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HOUSING FOR THE DISABLED, Green
449
is presently available to begin to eliminate these
References
problems.
1. U. S. Department of Housing and Urban Develop-
A suitable living environment is an essential com-
ment. Housing for the Physically Impaired: A Guide
ponent of the total rehabilitation process together
for Planning and Design. Washington DC, US Govt
with physical restoration and social and vocational
Print Office, 1968
reintegration. In the "Bill of Rights for the Dis-
2. 4.3% of males and 1.5% of females found disabled by
chronic disease. Medical Tribune, August 15, 1973
abled," drawn by Abramson and Kutner,⁷ three of
3. Columbus D, Fogel ML: Survey of disabled persons
the 16 articles are concerned with housing and archi-
reveals housing choices. J Rehabil 37:26-28, Mar-Apr
tectural barriers. We have shown that disabled indi-
1971
viduals can be deinstitutionalized and can maintain
4. Columbus D, Fogel ML: Housing for the disabled: II.
themselves in the community if provided with suit-
Characteristics of those willing to move to specially de-
signed facilities. Percept Mot Skills 32:212-214, 1971
able housing facilities. Increased activity in this area
5. Fenton J: Long term residential facilities: The unre-
by all concerned with rehabilitation is suggested.
solved problem for nonretarded severely disabled adults.
Rehabil Rec 13:4-7, Nov-Dec 1972
6. Jeffrey DA: A living environment for the physically dis-
ADDRESS REPRINT REQUESTS TO:
abled. Rehabil Lit 34:98-103, Apr 1973
Ronald F. Green, M.D.
7. Abramson AS, Kutner B: A bill of rights for the dis-
Bird S. Coler Hospital
Roosevelt Island, NY 10015
abled. Arch Phys Med Rehabil 53:99-100, Mar 1972
KEY WORDS: After care; costs and cost analysis; health survey; questionnaire; rehabilitation
Variables Related to Success in a
Medical Rehabilitation Setting
Stanley J. Smits, Ph.D.
Structured interviews were used to obtain follow-up data
spending, that is, $3.1 billion.¹ In brief, Americans
three years after inpatient services had been rendered. The
are investing their personal, philanthropic and gov-
purpose was to evaluate program effectiveness, patient
ernmental resources in the services which are avail-
satisfaction with services, costs and the variables related
able to them. While this investment is a testimonial to
to success. Outcome was operationally defined using ten
the scientific and technological advances of the field,
Likert-type scaled items which were summed to provide a
numerical index of success. Statistical analyses indicated
the health delivery system and the costs involved are
that the former inpatients expressed a high degree of satis-
under attack from consumers, public leaders and gov-
faction with the services they received; that the average
ernmental agencies. The health field is described as
patient was "moderately successful"; and that the degree
"restlessly in transition," faced with a "serious
of success was related to age, medical diagnosis and to
crisis,"3 confronted by "new priorities"⁴ and said to
extrahospital environmental factors. Implications are dis-
be "recognizing the necessity for changes in the
cussed for maximizing success, the role of the family and
system."⁵
the importance of aftercare.
Concern seems to be especially strong in the field
of rehabilitation medicine. Speaking about rehabili-
In addition to their obvious concern about disease
tation medicine in his presidential address before the
processes and treatment modalities, medical and
49th Annual Session of the American Congress of
closely related publications are communicating a
Rehabilitation Medicine, Policoff concluded:⁶
growing concern about the effectiveness of the sys-
if rehabilitation medicine wishes really to meet the
tems through which health services are delivered.
needs of the disabled, it will have to come out of the aca-
The concern is expressed in themes such as costs,
demic ivory towers and the scientific laboratories
The
effectiveness, accessibility, planning, coordination and
ecology of disability, the economics of poverty and of
manpower. During 1970, Americans spent 7.3% of
the gross national product, or $71.2 billion, for health
From the Department of Counseling and Psychological Services,
care. Hospital care was the largest item of expendi-
Georgia State University, Atlanta.
The study was supported in part by the Social and Rehabilitation
ture, that is, $28 billion; while nursing-home care
Service through Project No. SRS 16-P-5680-7/4-08, under the direc-
tion of John M. Miller, III, M.D., Chairman, Department of Reha-
registered the largest increase in personal health care
bilitation Medicine, the University of Alabama in Birmingham.
Submitted for publication October 1, 1973.
Arch Phys Med Rehabil Vol 55, Oct 1974
450
VARIABLES IN SUCCESSFUL REHABILITATION, Smits
health care delivery and the principles of consumerism and
able to participate in the follow-up interviews. Of the
of political action may become more pertinent to our lives
141, 77 (55%) were male; 26 (18%) were minority
and our professional survival than the biochemical princi-
group members; and 101 (72%) came from families
ples of muscle contraction.
The study reported here is an attempt by the Uni-
rated as "lower socioeconomic" using the Hollings-
versity of Alabama Medical Rehabilitation Research
head criteria. Seventy-four (52%) had less than a
and Training Center to obtain systematic follow-up
high school education, while 13 (9%) had been grad-
information from former inpatients of the Spain Re-
uated from college. Prior to their disabling conditions,
habilitation Center (SRC). The primary purposes of
57 (40%) were either unemployed or working at un-
the study included an attempt to assess the following
skilled jobs, 23 (16%) were semiskilled workers, ma-
factors: (1) the patient's physical, social, psycho-
chine operators or tenant farmers, and 25 (18%)
logical and vocational status three years after receiv-
were employed in business or a profession. The re-
ing inpatient services; (2) the degree to which the
mainder was employed in clerical, sales, technical
former patient was satisfied with the services he had
and skilled-manual positions.
received at the SRC; (3) the cost/benefit of the
The mortality rate at follow-up seemed to be
services; and (4) the relationship of rehabilitation
principally the result of aging and associated medical
success/failure to the medical and demographic char-
problems. The mean age of the 64 former patients
acteristics of the former patients.
found to be deceased at follow-up was 60.7 years at
the time of their admission to the SRC approximately
three years earlier. Half of the deceased were victims
Method
of strokes with a mean age at admission of 64.5 years.
Pulmonary disabilities had the highest rate of mor-
SAMPLE
tality (54.5%) and a mean age of 63.5 years at
The follow-up subjects were selected on the basis
admission. The nine spinal cord injured persons
of a time sample. The entire SRC inpatient popula-
(31.0%) who did not survive were the only excep-
tion of the year 1968 was included in the study. Their
tion to the observation about aging. Their mean ages
demographic and medical characteristics are shown
at admission were 45.8 years for the five paraplegics
in table 1. In 1971 when the follow-up interviews
and 38.3 years for the four quadriplegics.
were conducted, 26 (10%) of the 1968 inpatients
either could not be located or were known living in
FOLLOW-UP PROCEDURES
another state and 64 (25%) were deceased. Of the
A 91-item survey form was developed through a
170 still living, 141 (83%) were willing and physically
process of pilot testing and revision during 1970-71.
The final version of this survey instrument included
sections dealing with personal data, relevant informa-
Table 1: Characteristics of Sample
tion from the hospital records, the patient's evalua-
tion of SRC services, his status prior to the onset of
Patients
Characteristics/categories
No.
%
disability, and his physical, social, psychological and
Age, yr, at admission to SRC
vocational status at follow-up. Each follow-up inter-
20 and younger
22
8.5
21-30
22
8.5
view was conducted in the patient's home environ-
31-40
29
11.1
41-50
29
11.1
ment by the same interviewer, thus maximizing inter-
51-60
52
20.0
view consistency. The interviewer was well qualified
61-70
78
30.0
71 and older
28
10.8
for the assignment by virtue of a graduate degree in
Days in SRC, initial admission
rehabilitation counseling.
1-30
139
53.5
31-60
75
28.8
The survey form contained items requesting factual
61-90
21
8.1
90 or more
25
9.6
and judgmental information from the former patient
Readmissions to SRC
and his family. Examples of factual information in-
None
188
72.3
cluded items such as his, or her, monthly earnings;
One
42
16.2
Two
17
6.5
sources of income; whether or not he received medi-
Three or more
13
5.0
cal services since being discharged from the SRC.
Medical diagnoses
Rheumatoid arthritis
56
21.5
Judgmental items were recorded using Likert-type
CVA, dominant hemisphere
53
20.4
CVA, nondominant hemisphere
42
16.2
scaled items. Some of these asked for judgments di-
Quadriparesis, traumatic
17
6.5
Paraparesis, thoracolumbar, traumatic
16
6.1
rectly from the former patient:
Pulmonary disability, medical
13
5.0
Compared to before you were admitted to the SRC, how
Parkinson's disease
9
3.5
Posttraumatic brain syndrome
8
3.1
would you describe your present level of physical function-
Leg bones, fracture or operation
7
2.7
ing?
Paraparesis, thoracolumbar, nontraumatic
6
2.3
Other diagnoses
33
12.6
1. Great improvement
2. Some improvement
Status at follow-up in 1971
Out-of-State resident, or unable to locate
26
10.0
3. No change
Deceased
64
24.6
4. Some deterioration
Alive
170
65.4
5. Great deterioration
Arch Phys Med Rehabil Vol 55, Oct 1974
VARIABLES IN SUCCESSFUL REHABILITATION, Smits
451
Others required extensive interviewing of the former
Results
patient and others, such as members of his family,
SATISFACTION WITH SERVICES
with a subsequent judgment made by the interviewer:
Patient's participation in family affairs may be described
The former patients expressed a high degree of
satisfaction with the services they received. When
as:
1. Highly participatory
asked the degree to which their objectives had been
2. Quite active
achieved, 96 (68%) chose "completely" with 32
3. Somewhat active
(23%) indicating partial achievement. Eleven (8%)
4. Quite passive
5. Totally passive
said their objectives were not met by the services they
Still others required overall judgments by the inter-
received. In response to the other questions in this
viewer based upon information and her observations:
area, 114 (81%) indicated that they felt that their
The patient's present affective outlook is:
objectives could not have been accomplished as well
1. Consistently positive
in another way, and 133 (94%) said they would rec-
2. Usually positive
ommend the Spain Rehabilitation Center to a friend
3. Vacillates between positive and negative
who needed treatment. Additional questions regard-
4. Usually pessimistic and depressed
5. Consistently pessimistic and depressed
ing satisfaction revealed that most felt they had been
The survey instrument was designed to obtain a
helped by at least 2 of the 13 groups of professional
multifaceted picture of the former patient at follow-
and related personnel involved in the service delivery
up.⁷
system at the Spain Rehabilitation Center. The small
The inpatients of 1968 were contacted by letter in
percentage indicating some dissatisfaction with the
groups of 20, and if necessary by telephone, asking for
services said they should have been helped more medi-
their cooperation and scheduling the interview. Inter-
cally (4%) and psychologically (2%).
views, ranging from 45 minutes to 2½ hours, were
EFFECTIVENESS OF SERVICES
conducted on an individual basis during the period
The multidisciplinary array of services offered to
from March-December 1971. Narrative records were
the patients may be judged by using the ten-variable
kept by the interviewer dealing with her observations
definition of rehabilitation success. The results are
and any comments made by the patient which were
shown in table 2. Using a five-point scale where "1"
not covered in the survey form.
and "5" indicate the extremes of "failure and "suc-
CRITERION MEASURE
cess" respectively, it can be seen that the most success
Included among the 91 items were ten Likert-type
was achieved in the area of instilling an "independent
scaled items which were summed to provide an out-
attitude" in which the patient "wants to be as inde-
come measure which was operationally defined as
pendent as he can." In contrast to this high average
"rehabilitation success." Because the outcome meas-
rating of 4.64, the least successful area, "employment
ure covered the patient's physical, social, psychologi-
status," had an average rating of 2.35. Since "5"
cal and vocational status, it was felt to be superior to
equalled "fulltime employment" and "1" equalled
the narrow outcome measures used in most attempts
"unemployed," the 2.35 rating means that the aver-
to quantify success.
age former patient was somewhere between "retired,"
Table 2: Rehabilitation Success Factor rcorrelations, Means, Standard Deviations
Success variables
1
2
3
4
5
6
7
8
9
10
Total
1. Employment status
-
0.13
0.41*
0.25+
0.26+
0.36*
0.37*
0.46*
0.28t
0.33*
0.60*
2. Physical functioning
-
0.33*
0.22+
0.211
-0.04
0.13
0.15
0.08
0.11
0.35*
3. Self-care
-
0.38*
0.39*
0.12
0.40*
0.61*
0.35*
0.33*
0.68*
4. Activities outside home
I
0.67*
0.27+
0.51*
0.45*
0.34*
0.33*
0.69*
5. Self-consciousness
-
0.12
0.61*
0.50*
0.33*
0.40*
0.72*
6. Knowledge about condition
-
0.25+
0.201
0.26
0.32*
0.49*
7. Social relationships
-
0.59*
0.46+
0.44*
0.73*
8. Participation in family
-
0.65*
0.60*
0.79*
9. Independent outlook
-
0.43*
0.65*
10. Affective outlook
-
0.65*
Means
2.35
3.38
3.95
4.09
3.22
4.07
3.77
3.94
4.64
3.71
36.98
Standard deviations
1.45
1.40
1.24
1.38
1.26
1.26
1.29
1.22
0.88
1.04
7.60
*p < 0.001.
tp < 0.01.
Ip < 0.05.
Arch Phys Med Rehabil Vol 55, Oct 1974
452
VARIABLES IN SUCCESSFUL REHABILITATION, Smits
"intraining" or a "volunteer worker," each of which
At follow-up, 35 people expressed a need for serv-
had a rating of "2," and "parttime employment-up
ices which were not being provided in their communi-
to 20 hours per week" which had a rating of "3."
ties. These included such things as economic assist-
Another way of looking at the effectiveness of the
ance, relief from pain, houschold help, mental stimu-
services, is to ask which medically defined groups were
lation, companionship, nursing home care, speech
helped most and which were helped least. Since the
therapy, intensive counseling and improved housing.
rehabilitation "success" scores ranged from a low of
The interviewer helped mobilize resources to help 26
16 to a high of 49 with a mean of 37, it is obvious
of these people meet their needs.
that some patients profited little from the services
VARIABLES RELATED TO SUCCESS
while others were highly successful. A comparison of
The variables related to success were identified
mean scores for each of the major diagnostic cate-
gories described earlier in table 1 provides a rank of
statistically by use of t tests and the Chi square sta-
the success obtained. The average success scores are
tistic. Fifteen major variables were statistically signifi-
shown in parentheses:
cant in terms of success as it was operationally defined
1. Categories helped most
in this study. Fourteen variables were identified by
Pulmonary disability, medical (42.0)
use of Chi square (table 3). The "high" success
Paraparesis, thoracolumbar, traumatic (39.9)
group was defined as those former patients who
Quadriparesis, traumatic (38.7)
scored one-half standard deviation or more above
Rheumatoid arthritis (38.0)
the mean on the ten-variable success measure (41
2. Categories helped least
Parkinson's disease (29.5)
Table 3: Comparison of High vs Low Success Groups on
Posttraumatic brain syndrome (32.0)
Selected Survey Variables
CVA, nondominant hemisphere (34.0)
CVA, dominant hemisphere (34.3)
Variable
Chi square
df
p*
COSTS
Sex
0.02
1
ns
The costs involved in disability may be measured in
Race
0.00
1
ns
Marital status prior to disability
2.76
2
ns
several ways. The 260 inpatients in 1968 spent an
Marital status at survey
2.08
3
ns
average of $4,188 for their stay in the hospital. In
Source of referral
0.05
2
ns
addition, 42 of the follow-up patients indicated that
Admitting service
3.64
2
ns
Sponsorships (financial)
6.39
6
ns
they had spent a little more than $600 each to modify
Medical diagnosis
11.42
5
0.05
their places of residence in order to accommodate
Number of readmissions
2.89
5
ns
Respondent (for survey)
12.19
3
0.01
their conditions. They were also paying an estimated
Number admissions to other hospitals
4.08
3
ns
$100 per person for extra costs of living such as trans-
Helped most by whom ?
