| | Tub benches for people with spinal cord injury: luxury or necessity?☆☆☆
Rehabilitation case managers are concerned about making cost-effective choices that benefit patients. Decisions about adaptive equipment or assistive technology may generate such questions as which devices are really needed, which will be used and for how long, which are luxuries for patients, and which are best for which clients.
Providers, on the other hand, often are frustrated when patients are denied equipment that they view as a necessity. Given the expenses of rehabilitation and the complex needs of people with spinal cord injuries (SCIs), decisions about simple bathing equipment are relatively low in priority, and little data can be found to guide case managers' decisions. Nonetheless, patients find the everyday tasks of life and their participation in regular routines, such as bathing, very important.
This study was spurred by a single occupational therapist who persistently asked whether tub benches are luxuries or necessities for people with spinal cord injuries. This study provides a model of how to investigate that and other questions of necessity and use of equipment.
Background  Assistive technologies are defined as equipment that helps an individual carry out a functional activity,1 often with the intent of increasing independence. If assistive technologies increase independence for people in rehabilitation, case managers need to know who benefits from what type of assistive technology to make cost-efficient, consistent, and high-quality decisions. People faced with a physical inability to do a self-care task have 5 rehabilitation options: restore function, build compensatory skills, use assistive technology, change the task or task expectations, or accept physical assistance from another person.2 To illustrate these options, the person with an SCI who needs to take a bath could seek medical help to restore function (in this case reduce paralysis) or develop compensatory muscular strength to independently shower or bathe. Given a stable level of restoration, this person could use a tub bench or shower chair to increase her independence and compensate for muscular weakness and balance impairments. She could take a sponge bath and eliminate transferring into a standard bathtub or shower altogether, or she could rely on another person to transfer and bathe her. The bathing choices for people with SCIs, after paralysis is reduced and strength is maximized, usually are limited to the last 3. Historically, studies concluded that assistive devices were needed early in rehabilitation, but many devices were discarded when strength increased or when they were inconsistent with the person's postrehabilitation lifestyle.3, 4, 5 Garber and Gregorio6 found that only 45% of equipment prescribed for people with quadriplegia from SCIs (n = 56) was still used after the first year of rehabilitation and 35% was still used 2 years after rehabilitation. Forty-five percent of participants discarded the equipment because of improved physical function; another 45% discarded it because they found alternative solutions. Nonetheless, participants continued to use more expensive devices, such as orthotic equipment, slings, or communication devices, and discarded less expensive grooming and feeding devices. Among the elderly, the rate of continued assistive device use ranged from 70% to 89%7; satisfaction with assistive devices was also high, ranging from 87% to 91% among those who expressed strong satisfaction.8 For people with SCIs, the use of a tub bench or shower chair is indicated to promote independence in bathing or ease caregiver assistance.9 A survey of 800 members of the Paralyzed Veterans of America found that 63% used a tub bench and 72% were satisfied with the device.10 A tub bench or a shower chair is a seat-like piece of equipment that may or may not have a backrest, wheels, cutout seat for toileting, suction cups for the tub, arm rests, and multiple other options. These devices are called various names in the literature; to simplify the discussion here, we will refer to all these devices as tub benches. Bathing devices have been specifically studied by Mann and his colleagues.7, 8, 11 Bathroom equipment was the third largest group of equipment used by people with arthritis,8 and tub benches were the third most common device used by adults with disabilities.12 Although people with disabilities desired to have grab bars and bathroom equipment more than most other devices, they reported that the devices were too expensive and not reimbursable under third-party payment systems; more than half purchased devices with their own out-of-pocket funds.7 A greater tendency to use assistive technology was associated with a higher quality of life and fewer depressive symptoms13 and a sense of autonomy and psychologic well-being.14 This previous research suggests that bathing devices are desired by many with disabilities and that people with SCIs often use a tub bench. Nonetheless, most third-party insurers do not consider bathing devices as a medical necessity and therefore do not cover it. The effects of owning or not owning a tub bench had not been studied among people with SCIs. The purpose of this study was to examine the use of tub benches by members of this population who were beyond acute rehabilitation and living in the community. We reasoned that people with SCIs who have an appropriate tub bench might be more independent in bathing, have fewer skin sores, require less caregiver assistance, and have a higher overall quality of life. Because insurance reimbursement often is unavailable for such devices, we also reasoned that