AT took place in 2012 at Johns Hopkins Hospital and the Workforce & Technology Center AT laboratory in Baltimore, Maryland. This teaching session served as a learning experience and informational session for health care providers in PM&R to acquaint them with strategies for incorporating AT into treatment arenas. Emphasis was placed on enabling people with disabilities or age-related impairments to reenter or competitively remain in the workforce (Young, Tumanon, & Sokal, 2000). On an international level, there have also been several seminal meetings, such as the 2009 International Neurorehabilitation Symposium, which have focused on emerging technologies and the critically important role of technology-assisted neurorehabilitation. Although there are an increasing number of commercial technology and fee-based "add-on" programs available to meet the needs of persons with disabilities, this chapter emphasizes emerging technologies and basic complementary computer-based commercial applications, which are commonly found as part of standard operating systems. Computer technology, including Internet applications, serves as an indispensable tool to enhance vocational reentry and personal satisfaction. This chapter has a major emphasis on profiling specific AT solutions that enhance prognostic efficacy of vocational rehabilitation programs. Job descriptions and the series of steps a patient may need to complete in-work tasks need to be sequential, simple, adaptive interventions, introduced to produce efficiency and ease of work. This simply entails users turning functions on or off, or adjusting intensities or other such settings for optimal personal use on their electronic devices. Enhancing quality of life for people with disabilities is an overarching goal of rehabilitation, and health care providers treating people with disabilities must be well versed in AT solutions to better serve patients (Stiens, Biener-Bergman, & Formal, 1997). When physical limitations and impairments hamper ADLs and functional skills, health care providers must serve as vital intermediaries to suggest solutions. DISABILITY RIGHTS LAWS: ENTITLEMENT TO ASSISTIVE TECHNOLOGY AND REHABILITATION SERVICES

In 1989, the Office of Special Education and Rehabilitative Services in the U.S. Department of Education issued a statement saying, ". . . for some individuals with disabilities, assistive technology is a necessity that enables them to engage in or perform many tasks." Since this declaration, many laws addressing AT have been passed. The Technology Related Assistance for Individuals with Disabilities Act of 1988 (P.L. 100-407) provided federal funding to states to develop training and delivery systems for AT. The Assistive Technology Act of 1998 (P.L. 105-394) was an amendment to the previous Tech Act that extended the funding to develop "permanent, comprehensive, statewide programs of technology-related assistance." The Americans with Disabilities Act (ADA) of 1990 (and amendments of 2008) prohibits discrimination against individuals with disabilities in employment, transportation, public accommodation, communications, and governmental activities, often satisfied utilizing AT. The Individuals with Disabilities Education Act (IDEA), 1990 (P.L. 101-476) and 1997 (P.L. 105-17) outlined the responsibilities of school districts to provide AT to students with disabilities. AT must be "considered" on all individualized education plans (IEPs) to determine which AT devices or services are needed in order for the district to provide the student with a free and appropriate public education (FAPE). The 21st Century Communications and Video Accessibility Act of 2010 (P.L. 111-260) updated the nation's telecommunications protections for people with disabilities, including access to broadband, digital, and mobile innovations. The Workforce Innovation Opportunity Act (WIOA) was reauthorized in July 2014 and took effect in July 2015. This law mandates that AT devices and services be utilized with vocational training and in transition to employment. Education, vocation, and rehabilitation services are increasing major sources for funding of AT. ASSISTIVE TECHNOLOGY TOOLS: PERSON-CENTERED, UNIQUE APPLICATIONS, AND UNIVERSAL INSTALLATIONS

Assistive technology tools span a large range, from simple machines to some of the most cutting-edge technology on the market today. Because of the expansive range of types and complexities of AT available, it is important for health care professionals to keep up-to-date with what can be utilized by their patients, and ways to adapt the tools for individual use. AT must be considered in context, with the patients as developing individuals within their environments of choice. Each clinician must develop their concept of each patient within their environment in order to develop a consistent routine for assessment, AT intervention, and evaluation of outcome. A concentric model of the environment (see Figure 32.2) has been designed to relate the spaces spanning from inside a person out to the natural environment, which is not altered by adaptations for personal use. Within the environment, AT acts as a catalyst for function at various interfaces between environmental sectors. A series of examples includes a heart valve within the heart guiding blood flow; a pacemaker on the surface of the heart sequencing contraction of heart chambers; and an ankle foot orthosis fitted over the calf and across the ankle levering the person up as he or she leans forward for push off in gait. In the community environment, there may be ramps for access to higher surfaces, and synthetic voices and light signals to guide pedestrians safely across the street. This constellation of AT, either applied individually and prescriptively in person-centered rehabilitation of individuals, or governmental innovations to make cities more universally accessible, work synergistically to maximize independence of persons, and create potential for participation through collaboration to contribute to society.

