Running head: ASSISTIVE TECHNOLOGY UPPER EXTREMITY
Assistive Technology Considerations for Weak or Nonfunctional Unilateral Upper Extremity
Rachel E. Zimmerman
Touro University Nevada
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ASSISTIVE TECHNOLOGY UPPER EXTREMITY 2
Introduction
In creating assistive technology for weak or nonfunctional upper extremity conditions, existing devices for various occupational needs must be considered. Individuals with conditions including upper extremity amputation, stroke, and rheumatoid disease are faced with challenges in occupations that typically require the use of both upper extremities. Touwen (1972) explained that despite a genetic predisposition to selection of preferred hand use, individuals with congenital absence of one upper limb can develop handedness in the existing upper extremity. Adjusting one’s actions and routines based on physical deficits demonstrates the human ability for adaptation; however certain assistive technology devices may promote compensation techniques in meaningful occupations, as well. Analysis of assistive technology currently available is necessary in understanding the reasons individuals choose to use, or not use these devices. In a sample of individuals with rheumatoid arthritis, several reasons were listed for not using assistive devices they were given on a regular basis. Reasons included the device being awkward to use, defective, too heavy, or finding another device that functions more optimally
(Kulp, 1988).
The following review will primarily focus on assistive technology that is currently being used by individuals with upper extremity amputations for various occupations, as well as the areas in which assistive technology could be expanded. Additionally, other conditions that involve a weak or nonfunctional upper extremity will be examined in the context of assistive technology, and a proposed new assistive device. An assistive device designed to stabilize mixing bowls will be introduced in order to create a way to maximize function of the remaining or functional upper extremity. Using the Assistive Technology Device Usage Prediction Model
(ATD Usage Prediction Model) as a framework, occupational needs in conjunction with pragmatic issues regarding the proposed device will be considered.

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Occupational Profile
Population
Individuals with upper extremity amputations are likely to experience several changes in daily life that will affect their occupational performance, daily routines, and roles. Over 150,000 individuals in the United States will undergo an amputation every year, with one out of three experiencing some form of upper limb amputation. Leading causes for amputations include burns, peripheral vascular disease, diabetes, infections, malignancies, contractures, and congenital deformities (Stubblefield & Armstrong, 2008). The population of focus in the current analysis is individuals with unilateral upper extremity amputations.
Reasons for Seeking Occupational Therapy Services
Occupational therapists are integral to the interdisciplinary rehabilitation team in treating individuals with upper extremity amputations. The client will likely require strategies in reducing edema and pain, maintaining skin integrity, joint mobility, as well as prosthetics training following amputation. Additionally, the occupational therapist will address performance of selfcare activities of daily living (ADLs) and other occupational activities using the new prosthetic device, or using adaptive techniques that do not involve the prosthesis (Stubblefield &
Armstrong, 2008).
Issues in Occupational Performance
Individuals who have had the dominant limb amputated will require training in using the remaining upper extremity for activities. For individuals who have undergone amputation of the non-dominant upper extremity, adaptive and compensatory strategies are necessary in relearning tasks that typically require use of both upper extremities. Additionally, the occupational therapist will recommend and provide education on various assistive devices that are appropriate for the client’s occupational needs.

ASSISTIVE TECHNOLOGY UPPER EXTREMITY 4
Contexts and Environments
In treating individuals with upper limb amputations, occupational performance in specific contexts and environments must be considered. For example, the assistive technology device that will be proposed accommodates the personal and physical contexts of an individual who wishes to engage in meal preparation as an instrumental activity of daily living (IADL), or as a leisure activity. The individual may or may not wear a prosthetic device, however wishes to independently function in the kitchen environment.
Assistive Technology Device Usage Prediction Model
Rogers and Holms (1992) proposed the ATD Usage Prediction Model to better comprehend the reasons individuals choose to use specific assistive devices. Characteristics of the person, environment, therapist prescribing the device, and the device itself are evaluated in this model.
Person and Environment
Personal and environmental factors included used to predict ATD usage include sex, age, socioeconomic status, living situation, specific diagnosis, severity of diagnosis, and coexisting diagnoses. Additionally, movement capabilities, self-care capacity and values, attitudes towards assistive devices, depression, pain, anxiety, perceived self-efficacy, and assistive technology mastery are evaluated (Rogers & Holms, 1992).
Therapist Prescription of ATD
The therapist’s education level, years of experience, amount of continuing education, rationale for prescribing the specific device, training in device use, and immediate device provision are predictors for ATD usage (Rogers & Holms, 1992).