only half of our sample would own a tub bench. We wanted to describe the bathing devices and processes used by people with SCIs, their satisfaction with these devices, the method by which they obtained these devices, and training in their use. In addition, we wanted to compare owners and nonowners of tub benches on the amount of assistance required for bathing, skin sores, a variety of other measures, and overall quality of life. Methods Participants Participants were individuals who received services through an SCI follow-up clinic in a nationally known Midwest rehabilitation center. Participants all had a C5 (cervical injury at fifth vertebrae) or lower SCI or an incomplete injury. People with a complete C4 or higher injury were not included because they are likely to be very dependent in all self-care, even with assistive technology. All participants completed at least 1 inpatient stay in a rehabilitation hospital. Measures Participants completed a brief demographic data sheet to describe their age, general characteristics, current living status, and employment. A survey was designed for this study with the categories of outcome measures suggested by DeRuyter15 and Smith,16 such as cost, frequency of use and repair, additional assistance, training, and perceptions. Other questions were added based on findings from previous studies and our own research hypotheses. Several versions were developed and briefly piloted with a few clients, therapists, and university faculty to improve readability and scaling. The survey was composed of closed-end questions that could be answered by using circles or checks, enabling people with SCIs to complete this independently or with minimal assistance. The scale was devised by using interval data (eg, the number of bedsores rather than categories) when possible and a 5-point scale for ratings of satisfaction and other perceptions. The final measure was a 34-item survey with some questions specifically for those who owned a tub bench and others specifically for those without one. The Quality of Life Rating is a 20-item self-report instrument that uses a 5-point scale to measure perceptions of the quality of life aspects compared with expectations. Total scores range from 20 to 100, with higher scores indicating higher perception of quality of life. The Quality of Life Rating has an internal consistency alpha level of 0.87 and correlations with measures of satisfaction with life of 0.65, supporting both reliability and construct validity.17 The total score was used in this study to measure global perceptions of quality of life. Procedures People with SCI were approached and asked to participate in the study by the third author of this article when they were at the SCI clinic for a follow-up visit. They completed the survey while waiting for their appointment or other tests. Individually designed modification, most often assisting with recording the responses, allowed all interested individuals to participate. Data analysis and use Descriptive statistics were generated for all participants and then for each group—owners and nonowners of a tub bench or shower chair. Chi-square tests of distribution and 1-way analysis of variance (ANOVA) procedures were used to test the significance of between group differences on select items. Results Thirty-nine people with SCI participated in the study: 33 were men, and 6 were women with an average age of 39 (range 16-55); 89.7% (35) were white. All participants lived in the community and were not hospitalized at the time of the study. Education level varied from third grade to a graduate degree, with an average of a 12.5 grade level of education. Nineteen (48.7%) were single, 10 (25.6%) were married, and the rest were divorced or separated. Eight (20.5%) lived alone; the rest lived with their family, spouse, or another individual. Eighteen (46.2%) were unemployed, and 5 did not complete this item. An average of 48.9 months had passed since their injury (range 2-176 months). The level of SCI and the functional use of arms and legs are displayed in Tables 1 and 2.
Findings for tub bench owners Twenty-nine participants reported owning a tub bench with a range of ownership from 2 months to 176 months (median 24 months) and an average of 43.36 months. Insurance reimbursed the cost of the tub bench in 12 cases (41.4%); the other 17 owners paid for this themselves or received it as a gift. Other findings about tub bench owners were these:
•Twenty-five (86.2%) purchased the chair through a medical supply store.
•All women owned a tub bench.
•Five individuals were competitively employed full-time, and 5 were full-time students.
•Respondents were asked the cost of their tub bench in both dollars and categories: 41% reported that the bench cost between $50 and $100, and another 41% said theirs cost more than $150. The average cost for the 9 who wrote a specific price was $450 (range $75 to $1400).
•Eight (28%) used their tub bench for both bathing and their bowel program.
•One respondent had never used it. That person had an incomplete C6 injury with little loss of either upper extremity or lower extremity function, was unemployed, used a manual wheelchair, and showered in a tub.
•Sixty-seven percent used their tub bench or shower chair at least once per day. The others used their chair on a varying daily schedule, with only 1 person using it only once per week.
•Sixty-nine percent could transfer onto the tub bench without assistance, and 65.5% were independent in bathing.
•In all but 2 cases, an occupational therapist recommended that they have a tub bench or shower chair. In the other 2 cases, a friend or family member recommended it.