FIGURE 32.2 Individual person living in disablement. The sector inside the person is called the internal environment; the immediate environment is in contact with the person and travels with the person (i.e., clothes, braces, mobility devices, and communication devices); the intermediate environment includes the areas adapted for and used by the person (i.e., home and adapted vehicle); the community environment is managed by the local government and is as accessible as mandated by local law; the natural environment is unaltered and accessed as adaptive mobility solutions or trails will allow. Source: Reprinted with permission from Stiens (1998). The variety of conceptual models constructed to provide a big-picture understanding of AT intervention and outcomes are available for contemplation and comparison. Each clinician should explore descriptions of a subset of these models in order to construct his or her working model for clinical practice in order to have a vocabulary for interaction with institutions, interdisciplinary colleagues, patients, and families. Rehabilitation models illustrate relationships among measures of human performance, task completion, and societal impact. They depict relationships among current knowledge and provide a framework for consideration of new interventions, patient outcomes, and interdisciplinary strategies. Lenker and Paquet (2003) compared conceptual models examining the impact of AT. They considered models' descriptive characteristics, validation by literature, predictive characteristics, and utility to clinicians, developers, consumers, and payers. Lewin published Principles of Topological Psychology in 1936 and articulated the roots of person-environmental models by suggesting individual's thoughts and behaviors result from the interaction between the person and the environment, and the best convergence produces the best outcomes. AT was categorized in an original, comprehensive text by Cook and Hessey published in 2002. They utilized a human activity and assistive technology (HAAT) model, including three components: human, activity, and assistive technology. They included the physical environment but added social and cultural influences to define "context." The human component includes innate capabilities and acquired skills at various levels of proficiency. Activity includes tasks in three principal life roles: self-care, work and school, and play and leisure. The AT device has a human-technology interface, a processor, and mechanical linkages to produce activity output. The activity output impacts the environment and is played out in the environment, including physical and social contexts. This model successfully accounts for variance in user, skill acquisition, AT device efficiency, and the influence of the environment and culture on task performance. The multiple variables considered provide the option of attempted standardization for case analysis and research. The World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF), revised in 2001, is a very useful model. Individuals are viewed from six perspectives: body structure and function, activity, perception of activity, and participation with awareness of environmental and personal factors. Activities and participation are carried out in the environment, which includes physical and sociocultural contexts. AT devices fit in the environment as indicated to improve activity and participation. The model provides a structure to classify AT devices. This model has transformed medical, and now rehabilitation research, from a problem-in-person perspective to consideration of an entire conceptual framework with multiple variables as foci for intervention and assessment (WHO, 2001). Such models provide an abstraction of the actual system providing variables that remind us to assess when planning AT intervention and to watch as AT implementation progresses in order to expect, facilitate, and recognize improvement in patients' participation, for example. Universal Design: Adaptations to Maximize Function in Community Use Global application of AT can be achieved through universal design, which is the process of designing products and spaces in a way that is accessible to the widest range of people possible (Rogers, 2015). Ronald Mace coined the term in 1997, and collaborated with architects, product designers, engineers, and environmental designers to develop the seven principles of universal design: equitable use, flexibility in use, simple and intuitive use, perceptible information, tolerance for error, low physical effort, and size and space for approachable use. This differs from mandates set forth by the ADA in that the ADA standards are the bare minimum design adjustments required to curb discrimination against people with disabilities, whereas universal design strives to make things safer, easier, and more convenient for everyone, regardless of disability status. For example, a ramp constructed next to a set of stairs may make a business ADA compliant, while a universally designed business might not have stairs at all, but rather a smooth, wide ramp entrance. Everything can be universally designed, from door handles to smartphones, and even teaching methods. Everyone benefits from universal design because it takes into account the full range of human diversity, including physical, cognitive, and perceptual differences, as well as differences in body shapes and sizes (Rogers, 2015). In 2012, Steinfeld and Maisel created a list of goals to complement the principles of universal design, including body fit, comfort, awareness, understanding, wellness, social integration, personalization, and cultural appropriateness. Simple Machines: Low Tech, High Impact Not all AT is brand new and high or complicated tech. The greater goal of ATto promote greater independence through enabling people to perform tasks that they were previously unable to docan often be handled quite well with simple machines. Wedges, for instance, can be great positioning aids. Wedges are also utilized in the form of ramps, to lift people who cannot navigate steps or uneven surfaces. Wheels are another example of important AT, particularly for people who may need mobility assistance or aid in moving objects that would otherwise be too heavy. Levers are used as door handles and as joysticks, which are easily manipulated and can give input to other devices. Pulleys are often utilized for positioning or to complete strengthening exercises. Simple machines were some of the earliest tools utilized by humans. Many contain components of universal design, and are still extremely helpful in aiding people with disabilities and able-bodied people alike. The Computer Age: A Renaissance in Enablement This chapter would not be complete without a brief discussion of new frontiers and novel horizons in the field of AT. Undoubtedly, the emergence of new and unique computer, Internet, cyberspace technology, and program applications has revolutionized accessibility for people with all types of disabilities. It is estimated that more than 277 million Americans (87%) currently use the Internet (Internet World Stats, 2014). The computer revolution resulted in a growing commitment of rehabilitation providers and their patients to successfully deploy technology to creatively accommodate impairments (Young et al., 2000). The global proliferation of desktops, laptops, notebooks, tablets, E-readers, personal