12.63
8
ns
portation, nursing care, oxygen, on a monthly basis.
How helped most ?
1.62
4
ns
Would recommend to friend ?
0.12
1
ns
At follow-up, 70 of the 141 patients were receiving
Referrals to community agencies
3.12
2
ns
no form of disability compensation, relying instead
Current status with voc. rehab. services.
9.54
3
0.05
Reasons for unemployment,
upon earnings and retirement benefits, while the re-
if unemployed
33.50
6
0.0001
mainder received funds each month ranging from
Medical services in community
1.58
1
ns
$40 to a high of $650. "Earnings" were significantly
Social services in community
11.78
1
0.001
Economic services in community
7.31
1
0.01
related to "success" scores in a positive direction
Vocational services in community
3.05
1
0.10
(r = 0.34) ; while "compensation" was significantly
Educational services in community
5.10
1
0.05
How was employment obtained
10.17
4
0.05
related to the "number of days in the hospital" in a
Job change
8.46
3
0.05
positive direction (r = 0.34) ; that is, the longer one
Educational level prior to disability
5.87
6
ns
Educational level at survey
6.45
stayed in the hospital, the more compensation he was
6
ns
Occupational level prior to disability
6.36
6
ns
receiving at follow-up.
Place of residence
2.42
3
ns
AFTERCARE
Type of residence
9.16
6
ns
Change of residence due to disability
5.27
4
ns
Severely disabled persons often continue to need
Cost of modifying residence due to
disability
care when they return to their home communities
1.53
4
ns
Increased cost of living due to disability.
1.53
4
ns
following a period of inpatient treatment. At follow-
Primary source of income prior to
services
7.87
6
ns
up, the following percentages of 1968 inpatients were
Primary source of income at survey
9.89
8
ns
receiving services in the community: medical (92%),
Actual limitations of disability
44.69
4
0.0001
social (25%), vocational (11%), educational (9%)
Who helped you understand disability ?
4.26
3
ns
Family's knowledge about patient's
and psychological (1%). Vocational Rehabilitation
limitations
5.79
4
ns
Services (VRS) had been offered to 37%. Of these,
Family allows independence
26.14
3
0.0001
Family unity/cohesiveness
16.84
3
0.001
VRS had closed 14 as employed, 20 as unemployed
Family facilitative of patient's
rehabilitation
and 15 remained on active status with the agency at
15.46
3
0.01
the time of follow-up.
*ns, not significant.
Arch Phys Med Rehabil Vol 55, Oct 1974
VARIABLES IN SUCCESSFUL REHABILITATION, Smits
453
or higher) whereas the "low" success group scored
titudes, stimulating activities outside the home,
one-half standard deviation below the mean (33 or
imparting knowledge about the patient's condi-
lower). The significant characteristics of the success-
tion, encouraging self-care and patient partici-
ful group seem to be associated with the family's
pation in family affairs (table 2) ; and providing
response to his condition, the services he receives in
needed services to persons with pulmonary prob-
the community, his medical diagnosis, vocational
lems, rheumatoid arthritis, and to the spinal
status and his own perception of his limitations. In
cord injured.
addition to the 14 variables shown in table 3, age at
4. The SRC was somewhat unsuccessful in the
the onset of disability separates the successful from
areas of vocational adjustment and self-con-
unsuccessful former patients. The successful former
sciousness about the disability (table 1) ; and in
patients were significantly younger at the onset of
meeting the needs of stroke and other brain-
disability (33.2 vs 48.5; t = 6.09; P < 0.001).
injured persons.
The results presented here give us a composite
5. Aftercare services in the community and the
picture of the successful former patient at follow-up:
family's reaction to the patient and his condition
(a) Demographically, he may have been of either sex
are critical areas in terms of success vs failure
or any race; his marital and financial status at the
(table 3).
time of treatment were not related to his later degree
6. As judged by success, the services offered at the
of rehabilitation success, but his disability had its
SRC are unbiased in terms of sex, race, marital
onset when he was in his early thirties. (b) Medically,
status, sources of referral and financial sponsor-
he probably received treatment for pulmonary prob-
ship (table 3).
lems, spinal cord injury or arthritis; he was physically
capable of being the principal respondent for the
Discussion
survey; at follow-up he was receiving approximately
the same medical services in his community as were
The relative independence of the "level of physical
his unsuccessful counterparts. (c) Geographically, he
functioning" and "knowledge about one's condition"
was living in a community where several aftercare
as variables in the operational definition of success
services were available to help him. (d) Vocationally,
suggests several interesting possibilities. An increase
he received services from vocational rehabilitation;
in the level of physical functioning may be expected
if unemployed, it was not because he was at retire-
to be accompanied by an increase in employability,
ment age and not because of medical prohibitions.
self-care and activities outside the home and a de-
(e) Familially, he was a member of a close family
crease in self-consciousness. However, an increase in
unit which responded appropriately to his disability,
the level of physical functioning would not be ac-
for example, helped him with his rehabilitation ef-
companied by increased psychosocial adjustment or
forts and encouraged him to function with as much
knowledge about one's condition. In a similar fashion,
independence as possible. (f) Personally, he did not
increased knowledge about one's condition would not
allow the limitations imposed by his disability to
be accompanied by improvements in self-care or de-
interfere substantially with the life-style he had been
creased self-consciousness. However, all of the other
following prior to its onset.
eight success variables are highly intercorrelated in a
positive direction. Therefore, an improvement in one
MAJOR OBSERVATIONS FROM THE DATA
area may be expected to be accompanied by improved
The principal results may be summarized as fol-
functioning in the other seven areas. These observa-
lows:
tions suggest that while treatment efforts aimed at
1. The operational definition of success includes
improved physical functioning and an understanding
several variables which are highly intercorre-
of the technical aspects of one's conditions may have
lated; although "physical functioning level"
a definite impact on other desired outcomes, the gen-
and "knowledge about condition" are relatively
eralization effect will be limited and psychosocial
independent measures (table 2).
problems may remain unresolved.
2. The 1968 patient population was skewed in
Age seems to be the critical variable in terms of
terms of age with 41% beyond the age of 60
success. The significant difference in age between the
years at the time of their initial admission (table
high and low success groups suggests that a medical
1). This probably accounts for the low success in
rehabilitation program may improve its success ratio
the vocational area (table 2), the high mortality
by selecting younger patients. Selection would not
rate and the existence of "rheumatoid arthritis"
only improve success at follow-up, it would be accom-
and "CVA, dominant hemisphere" as the pri-
panied by a decrease in those medical problems asso-
mary diagnostic categories (table 1).
ciated with aging and it would result in a longer
3. The SRC was highly successful in several areas:
period of adjustment. Stated briefly, medical reha-
Consumer satisfaction ;instilling independent at-
bilitation programs serving elderly patients must ac-
Arch Phys Med Rehabil Vol 55, Oct 1974
454
VARIABLES IN SUCCESSFUL REHABILITATION, Smits
cept the fact that costs will be high, posthospitaliza-
services they received; that the average patient was
tion vocational activities will be minimal and mor-
"moderately successful" using a ten-variable opera-
tality rates will be high. This is not to imply that the
tional definition of success; and that the degree of
elderly should not be served; it is, however, intended
success was related to the patient's age and medical
to imply that facilities serving the elderly should
diagnosis and to extrahospital environmental factors.
posit reasonable success goals for themselves which
Three major conclusions may be reached from this
are different from those selected by facilities serving
study: (1) Different goals need to be specified for
younger patients.
elderly and youthful patients. (2) Aftercare services
The role of the family in the daily adjustment of
are essential in order to maximize the impact of hos-
the severely disabled has been documented by these
pital-based services. (3) Families need to be prepared
results. The investment of time and money in the
to reassimilate the former patient.
medical treatment of the patient should be accompa-
ADDRESS REPRINT REQUESTS TO:
nied by similar efforts to treat his family if success as
Stanley J. Smits, Ph.D.
Counseling and Psychological Services
measured by these ten factors is the desired outcome.
Georgia State University
Atlanta, GA 30303
Social workers and nurses have important educational
and therapeutic roles to play in equipping the family
References
to handle the care of the patient once he is sent
home. If the family does not facilitate his rehabilita-
1. Cooper BS, Worthington NL: National Health Care
tion, if they do not allow him to be as independent as
Expenditures, Calendar Years 1929-1970. Washington,
DC, Social Security Administration, Office of Research
possible, and if they are not a cohesive, well-adjusted
and Statistics, Jan 14, 1972
unit, these data indicate that the patient will end up
2. McNerney WJ: Health care financing and delivery in
in the low success group.
decade ahead. JAMA 222: 1150-1155, 1972
The importance of aftercare community services is
3. James G: Critique of systems of health care in United
also substantiated by these results. The patient may be
States and of delivery of services by professions. Hosp
Management 110 34-35, Sept 1970
treated in the hospital, but he must eventually live in
4. Harper AC: Towards job description for comprehensive
the community. The availability of social, economic,
health care-framework for education and management.
vocational and educational services in the community
Soc Sci Med 291-301, 1973
contributes significantly to his successful adjustment
5. American Hospital Association: Statement on consumer
whereas the reverse is true in their absence. Medical
representation in governance of health care institutions.
Hospitals 47: 113, 1973
services seem to be available to an adequate degree in
6. Policoff LD: Rehabilitation medicine revisited. Arch
the community and are therefore not critical to the
Phys Med Rehabil 54: 1-6, 1973
degree of success in this study.
7. Smits SJ: Model for Conducting Followup Studies in
In summary, the follow-up study of inpatients of
Medical Rehabilitation Settings. Birmingham, AL, Medi-
cal Rehabilitation Research and Training Center, Uni-
1968 from the SRC has shown that the former pa-
versity of Alabama in Birmingham, 1973 (Monograph
tients express a high degree of satisfaction with the
#4)
Chapter V
Social Factors in the
Adjustment to Spinal Cord
Injury
A. Introduction
Rehabilitation efforts have traditionally focused on teaching the person with
cord injury the ADL and mobility techniques that he or she needs focus to cope on
spinal the world. In fact, most measures of success in rehabilitation centers these tasks
with skills, and a discharge date is defined in terms of mastering criteria of
physical and Higgins, 1977). But are physical skills the appropriate wheelchair and to
(Albrecht in rehabilitation? Do the ability to transfer in and out of a Do the
success oneself ensure success in coping with the world as a disabled person? able bodied
groom to walk and to groom oneself ensure success in the world for bodied an
ability These are tasks that are mastered at ages 5-7 in most able and persons. the
person? remainder of life consists of learning to interact with people define the
The in order to get some degree of satisfaction. Thus, we with
environment successful able bodied adult as one who accepts himself and is able to interact
his world to achieve a certain portion of his dreams.
the onset of a disability, such as spinal cord injury, has tremendous social
But for the disabled person (Safilios-Rothschild, 1970). He perceives to him.
implications different, and this is repeatedly confirmed by other's reaction order to
himself to as with the world, he needs to learn a variety of social skills This in chapter
Thus, the cope devaluation and rejection he will experience from others. and to
combat will attempt to outline some of the social implications of spinal cord injury
define areas for future research.
B. Social Implications of Disability.
Caywood (1974) has described his adjustment to quadriplegia around in a most him
manner. Very soon after his injury, he realized that people watch for
eloquent pity, sadness, confusion, guilt, and curiosity, and he learned to couple of
displayed facial expressions in order to anticipate people's reaction to him. Within a at ease,
weeks after the injury, he knew that it was his responsibility to put people
73
74
Social Factors
and he believes that this becomes a critical skill in the ultimate adjustment to
disability.
Several months after his injury he was shocked to realize how much his body
had changed. He did not recognize himself in the mirror; he had lost fifty pounds,
and his clothes were too big for him. Before the accident, he had been very strong,
but in therapy, the task of listing five pounds seemed like an insurmountable
challenge. Thus, the person that he used to be was no longer present. He saw himself
as very different, and he knew that others saw the difference also.
Towards the end of his inpatient rehabilitation, he was afraid to go home. At
the rehabilitation center, he was surrounded by people in the same predicament as
his, which was some comfort, and in addition, the staff were paid to assist him. Now
he was afraid to be a burden to his family, and he felt guilty about disrupting their
lives. Indeed, after discharge, it became apparent that the entire family's schedule
did revolve around him. Yet soon his worry about his family decreased because they
seemed more than willing to help him. However, the real shock came when he
discovered that the home that he remembered fondly was now a house filled with
obstacles.
As a quadriplegic, he was not able to go anywhere without assistance from his
family, and this was a frustration. But at the same time, he did not want to got out
into public again. He describes himself as an introvert, especially in large groups of
people, but, in addition, he was now self-conscious about being in a wheelchair. His
biggest problem in resocialization was the conflict between what he was now,
disabled, and how society is structured.
"Society demands that people act and be 'normal,' not deviate. At the
same time, I was constantly reminded that I was not 'normal,' through
interpersonal relationships, architectural barriers, and vocational goals."
(Caywood, 1974, p. 25)
Thus, Caywood outlines some of the social changes that occurred in his life
because of his physical limitations and because of people's reaction to him. As a
result, social isolation is a frequent and, perhaps, natural feature of post-discharge
life unless the person actively fights against it. To assess this issue of social
discomfort, Dunn (1977) developed a 20 item social discomfort scale and asked
persons with spinal injury to rate the degree of awkwardness they would feel in
these situations. In order of importance, these are the situations which produce the
most discomfort:
1. Accidental bowel movement.
2. At a party and discover that external catheter has popped.
3. Falling out of the wheelchair.
4. People who do not move out of the way.
5. Putting wheelchair in the car and a passerby insists on helping.
6. At a bar and a drunk comes up and starts telling you how brave you are.
7. Spasms.
Social Factors
75
8. Getting on an elevator and a young girl pats you on the head and says,
"poor dear."