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Assistive Technology Devices
Technical adequacy, durability, dependability, safety, and efficiency are assessed when predicting if, and how often the individual will use the assistive device (Rogers & Holms, 1992).
Prediction of ATD Usage
A simple use index, or the number of assistive devices used by the individual divided by the number of devices prescribed, is first calculated. Additionally, the extent use index, or the number of times the individual uses the device in relation to the number of usage opportunities is measured. An ideal usage score is determined by adding usage opportunities for all prescribed assistive devices that may be used by the individual (Rogers & Holms, 1992).
Implications of ATD usage prediction model.
Careful consideration of an individual’s intrinsic and extrinsic factors is integral in the process of determining assistive technology that is not only appropriate for the diagnosis, but is likely to be used on a consistent basis. Furthermore, the therapist must evaluate the occupational needs of the individual, taking into account ADL,
IADL, leisure, and other occupational domains.
Assistive Technology for Individuals with Upper Extremity Amputations
Prosthetic Training
Addressing the occupational needs of individuals who have undergone upper extremity amputation becomes increasingly important throughout the recovery process. In a study regarding military personnel who were medically stable following amputation surgery, setting occupational-based goals was the found to be the next step in gaining acceptance of their prosthetic devices, and resuming military or civilian life (Smurr, Gulick, Yancosek, & Ganz,
2008). Thorough prosthetic training for military personnel often focuses on military warrior tasks, yard work, community reintegration, shopping, driving, vocational training, recreation and

ASSISTIVE TECHNOLOGY UPPER EXTREMITY 6 sports activity, child care, pet care, home repair and maintenance, as well as meal preparation.
Most occupational categories described in military prosthetic training can be applied to nonmilitary individuals who are completing the acute stage of recovery.
Prosthetic Terminal Devices
Advances in the types of terminal devices available to attach to upper limb prosthetics offer individuals more control over the occupations in which they choose to engage. Bodypowered hook terminal devices can either be voluntary open or closed in order to manipulate items for various activities. Individuals must be instructed to use the remaining part of the upper limb to apply force to bands on the prosthetic. Not only is the hook attachment lightweight, but it allows for refined manipulation and grasp that are not present in a hand terminal device. Still, the hook can be switched with a body-powered hand device when the individual seeks to use a more inconspicuous attachment, such as in social situations (Fletchall & Atkins, 2011).
Other prosthetic terminal devices that are not body-powered include the Greifer and i-
LIMB. These devices use either myoelectric or electrical elements to control the device. For myoelectric terminal devices, electrodes are positioned over muscles in the residual limb, while electronic terminal devices use a built-in switch to manipulate functioning. An electronic hand device can be used for many light ADL tasks, while the Electric Greifer is typically used for heavier tasks (Ottobock, 2013). The i-LIMB enlists a rotatable to accomplish fine motor grasps including the key, tip, three-jaw chuck, cylindrical, spherical, and hook grasps (Touch Bionics,
2013). Ability to perform these grasps promotes independence in ADLs and IADLs.
Although evident that various high technology prosthetic options increase ability to participate in occupations, the costs of such devices must be considered. Unilateral bodypowered prosthetics can range from $15,000 to over $80,000 for uncomplicated upper extremity