•All but 2 were satisfied or highly satisfied with the training they received to use the tub bench.
•All but 1 person considered the tub bench or shower chair a vital necessity rather than a luxury.
•Sixty-two percent never needed to repair their tub bench or shower chair. One person who reported that his chair required frequent repairs used his tub bench twice per day, including for a bowel program. All respondents who reported that their tub bench needed some repair (n = 11) used it at least once per day.
•Eighty-two percent were satisfied or very satisfied with their tub bench or shower chair.
•Owners also used a hand-held shower (n = 19), a long-handled sponge (n = 3), and/or grab bars in the bath (n = 7).
Participants without a tub bench Ten people reported that they did not own a tub bench or shower chair; of these only 1 person did not want one. Four had a bathroom that was too small, and 5 reported that the cost, not covered by insurance, prevented them from having a tub bench. All 9 of these people wanted to own a tub bench. Comparisons of owners versus nonowners Owners and nonowners of a tub bench were similar in SCI level, amount of upper and lower extremity function, age, months since injury, wheelchair use, current living situation (person lived with or residence), marital status, and race. We compared owner and nonowner groups on a number of variables displayed in Table 3.
No statistically significant difference arose between owners and nonowners of tub benches in their perception of total quality of life, employment status, or satisfaction with current bathing methods. Two items approached statistical significance between groups, despite a very small sample size. We asked participants to circle the number of bedsores they had in the past 12 months. Based on a chi-square likelihood ratio, owners tended to be freer from bedsores than nonowners, but the difference was not significant at the .05 level. Similarly, owners required less assistance in bathing; this result is visibly different between groups, demonstrating the clinical significance. Although we asked about the cost of the assistance provided for bathing, few respondents completed this item. The only item that was significantly different between owners and nonowners of tub benches was the current bathing method. These differences are outlined in Table 4.
Nonowners were more likely to bathe in a standard tub or have a sponge bath. Owners were more likely to have a walk-in shower. Discussion To check the effects of other variables, we examined selected correlations between variables. A positive correlation existed between greater upper extremity function and the amount of assistance needed in bathing (r = .56, P = < .001) and between satisfaction with current bathing and the amount of assistance needed with bathing (r = .34; P = .03). That is, those who had more upper extremity impairment required more assistance in bathing (amount of lower extremity function was not significant). Those who needed less assistance in bathing were more satisfied with their current bathing status. No other significant correlations emerged among other variables. Conclusion Although this small study was conducted at one rehabilitation center, it importantly demonstrates that tub benches or shower chairs are used regularly and over a long period by owners with an SCI. This finding contrasts with the historical literature that suggests that most devices are discarded after rehabilitation. Sixty-two percent of owners of a tub bench paid for it themselves, demonstrating its worth to them. More than half of the nonowners were prohibited from getting a tub bench by its cost. Tub benches or shower chairs were used by people with a range of functional abilities, suggesting that the balance and fatigue limitations associated with SCI are as important as the specific level of injury in dictating a need for a tub bench. Only 1 of 39 people in this study did not want a tub bench. Although not statistically significant, the owners tended to need less assistance and have fewer bedsores than nonowners. Assistance and treatment of bedsores is expensive in both dollars and stress among people with SCIs; the use of tub benches may be one factor in reducing these complications. These findings suggest that a tub bench is a necessity for nearly all people with SCIs. Given the conclusion that people with an SCI are likely to benefit over a long period from a tub bench, the more pertinent questions are which tub benches are the best and what are the guidelines for recommended benches? To answer these questions about service delivery and product superiority that ensure that insurance reimbursement is maximizing benefits at the most reasonable cost, we need to create shared databases and have stakeholder participation in outcomes research.18 In this study, we did not identify which brand or style of tub bench the participants used, and the cost of equipment varied among participants. Information about costs, use patterns, injury levels, and product performance could be collected in a shared database to enable informed decision-making and best practice standards. We found only one study that compared different types of reaching equipment by using consumer input to formulate guidelines and recommending products with the highest ratings.19 Because occupational therapists often recommend assistive technology to clients, and case managers decide what can be paid for, these 2 professionals are natural allies to create shared databases, describe guidelines for selection, and make recommendations for assistive technology products that will best meet the needs of specific populations with disability. As more technology is produced, the complexity of prescribing and paying for technology also increases. Now is the time to proactively design and implement consumer-based research to help rehabilitation case managers and occupational therapists make wise and cost-efficient decisions that will ensure consistent and high-quality technology delivery. References 1.