9. Going into a restaurant and waiter asks wife or date, "How many please?"
Furthermore, Dunn found that persons older than age 35 admit to more difficulty in
these situations than younger men do.
Cogswell (1968) studied a group of 35 persons with paraplegia who had been
out of the rehabilitation center for quite a while (unspecified). She found that in
comparison to pre-trauma life, all of the persons with paraplegia, upon returning
home, had a marked reduction in: 1) number of social contacts with others in the
community, 2) frequency in entering community settings, and 3) number of roles
that they played. All of the persons in her study eventually showed an increase in
these three activities, but there was wide variability in the extent of the increase.
Cogswell and Dunn confirm some of Caywood's observations about the process
of adjustment to spinal injury, and their data suggest that there is a considerable
degree of agreement as to the social implications of a disability. The concept of self
undergoes a change as one learns that people respond differently now that one is
disabled. But more importantly, Goffman (1963) believes that the self-concept
changes because upon becoming disabled, one perceives oneself as negatively as one
had viewed others with disabilities or stigmas prior to the injury.
"The painfulness, then, of sudden stigmatization can come not from the
individual's confusion about his identity, but from his knowing too well
what he has become." (Goffman, 1963, p. 133)
Goffman believes that shame becomes an issue in learning to live with a disability
and overcoming this shame becomes central to the acceptance of oneself.
We readily categorize people and develop a set of expectations as to how we
will react to persons in various categories. But when we meet a person who does not
fit these categories, our expectations become disrupted and we became uneasy in
our interactions with this person. This tendency to categorize people and to develop
expectations regarding them occurs at an early age and becomes a central feature of
our interpersonal relationships.
Jones and Sisk (1970) presented 230 children between the ages of 2 and 6,
with pictures of orthopedically disabled children and nondisabled children and asked
a series of questions designed to elicit their reactions to the pictures. Children aged 2
and 3 did not refer to any disabling feature which differentiated the pictures.
However, by age 4, the children were referring to the braces on the legs in the
pictures. At age 5, the children spontaneously referred to the children in the pictures
as crippled. Thus, as age increased, there was greater accuracy in describing the
pictures, and the incidence of perception of disability increased. By age 4, the
children were already aware the the functional limitations imposed by an orthopedic
disability and had begun to expect different behaviors from those with disabilities.
Richardson (1971) demonstrated that children, aged 10-11, tend to prefer a
nonhandicapped white child, a nonhandicapped black child, a facial disfigurement,
76
Social Factors
use of a wheelchair, crutches and leg braces, obesity, and amputation in this order.
In another study, Richardson and his colleagues (1961) found that handicapped and
nonhandicapped children of many cultures rank nonhandicapped children as the
preferred companions. Furthermore, he found that disability is a more salient
feature in establishing preference than skin color (Richardson and Royce, 1968).
Consequently, it would seem that at an early age, we all learn to perceive the
differences among people, to form categories, and to place a different valuation on
these categories. We prefer some people as companions and reject others. Children
learn to reject persons with disabilities although most of them have had little to no
contact with disabled children. Thus, we have the concept of difference which seems
to be a consistent factor in all prejudice. Friedson (1965) notes that to be
handicapped is to be perceived as having an undesirable difference from other
people. This early learning of the concept of difference and the rejection of that
which is different are reinforced by literature, particularly children's stories which
are peopled with ugly witches, hunchbacked gnomes, one-legged evil pirates, and
deformed beggars (Reynales, 1976). Advertisements and commercials exalt the
glories of youth and beauty and suggest that the beautiful people are the most
successful and happiest. Products are promoted with the subtle insinuation that use
of the product will increase one's attractiveness. Therefore, physical attractiveness
and one's perception of one's body do indeed become important aspects of
self-concept in adulthood.
Robertiello (1976) believes that there is a double standard in the importance of
physical attractiveness between males and females. Men are judged to be desirable
because of their personality, intelligence, or success. However, a woman's value is
very much judged to be on the basis of her physical attractiveness. Other qualities do
not seem to be able to make up for the lack of it.
Berscheid and Walster (1974) tend to agree, but their research shows that
physical attractiveness is of major significance for both sexes in dating choice.
However, males report that they place more emphasis on physical attractiveness in
choosing a partner than women seem to do. These authors review a large amount of
research which suggests that physically attractive persons are perceived more
favorably along many dimensions than unattractive persons and that this perception
is present among children as early as nursery school age. By age 8-10, children rate a
pretty face as a primary feature of femaleness and a tall muscular physique as a
criterion for maleness.
If the rejection of differences, disability in particular, and preference for
physical attractiveness is learned at an early age and persists into adulthood, then
persons who suffer a spinal cord injury have learned these preferences also. Thus,
one factor in determining the impact of spinal cord injury may be the emphasis that
the person had placed on physical attractiveness or prowess as an issue in interacting
with the world. Do very attractive persons have a more difficult time adjusting to
spinal injury or does the self-confidence they had previously developed assist them
in facing social situations? This becomes an interesting issue for research.
If the person with spinal injury has learned to prefer physically attractive
people prior to injury, his self-concept will be challenged by the onset of his
Social Factors
77
disability. He may be very rejecting of this new image of himself and find
confirmation of this change in himself by the actions of others.
Wittreich and Radcliffe (1955) found that nondisabled men took a significantly
greater amount of time to perceive simulated mutilation of the human figure than
non-multilated figures. They suggest that perception of a disabled person leads to an
emotional response which is probably the reason for the lack of acceptance of
disabled persons in society. Doob and Ecker (1970) found that housewives were
likely to comply with a request to fill out a questionnaire when the request
more made by a stigmatized person (wearing a black eye patch) than by a
was nonstigmatized person. These researchers emphasize that these results hold and for
situations in which there is no further contact required between the stigmatized
nonstigmatized person. They do not know if such compliance would be obtained if
compliance entailed further face-to-face interaction.
Kleck and his colleagues have conducted a series of studies regarding the effects
of physical deviance on face-to-face interaction. Kleck, Ono, Hastorf (1966) found
that uncomfortableness, strangeness, and uncertainty in an interview situation lead
to stereotyped and highly controlled behavior. The subjects interacting with an
apparently physically disabled person demonstrated less variability in their behavior
as a group, expressed opinions that were less representative of their actual beliefs,
and terminated the interaction sooner than did subjects interacting with a
nondisabled person. Kleck (1966) also found that subjects report less emotional
comfort when interacting with an apparently disabled person. In a further study
Kleck (1968) found that interactions with an apparently disabled person were
associated with motoric inhibition, a more positive impression of the disabled
and a distortion of opinion in the direction of making them more consistent in
person, with those assumed to be held by the disabled person. There was no difference
contact between the disabled-nondisabled interview and the nondisabled- which
eye nondisabled interview. These results were duplicated in another experiment
required longer interactions between apparently disabled and nondisabled persons,
but the effects diminished slightly as interaction time increased (Kleck, 1969).
Thus, Kleck interpreted these results as confirming Goffman's (1963) hy-
potheses about stigmatized persons. Interactions with stigmatized persons are
avoided as much as possible and if interaction is necessary, the nondisabled person
becomes somewhat emotionally aroused which produces inhibited constricted
behavior. Nondisabled persons tend to become overly anxious to please the disabled
person by complying with requests or shading their opinions to be consistent with
what they think the disabled person believes.
An attempt to review the extensive literature on attitudes toward disabled
will not be made in this document. However, for information on this topic,
persons the review by English (1971) is recommended as a general introduction to this area.
In addition, Wright (1960) has provided an excellent description of the psychosocial
reactions to disabled persons and should be consulted for a more in depth discussion
of the issues presented in this Chapter.
However, we can summarize some of these issues by comparing disabled
persons to a minority group that is devalued in various ways. Wright (1960) believes
78
Social Factors
that one characteristic of this minority group status is to be perceived as
underpriviledged and according to the stereotype of one who has suffered a great
misfortune and whose life is consequently disturbed, distorted and damaged. As a
minority group, contact is avoided which prevents the nondisabled person from
learning to behave more naturally around disabled persons.
Several studies have demonstrated that contact with and information about
disabled persons can improve attitudes of the nondisabled toward the disabled. In
fact, Anthony (1972) found that a combination of both contact and information is
better than either of these alone. Clore and Jeffery (1972) found that role playing
(traveling around campus in a wheelchair) was an effective means of improving
attitudes toward the disabled. Rapier and others (1972) found that integrating
disabled children into classes with nondisabled children led the older children to
develop more realistic attitudes about disabled children. Younger children were less
realistic in their attitudes. Euse (1975) found that covert positive reinforcement was
associated with improved attitudes and increased time spent looking at pictures of
disabled persons.
Consequently, it appears that we all learn to perceive differences among people
and to value those who are most physically attractive. We tend to avoid those who
markedly deviate from our expectations and standards of appearance and, thus, do
not learn how to behave in their presence. Initial contact with a disabled person
apparently leads to anxiety, inhibited behavior, and attempts to please the person by
complying with requests or giving opinons that are not necessarily our own but
those we think will be consistent with those of the disabled person. However,
contact with disabled people plus information about the disability appears to lead to
more relaxed and natural social encounters.
C. Family Relationships.
There is no article or research project which deals with the reactions of parents
to their teenagers or early adults who suffer spinal injury. What little has been
written deals with issues of satisfaction within marriage for disabled groups in
general and statistics on marriage and divorce among veterans with spinal injury.
Skipper, Fink, and Hallenbeck (1968) and Fink, Skipper, and Hallenbeck
(1968) report the results of a study of marital relationships when the woman
becomes disabled after marriage. They studied 36 disabled women and their
husbands but did not report what types of disabilities were present in their sample.
They found that there was little correlation between the husband's need satisfaction
and the degree of the wife's physical disability, and there was no relationship between
degree of disability and total marital satisfaction. With high degrees of disability,
however, the husband was less likely to feel compansionship satisfaction. That is,
while he got companionship at home, he did not have his wife's companionship on
many outside physical activities which they used to share. Thus, the authors
concluded that little could be predicted about a disabled woman's or her husband
marriage satisfaction on the knowledge of physical disability alone.
Klein, Dean, and Bogdonoff (1967) noted that the spouse of a chronically ill
Social Factors
79
person will experience significant tension during the initial phases of the illness and
that part of this tension is related to disruption of the usual roles which each plays
in the marriage.
There have been references to role reversal which spinal injury may impose on
married couples when the man acquires a spinal injury (Christopherson, 1968;
Dinsdale, Lesser, and Judd, 1971), but we do not have any good data to assess this
factor. Ludwig and Collette (1969) studied families of applicants for Social Security
disability in Ohio and found that severely disabled men (many different disabilities)
were less likely to respond positively to the item, "The man is always head of the
household" than less severely disabled men. Fewer severely disabled men than less
disabled computed the family income tax and made the decision on the purchase of
a new car, but the low frequencies in each of these categories suggest that the base
rates for this sample are for the wives to carry out these activities regardless of level
of disability. Therefore, this study does not really assess the factor of role reversal
and may be somewhat archaic in its definitions of sex roles in marriage. In any study
of role reversal, we will have to determine the base rates of certain activities
according to sex of the partner, and age of the couple will probably be a significant
factor in the outcome. Couples married more recently may display more equality
and less rigidity in definition of the roles in a marriage than older couples.
Socio-economic status, ethnic group, and educational level may also be important
variables in the outcome of such research. Thus, we will have to await future
research before we can comment definitively on this factor of role reversal in
marriages when one partner is disabled.
Many authors comment on the importance of the family in determining the
outcome of our rehabilitation efforts. Harris and associates (1973) believe that the
family determines the reaction of patients to their disability as does Margolin
(1971). Margolin reports unpublished data by Lowery which indicates that the
quality of the interpersonal relationships within the family are more important than
the disability itself. Lowery proposes that if rehabilitation fails for no apparent
reason, the family dynamics should be examined. If the family communicates an
attitude of worth to the patient, his self-concept will be maintained, and he is more
likely to participate in the rehabilitation process.
Litman (1962, 1964) studied 100 orthopedically disabled patients and found
that those who were able to maintain a positive conception of self consistently
responded to treatment while those with negative self-conceptions tended to
perform and of function entailed. the worth. attitudes below of (This He the also expectations. degree finding of others found of tends understanding toward that Self-conception the to himself challenge degree which as of well the was adjustment the strategy as defined patient his sense to as of had the the of rating as disabled person's personal to adjustment what evaluation role adequacy that was role to a
disability while the person is still hospitalized.) Litman found that family solidarity
per se was not related to rehabilitation outcome, but amount of positive
reinforcement received from the family was related to better performance in
rehabilitation. Furthermore, patient performances seemed to be enhanced when
therapy could be viewed in terms of re-entry into an established family
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Social Factors
constellation. Previous social involvement favored participation in rehabilitation
activities as did a prior history of extensive physical activity.
Kerr and Thompson (1972) found that all the patients in their sample who
were rated as having made an excellent mental adjustment to spinal injury had
satisfactory lives prior to injury and most came from exceptionally warm and loving
backgrounds. Kemp and Vash (1971) found that interpersonal support was
positively correlated with degree of productivity in persons with quadriplegia, but
this relationship did not hold for persons with paraplegia. And Cobb (1976), while
not referring to physical disability per se, does emphasize the importance of social
support as a moderator of life stresses in a large number of situations. He defines
social support as information leading the person to believe that he is cared for or
loved; and/or information leading a person to believe that he is esteemed and valued;
and/or information leading the person to believe that he belongs to a network of
communication and mutual obligation.
At the consumer conference sponsored by this project, there was considerable
discussion about the conflicts which a disabled woman experiences and the
difficulties that a family experiences when the woman is disabled. If there are
children in the family, the mother who has a disability often worries that she is
asking too much of her children since she needs their assistance with many daily
activities. Without children to help, it is difficult to manage all of the daily activities
when the woman has quadriplegia, for example. The attendant will only do certain
activities, and hired help will do only what they are told to do, no more, usually.
The family schedule revolves around the times the attendant will be available to
assist with the bowel program which places constraints on a social life. Spontaneity
in such situations is very difficult. When the husband is employed or in school, there
is great strain on him to fill in at home with all of the extra chores that need to be
done. Because she realizes how hard he is working at all of these tasks, the wife may
feel that she cannot ask him for a favor since she has used up her "allotment" of
requests, so to speak.