ASSISTIVE TECHNOLOGY UPPER EXTREMITY 7 amputations. Bilateral, electronic, myoelectric, as well as custom designed prosthetics for more complicated amputations can easily cost an individual significantly more (Fletchall & Atkins,
2011).
Prosthetic Attachments
Currently, various devices are available to attach to upper extremity prosthetics to support occupational pursuits. An example of a device that assists with a specific leisure occupation is the crochet aid, originally designed to meet the needs of a client with a hand amputation below the elbow. Matsusima (1986) used a Polyform tray and the finger hooks of the prosthesis terminal as means to thread yarn, with the assistance of the non-affected arm. The crochet aid assisted with the speed and dexterity required to complete crochet activities.
An additional example of a device that attaches to the prosthesis is the adapted fishing rod. The occupation of fishing, whether for done for leisure, social, or work purposes, is made possible for individuals with upper extremity amputations with the use of the adapted fishing rod. Sabolich (1972) developed this device to attach the fishing rod to the wrist of the prosthesis, securing a stronger hold than if the rod were attached to a prosthesis hook. In a similar fashion to the adapted fishing rod, a guitar cap rod was designed to attach to a 14 year-old male’s prosthetic terminal device to promote his engagement in the occupation of playing the guitar (Zatlin,
Hemmen, Krouskop, & Sklan, 1981).
Concerns in Assistive Technology for Upper Limb Conditions
For individuals with a nonfunctional or weak unilateral upper extremity, training must be provided on using the non-affected extremity to perform occupations. For individuals with an upper extremity amputation, training should include techniques on both using and not using the prosthesis to stabilize items while the non-affected limb handles the majority of the task

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(Fletchall & Atkins, 2011). Additional conditions that affect the upper extremity, including strokes and rheumatic diseases, would benefit from assistive technology that aids in energy conservation and “adapting the task object” (Moyers, 1999, pp. 276–277) to promote occupational performance. Additionally, it is important that the individual gains mastery in onehanded ADL and IADL strategies, as there might be times when the prosthesis is unavailable
(Smurr et al., 2008).
Proposed Assistive Device
The proposed assistive device addresses meal preparation as either an IADL or leisure occupation. Smurr et al. (2008) found that training in meal preparation during the amputation rehabilitation process contributes to a sense of accomplishment and independence. Though meal preparation should be addressed in the prosthetics training process, it is also important to teach the individual one-handed techniques for times when the prosthesis is not worn. For example, when the individual’s prosthesis is being re-fitted or cleaned, one-handed techniques and adaptive equipment will promote continued independence in occupations.
Currently, several assistive devices exist to aid in meal preparation, with some specifically addressing deficits in bilateral upper extremity use. An affordable device that does not require use of any prosthetic device or attachment is a cutting board with nails to stabilize food while chopping or dicing (Patterson Medical, 2013). Using the concept of a stabilizing kitchen device, a search was conducted to locate stabilizing devices that assist with other aspects of meal preparation, such as mixing food for the purposes of cooking or baking. Stabilizing devices that currently exist are either expensive, or not sturdy enough to accommodate stirring more substantial ingredients with one arm (see Table 2). The proposed kitchen arm bowl

ASSISTIVE TECHNOLOGY UPPER EXTREMITY 9 stabilizer is specifically designed for individuals with unilateral upper extremity amputations who will use the remaining extremity to mix ingredients, rather than to stabilize the bowl .
To construct the device, a cordless drill was used to cut small holes in pieces of aluminum plates, as well as a swivel clamp and hand clamp. The aluminum flat plate pieces and clamps were fastened together securely with hardware to ensure the kitchen arm was not only secure, but able to be positioned at different angles to accommodate mixing bowls of various sizes and heights. The swivel clamp was designed to clasp onto the edge of a kitchen counter, or area where the kitchen sinks meets the kitchen counter, while the hand clamp is angled to attach to the side of the various mixing bowls. The prototype of this device is fairly inexpensive (see
Table 1), and able to be manipulated with one hand. Each clamp can be easily adjusted to tighten to the counter or mixing bowl, and loosened to release the tight grasp.
Alternative Populations for Proposed Assistive Device
Rheumatic diseases. Individuals with rheumatic diseases, including rheumatoid arthritis
(RA) and osteoarthritis (OA), benefit from assistive devices that compensate for joint limitations and deformities, decreased strength, high levels of fatigue, as well as joint tenderness and pain
(Yasuda, 2008). Assistive technologies recommended to individuals with rheumatic conditions are intended to limit stress to the joints, and maintain energy conservation. Current assistive technology for meal preparation include built-up handles for utensils, angled cutting knives, electric can openers, cutting boards with nails to stabilize food, electric choppers, and knob turners for the stove (Yasuda, 2008). The proposed assistive device would aid in energy conservation by requiring use of only one upper extremity.
Strokes. Motor impairments involving the upper extremity are common among individuals who have sustained a stroke. This outcome frequently affects the individual’s ability to participate in various meaningful occupations (Nilsen, Gillen, & Gordon, 2010). For

ASSISTIVE TECHNOLOGY UPPER EXTREMITY 10 individuals who do not fully recover upper extremity range of motion and strength unilaterally, the proposed assistive device offers a mixing technique that requires use of only the uninvolved extremity.