digital assistants (PDAs), smartphones, and various other forms of technology has been met with a simultaneous increase in the number of persons with disabilities who use these devices for a wide range of purposes. Some of these include social (establishing friendships, relationships, and support); medical (providing data and information about conditions and treatment options, and telehealth, which is the act of seeing a clinician for a visit entirely on a computer screen); personal and household (accomplishing daily activities, such as shopping and ordering meals); psychological (providing access to resources); and vocational (optimizing employment outcomes and possibly securing home-based work) purposes (National Council on Disability, 1993). Microsoft, Apple, Google, and other manufacturers have web pages dedicated to accessibility for their operating systems and devices (see Microsoft Accessibility: www.microsoft.com/enable; Apple Accessibility: www.apple.com/accessibility; Google Accessibility: www.google.com/accessibility). With the maturation of cyberspace, cell phone technology, and the introduction of new services and innovative applications, many new programs and imaginative products originally intended for the general public have proven to serve as a viable means of accommodation for persons with disabilities. Voice dictation is now widely available on Android, iPhone, and iPad. Users speak what they want dictated, including punctuation, and the device converts it to text. Voice dictation is also available for languages other than English. Composing and sending text messages, e-mails, and files by voice may be of benefit for persons with physical impairments of the upper extremities or visual impairments (see www.howtogeek.com/177387/use-voice-dictation-to-save-time-on-android-iphone-and-ipad for voice dictation instructions for your device). Built-in "personal assistants" on smartphones are also a beneficial form of AT, sending messages, placing calls, searching the web, adding appointments, finding directions, and much more, all through voice command interactions with the user (see support.apple.com/en-us/HT204389 for Apple's Siri; windows.microsoft.com/en-us/windows-10/getstarted-what-is-cortana for Windows' Cortana; or www.google.com/landing/now/#howtogetit for Google Now). In addition to the built-in personal assistants, many apps provide alternative options that differ in settings and interface. With so many options and settings available through operating systems and apps, it really comes down to user preference and frequency of upgrade path possible for the individual and his or her budget. Cutting-edge research developments recently spawned the growth of a new generation of AT, which successfully deploys robotics controlled by a neural-computer interface. Neural interface systems (NISs) have garnered much attention in the past few decades and represent a unique approach to restoring function and to managing nervous system disorders. NISs are devices placed into neurological tissue, such as the brain, which record and/or stimulate the tissue through electrode sites. Unfortunately, there are several issues with the current NISs, including poor reliability and degradation of the implant over time, and tissue trauma at the implant site (Anderson et al., 2015). Examples of currently used NISs include cochlear implants (CIs) for restoration of hearing, which came about in 1984, and deep brain stimulators (DBS), which began to be used in 2000, to attenuate tremor in patients with Parkinson's and other movement disorders (Pea et al., 2007). Motor cortex-based NISs that produce robotic motor movements in patients with tetraplegia and other paralytic states are in the early stages of development, and show tremendous promise as a new neurotechnology (Donoghue et al., 2006). Chou et al. (2015) have been working with a closed-loop neural interface to enable bidirectional communication between the biological and artificial parts of a hybrid system. This technology holds promise for increased performance of future NISs. Another piece of cutting-edge AT being developed is brain-machine interface (BMI). BMI systems are able to infer user intent from neural data and transform it into output to control screen cursors, prosthetics, orthotic devices, and so forth, in real time (Venkatakrishnan, Francisco, & Contreras-Vidal, 2014). Important methods that need further development include training users to produce consistent electroencephalogram (EEG) signals and providing accurate EEG signals under subject-specific conditions. Signals are processed including incorporation of context and language information designs, and as with all AT, tailored to individual users (Akcakaya et al., 2014). Social Media: An Environment That Neutralizes Disabilities Since its inception in the late 1990s, use of social media has exploded. People of all ages from all over the world are utilizing social media. Some easy guidelines to remember are to use styles that help screen readers navigate content in the correct order, refrain from setting type in smaller than 12-point font, and make sure every picture has a caption that accompanies it and adequately describes it. Several accessibility checkers exist on the World Wide Web. In 2011, Dr. Scott Hollier, a researcher with Media Access Australia and The Australian Communications Consumer Action Network (ACCAN), set out to analyze the accessibility of social media and provide practical guides for social media use and how to overcome accessibility issues for some of the major forms of social media (Facebook, LinkedIn, YouTube, Twitter, blogging, and Skype). Major themes include the benefits of persons with disabilities to have access to personal, social, professional, educational, and entertainment resources without having to navigate difficult physical or social terrains. Overviews of practical tips and tricks users have used to make the different platforms more accessible are provided. Hollier's full report can be downloaded here: www.mediaaccess.org.au/web/social-media-for-people-with-a-disability The Virtual Self: Living Other Lives Independent of Impairments Recent attention has been drawn to the experiences of people with lifelong disabilities and their presence in virtual worlds as avatars. Such experiences provide out of body lives in separate prosthetic environments. Avatars can be created with and without visible disability, allowing people to disclose as much or as little as they choose about their disability status as they interact with others embodied in the environment. In 1998, Witmer and Singer created a presence questionnaire (PQ) to measure presence in virtual environments and an immersive tendencies questionnaire (ITQ) to measure different tendencies in the experience of presence. Stendal, Molka-Danielsen, Munkvold, and Balandin (2012) looked at this phenomenon through the lens of embodied social presence (ESP) theory and found users felt a sense of connectedness with others, and experienced users felt a strong connection with their avatars and had an understanding that other humans are represented by their avatars as means for visual and simulated physical encounters for communication. This form of interaction allows people with disabilities to present themselves in ways that may avoid their insecurities and the biases present in the real world. ASSESSMENT OF THE PATIENT: PERSON-CENTERED APPLICATIONS