In addition, one key way of coping with a severe disability is to learn to
minimize the problems and hassles, especially in regard to quadriplegia. This is not a
denial, but rather a matter of orientation. There are SO many difficulties, that one
needs to focus on the positive side of life and learn not to dwell on the
inconveniences. However, this may lead to difficulties between a married couple as
the disabled partner seems to be minimizing the difficulties involved in every day life
and the able bodied partner is all to well aware of the difficulties. Therefore, open
lines of communication are necessary for the survival of the marriage.
There are constant constraints on the freedom of the able bodied partner which
add pressure to the relationship. The nondisabled partner may feel that they do not
have as many options to be late coming home or to stop for a beer with co-workers
after work. There is a subtle sense of guilt hich they feel; it is often self-imposed.
The financial pressures of having to hire attendant and housekeeper services add to
the difficulties of a marital relationship unless the able bodied partner does not work
and is prepared to do this work 24 hours a day for seven days a week, every year.
When the attendant suddenly quits, the able bodied partner must perform the
Social Factors
81
ADL and transfer activities which are necessary for survival. Many partners find that
the bowel and bladder care are unpleasant and participation in such activities may
possibly interfere with the quality of the relationship over time in some cases.
Having attendant care available puts a constraint on any vacation planning unless the
able bodied partner is prepared to assume responsibility for these tasks while the
couple is away. (Consumer Conference, 1977)
In a general sense, the process of mothering and fathering need not be
influenced by severe disability. But at young ages, children need things done for
them, and the mother with quadriplegia must watch while someone else puts the
bandage on the skinned knee. The subtle competition that can arise between
housekeeper and the mother in regard to caring for the child will require great
strength and social skill on the part of the disabled woman. In addition, if the couple
choose to adopt a child, adoption agencies often reflect all of the prejudice and
negative stereotypes of the disabled as found in the general population. Because of
the disability, the agency assumes that it would be inappropriate to place a child in
the family. Great efforts have to be made to convince the agency that this is not the
case. Thus, in many ways, the presence of a disability will introduce a number of
complications into a relationship which will require an open and sharing relation-
ship. Despite these difficulties, the majority of marriages in which one partner is
disabled survive.
Comarr (1962, 1963) provides data on the marriage and divorce rate among
veterans with spinal injury, but since these data may be somewhat out of date, we
shall concentrate on the findings of El Ghatit and Hanson (1975 and 1976) who
also studied United States veterans. Apparently, their data overlap with that of
Comarr.
In a study of pre-injury marriages, El Ghatit and Hanson (1975) found that
26.7% of the men who had been married at the time of injury were divorced at the
time of the study. Of this group of divorced men, 76.4% reported that the injury
had played a big role in the divorce. The authors note that the 26% divorce rate is
lower than the base rate for the United States which is 33% and much lower than
the base rate for divorce in California (the residence of most of the study sample)
which is 50%. The divorce rate following onset of disability varied according to
whether the person had ever been divorced prior to injury. Those in their first
marriage at injury had a divorce rate of 27%, but those who had been married more
than once had a divorce rate of 42%. Level of injury was not significantly related to
incidence of divorce. The divorce rate was higher for couples who had pre-injury and
post-injury children in comparison to childless couples. This contradicts the
impression that children have a stabilizing effect on marriages. Employment status
was correlated with divorce rate. A lower divorce rate occurred in the men who had
not been employed since injury or who were employed at the time of the study. The
highest divorce rate occurred in men who had been employed at some time
post-injury but did not sustain the employment (37.7%). The lowest divorce rate
occurred in those currently employed (17.6%).
Data on marriage and divorce after onset of spinal cord injury are supplied by
El Ghatit and Hanson (1976). The overall divorce rate of those who had been single
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Social Factors
at injury was 24.6%. Of those divorced, only 41% thought that the spinal injury was
a significant factor in the divorce in contrast to the 76% for divorces of pre-injury
marriages. This divorce rate is not significantly different from the divorce rate of
pre-injury marriages and also not significantly different from the overall United
States divorce rate. Level of injury was significantly related to divorce rate of those
who had been single at injury, persons with high thoracic lesions having the highest
rate. However, considering all post injury marriages, whether or not it was a
remarriage, level of injury was not related to divorce rate. For those who were single
at injury, the presence of post injury children (whether natural or adopted) was
associated with a significantly lower divorce rate (7.4%) in comparison to those who
had no children living with them (25%). The presence of children was not related to
divorce rate in persons who remarried after injury.
Interestingly, of those who remained single even after injury, they were less
likely to have improved their educational status than those who were married.
However, post injury education was not related to divorce rate. In addition, males
who remained single were less likely to obtain employment than those who were
married. But of those who did obtain post injury employment, those who were
single were more likely to sustain the employment. No relationship between current
employment and divorce rate was found for post injury marriages.
Deyoe (1972a) reports data on marriage among United States veterans in the
northeastern part of the USA and claims that there was a greater stability for
marriages contracted following injury. Also he states that there was no difference
between the veterans with service-connected versus nonservice-connected disabilities
in divorce rate, but he does not provide data on this factor.
These data on marriage and divorce should be considered to be hypotheses
which require further testing. The individuals at the Consumer Conference (1977)
sponsored by this project strongly cautioned that these data on marriage and divorce
rate among United States veterans are not representative of the civilian spinal cord
injury population. They claimed that the financial security of the service-connected
veteran puts them into a separate category, and a study should be conducted on a
civilian group. Deyoe (1972a) claims that this was not a factor in his study but does
not provide data to substantiate this. Furthermore, it is possible that even the
nonservice-connected veteran may not be representative of the civilian population.
Therefore, these questions should be tested.
Future research on this issue should be possible using data collected by the
National Spinal Cord Injury Data Research Center in Phoenix, Arizona. Researchers
should consider the El Ghatit and Hanson studies as a model of how the data should
be analyzed. Detailed statistical analyses are necessary in order to assess the
multitude of variables which are associated with divorce. Following the style of
these authors, it is recommended that the data be considered separately for those
who have been married pre-injury and those who contract their first marriage
following injury. The financial security of the couple should be assessed because
Kerr and Thompson (1972) found that this was an important factor in the
adjustment to spinal injury.
Clinical impression suggests that those marriages which are unstable prior to
Social Factors
83
injury will be further stressed by the injury. Does this group have the highest divorce
rate? Are marriages contracted after injury more stable? El Ghatit and Hanson say
no and Deyoe say yes. What are the stresses on a marriage when spinal injury hits
one partner? We have no data. Is role reversal a problem and how do we define it?
What happens to marriages in which the female is the disabled partner? Are females
who are single to onset of spinal injury less likely to contract a marriage than males
because of the double standard regarding physical attractiveness? What is the role of
culture and ethnic group on marriages among those with spinal injury? Do men of
some ethnic groups reject their wives who sustain a spinal injury because they fear
that their masculine image is hurt? Are women of some ethnic groups less likely to
marry a man with spinal injury? There are many questions to which we have no
answer. In addition, we must ask if there are strategies that would be successful in
assisting the person-with spinal injury as he tries to cope with the complicated
social world he will face after discharge from the rehabilitation center.
D. Demographic Variables
There is some evidence to support clinical intuition that certain demographic
variables, along with severity of disability, may influence the process of adjustment
to spinal cord injury in certain individuals. Thus, we will examine the literature to
determine what we know and do not know about the influence of age at onset,
severity of disability, duration of disability, socio-economic status, sex, ethnic
background, urban-rural residence, and financial security.
1. Age
Data from the National Spinal Cord Injury Data Research Center in Phoenix,
Arizona (Young, 1977) confirms our suspicion that spinal cord injury affects the
young. Based upon a national sample of 1687 persons injured in 1973 through 1976,
we find that injuries resulting in paraplegia (n=818) are most likely to occur to
persons age 30 or under. Sixty-seven percent of those with paraplegia were injured at
age 30 or less, the most frequent age group being ages 15-20 which has 27% of the
cases. The data is even more striking for persons with quadriplegia (n=869), 62% of
the injuries occurring in persons under age 25, with the most frequent age group
being ages 15-20, which accounts for 34% of the injuries. Spinal injury occurs after
age 45 in only 9.3% of the total cases in this national sample.
Wilcox and Stauffer (1972) followed 423 persons from Rancho Los Amigos
Hospital and looked at what happened by age category. Of those who were over age
40 at injury, 25% were dead at follow-up in contrast to 9% death rate in those
injured between ages 14 to 19 years. They note, however, that the group aged 20 to
40 at injury seemed to have the greatest amount of troubles. In this age group
occurred the most suicides, the highest incidence of unlawful behavior prior
to injury and the highest percentage of persons living in nursing homes. The
employment rate was 3% higher than for the younger group, but the college
enrollment rate was 20% lower than the younger group. Wilcox and Stauffer
state:
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Social Factors
"This middle group reflects some habits of both extremes. Some are still
being propelled forward by their individual life-styles; some seem to have
had their early aspirations blunted by exposure to the world after leaving adults.
home and before they became fully established as independent and
They of the three groups appear to be the most vulnerable to tragedy and
the least predictable, and defied categorization in this study." (Wiicox
Stauffer, 1972, p. 121)
Kerr and Thompson (1972) followed 181 persons with spinal injury and rated is
their mental adjustment to the spinal cord injury (methodology of excellent rating
them unspecified). on They found that 83% of those aged 10-20 made a good or percent
adjustment, over 45 who were rated as not having adjusted were dead in
61% of those aged 20-45, and 41% of those over 45. Fifty-one at time of
of those Regarding the 20-45 age group, the authors conclude that differences roles in
follow-up. and home circumstances seemed to play very important is a
personality determining outcomes. Thus Kerr and Thompson conclude that age very
important factor, the young adjusting better than the old.
Hallin (1968) noted that while level of lesion had a great effect on
independence, quadriplegic category. Older persons with incomplete quadriplegia were less
age did also. This was especially apparent in the incomplete likely to
be independent in function than their younger counterparts.
Dinsdale, Lesser, and Judd (1971) divide their patients into three categories male
to constellation of problems presented. They believe that the young
according the most difficult adjustment problems as defined by the number of problems do not
has listed using the Problem Oriented Medical Record approach. However, they number of
follow-up data to determine whether there is a correlation between actual
have problems identified during inpatient rehabilitation versus number Kerr of and
potential problems following discharge. Judging by Wilcox and Stauffer's and
Thompson's data, this group might do very well.
Ludwig and Adams (1968) noted that the very young and very old were more
to complete rehabilitation services than the intermediate age group. They in
likely interpret this in terms of ease in assuming the client role by those who already are
dependent or subordinate social roles outside of the hospital.
Kemp and Vash (1971) found an interaction between age and number of
reported goals. Amongst those reporting a high number of goals, the younger less
individuals were more productive and the older persons were somewhat
productive. Consequently, there seems to be some consensus that the very young may have
less difficult time adapting to the changed life circumstances that disability better
a Onset before age 20 seems to be associated with somewhat individual
requires. on the whole than later onset although there are tremendous 38% of
adjustment differences. Using the national data on spinal injury during years 1973-1976, between
the injuries occur before age 20, 30.6% between ages 20 to 30, and 13.6% the social
30 and 40. It is not that age per se is the factor but more likely it is
psychological stage of adulthood that accounts for the differences.
Social Factors 85
Sheehy's book Passages (1974 and 1976) may provide some interesting clues as
to the types of adjustments that a nondisabled person is making at various points in
adult life which then become additional pressures at the time of disability. In
essence, Sheehy states that the ages of 20 through 35 are very formative years as the
person establishes an identity and creates a role for himself which provides the
opportunity for self-acceptance and stability later in life. Within this context, those
injured before age 20, may not have begun or gotten very far into this process and,
therefore, they can establish an identity in which the disability becomes an integral
part of who they are. Within the 20's and 30's, however, there may be more
readjustment required of the newly disabled person and for this group "inner
strength" and all that this implies is a more critical variable. Disability after age 40
might produce two groups: those who "give up" and those who still have some
important items on their agenda, so to speak. In these latter two age groups, one
might speculate that those with an internal locus of control would be more
successful than externals. However, this is a question for research. But books such as
Passages and the research upon which it is based suggest that we should give more
than passing attention to age of onset as a factor in adjustment to spinal injury.
2. Severity of Disability.
Quadriplegia imposes greater limitations on a person than paraplegia, and the
question then arises as to whether persons with quadriplegia, on the average, are less
well adjusted than paraplegics. Therefore, we will examine any study that does
provide any information related to severity of disability.
Ludwig and Adams (1968) found that severity of disability was a factor
associated with the completion of rehabilitation services and discuss the data in
terms of the ability to assume the client role which entails some degree of
dependence and subordination. However, in the case of severe disability, it may be
that the person believes that he has fewer options and, therefore, had better
complete the services in order to attain as much skill as possible. Unquestionably, a
person with less severe disability can quit a rehabilitation program and still do well if
he chooses.
Seymour (1955) studied the social and personal adjustment of persons with
paraplegia and quadriplegia. Social adjustment was rated by ward staff on an
instrument designed for the study. No validity data was presented. Personal
adjustment was judged by blind analyses of Rorschach protocols. She found that
persons with quadriplegia were rated as more socially adjusted than those with
paraplegia. There was no difference in personal adjustment between these two
groups. She comments, however, that the adjectives applied to those judged to be
socially adjusted were "compliant," "co-operative," "gives little trouble," "is quiet,"
"is nice," which may not be a desirable situation from the standpoint of good
psychological health." (Seymour, 1955, p. 693) We must realize that this study was
conducted in the early 1950's on a Veterans Administration hospital population. We
have no information of duration of the disability and wonder if the persons with
quadriplegia were living in the hospital rather than receiving initial rehabilitation
services. We have no information and, therefore, must treat these data with caution.
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Social Factors
However, we can say that the persons with quadriplegia had, indeed, identified what
behavior was necessary in order to get along with the staff on whom their survival
depended.
Cull and Smith (1973) found that incidence of decubitus ulcers was unrelated
to any of the variables which they studied except sex. Males were more likely to
experience skin breakdowns than women. Severity of disability was not a factor.
However, Anderson and Andberg (1977), in a truly excellent study, found that as a
group, persons with quadriplegia had a lower incidence of pressure sores than the
group with paraplegia.
Hohmann (1966) found a tendency for the experience of emotional feelings to
be reduced with increasing severity of disability. Jasnos and Hakmiller (1975) found
persons with cervical lesions less responsive to sexual stimuli than persons with lower
lesions. However, this study was criticized earlier on methodological grounds and the
results must be considered tentative. At this time there is no evidence that a
reduction in experienced emotional feelings is an advantage or disadvantage in
adjusting to spinal injury. Therefore, this becomes a question for research.
Kemp and Vash (1971) found a significant interaction between level of injury
and interpersonal support as factors in productivity. With high interpersonal
support, there was no difference between persons with paraplegia and quadriplegia.
But with less support, persons with quadriplegia were significantly less productive.