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References
Fletchall, S. & Atkins, D.J. (2011). Managing daily activities in adults with upper extremity
Amputations. In C.H. Christiansen & K.M. Matuska, Ways of living: Intervention strategies to enable participation (4th ed., pp. 315-347). Baltimore, MD: AOTA Press.
Kulp, C. S. (1988). The use of adaptive equipment by rheumatoid arthritis patients.
Unpublished master's thesis, Virginia Commonwealth University, Richmond.
Matsushima, D.S. (1986). Crochet aid for the amputee. Am J Occup Ther , 40 , 495-
496. doi:10.5014/ajot.40.7.495
Moyers, P. A. (1999). The guide to occupational therapy practice [Special issue]. American
Journal of Occupational Therapy, 53 , 247–322.
Nilsen, D.M., Gillen, G., & Gordon, A.M. (2010). Use of mental practice to improve upper-limb recovery after stroke: A systematic review. American Journal of Occupational
Therapy, 64(5), 695-708.
Ottobock (2013). Electric Greifer.
[Information on a page]. Retrieved from http://www.ottobock.com/cps/rde/xchg/ob_com_en/hs.xsl/3359.html
Patterson Medical (2013). Deluxe Paring Board. [Information on a page]. Retrieved from http://www.pattersonmedical.com/app.aspx?cmd=getProduct&key=IF_921001485
Rogers, J.C. & Holm, M.B. (1992). Assistive technology use in patients with rheumatoid disease:
A literature review. American Journal of Occupational Therapy, 46 (2), 120-127. doi:10.5014/ajot.46.2.120
Sabolich, L. (1972) An adapted fishing rod for arm amputees. Inter-Clinic Information Bulletin,
12 , 13-15.
Smurr, L.M., Gulick, K., Yancosek, K. & Ganz, O. (2008). Managing the upper extremity

ASSISTIVE TECHNOLOGY UPPER EXTREMITY 12 amputee: A protocol for success. Journal of Hand Therapy, 21, 160-176.
Stubblefield, K., & Armstrong, A. (2008). Amputations and prosthetics. In M.V. Radomski &
C.A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6 th
ed., pp.
1265-1294). Baltimore, MD: Lippincott Williams & Wilkins.
Touch Bionics (2013). Active Prosthesis [Information on a page]. Retrieved from http://www.touchbionics.com/products/active-prostheses/
Touwen, B. C. (1972). Laterality and dominance. Developmental Medicine and Child Neurology,
14, 747-755.
Yasuda, Y.L. (2008). Rheumatoid arthritis, osteoarthritis, and fibromyalgia. In M.V. Radomski
& C.A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6 th
ed., pp. 1214-1243). Baltimore, MD: Lippincott Williams & Wilkins.
Zatlin, C.R., Hemmen, E., Krouskop, T.A. & Sklan, M. (1981). Guitar capo for a bilateral upper extremity amputee. American Journal of Occupational Therapy, 35 (1), 736. doi:10.5014/ajot.35.11.736

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Table 1
Cost Analysis of Proposed Product
Materials
6” Swivel Clamp
2” Hand Clamp
3”x 3” T-plate zinc
Retail Outlet
Home Depot
Home Depot
Home Depot
Quantity
1
1
1 (2 pack)
Price
$15.97
$5.97
$2.78
Assorted Screws and
Hardware
Aluminum Flat Plat
Home Depot
Home Depot
1 (includes different varieties)
1
$5.45
$6.83
Subtotal (before tax)
$37.00

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Table 2
Comparison to Similar Purpose Products
Product Purpose Price Picture
Staybowlizer
Silicone Bowl
Stabilizer
Holds bowl in place without use of arms
*Bowl must be a minimum of
6” in diameter
$19.99
Retrieved from http://www.amazon.com/Staybowlizer-Silicone-
Bowl-Stabilizer-Orange/dp/B00A6S6RLC
KitchenAid
Stand Mixer
Sturdy stand mixer does not require any hand mixing
Mixes, kneads, whips ingredients using different attachments
$299.99-
$599.00
Retrieved from http://www.kitchenaid.com/