AT can be useless if it is not adapted for the use of the specific individual (Stiens, Shamberg, & Shamberg, 2008). Prosthetics need to fit appropriately, technological innovations need to be understood and easily managed by the user and hearing aids need to be adjusted to the perceptual needs of the user. Even if a similar device is being used with multiple patients, the specific user's personal needs and life aspirations are of the utmost importance in the choice and customization of AT. Fit and settings vary widely from one user to another. Person-centered application plays a vital role in the utilization of AT. There are a number of interventions and strategies that may be used to aid in the successful application of AT. Physicians, occupational therapists, and biomedical engineers can work with individuals to ensure appropriate fit or settings on prosthetics and perceptual aids. Physical and occupational therapists can aid in the proper utilization of AT devices for clinical purposes and make referrals to other providers for topics outside the clinic's scope. Psychologists, counselors, social workers, and palliative care teams work with patients and families to elicit values, develop goals, and seek resources for procuring and paying for AT devices (some pertinent resources can be found at resnaprojects.org/statewide/resources.html and www.rmmor.org). It is extremely important for these health care professionals to work together and with the patient to provide the most efficient care possible and have the best practical outcomes. In the past two decades, shared decision making (SDM) has become an important model for patients, families, and health care providers to communicate and determine the best treatment plan for the individual. The provider brings clinical evidence, the patient and family bring personal values, and a discussion of clinical risks and benefits, quality-of-life considerations and ethical considerations allows for informed, collaborative decisions to be made (Nelson & Mahant, 2014). It is important to remember that these discussions may need to be repeated and adjusted as treatment progresses, and that other health care professionals that the family trusts can be added to the decision-making team. Counselors, social workers, or palliative care teams may help the family consider hopes and concerns around both daily living and the broader picture; understand family structure, support and finances; and possibly even be able to link patient families to other families and resources, such as listservs, blogs, or online support groups, for support and discussion. SDM lends itself well to overall patient and family satisfaction, and can be particularly useful with elderly, pediatric, or incapacitated patients whose families may have a larger role in the decision-making process. AT evaluation and implementation are subcomponents of the process of rehabilitation. Rehabilitation is the process of development of a person to his or her fullest physical, psychological, social, educational, and vocational potential by eliminating or compensating for any biochemistry/pathophysiology, systemic impairment, activity limitation, or environmental barrier (Stiens, O'Young, & Young, 2008). The purpose of the AT assessment is to determine the specific equipment and services needed to help the patient meet health and functional life goals. The process can begin the first phase with a consult from a physiatrist, or by recognition of need by an allied health clinician. Assessment should be driven by the therapist or clinician most familiar with the problem (impairment, disability, or participation barrier). Patient and family interviews provide sufficient information for identification of impairments, task limitations, and participation barriers that prevent essential life roles and personal passions. Specific target activities are identified, such as attendance at school when at home or on required bed rest. Specifications are defined, such as computer keyboard control, adjustable gaze in the classroom, and sufficient voice volume to be heard in class. The second phase begins with device trial and training. The patient, family, and attendants trial screen options for telepresence starting with Skype and Facetime, and continuing to robotic options that can be driven through the classroom. The clinician must carefully match and adapt each device for ideal trial, and provide a perspective for the amount of training or practice required to achieve best proficiency. The aim is to design a match that will achieve training to acceptance and efficient functions used to meet person-centered life goals. Abandonment can be prevented with attention to patient characteristics, environmental factors, and AT device technology (Galvin & Scherer, 1996). Environmental factors need to be addressed with intensive training in environment of use, minimization of obstacles, and establishment of a sound financial plan. AT device specifications need to meet functional performance. There must be compatibility with user capabilities, sufficient training, dependability, usability, and aesthetics. Patient-centered characteristics must include minimal needs, activity prioritized by high motivation, fluctuation in strength, daily schedule, and lifestyle, assistance available to sustain device use, self-esteem, status, and independence associated with device use. IMPAIRMENT-SPECIFIC ASSISTIVE TECHNOLOGY: UNIQUE APPLICATIONS