Meyerson (1968) found that internal versus external locus of control was not
related to level of injury. Dinardo (1971) found that those with severe disabilities
were somewhat more depressed than those with less severe disabilities regardless of
their locus of control or position on the repressor-sensitizer dimension. Among those
with less severe disabilities, internal repressors were less depressed than external
sensitizers. Swenson (1976) found that locus of control and satisfaction with life
were unrelated to level of disability.
And finally we have a study by Golightly and Reinehr (1972) which questions
whether the psychological environment and the reality of the disability might be
very different for persons with quadriplegia versus paraplegia. They wonder if those
with quadriplegia become psychologically different from those with less severe
disabilities and the nondisabled. Thus, they administered the Holtzman Inkblot
Technique to 16 persons with quadriplegia who were residents of a domiciliary
workshop. These persons had previously been receiving custodial care before entry
into the workshop program. They describe the results in these terms:
"The subjects in the present sample are least like college students and
most like 5 year olds in their pattern of responses to the inkblots. They
are also rather more similar to the 'pathological' groups (Schizophrenics,
Mentally Retarded, Depressed patients) than to the 'normal' groups."
(Golightly and Reinehr, 1972, p. 48)
The question which these researchers planned to study is an interesting one and
it is too bad that they did not test the question. An alternative and highly probable
interpretation of their data is that they reflect the effects of social and psychological
Social Factors
87
stagnation which extended institutionalization can produce no matter what the
disability might be. The authors give no information on duration of disability, length
of institutionalization, age, or the reasons that these persons were not out in the
community. They observe that it is difficult, if not impossible, to obtain an
adequate control group for their sample which seems to be an implicit recognition
on their part of the unrepresentativeness of their group to the population with
quadriplegia. Otherwise, a sample of persons with paraplegia would be nice as a
minimum, in addition to a sample of persons without spinal injury who have been
institutionalized for a similar (but unspecified) period of time. Another control
group would be a sample of able bodied subjects who have been participants in a
sensory deprivation experiment. While the authors admit that this is a preliminary
investigation and that only limited inferences can be drawn from such crude
data" (Golightly and Reinehr, 1972, p. 48), we do not believe that such disclaimers
reduce the obligation that researchers have to submit for publication only those
works which have some degree of methodological soundness as a basis for
interpretation of the results. Golightly (1978) fully concurs with these observations
and regrets that the study was published.
Thus, in terms of severity of disability, we do not have, at present, any
evidence that higher levels of injury and greater functional limitation lead to a
poorer adjustment to spinal cord injury. One wonders if the physical and
psychological reality of quadriplegia versus paraplegia leads to differences in how
one adapts (although level of adjustment would be similar depending upon the
person and the environment), and this is a question to be tested in the future. Nagler
(1950) discusses quadriplegia as a separate reaction type, but we have no evidence
that this is, in fact, the case. One wonders if persons with quadriplegia need to
develop a greater skill at coping with interpersonal relationships than persons with
paraplegia because the former group's very survival often depends upon their ability
to get along with those around them. However, future research into spinal cord
injury should specify the level of injury or severity of disability so that we can test
some of these questions.
3. Duration of Disability.
We talk about the process of adjustment to disability and believe that it occurs
over a period of many years. Carter (1977) and Kerr and Thompson (1972) believe
that at least two years are needed before the person achieves some sense of stability
in his life. However, amazingly enough, we do not have any data to document this
course of adjustment to spinal cord injury. Very little of our data is longitudinal in
nature, and many studies in the literature do not even specify the duration of
disability of persons in their samples. When they do specify duration, the average
duration is given, and from the range, one knows that the standard deviation must
be high. Can we assume that the reactions of a person injured for 6 months are
similar to the reactions of someone injured for 5 years?
Longitudinal research is needed to study this issue. Willems (1976a & b) and his
associates have been following a series of persons with spinal injury for a number of
years, but data are not yet available on the long term adjustment of these people.
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Social Factors
This issue requires study by other researchers, but in the meanwhile, all studies
should specify duration of disability and reduce the size of the standard deviation of
this parameter.
4. Sex
Data from the National Spinal Cord Injury Data Research Center (Young,
1977) indicates that approximately 20% of the spinal injuries occur in women, but
there is a slight difference in incidence of paraplegia and quadriplegia. In the
national sample of 1687 cases, injured between 1973-1976, we have the following
information:
Quadriplegia
Total
Paraplegia
Male
649
(79.3%)
727
(83.7%)
1376
(81.6%)
Female
169
(20.7%)
142
(16.3%)
311
(18.4%)
Total
818
(100%)
869
(100%)
1687
(100%)
It appears that 54% of the women who are injured incur paraplegia and 46% sustain
a quadriplegia, whereas, in men, 47% become paraplegic and 53% become
quadriplegic.
Most of the studies do not refer to sex of the persons with spinal cord injury
and the number of women in any sample would admittedly be small. However, we
have no data as to whether women react differently to spinal injury than men, and
until this issue is studied, it is not appropriate to group all persons with spinal injury
together into one unisex category. Since women, according to our records, do
account for 18% of the total sample, it seems appropriate to study this issue.
However, since 82% of the spinal injuries occur in men and most of the data
reported is based on samples of males, the masculine pronouns have been used in
this document in a generic sense for the purpose of convenience and simplicity. This
usage of language should not be interpreted to suggest that we believe that women
are less worthy of consideration on any of the issues discussed in this document.
5. Socio-economic Status and Culture.
Socio-economic status (SES) can influence the reaction to spinal cord injury in
several ways: it has played a role in shaping the person's personality style up to the
point of injury, and it correlates highly with the environmental resources which the
person has available to him as he faces the world as a person with a disability.
Lefcourt (1976) reports that SES correlates with locus of control. Persons from
less affluent or deprived backgrounds are more likely to perceive that the world's
resources are outside of their control. The person sees himself as a victim of fate,
luck, or chance, and tends to have an external locus of control. This personality
factor may be a very important one in the ultimate adjustment to spinal cord injury.
Amount of education and attitude toward educatio may vary according to SES and
this may be a very influential factor on outcome after spinal cord injury.
Consequently, all of the parameters of SES should be investigated and related to
adjustment to spinal cord injury.
Social Factors
89
Meyerson (1968) found that race was one of the few factors that correlated
with his measure of locus of control. Blacks were more external than whites. Kalb
(1971) reported that social class and incidence of depression predicted post-
discharge outcomes. Persons of a lower SES who were depressed did poorly after
discharge. Lugwig and Adams (1968) found that nonwhites, the unemployed, and
those referred by public agencies were persons most likely to complete rehabilitation
services. They interpret these data in terms of ability to assume a dependent and
subordinate role. Kerr and Thompson (1972) found that examples of good
adjustment to spinal injury were found in all social classes in their sample. But they
report that persons in the best adjusted category had more education than those in
the less adjusted categories. Furthermore, they state that financial hardship was
certainly a deterrent to good adjustment. In 30 cases rated as excellent in
adjustment, there was only one in which financial hardship might have been a
problem.
Culture and ethnic background play a similar role as SES; they influence the
person prior to injury and continue to do so afterwards. Spinal injured males from
cultures in which masculinity is equated with physical prowess, success with females,
and fathering many children may have a more difficult time in adjusting to spinal
injury. True or false?
There are many issues which affect a person's life and which may correlate with
adjustment to spinal injury. But we do not have any data to document these
influences. Consequently, future research should specify the nature of the subject
population more precisely so that we can begin to access the role of socio-economic
status and culture as factors in the adjustment to spinal cord injury.
6. Urban-Rural Residence.
We can speculate as to the advantages and disadvantages of urban versus rural
residence, but we have no data available to determine if this is a factor in outcome
after spinal cord injury. Urban areas may have more resources for medical attention
and for education and social outlets (if they are physically accessible), but cities may
be lonely places with greater social isolation than small communities. Rural areas
may provide more interpersonal support and the historical ties to the region may
cover several generations in contrast to urban residents. Whether these environ-
mental factors are influential in the ultimate adjustment to spinal injury, we do not
know. Thus, this becomes another area for research.
E. The Task of Socialization.
Kahn (1969) notes that the current system of medical care does not improve
the self-esteem of anyone with spinal injury.
"Current medical care is structured to gain control of the patient through
depersonalization and infantilization, which reinforce the regression in
social functioning that occurs in any illness experience, let alone one of
catastrophic dimensions. The patient's already shaken self-image is further
90
Social Factors
weakened when he is tagged for identification and divested of his clothes are
and other personal belongings, and when he realizes that others to
planning his daily schedule. His control and right to privacy medical seem team
vanish he becomes open territory for any member of the is
who wants as to ask him questions or to examine him. His self-image and
further damaged by hospital personnel who call him by his first name
coax him as though he were a child." (Kahn, 1969, pp. 757-758)
the analogy of physical rehabilitation, Kahn goes on to point out the necessity sores,
Using social problems, just as we focus on preventing pressure and
of preventing and bladder stones. The patient must be involved in all treatment. planning
contractures, decision making, and the family should be included in all phases of the detail,
and Kutner (1967) elaborate on these ideas and discuss, in the
Weissman that may develop with extended hospitalization. The disabled person and
role disorders overly preoccupied with himself because of the monotony his
can become nature of hospital environments. He is unable to influence making.
constricting because most hospitals permit little individuality in decision there
environment the hospital may unintentionally undermine social competence because disability is
Thus, opportunity to practice social skills. Basically, the person with would a feel
is little subordinate position through out the hospitalization and, thus, very The
in a at coping with the devaluation he will experience after discharge. routine
unskilled relationships are tenuous and transitory, and the hospital During the
patient-patient interfere with the close personal contact between intimates. and
does he is on a leave of absence, so to speak, from his job, school,
hospitalization, social life. Consequently, all of these factors, these realities of hospitalization
impinge at a time when he, himself, questions his self-image.
on hospitalization a person process does have positive features, however. Spinal that cord he
The centers provide the newly injured person with models and peers basic so survival
injury feel so tremendously isolated from others. In addition, the the
need not will be learned in a supportive and encouraging atmosphere. And, thus, social
skills becomes, can we modify our present procedures to enhance rehabilitation later
question functioning or should we introduce social skills training as part of the
process. Perhaps (1967, we should 1968) try points both. out that in contrast to the sheltered real social and
Cogswell of hospital and home, the community is a setting where the varies
environment stigma of disability reach their height of salience. Salience of stigma definition
perceived with the of social other and type of social setting, with the person's other's
type of self as worthy or demeaned, and with his skill in managing
and definitions projection of him. Thus, persons with spinal injury may reduce the stigmatizing where
disability by limiting social encounters to others and social settings which
effects feel of the stigma is less salient, by projecting a definition of self as worthy, in eliciting
they tends to counter negative definitions by others, and by becoming skilled
positive definitions of self from others.
Cogswell hypothesizes that following discharge, persons with spinal injury tend with
to phase out relationships with pre-trauma friends, develop new friendships
Social Factors
91
lower status others, and then finally acquire new friends of similar pre-trauma status.
She believes that situations in which both persons have social handicaps allow the
person with the disability to have the opportunity to experiment with new behavior
in less threatening situations. The person with a new spinal injury will select social
settings depending on the physical accessibility, the flexibility for leaving the scene,
and the salience of the stigma. She further categorizes physical accessibility as those
settings where the person can go and remain in his car; those allowing easy
wheelchair maneuvering; those that can be easily entered by wheelchair but require a
transfer out of the wheelchair to a different seat; those in which physical assistance
is required in order to enter the setting.
This outline of the socialization process, presented by Cogswell (1967, 1968),
seems to be based on her observations of and interviews with a series of persons with
spinal injury. She does not present data, and, therefore, we must consider the above
to be hypotheses about the process of socialization which can be the subject of
research. She defines socialization as a continuous process of learning to abandon
old roles and self-conceptions and to acquire new ones, and she chastizes sociologists
for attempting to study socialization as a static phenomenon rather than a dynamic
process. This criticism echoes the ones presented by this reviewer in the previous
chapter; therefore, longitudinal research seems to be the most appropriate technique
to enhance our knowledge of the changes that occur following spinal injury.
However, an example of good cross-sectional research was performed by
Mesch (1976) who studied the content of verbal interactions between college
students with spinal injury and with no disability. She found that dyads consisting
of two nondisabled partners exhibited the least amount of self-disclosure at all levels
of topic intimacy, while dyads consisting of two disabled partners exhibited the
greatest amount of self-disclosure on low and medium intimacy topics. The mixed
dyads, consisting of one disabled and one nondisabled partner, exhibited the greatest
amount of self-disclosure on the high intimacy topic. She states that in the mixed
dyads, the subjects appeared interested in each other but proceeded cautiously using
the experimental task as a vehicle for getting to know each other. The quality of the
interaction appeared to be partially dependent on the degree to which the disabled
subject could establish rapport with his nondisabled partner. In dyads in which a
positive interaction occurred, the disabled partner demonstrated initiative in
volunteering information, openness about himself and his experience, and respon-
siveness to his partner's disclosures.
Davis (1961) provides an excellent sociological analysis of the interaction
process between a disabled and nondisabled person based on interviews with eleven
socially skilled visibly handicapped persons. These informants substantiate the
observations by Mesch that the success of the interaction is usually a function of the
skill with which the disabled person puts the nondisabled person at ease. The person
with a disability must learn techniques to overcome the initial strain in the
interaction and must find ways of establishing rapport so that the nondisabled
person can learn to forget the presence of the disability.
Consequently, the person with spinal injury faces a formidable task. Not only
must he learn to mobilize himself and function despite the motor and sensory loss,
92
Social Factors
but he must learn to put people at ease. Unfortunately, we have emphasized those
tasks relating to physical functioning and have essentially ignored those tasks
relating to social functioning.
Romano (1976) has called for increased social skills training for the newly
handicapped as a means of ensuring success of our rehabilitation efforts. She
describes social competence as those adaptive verbal and action skills which permit
people to have some control over their interactions with others. This training would
recognize an individual's strengths and use behavioral rehearsal and assignment in
which a person considers a given situation, identifies the alternative types of
responses, and practices a chosen response in a situation which provides him with
feedback. Although data are not presented, Romano states that patients who have
participated in social skills training during rehabilitation hospitalization report that
they enter social situations more readily and with less anxiety after discharge.
It is recommended that social skills training become an integral part of all
rehabilitation programs and that research be conducted to assess its value. In this
chapter, we have described the various factors that complicate the social life of the
individual following spinal injury or any disability, but there has been little
definitive research in this area. We must specify the behaviors that a person with
spinal injury needs in order to cope with nondisabled persons and teach these skills
as part of rehabilitation. Whether these skills should be included as part of the
inpatient rehabilitation program or should be considered to be a second phase in the
rehabilitation process should be studied. At this time, there are some attempts to
include transitional living experiences during the inpatient rehabilitation phase.