1
Cook AM, Hussey SM.
Assistive technologies: principles and practice.
St Louis: Mosby; 1995;. 2.
2
Christiansen CH, Ottenbacher KJ.
Evaluation and management of daily self-care requirements.
In: 3rd ed.
DeLisa JA, Gans BM editor.
Rehabilitation medicine: principles and practices. Philadelphia: Lippincott; 1998;p. 137–165. 3.
3
Rogers JC, Figone JJ.
Traumatic quadriplegia: follow-up study of self-care skills.
Arch Physical Med Rehab. 1980;61:316–321. 4.
4
Symington DC, Mackay DE.
A study of functional independence in the quadriplegic patient.
Arch Physical Med Rehab. 1966;47:378–392. 5.
5
Welch RD, Lobley SJ, O'Sullivan SB, Freed MM.
Functional independence in quadriplegia: critical levels.
Arch Physical Med Rehab. 1986;67:235–240. 6.
6
Garber SL, Gregorio TL.
Upper extremity assistive devices: assessment of use by spinal cord-injured patients with quadriplegia.
Am J Occup Ther. 1990;44:126–131. MEDLINE 7.
7
Mann WC, Hurren D, Tomita M.
Comparison of assistive device use and needs of home-based older people with different impairments.
Am J Occup Ther. 1993;47:980–987. MEDLINE 8.
8
Mann WC, Hurren D, Tomita M.
Assistive devices used by home-based elderly people with arthritis.
Am J Occup Ther. 1995;49:810–820. MEDLINE 9.
9
Nawoczenski DA, Rinehart ME, Duncanson P, Brown BE.
Physical management.
In:
Buchanan LE, Nawoczenski DA editor.
Spinal cord injury: concepts and management approaches. Baltimore: Williams & Wilkins; 1987;p. 125–184. 10.
10
Malassigne P, Amerson TL.
A survey of the usage of bathroom fixtures by disabled people.
In: Toronto: proceedings of the RESNA International '92 Conference. 1992;p. 273–275. 11.
11
Mann WC, Hurren D, Tomita M, Charvat B.
Use of assistive devices for bathing by elderly who are not institutionalized.
Occup Ther J Res. 1996;16:261–286. 12.
12
Phillips P, Zhao H.
Predictors of assistive technology abandonment.
Assistive Technology. 1993;5:36–45. MEDLINE 13.
13
Scherer MJ, Cushman LA.
Predicting satisfaction with assistive technology for a sample of adults with spinal cord injuries.
Psychol Reports. 2000;87:981–987. 14.
14
Jutai J, Rigby P, Ryan S, Stickel S.
Psychosocial impact of electronic aids to daily living.
Assistive Technology. 2000;12:123–131. MEDLINE 15.
15
DeRuyter F.
Evaluating outcome in assistive technology: do we understand the commitment?.
Assistive Technol. 1995;7:3–16. 16.
16
Smith RO.
Measuring the outcome of assistive technology: challenge and innovation.
Assistive Technol. 1996;8:71–81. 17.
17
Huebner RA, Allen JB, Inman T, Gust T, Turpin SG.
Quality of life rating: psychometric properties and theoretical comparisons.
J Rehab Outcomes Measure. 1998;2:8–16. 18.
18
Fuhrer MJ.
Assistive technology outcomes research: challenges met and yet unmet.
Am J Physical Med Rehab. 2001;80:528–535. 19.
19
Chen LK, Mann WC, Tomita MR, Burford TE.
An evaluation of reachers for use by older people with disabilities.
Assistive Technol. 1998;10:113–125. Ruth A. Huebner, PhD, OTR/L, FAOTA, is a professor in the department of occupational therapy at Eastern Kentucky University in Richmond. Linda Bales, OTR/L, is an occupational therapist at Cardinal Hill Rehabilitation Hospital in Lexington, Ky. Melba Custer, MS, OTR/L, is an occupational therapist with Professionals Rehabilitation Associates at Clark Regional Medical Hospital in Winchester, Ky. ☆ Acknowledgment The authors thank Sandra Chilton at Cardinal Hill Rehabilitation Hospital for assisting with this study. ☆☆ Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. YMCM 4 PII: S1061-9259(02)03704-9 doi:10.1067/mcm.2003.4 © 2003 Mosby, Inc. All rights reserved. | |
|
FULL TEXT