Motor and Dexterity: The Human Path of Ambulation and Manipulation According to the U.S. Census Bureau (2014), 7.1 % of the population has ambulatory difficulty. Increased motor impairment in the aging population, and returning war veterans who have experienced traumatic injury, are two populations increasingly utilizing mobility AT. Although voice-recognition technology is often useful in helping motor- and dexterity-impaired patients meet their needs, many of these patients prefer to initially use whatever residual dexterity and motor functioning they have. In addition, patients with quadriplegia, stroke, amyotrophic lateral sclerosis, amputations or cerebral palsy can benefit from using environmental control units (ECUs), more broadly described as electronic aids to daily living (EADLs). ECUs are apparatuses that control household systems and devices, such as lamps, televisions, telephones, and alarm systems. Similar to television remote controls, they are typically switches manipulated by the lips, chin, eyes, or other body or muscular movements. One such method, sip-and-puff (SNP), sends signals to a device using air pressure: "sipping" (inhaling) or "puffing" (exhaling) on a straw, tube, or wand. Examples of such ECUs using SNP include doors equipped with electronic openers, electronic locks, coffee makers, lights, call buttons, and TV sets controlled by switch control. It is common for these ECUs to be in place in the home setting, and workplaces can also utilize them to appropriately accommodate employees with motor or dexterity impairments. Persons with disabilities or elderly persons with mobility issues can often benefit from AT that assists with ADLs. AT devices like the Roomba, Scooba, and Braava, which use sensors to navigate floor space and vacuum, scrub floors and mop with the push of a button, provide accessible cleaning options. A similar device, the Mirra, cleans pools. This robotic technology doesn't just assist, but actually completes tasks independently, allowing people to save valuable time and complete other tasks. Computer Use Dexterity impairment and difficulty with coordination are caused by a number of neurological and musculoskeletal conditions, including stroke, carpal tunnel syndrome, arthritis, cerebral palsy, Parkinson's disease, multiple sclerosis, loss of limbs or digits, spinal cord injuries, and repetitive stress injury, among others. In their book, Physical Disabilities and Computing Technologies: An Analysis of Impairments, Sears and Young (2003) comprehensively survey health conditions that induce impairments affecting computer use. A new and evolving generation of AT has facilitated the use of computers by people with motor or dexterity impairments. The Microsoft and Apple accessibility web pages have sections that specifically address dexterity and mobility impairments. These highlight settings that can be adjusted on devices, such as keyboard shortcuts and mouse keys. People with motor or dexterity impairments often encounter difficulty using standard "hands-on" input items such as the keyboard, mouse, or track pad. Several hardware and software alternatives or enhancements are available. A chin mouse, a headset that generates a radio signal, an eye-gaze unit, a mouth stick, or other hands-free signaling units can aid users with independent computer access. There are also frames that fit over a keyboard that help reduce errant keystrokes. Other physical interventions include adjusting settings on a programmable mouse or keyboard guard to best suit the user. Individuals who have little or no use of their hands need on-screen keyboards with user-selectable functions. The user selects the keys with a mouse, touch screen, trackball, joystick, switch, or electronic pointing device that allows the user to control his or her computer entirely without a keyboard. Keyboard filters include typing aids such as word prediction utilities and add-on spell-checkers. This technology reduces the minimum number of keystrokes and enables users to quickly access letters and avoid selecting the wrong keys. Touch screens are devices placed on the computer monitor (or built into it) that allow direct selection or activation of the computer by touching the screen and completely eliminate the need for a mouse. Brain-machine interfaces are also being explored for this medium (for a comparison of hands-on versus hands-free modes of computer-related AT for people with motor impairments, see Table 32.1). Software-Based (Operating System) Adaptations: Keystroke Modifications In addition to input devices, there are various software-based adaptations to help people with motor impairments operate computers more easily. For instance, the Microsoft filter key feature blocks repeated keystrokes, ignores rapid or extraneous keystrokes, and slows down repeated key rates. This enables quick access to letters and helps users avoid inadvertently selecting the wrong keys. The filter key feature can help patients suffering from chronic neurological disorders such as parkinsonism or other conditions that manifest symptoms such as tremors, stiffness, or poor coordination. Voice-to-text software, such as Dragon Naturally Speaking, also assists these users, especially in initial stages of progression. Individuals who are mobile and lucid, but experiencing significant tremor or varying levels of speech acuity, are good candidates for this technology. They want to make the most of the functional capacity they have at any given moment. TABLE 32.1