Manley and Armstrong (1976) describe the use of a transitional living facility at
one of the regional spinal injury centers. During the last two weeks of rehabilitation,
the patients are requested to reside in an apartment complex with their families in
order to test the skills and techniques learned in the rehabilitation program. The
patients are still under the supervision of the hospital staff so that problems can be
identified and corrected and self-confidence can grow before actual discharge. They
report that those discharged after the transitional living experience have fewer
medical complications and social crises than patients discharged without this
experience. Unfortunately, we have no data to substantiate this report, and a
research project should be devised to assess the benefits of such experiences.
In the last several years, there have developed centers for independent living
run by the disabled for the disabled. Peer counseling regarding daily life experiences
has been included and is another attempt to fill the gap between the physical skills
learned in the traditional rehabilitation center and the skills needed to cope with the
world. Some of these programs have residential facilities and others do not. These
programs will be discussed in more detail in Chapter IX.
F. Recreation.
'The onset of spinal injury may interfere with a certain number of recreational
activities that a person had enjoyed prior to injury, especially if these activities
involved physical performance. Since recreation is part of everyone's life in some
Social Factors
93
form and is viewed as essential for reducing tension and offsetting the hard work of
daily life, it is especially important in the life of a person with a disability. Since
80% of spinal injuries occur to males and a large proportion of them are young,
recreation can provide some rewards and opportunities for physical activity and even
competition which was a part of their life prior to injury.
Guttmann (1976) has recognized the importance of recreation, and athletic
competition, in the lives of persons with spinal injury. He believes that sports can
improve physiological functioning and can be a means of maintaining cardio-
pulmonary conditioning and general health. Strength, endurance, and coordination
may improve as the result of participation in athletic activities. Furthermore, he
believes that, in addition to the physical benefits, athletics have psychological and
social benefits as well. Participation in sports activities can be one means of
developing self-confidence and can become one avenue through which the person
can re-enter community life.
Annually, competitions are held at Stoke Mandeville Hospital in England and
during olympic years, these competitions are held in the same country as the
olympic games if possible. National and regional competitions are held around the
United States and many have endorsed recreation as an important part of a
rehabilitation program (Crase, 1972; Lynch, 1972; Sheredos, 1973; Jochheim and
Strohkindle, 1973; Robinson, 1973). Haskin and associates describe the advantages
of horseback riding for persons with disabilities, and swimming is favored by others
(Tomita and Matsubayashi, 1964; Geis, 1975). Gutmann and Mehra (1973) are
particularly impressed with the value of archery since it may be one of the only
sports in which the disabled person can compete on equal terms with able bodies
persons.
Martial arts may be another area that might be rewarding to persons with
disabilities. Able bodied persons report an increase in self-confidence as a result of
such training. Thus, this should be included as an option for persons with
disabilities.
Since everyone needs a reason for getting out of bed in the morning,
recreational activities should be a part of a rehabilitation program. The purpose of
these activities should not only be entertainment, but rather they should be
considered to be therapeutic activities. They should focus on teaching the person
with the disability skills that he might find rewarding later in life.
It would be interesting to compare two groups of persons: those with no
recreational training and those given significant training and opportunity to practice
a sport of their choice. Does the latter group participate in a wider variety of
activities following discharge than the group without such training? This should be
tested.
G. Aging.
At this time within the history of the treatment of spinal injury, we are
approaching an issue which has never been a concern until now. That population of
persons who sustained their spinal cord injuries during World War II are
m spinces
INT'L. J. PSYCHIATRY IN MEDICINE, Vol. 11(2), 1981-82
my
2019
EMOTIONAL REHABILITATION OF THE
PHYSICAL REHABILITATION PATIENT
DAVID W. KRUEGER, M.D.
Director, Baylor Psychiatry Clinic
Associate Professor, Baylor College of Medicine
and Staff Physician,
Texas Institute of Rehabilitation and Research
ABSTRACT
Emphasis on the process and content of the emotional aspects of rehabilitation are
presented as a process interwoven with a patient's physical rehabilitation. The
impact of trauma and subsequent rehabilitation involves for patients the resolution
of these stages: shock, denial, depressive reaction, reaction against independence,
and adaptation. Factors which facilitate and impede the negotiation of these steps
on both the part of the patient and attending staff are examined from the prospective
of the psychiatrist as a member of the medical rehabilitation team.
INTRODUCTION
Every individual who enters a physical rehabilitation program has experienced a
major loss, and for many it is the most devastating loss of their lives. The
emotional significance of this loss is equivalently great, even though relatively
few physical rehabilitation patients manifest symptoms serious enough to
require psychiatric intervention. These emotional symptoms may include overt
syndromes such as depression, anxiety, or substance abuse, or it may involve
more complex issues such as interference in the progress of rehabilitative efforts,
not achieving rehabilitative goals which are feasible, or interactional difficulties
between patient, staff, families, or physicians.
This paper will examine some emotional aspects of the rehabilitation process
as they occur in psychiatrically healthy patients as well as in patients with
existing psychopathology. Although we will consider overall grief and mourning
processes which many patients can and prefer to experience alone, with close
183
© 1981, Baywood Publishing Co., Inc.
RECEIVED SERIO 1981
184 / DAVID W. KRUEGER
friends and loved ones, or with their primary physicians, there will be particular
emphasis upon those few patients who need psychiatric assistance in completing
what amounts to a necessary developmental stage in accommodating to loss,
altered body image, and altered abilities.
Any psychiatric evaluation or intervention is a medical procedure, with clear
definition of the psychiatrist as a physician and proper attention directed to
physical complaints before the focus is extended to emotional rehabilitation.
Possible resistance to psychiatric assistance will diminish only after the patient
recognizes the psychiatrist as a member of the medical team with an interest in
total rehabilitation.
The nature and extent of the loss and the emotional significance of the loss
must be determined for each patient. It is more devastating for the patient to
have an impairment which interferes with his cognitive processes if his career,
recreation, self-esteem, defensive and coping mechanisms are predicated on
intellectual functioning. Likewise, a patient whose esteem, work, coping,
interests, and lifestyle are centered around physical activities will have a more
marked reaction and greater difficulty in adjustment when a physically
debilitating injury has occurred.
SHOCK
A disabling injury or illness initiates a series of dynamic events, which may,
for many patients, be composed of some of the following elements or steps.
An immediate reaction to a trauma may be a sense of shock, numbness and
the inability to integrate or comprehend the magnitude or severity of the event.
This may last for several hours, and usually occurs before a psychiatrist sees the
patient.
DENIAL
A component of the initial reaction may be denial. The period of denial may
last from a few days to two or three months. The denial may incorporate the
initially useful stance of maintaining that recovery will be vigorous and complete.
Denial is a necessary defense mechanism, since it is beyond the capacity of most
individuals to easily accept such a sudden drastic change in their self concept, the
realization that they will remain permanently as they are at that moment. At
this point denial of the severity or irreversibility of the trauma is maintained,
with the hope that there will be a reversal of the situation in the future. There
is as yet no depression because there is no conscious acknowledgement of the
permanence or severity of the loss. Depression, manifesting the reaction and
the recognition of loss, is delayed until the patient accurately perceives the
extent of his dilemma.
EMOTIONAL REHABILITATION / 185
The process of denial is adaptive and protective to the patient who has a
sudden onset of severe physical disability and thus a lifecrisis of major
proportions. Only when denial becomes maladaptive and begins to interfere
with rehabilitation efforts or plans must it be scrutinized and mitigated.
Maladaptive denial may manifest in resistance to remodeling the home to
accommodate the injury, insistence by the patient that he or she is going to
walk when such hopes are no longer feasible, or the persistence of dreams and
daydreams of a lost function or limb still being present. The family as well as
the patient may collude in denying that nothing is wrong or that everything will
be as it once was. The denial of his condition may manifest in such features as
the patient forgetting to lift himself for pressure point relief, or forgetting to
empty his bladder at the proper time [1]. One patient who had his arm severed
traumatically nine months previously would awaken from dreams in which the
trauma was relived, would lie awake sometimes for over an hour believing his
arm was intact, but not wanting to check to see whether it was present or absent.
Only after finally verifying that it was gone would he feel rage and depression.
DEPRESSIVE REACTION
As denial diminishes, grief and depression emerge. The loss may hasten the
developmental tasks of accepting the reality and altered potential of the present
as well as the future, normally seen in such things as a "mid-life passage" and
waning function in older age. Gradual onset of functional losses, such as aging,
are nevertheless easier to accommodate both physically and psychologically than
the sudden impact of a traumatic loss, for which there is no anticipatory
mastery. The denial is not of the reality of the event but of the significance,
seriousness, and permanence of its effects.
A lost limb or function is felt to be intact or present, although perhaps not
functioning or touchable currently. Dreams and daydreams are often a
repairative fantasy in which one is functioning wholely and intactly.
Rehabilitative efforts or the fitting or a prosthesis abruptly confront the patient
with undeniable evidence of irreversible loss.
Depression is, in one sense, the reaction to the ego's awareness of helplessness
in regard to what it must do to maintain self-esteem. If there is a sense of
helplessness, and self-esteem cannot be maintained, depression ensues. Two
important questions to be asked are how the patient maintained self-esteem
prior to the injury, and how the losses suffered will disrupt those efforts.
One aspect of the depressive reaction may be characterized by withdrawal
and internalized hostility at the fate which has befallen him or which is his
fault [2].
Depressions caused by losses associated with physical disability are more
186 / DAVID W. KRUEGER
reality-based than depressive episodes based on guilt or unexpressed hostility,
which may be components of neurotic depression [3]. More directly underlying
the patient's depression and grieving may be the sudden ineffectiveness of his
behavior or the deprivation of the gratifying responses from others now that he
is disabled [4].
Due to the nature of the trauma, both physical and emotional, anxiety,
sadness, and grief are to be expected as natural and appropriate. Often there is
some impairment of self-esteem as well [5]. Severely diminished self-esteem
may manifest as a sense of helplessness, feeling oneself to be a burden to others,
and feeling that one has nothing to offer others [6]. The initial depressive
reaction involves difficulty in integrating the acute loss and residual impairment
into a new self concept.
Even the patient with no preexisting psychopathology may, as he becomes
uncommunicative and withdrawn, wish he were dead, or think vaguely of
suicide. If this idea develops into a specific plan, a specific time, circumstance,
condition, or method of suiciding, then there is considerable danger of actual
suicide, and immediate intervention becomes mandatory. It is a mistake to
believe that the patient, because he is disabled, is mechanically unable to commit
suicide. If the patient begins to think along these lines, an examination of pre-
injury history should be more carefully scrutinized, as there may be psycho-
pathological indicants of this pre-disposition which were not previously detected.
The immediate phase of withdrawal and hostility is a frustrating time for
medical professionals, because the patient is often unable to demonstrate or
feel motivation for activity and concerted rehabilitative effort.
Externalization of hostility and blame for his loss may then ensue and the
doctor, family, friends, employer, staff or others may be seen as responsible for
his situation. His hostility and anger must be channelled into productive
activity at this time to effect positive rehabilitation gains and control to direct
such feelings. This is a prime time for countertransference reactions in medical
staff members who might take personally the externalization of his anger, as it
may hitchhike on something done to him or not done for him.
The role of the family from which the patient comes and to which he must
return is extremely important, and can either enforce or sabotage rehabilitative
efforts. The alliance for treatment between the patient and the medical staff
must also include the family, and the functions they serve for the patient. An
assessment of familial characteristics and interactions, as well as potential
family pathology, that may facilitate or impede rehabilitation efforts is a
critical element of the diagnostic work.
Many patients mitigate their grief or mild depression by responding
positively to the abundance of support and reinforcement for their rehabilitative
efforts expressed by a medical staff who minimize failure and criticism. This
approach alleviates much depression by focusing on behavior rather than trying
to treat the depression as a way of influencing the behavior [3].
EMOTIONAL REHABILITATION / 187
REACTION AGAINST INDEPENDENCE
When the patient makes gains in rehabilitative efforts and self-care to the
point of achieving some independence, there may be a marked reaction against
independence. This is especially noteworthy in two groups of patients. One
group includes those patients, especially late adolescents and young adults, for
whom separation, autonomy, and independence are so new and so recently
achieved that any regression to a dependent posture is threatening. For another
group of patients with long-standing latent conflicts of dependency-versus-
independence in the developmental phase of separation and individuation, the
scales tip toward dependence in the need for physical nursing care, and gradual
withdrawal of total nursing care may be protested.
For these patients, it is imperative to understand the developmental issues
behind this response in order to confront the current manifestations and
intervene meaningfully. These internal struggles can be more fully illuminated
by inquiring about the kinds of responses engendered and actions elicited in the
staff. These manifestations of transference in the patient and counter-
transference in the staff are re-creations of a developmental issue being
negotiated, now with considerable intensity due to the stress involved.
Patients with ample amounts of passivity and dependence woven into the
fabric of their character may have a difficult time in rehabilitation and may
resist efforts to place limits on their sick role and associated dependency. For
these patients, as well as the patient who acts out or resists treatment for other
reasons, there must be limits placed on regression and consistent, clearly
expressed expectations for cooperation and participation by the patient from
the entire treatment team. These limits must be established and uniformly
adhered to, or the patient will find a "softhearted" link in the chain.
During these later phases of initial rehabilitation the process of return to
normal personality traits may be overlaid with an intensification of these traits.
Any stress will cause a heightened use of defense mechanisms, and there is
continuing stress of considerable magnitude. The dependent patient will
become more dependent: the conscientious responsible patient will intensify
these characteristics in an effort to compensate for the disability. Some traits
are more adaptive for the patient role (e.g., allowing oneself to be dependent
and taken care of), and others work better for rehabilitation efforts (e.g., overly
conscientious and independent-striving), while others work for neither (the
borderline patient with no consistent internal sense of self or goals). The
particular ways in which grief is displayed vary in accordance with the patients'
personality.
ADAPTATION
A consistent reaction to any permanent disability is grief. The emotions a
person feels at the loss of a limb or a motor function are analogous to emotions
of grief at the death of a loved one. There is also mourning, not only for the
188 / DAVID W. KRUEGER
function, but the body image, the satisfaction that the function gave him which
are now denied, and the grieving for future expectations based on the assumption
of having that function. It is only after the grief and mourning for these losses,
and the relinquishment of the hope of return, that new roles based on new
potentials within different limitations can be achieved.
An initial focus is to assess the coping strategies that the patient has used in
dealing with previous stresses [1]. Coping may be viewed as the behavioral
strategies designed to solve problems and reduce stress. The predominant
strategies of coping used by a patient can be maximized to help him in his
rehabilitation efforts. Coping strategies and defense mechanisms are not exactly
the same. Defense mechanisms operate to avoid anxiety, depression, or psychic
pain, and are formed initially in reaction to internal conflictual issues. Coping
involves the capacity and process of adapting reasonably and advantageously to
the environment. Changes of considerable magnitude, especially those changes
which defy familiar patterns of behavior, are supreme tests of one's coping
ability.