HANDS-ON VS. HANDS-FREE ASSISTIVE TECHNOLOGY AT INPUT MODES

Hands-On Hands-Free

Keyboard Sips and puffs (SNP)

Mouse Head movement

Joystick Eye movement

Trackball Foot movement

Touch pads Switches manipulated by other body parts

Touchscreen Brain-machine interfaces (BMI)

Spelling-prediction software is a good example of universally designed AT, making things like texting quick and convenient for users of all abilities. When using spelling-prediction software, a list of predicted words appears as each key is typed, in the hope of finishing user words in the least amount of keystrokes. The software also predicts the next word (word prediction) and offers abbreviation expansion and speech output. Spell check is another feature of spelling prediction software, reducing the number of keys typed and improving word accuracy. Visual: Acuity Enhancement, Auditory Cues, and Tactile Compensations Auditory stimuli are often valuable for persons with vision impairments. Listening to audiobooks or to radio stations that broadcast readings are two viable forms of AT. Various read-aloud devices, including watches, clocks, thermostats, calculators, microwave ovens, money identifiers, compasses, toys, dictionaries, e-readers, and medical devices such as thermometers, scales, sphygmomanometers, and glucometers, are all valuable tools that aid in ADLs, medical, recreational, vocational, and educational activities. For people with low vision, many magnification options, including handheld optics and monocular glasses, are available. For greater magnification, closed circuit television (CCTV) or software may be used to magnify and enhance images and text for those with residual vision. CCTVs are readily available in a variety of formats, including smaller handheld cameras, self-contained units with folding flat screens, and virtual-reality helmets. Braille technology combined with voice applications promotes self-sufficiency in ADLs, such as walking and wayfinding. A new AT system has been designed to aid vision-impaired people in wayfinding through the use of a camera cell phone, to find and read aloud specially designed signs in the environment. These signs are wayfinding barcodes marked with simple color patterns (targets) that can be quickly and reliably identified using image-processing algorithms running on the camera cell phone (Coughlan & Manduchi, 2007). Another approach is the application of Braille or other tactile markings on items such as thermostats, telephones, rulers, clocks, calendars, ATM machines, and keyboards. Computer Use Persons with visual impairments using a computer with a QWERTY keyboard layout can obtain output through the use of screen-reader software, which provides computer-synthesized voice output. For those who prefer to obtain Braille output, refreshable Braille displays are available. This display, which is hardware that is attached to a computer, receives messages from the computer through screen translator software and presents these messages to the user in Braille. The Braille display updates as the user moves the cursor on the computer screen. Screen color configurations, screen magnification, and cursor enhancements can also be altered and utilized to match the requirements of computer users with vision impairments. Several screen magnification programs, most significantly Zoom Text, offer a connected speech component that supplements the visible text with voice interpretation. Persons who are blind or visually impaired often benefit from using text-to-speech software, such as JAWS or NVDIA, which read aloud the text that is on a computer screen. A host of solutions are also available to make a keyboard and mouse easier to use, or completely eliminate their use for those who are completely blind. A user can dispense with mouse and keyboard altogether by typing on screen and by using speech recognition software. A growing number of Certified Vocational Rehabilitation Programs throughout the United States, including the Workforce & Technology Center in Baltimore, Maryland, have pioneered technology programs for blind patients seeking to mainstream back into the workplace using these technologies and strategies (Young, Desai, & Young, 2009). Considerations for Patients With Diabetes In the acute inpatient rehabilitation setting and in the subacute and outpatient arenas, diabetes-related visual impairments often become obvious to the clinician. For those diabetic patients identified in the rehabilitation setting who do not have visual disturbances or other forms of secondary diabetic complications, the rehabilitation team can play an essential preventive and educational role in averting the long-term consequences of the disease. However, if the disease has progressed such that a diabetic patient experiences serious visual impairment, the job of the physicians becomes much more challenging, and disease management becomes more complicated. The blind diabetic patient poses a special rehabilitation challenge because of the critically important goals of balancing optimal management of glycemic control (maintaining sugars at a normal level) and increasing the ability to perform essential ADLs, thus improving overall functional status. Blind diabetic patients who live alone often encounter problems reading standard glucose meters. This may lead to worsening of complications of many diabetes-related conditions. It is important to understand the relevance of vision-related problems in diabetic patients and the respective challenges they pose for physicians and caregivers alike. A better understanding on the part of physicians can enhance their ability to provide better care and more thorough chronic disease management for this population. Devices like talking glucometers "speak" blood glucose concentrations, time, date, and historical blood glucose levels. Use of this device has revolutionized the lives of diabetic patients with vision impairments and other disabilities. For a vision-impaired diabetic patient who does not have access to help from others to monitor blood glucose, a talking glucometer can provide essential assistance. The talking glucometer is one type of AT that should be introduced as part of comprehensive management of diabetes-related vision impairment. Auditory: Amplification, Translation to Text and Visual Cues According to Blackwell, Lucas, and Clarke (2014), in their research for the National Center for Health Statistics, over 15% of U.S adults have some sort of hearing trouble without the assistance of a hearing aid. Hearing impairments, represented by a wide range of conditions from mild hearing loss to deafness, are often discovered on the rehabilitation unit or in the outpatient PM&R setting. Although the incidence of hearing impairments is higher among older individuals, no age range is excluded. Presence of auditory impairment may impede the rehabilitation process, and can severely decrease work productivity and efficiency in the occupational setting if unaddressed. Deafness is broadly defined as "a hearing impairment that impairs the processing of linguistic information through hearing, with or without amplification." Deafness can be viewed as a sensory state that prevents an individual from receiving sound in all or most of its forms. In contrast, "hearing loss" implies an impaired ability to sense sound but with some level of responsiveness to auditory stimuli, including speech. Amplification devices, such as hearing aids and amplification telephones, have long been the mainstay for people with hearing impairments (Ross, 2008). However, hearing aids can be incapable of providing adequate assistance in certain situations, like noisy environments. In such situations, hearing impairment may instead be remedied by use of directional microphones or devices based on induction loops, infrared, or frequency modulation. These devices make events such as watching movies, meetings, and seminars more accessible. An alternative AT solution is TV monitor closed captioning, which is mandated by the Federal Communications Commission for TV programs from video programming distributors, and can be utilized by other media as needed. Many AT devices are available to aid deaf people in common daily activities. These include signals that utilize senses other than hearing, such as flashing lights and vibrations, to alert of ringing phones, doorbells, smoke detectors, and alarm clocks. Vibrating watch alarms and pagers are other valuable assistive technologies for those with hearing impairments. Some people with hearing impairments, while unable to hear spoken words, may still be able to hear sounds. This should be taken into account when recommending appropriate AT. Computer Use With the prevalence of technology in modern society, it is important to understand the various challenges computers present for people with hearing impairments, and what clinicians, caregivers, and patients can do to overcome these challenges. Add-on software, allowing users to adjust volume and other sound options, enables computer users with hearing impairments to set settings that fit their individual needs, or receive information visually. Various software companies, including Microsoft and Apple, manufacture products that enhance computer accessibility for hearing-impaired and deaf people. Audio alerts can be replaced with visual alerts. Physicians and therapy teams can suggest some of these features to facilitate smoother use of computer operating systems for patients with hearing impairments. Some patients, particularly older individuals, may benefit from a referral to occupational therapy or community-based services for assistance in setup and use of newer technological interventions. Telecommunications State or federal funds support telecommunications relay service (TRS) for persons with hearing or speech disabilities. Some common forms of TRS are text-to-voice (TTY), voice carryover, and video relay service (VRS). Communication assistants (CAs) are intermediaries who facilitate the calls. TTY is the "traditional" form of TRS in which a person with a hearing disability communicates by text to the CA, who voices the messages to a hearing recipient and then responds what was said in response via text. However, with advancements in technology, this medium is becoming used far less frequently. Voice carryover allows a person with a hearing disability to vocalize outgoing messages while receiving responses via text from a CA. VRS allows persons who communicate in sign language to communicate with a CA in ASL who speaks what is signed to the called party and then signs back to the caller what was said. Persons who cannot speak may benefit from using synthetic speech software, which generates speech produced by an electronic synthesizer activated by a keyboard. Currently, programs such as Facetime and Skype enable people who communicate in sign language to communicate through video stream. Many of these programs are free and Internet-based, making them convenient and highly utilized forms of communication. Hearing With Visual: Utilizing Hybridized AT and Tactile Cues People with both hearing and vision impairments are sometimes referred to as being deaf-blind. Many of the technologies helpful to people with individual sensory impairments also apply to the deaf-blind population. However, adaptations are necessary. For example, telephone access can be optimized through the use of TTYs with large print capability. Amplification phones equipped with Braille markings may assist people with partial residual hearing (Fellbaum & Koroupetroglou, 2008). Computer operating systems can be adapted to enable those with visual or auditory impairments to enjoy unconstrained computer usage. Apple, Google, Microsoft, and others provide resources for this rich and varied area. Devices in the home and workplace can attract the attention of people who are deaf-blind to inform them of particular environmental circumstances. Alarm clocks equipped with crystal and tactile markings or pillow alarm shakers alert users who would otherwise be unable to hear or see standard alarms. Devices can use assertive vibration, scents or fan-driven air to alert of a telephone ringing or a smoke detector sounding. Given the prevalence of visual and hearing impairments of patients treated with rehabilitation, it is critical