A working alliance with the patient is predicated upon some form of under-
standing of both basic defense mechanisms and coping strategies. The coping
strategies can be discovered by eliciting from the patient information about his
customary way of handling other major stresses in his life. Like defense
mechanisms, coping strategies tend to be consistent over time, and exacerbations
of stress are met by an intensified use of coping strategies.
The following list of coping strategies is an adaptation from Weisman [7].
PREDOMINANT COPING STRATEGY
I. Affective
A. Passivity, isolation of affect, and not worrying.
B. Denial and reversal of affect (laugh it off).
C. Sharing feelings and reactions with others with much talk about the
adjustment.
II. Behavioral
A. Displacement and distraction with activities.
B. Confrontation with one's self and taking concerted action.
C. Acting-out.
D. Repetition using the same plans and activities as in previous stresses.
E. Avoidance and physical withdrawal from people, potential coping
situations.
III. Cognitive
A. Rational-intellectual, seeking information and intellectual control.
B. Rationalization by re-definition: accepting and making a virtue out
of the necessity.
C. Fatalist: stoic acceptance and preparation for the worse.
EMOTIONAL REHABILITATION / 189
D. Projection and externalization, including blaming others.
E. Strict compliance with authority: doing what is told.
F. Masochistic surrender: seeking blame, atonement, and self sacrifice.
One of the major tasks of the psychiatric consultant is to determine the
coping strategies utilized by a patient, and to determine if the coping strategy
will serve a positive purpose in rehabilitation. Those coping strategies which will
augment and enhance physical rehabilitation would then be supported and
further channeled into rehabilitation efforts, and maladaptive coping strategies
re-directed. For example, the patient who uses displacement and immersion
into activities could well utilize extremely active and early use of occupational
and recreational therapy, with a full schedule of rehabilitative therapy on a more
accelerated pace to meet his psychological as well as physical needs. Patients
who use intellectualization as their primary coping mechanism should be
allowed as much control and knowledge of rehabilitative procedures as is
reasonable. Stress to such patients is a threat because it limits their ability to
maintain control. Intellectually oriented patients may be allowed control by
participation in treatment planning, coordination of his rehabilitation efforts,
and thorough explanations of his conditions and procedures. Another patient
who would need to avoid and withdraw initially may do much better in a corner
bed than with explanations.
Continuing appraisal of the patient's coping mechanisms and his ability to
utilize them effectively in response to his changing status in treatment is
necessary throughout the rehabilitative process.
Patients with spinal cord injury in particular may have such massive denial
that extended evaluation and re-evaluation are necessary simply to establish a
psychological data base [1].
The patient's body image following a trauma is another subject for psycho-
logical scrutiny. The phantom sensations, phantom pains, feelings that
extremities are in an impossible position, dreams about still having the
amputated limb or walking again may not be mentioned by the patient for fear
of being considered crazy. Reassurance that such distortions are normal and
exploration of the grief and mourning which these reactions subsume can be
very valuable in the patient's emotional rehabilitation.
DEPRESSIVE ILLNESS
Factors which predispose toward depressive illness, as opposed to depressive
reaction, in patients post-injury include: a history of depressive illness, which
predisposes toward more marked and severe depressive illness post-trauma, a
family history of depression, and a sensitivity to or predisposition toward
depression. This latter predisposition includes such factors as a history of early
parent loss, and childhood trauma, overt or covert.
190 / DAVID W. KRUEGER
The loss of a parent during early development has been demonstrated to
influence the later development of clinical depression [8-10]. There is also a
correlation between the degree of depression during incapacitating illness and
the patient's history of emotional stability or instability [11]. Parent loss is
defined as the loss of a parent by divorce, death, or separation for a period
longer than one year occurring during childhood (generally before age eighteen).
The emotional impact of the loss of a parent during the child's development,
which is denied, has impact on one's self-representation and object relationships
[12]. Later losses, especially traumatic ones, reverberate with this earlier
unresolved traumatic loss, with a revisitation of issues such as helplessness and
anger.
Another predisposing factor exists in the patient who has experienced
childhood trauma, such as physical or emotional abuse. Current trauma
reactivates unresolved past trauma, which in turn amplifies reactions to the
current event.
One of the conflictual aspects of earlier trauma or severe intimidation is the
experience of passivity and helplessness, which lends a certain perspective to the
perception of current trauma. A trauma is broken into bits to be integrated,
digested, or repressed. These bits may later appear in some form in symptoms
or in dreams, or be in some way emotionally recreated by the current experience
of disabling trauma. Katz has demonstrated four factors in the past history
correlating with more severe depression in paraplegics [7]:
1. too many restrictions in early environment;
2. painful punishment or threats thereof in early childhood;
3. vocational and educational instability; and
4. feelings of rejection by wife or girlfriend at time of injury.
Most patients without significant psychopathology prior to trauma develop
adaptive coping mechanisms. This does not mean that there will be no
frustration, anger, or depressive reaction from time to time, but that given a
reasonably expectable environment, their lives can be meaningful, productive,
and gratifying.
SUMMARY
The emotional impact of a traumatic event resulting in body change and loss
of function can be seen as composed of five stages in most individuals:
1. shock;
2. denial;
3. depressive reaction;
4. reaction against dependence; and
5. adaptation.
EMOTIONAL REHABILITATION / 191
The stages appear even in patients without pre-existing psychopathology.
Additional aspects of the emotional impact of physical disability include the
existence of previous psychiatric illness, the predisposition to traumatic losses
and depression, the impact of the injury on the patient's coping strategies, the
patient's place in his life cycle, and the effect of the residual impairment on the
patient's capacity to maintain self-esteem.
REFERENCES
1. T. Stewart, Coping Behavior and the Moratorium Following Spinal Cord
Injury, Paraplegia, 15, pp. 338-342, 1978.
2: G. Hohmann, Psychological Aspects of Treatment and Rehabilitation of the
Spinal Cord Injured Person, Clin. Orthop., 112, pp. 81-88, 1975.
3. H. Steger, Understanding the Psychologic Factors in Rehabilitation,
Geriatrics, 31, pp. 68-73, 1976.
4. W. Fordyce, Psychological Assessment and Management, F. Krusen,
F. Kottke, and P. Ellwood (eds.), Handbook of Physical Medicine and
Rehabilitation, W.B. Saunders, Philadelphia, 1971.
5. J. Missel, Suicide Risks in the Medical Rehabilitation Setting, Arch. Phys.
Med. Rehabil., 59, pp. 351-376, 1978.
6. E. Bebring, Mechanisms of Depression, P. Greenacre (ed.), Affective
Disorders: Psychoanalytic Contribution to Their Study, International
Universities Press, Inc., New York, pp. 13-48, 1953.
7. A. Weisman, The Realization of Death, Jason Aronson, New York, 1974.
8. A. Beck, et al., Childhood Bereavement and Adult Depression, Arch. Gen.
Psychiat., 9, pp. 295-302, 1963.
9. F. Brown, Depression and Childhood Bereavement, J. Ment. Science, 107,
pp. 745-777, 1961.
10. B. Sethi, Relationship of Separation to Depression, Arch. Gen. Psychiat., 10,
pp. 486-496, 1964.
11. V. Katz, R. Gordon, D. Iversen, and S. Myers, Past History and Degree of
Depression in Paraplegic Individuals, Paraplegia, 16, pp. 8-14, 1978.
12. D. Krueger, Psychotherapy of Adult Patients with Problems of Parental
Loss in Childhood, Curr. Conc. Psych., 4, pp. 2-7, 1978.
Direct reprint requests to:
David W. Krueger, M.D.
Director, Baylor Psychiatry Clinic
Baylor College of Medicine
1200 Moursand Avenue
Houston, Texas 77030
THE PSYCHOLOGICAL,
SOCIAL, AND VOCATIONAL
ADJUSTMENT IN SPINAL
CORD INJURY:
A STRATEGY FOR
FUTURE RESEARCH
Final Report
Grant No. 13-P-59011/9-01
Roberta B. Trieschmann, Ph.D.
Project Director
Easter Seal Society of Los Angeles County
1545 Wilshire Boulevard
Los Angeles, California 90017
April 30, 1978
(Covers research performed from October, 1976 to April, 1978)
This study was supported in part by Research Grant 13-P-59011 from the
Rehabilitation Services Administration, Department of Health, Education, and
Welfare, Washington, D.C. 20201.
152
Therapeutic Techniques
self-management, such as a transitional living center. This issue should become a top
priority for research.
E. Milieu Therapies.
Kutner (1968) describes milieu therapy as a theory of treatment and a body
of associated methods in which the environmental or residential setting is utilized as
a training ground for patients to exercise social and interpersonal skills and to. test
their ability to deal with both simple and complex problems commonly experienced
in open society. This approach is particularly helpful with those patients who adapt
all too readily to hospital life and assume the dependent, chronic invalid role too
easily. Such programs have the advantage of preparing the person for the demands of
the extramural environment so that discharge does not lead to a decline in behaviors
emitted.
Abrahamson, Kutner, Rosenberg, Berger, and Wiener (1963) describe such a
therapeutic community in a hospital rehabilitation service. The patient should
participate in the decision making regarding his program, and he should assume
increasing amounts of responsibility for his own care. Hospital visiting hours can be
made more flexible to include the family and friends more readily. Extended home
visits and participation in out of hospital social events help to prevent social
isolation, they claim. It is not clear if this program was implemented as described and
we have no information on its success or failure.
Some of these procedures have been introduced gradually into other programs.
Johnson, Roberts, and Godwin (1970) report the implementation of a self
medication program on their ward, and Becker, Abrams, and Onder (1974) report a
joint patient-staff method of setting goals. None of these reports provide data which
allow us to compare the new approach with the old one, however. Therefore, these
remain in the realm of suggestions for future research.
Keith (1969, 1971) called for alternative models of rehabilitation care. He
proposed a residential unit in which patients accepted as much responsibility for the
management of the unit as they were capable. Sections of the residence would be
graded by the amount of assistance that was available. As patients progressed in
gaining degrees of function, they would graduate to the next section in which less
help was available, and the patient had to accept more responsibility for the
maintenance of his environment. At the highest levels of independence, cleaning,
laundry, and food preparation would be part of every day life, in addition to other
ADL tasks. An essential ingredient in Keith's proposal is understaffing, based upon
the finding of Barker (1968, 1976) that understaffed environments lead to more
independence, more acceptance of responsibility, and to a larger number of tasks
performed by each person. This concept within rehabilitation should be tested.
However, the gradual evolution of transitional living centers is one step in his
direction.
F. Chemotherapy.
The use of major chemotherapeutic tranquilizing agents soon after the onset of
Therapeutic Techniques 153
spinal injury to assist the person to cope with the emotional aftermath of the injury
be a controversial issue. Few physicians who are skilled in the treatment basis.
can procedures of spinal injury advocate such a course of action on a routine
However, it is an unfortunate fact that some physicians who have the responsibility
for treating persons with acute spinal injuries do, indeed, prescribe major
tranquilizers routinely to counteract the "massive depression" which they believe
follows the injury (Romano, 1978).
Therefore, let us review some of the evidence presented in Chapter IV. There is
evidence that the onset of spinal cord injury leads to psychotic reactions except
no in the extremely small percentage of cases in which there was evidence of profound
behavioral disruption prior to onset of the injury. Transient states of disorganization
related to sensory deprivation remit as a result of increased sensory inputs rather
than through the use of pharmacological agents. Evidence tends to suggest that most
with spinal injury do not suffer "massive depression," although some
persons depression is apparent in many. However, the depression is related to a reality event
about which most people are undecidedly unhappy. Therefore, the question arises:
is it necessary or appropriate to prescribe drugs to dull one's perception of the
unhappiness of the event?
Most clinicians who are experienced in the treatment of spinal injury find that
chemotherapeutic intervention is not necessary except the in the classic small signs percentage of a severe of
psychosis
or
cases depression: get cological begin are the prominent At that to person this maintain agent exhibit loss time going which in of the we the signs appetite, until person's can acts treatment of say some as a an pre-existing insomnia, that behavior. of energizer of the the spinal is opinion natural not and and cord appropriate psycho-motor appetite rewards of injury a large nationally stimulant of (Young, number progress retardation. is may of 1978). in that physicians rehabilitation be the A helpful However, pharma- routine who to
research prescription using of double major blind tranquilizers procedures would be helpful to test the question of the
efficacy of chemotherapeutic agents as treatments of the emotional concommitants
of spinal cord injury.
G. Alternative Models of Service Delivery.
In recent years there has been a growing realization that physical rehabilitation
procedures carried out in a hospital setting may not prepare a person adequately for
the demands of life outside of the hospital. As a result, some new approaches to
rehabilitation have evolved which relate to both Kutner's (1968) and Keith's (1969,
1971a, 1971b) suggestions regarding rehabilitation environments.
Manley and Armstrong (1976) describe a transitional living facility which is
part of a regional spinal cord injury center. The facility consists of a twenty unit
apartment building, each unit accessible and furnished for wheelchair use. The
original purpose for the facility was to provde a low cost environment for persons
with spinal injury who were returning to the center for a follow up evaluation. A
stay in the hospital for this period would cost 400% more than residence in this
facility. This finding has great implications for the cost of follow up care. However,
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Therapeutic Techniques
in addition, the facility has been used for a two week practice session of the skills
learned in the rehabilitation program. The patient and family can live together,
identify any areas of difficulty in functioning, and gain self-confidence while
maintaining a close liaison with the rehabilitation center. A comparison of those
discharged to the apartment complex and those discharged directly to home showed
that individuals and families who have had the benefit of the living experience
program have fewer medical complications and seem to encounter fewer problems in
re-establishing family roles. No data were given to substantiate this finding, but the
idea seems promising and should be investigated further.
Another project which seems promising is a cooperative living program (Stock
and Cole, 1977), which has evolved into the New Options Program, and which is
affiliated with another regional spinal cord injury center. A building which had been
originally intended to serve as an extended care facility was purchased. Forty
persons with paraplegia and quadriplegia entered the program during the project
period. Most had been living at home with family and were unemployed or were
residing in a nursing home. The average level of monthly income at admission was
$122.00. Most persons required assistance with a certain number of activities, and
thus, students were hired as attendants, and the help was shared among the patients.
A resident council and resident manager were in charge of the organization, and
social-interactional problems among the residents were handled by the council. Each
resident had a private room and was responsible for scheduling time for attendant
care.