for clinicians to understand the impact these disabilities have on the long-term well-being of their patients. With the goal of promoting better case management, clinicians can use AT as the instrument to assist in improving the quality of life of a deaf-blind patient. Cognitive: Multimodal Learning Methods, Cueing for Productivity, and Monitoring for Safety Approximately 7.0% of the U.S. civilian noninstitutionalized population has cognitive difficulty (U.S. Census Bureau, 2014). People with cognitive impairments include but are not limited to those with learning disabilities, psychiatric disabilities, Alzheimer's disease and other dementias, and traumatic brain injury. Cognitive impairments are often overlooked in the evaluation for AT; however, AT proves quite beneficial in providing aid and independence for patients experiencing difficulty with abstract thinking, decision making, long- or short-term memory, learning skills, perception, coordination, or concentration (Disability Rights New Jersey, 2015). AT utilizes the skills patients with cognitive disabilities have in order to offset skills they do not possess (Iowa Center for Assistive Technology Education and Research, 2015). AT is being highly utilized with student populations with cognitive impairments in the educational setting. Low tech AT, such as color-coding systems, can be used as organizational tools. Higher-tech solutions, such as speech recognition software and scan-and-read programs, can aid students with dyslexia and a host of other learning disabilities. Universal design for learning (UDL) consists of instructional approaches that incorporate multiple forms of materials, content, tools, context, and supports that allow students choices and alternatives that best suit their learning needs (Izzo & Bauer, 2013). Apps for tablets, speech-to-text programs, and other technologies are being integrated into IEPs (an "IEP" is an individualized educational plan customized and designed to meet the educational needs of persons with disability), 504 plans (a 504 is a civil rights safeguard that seeks to remove barriers from participation and facilitates students with disabilities to pursue educational opportunities no different than an able-bodied person). UDL methods often meet IEP objectives and also provide many benefits for the general education population. An estimated 5.3 million Americans had Alzheimer's disease in 2015, including one in nine people aged 65 and older (Alzheimer's Association, 2015). AT can be very beneficial for this population, supplementing human caregiving and fostering independence. Three pertinent goals of AT for cognition include providing assurance an elder is safe and performing ADLs, and if not, alerting caregivers; assisting with ADLs and providing compensation for impairments; and assessing an elder's cognitive status (Pollack, 2005). Assurance systems, such as sensors and monitoring systems, are currently available as commercial products; compensation systems, including navigational systems and schedule management, continue to be researched; and cognitive assessment systems that can be performed outside the clinical setting are emerging. Performance of ADLs within the home environment of aged persons (with and without Alzheimer's) is an essential requisite for independence. Home environmental skills and tasks, often taken for granted during earlier life, now frequently become an impediment to independent living. An example of this is home environmental maintenance, including custodial and cleaning tasks. The advent of robotic technology has mitigated this potential impediment. Service robots are a distinct category of functional automated technology that is designed to perform a precise task. Robotic cleaning products, such as the Roomba, provide automated robotic assistance to elderly people living alone. The Roomba is an example of a service robot in a domestic environment that vacuums the floor automatically (Forlizzi & DiSalvo, 2006). Improving socialization skills among Alzheimer's patients can also be optimized with AT and robotic technology. PARO is an advanced interactive robot that advances the benefits of animal therapy with aged patients in environments such as hospitals and extended care facilities. PARO is an example of a robotic animal (panda), which promotes interaction and social discourse among citizens with Alzheimer's disease. Burton (2013) examines the benefits and disadvantages of animal treatment modalities for persons with neurologic disorders. CONCLUSION: IDENTIFYING IMPAIRMENTS, PRESCRIBING INDIVIDUALIZED AT, AND RECOGNIZING EMERGING USEFUL TECHNOLOGIES

The coming of the computer age and the revolutionary array of Internet technologies have enabled persons with disabilities to optimize quality of life now more than ever through creative accommodation (Young et al., 2000). While the practice of medicine and the domain of PM&R have traditionally emphasized healing and rehabilitation through physical, pharmacological, and psychological interventions, the rehabilitation process often requires another critical, yet overlooked componentevaluation for and provision of assistive technology. This chapter has attempted to provide a comprehensive overview of available and emerging technologies that provide persons with disabilities the opportunity to further their rehabilitation process through accessibility and accommodation. After reading this chapter, we hope you have gained an understanding of the breadth of AT available for a variety of disabilities, and will seek out further and more specific knowledge as it applies to your own patients. AT has the potential to help people with disabilities function personally and professionally, and as health care providers, it is vital to be informed about different modalities, and assist patients in choosing, procuring, and funding AT that will benefit them the most.

In considering AT (Assistive Technology), what interests you the most? Have you a seen a device that you think is impressive, neat or would be amazing to have in your "took kit" for clients or patients? If so attach a link, provide information, or tell us what you have found.