During residence at the facility, the day's activities consisted of modules which
were designed to impart information and provide practice at coping with the
demands of the world. Financial management and budgeting, use of public
transportation, field trips to employment locations and community facilities were
among the activities. Attendant management, home management, problem solving,
sexuality, medical needs, leisure time use, mobility, educational and vocational
opportunities were also included as modules. The residents had a wide variety of
opportunities to socialize in many settings.
The results of this transitional living program were impressive. Based on 40
residents, 53% of the sample had an income of less than $100.00 monthly before
admission. As of January, 1977, only 5% of the participants had an income of less
than $100.00 monthly. The average income prior to admission to the program was
$122.59 monthly, and as of January, 1977, the average income monthly was
$496.91. This change in income was related to change in employment status. Prior
to entry in the program, one person was employed full time. As of January, 1977,
14 persons were employed full time and four part time.
The level of income of the 14 residents employed full time reflected the shift
to economic independence. Prior to the program, the average income of these 14
persons was $1447 annually, or $129.99 monthly. As of December, 1975, the
average annual income of these persons was $7560 or $630 monthly, an increase
of 488%. Three of the individuals who were employed full time after the program
had been residents of nursing homes prior to the program. These data are
particularly impressive since the figures in December, 1975, reflect actual earnings
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Therapeutic Techniques
problems and the resultant cost of rehospitalization was reduced. By helping the
person find some satisfactions and rewards in life, the number of medical
complications caused by neglect dropped in frequency, and yearly hospitalization
costs were reduced.
One feature of this program, which Barrie believes accounted for its success,
was the case manager approach (Barrie, 1973). One person, within the insurance
company, was assigned to manage the person's case. The nonmedical person was
responsible for overseeing the person's rehabilitation from the moment of injury and
for the rest of the person's life. Services were selected which were designed to
enhance the disabled person's functioning, and services were sought which indeed
accomplished this goal. The case manager was fiscally responsible for management of
the person's entire program; therefore, costs did not increase through fractionation
of care and periods of neglect. Money was spent to make the disabled person's life
more comfortable (purchase of a car with handcontrols, electric typewriter, etc.),
because this expense for psychosocial comfort was offset by lowered future
hospitalization bills associated with self neglect and medical complications.
This case manager approach has been adopted by the State of Arkansas which
has created a Spinal Cord Injury Commission which reports directly to the governor.
A rehabilitation counselor, with special training in spinal cord injury, is assigned to
be the case manager of each newly injured person and follows this person from
injury onward. The case manager has the fiscal responsibility to obtain the services
needed to enhance the functioning of the person with spinal injury (Carmack,
1977). This approach should be studied, and the costs of rehabilitation using the
case manager approach versus the usual approach in state Departments of
Rehabilitation should be compared for a ten year period. It may turn out that we can
no longer afford the fractionated care and limited services which a large proportion
of the spinal injury population receive (Professional Conference, 1977).
The state of Alabama has initiated a Homebound Rehabilitation Program
financed by the state legislature and initiated through the efforts of Governor
George Wallace. Any severely disabled person confined to his home is eligible for
services. There are no age limitations or eligibility for employment requirements.
Medical assistance is provided, when indicated, including hospitalization and
treatment. Attendant care, home modification and procurement of special equip-
ment and supplies through purchase or loan are available. A key feature of this
program is the home health team which visits persons in their homes to teach them
and their families to deal more successfully with their disabilities. Better health
habits are taught in addition to special exercises, skin care and prevention of medical
complications. Each home health team consists of a counselor, a registered nurse, a
physical therapist, and a secretary. The team works with local physicians and has
medical consultants available. Also they work with the local agencies and hospitals.
The state is divided into six regions, and there is a home health team for each region.
Both Alabama and Arkansas have initiated highly innovative programs of
service delivery which need to be examined and evaluated through 3 carefully
planned research program. We need to identify the objectives of these programs and
measure the outcomes and determine if these are viable alternatives to the present
158
Therapeutic Techniques
that the answer is yes. Therefore, this should become an issue for
Currently, clear we have no data what to evaluate the influence of peer counseling and
no guidelines best suited as to train constitutes peer counseling nor the type
they
procedures to peer counselors. In addition, when
'S
I
counseling end and more traditional psychological counseling begin? If does
deliver psychological counseling services by nonprofessional (and
the legalities of the activities (depending on state licensing) may become
persons, is this detrimental to the client? These last issues can become touchs
Nevertheless, it seems that CIL's can be a viable force in the community. and
activities should be evaluated through a well defined program of research.
A similar concept has been proposed by Hohmann (Professional
1977) who He believes that a tutorial method may be very helpful with newly Confirms
persons. proposes that the person with spinal injury, upon discharge Iron
rehabilitation center, would go to live for several months with a person
experienced in living with the disability. At the end of this period, be believes,
recently injured person will be much more sophisticated in his ability to cope
the world. Modeling is inherent in this approach and in the CIL's. Modeline
also be possible if persons with spinal injury were hired, when qualified,
positions at regional spinal cord injury centers or other rehabilitation centers.
the newly injured person is told that a full life is possible despite the disability
sight of persons with spinal injury functioning within the world will add
such prognostications. Thus, we should specifically research ways in which modely
can aid in the rehabilitation of persons with spinal injury.
I. Summary.
There are many articles which discuss the benefits of group therapy, best (vis
is not one which provides any evidence to substantiate this claim. Group
techniques may be an efficient method for having several persons share Mrai and
explore new ways of coping with a disability, but we need research to Sext
question. Group counseling, or therapy which focuses on developing Insight
improving self-esteem seems to be implicitly based on the assumption that
disability leads to psychological problems per se; however, there is no evidence
this is true. Logically, it seems more effective to improve self-esteem and
by experiencing success in coping with the real world. Thus, programs to
people the skills they need to do this should be the focus of rehabilitation.
Behavior therapy programs have been studied as methods of increasing that
intake, changing bed position, doing push ups, increasing upper extremity
improving personal hygiene, and other activities related to improved function. The
show that behavior modification programs do work when carefully planned
executed. Therefore, since rehabilitation is a learning process and all that
within the rehabilitation center is focused on modifying the behavior of the
with spinal injury, it seems obvious that the principles of learning should be
produce this behavior change in the most efficient manner possible.
Social skills training and assertiveness training have been studied only
166
Methodological Issues
(1976a) has found that there is a low correlation between ratings of capacity (what
the person can do) and the behavior that actually does occur when the person is in
his own environment. Sand, Fordyce, and Fowler (1973) concluded that the best
predictor of future fluid intake behavior was not the battery of psychological tests
but the actual fluid intake behavior in the first two weeks in the rehabilitation
center. They believe that rather than focusing on trying to predict who will behave
in what fashion, they recommended that we measure the behavior in question and
then apply strategies to shape the behavior to the desired level.
A fourth focus for our measurements is the behavior of the rehabilitation staff.
In our study of the environment and the rehabilitation process, it is important to
measure, not only the patients' behavior, but the behavior of the staff also. The
study by Mikulic (1971) is an important example of this approach. Marr,
Greenwood and Roessler (1977) are conducting a research project which will
provide a behavioral analysis of a rehabilitation service delivery system. They will
meet with clients and service delivery personnel in order to identify problems in
giving and receiving service. The antecedents of the problem are identified, along
with the behaviors, and the consequences. Through an innovative approach such as
this we may be able to identify ways to improve the efficiency with which we can
teach persons with spinal injury to cope with the disability. However, in order to do
this, we, rehabilitation personnel, must be willing to examine our own behavior
rather than restricting our focus to the behavior of the person with a disability.
Thus, in answer to our question, what do we measure, we must evaluate which
of these outcomes are relevant to the goals of rehabilitation. In this report we have
taken the position that rehabilitation is a behavior change process and that our
outcomes are those behaviors which the person emits in interaction with his
environment. Thus, psychological traits, per se, may not be the proper focus of
rehabilitation. Rather, improved psychological functioning will be a result of
learning and performing a set of behaviors which lead to rewarding experiences from
the environment. Psychological traits will be an important by-product of our
rehabilitation efforts but not necessarily the focus of our interventions. While
adjustment to disability is important, the definition varies and again, adjustment is a
by-product of our rehabilitation efforts.
Since the purpose of rehabilitation is to assist the person in developing a
repertoire of behaviors which are effective in dealing with the world, the focus of
our measurements must be this repertoire of behaviors. Therefore we must evaluate
the various measurement methodologies and determine their adequacy in giving us
the information we need: What does the person actually do?
D. Methods of measurement.
1. Self-Ratings.
Many studies cited in this document have used the self-ratings of the person
with the disability as the single measure or in conjunction with other measures. In
each case, what is being measured is the person's verbal behavior. Whether or not
this verbal behavior is the purported focus of the study varies, but often it is not.
Methodological Issues
167
Frequently, the purpose of a study may be to study the effect of spinal injury on
feelings of depression or the effect of group therapy on self-concept, for example.
However, the validity of the self-rating as a measure of depression or self-concept is
usually not reported because the researcher is satisfied with face validity.
Self-ratings may be very useful in research as one of many measures of an
outcome, as in Lawson's (1976) study of depression after spinal injury. Self-ratings
may be useful if the purpose of the study is to assess the effects of a treatment on
self-ratings per se. However, if generalizations of the data from self-ratings are made,
then evidence should be provided that such generalizations are appropriate. In an era
of accountability, interest in evaluation has increased and self-ratings are often used
as a substitute for other more complex but less readily available measures. But if we
are going to make progress in our efforts to increase our knowledge about the effects
of spinal injury, we will have to use more sophisticated and appropriate measures of
the intended effect.
2. Self-Report Through Interview or Questionnaire.
The validity of self-report measures has been a concern to scientisits for many
years (Webb, Campbell, Schwartz, and Sechrest, 1966; Franklin and Osborne, 1971)
and should be of greater concern to researchers in rehabilitation than it has been
apparently. Both methods may be very helpful in the collection of demographic
data, but the detail of the data obtained may vary across subjects because of the
highly structured and often restricted nature of the questionnaires and the
variability in the interactions between interviewer and subject. Many studies cited in
this document have described the adjustment to disability based on judgments made
by the interviewer, who was also the designer of the experiment or project. The
opportunity for bias is overwhelming and difficult to assess (Barber, 1976).
However, in the Kemp and Vash (1971) study, the data was obtained through a
structured interview conducted by one of the researchers, but judgments based on
that interview data were made independently by another group of professionals,
thus reducing the opportunity for bias.
Questionnaire and interview studies have the additional problems of self-
selection of the subjects and the degree of cooperation in complying with the
researcher's requests. This is a problem in many follow up studies, as noted by
Felton and Litman (1965), and Grynbaum and associates (1963). We do not know
how the sample that chooses to respond to a mailed questionnaire or to participate
in a study differs from the sample that does not participate. In addition, there is
concern that in questionnaire studies, the more successful group choose to respond,
whereas in interview studies for follow-up purposes, those who make themselves
available may have problems which need attention. Those who are successful are too
busy to give the time necessary to come back for an evaluation. These problems do
exist and can never be completely eliminated, but attempts should be made to
control for them. An unbiased interviewer is essential, and efforts should be made to
obtain a representative sample of the population. The follow up through the
National Spinal Cord Injury Data Research Center will be helpful, but there are
concerns about the representativeness of its sample (Professional Conference, 1977).
168 Methodological Issues
A major problem that interview and questionnaire techniques share is the
delimited nature of the data that they collect. The person, at one point in time, is
asked to describe his behavior which flows and evolves over time. Rates of behavior
and contingencies can only be estimated and depend largely on the accuracy and
cooperation of the subject. Data that is very important to an understanding of the
person's behavior may not be collected unless it is part of the questionnaire or
interview. Thus, our information gained through these techniques may not be truly
representative of what the person actually does.
3. Diary Kept by the Subject.
One method for obtaining a representative sample of the flow of a person's
behavior is to have him keep a diary of everything he does. The problem of
inaccuracy because of poor cooperation remains, but inaccuracy because of errors in
recall or estimation have been largely eliminated. This method has been used very
successfully by Fordyce and associates (1973) and Fordyce (1976) in the
management of patients with chronic pain. In addition, Willems (1976a, 1976b) has
been using this technique and has found it to be promising.
While the advantage of this method is its representativeness of the actual flow
of behavior over time in each person's unique fashion, a disadvantage is the need to
categorize the data in some manner in order to summarize the behavior of one
person over time or to compare the behaviors of many people. To use this method
adequately, systems for reporting and comparing the data in standardized terms will
have to be developed.
4. Ratings of Patient Behavior by Rehabilitation Staff.
Staff ratings of patient behavior are the foundation of many ADL and mobility
assessments, and this method has been applied to issues in psychosocial research as
well. However, the evidence presented in this document suggests that rehabilitation
staff are notoriously inaccurate when asked to rate the presence or degree of a
psychological trait in their patients. The evidence provided by Taylor (1967) has
been duplicated in many studies. Rehabilitation staff consistently overestimate the
degree of psychological distress in their patients. In addition, Albrecht and Higgins
(1977) compared multiple measures of success in a rehabilitation center, and they
found that the intercorrelations of staff ratings of patient adjustment, self ratings by
patients, and psychological test scores were very low.
The problem with staff ratings of psychological processes relates to the staff's
lack of training in assessment of these factors but more particularly to the nature of
the task itself. The psychological traits that the staff are asked to rate are abstract
concepts which cannot be measured directly. Rather these traits are composed of
many individual behaviors, which as an aggregate, are described by the summary
term, the psychological trait label. Thus, the staff have been asked to do a task for
which they have not been trained, and the component behaviors of the trait are
usually not specified.
5. Biochemical Measures of Emotion.
Measurement of emotions is a methodologically difficult problem. Hohmann
172
Methodological Issues
issue they are studying and select the types of measurement techniques which will
appropriately and accurately assess the effects they hope to study. We are convinced
that more productive research endeavors require a focus on observable and
countable behaviors and the use of measurement techniques which will provide such
data. Development of mechanical measurement devices which are unobtrusive
should be given great emphasis, as should the implementation of measurement
strategies which document the daily behaviors that occur in rehabilitation centers on
the part of patients and staff.
E. Methodological Issues in Future Research.
There are several methodological issues which must be considered in future
research in spinal cord injury if we expect future research efforts to advance the
state-of-the-art.
Greater care must be taken in the selection of a sample for a study than has
been done in the past. Evidence presented in this document suggests that the
population of persons with spinal cord injury is heterogeneous, but homogeneity has
been assumed in most studies. Sample characteristics should be documented and
studied in a controlled fashion.
The representativeness of a sample should be examined more thoroughly than
in the past. Follow up studies must make greater efforts to locate the entire group
under consideration and to assess the influence of the self selection factors discussed
earlier.
In addition, studies which use the population of persons treated at regional
spinal cord injury centers may be biased since only 10% of the national population
of persons with spinal injury come into contact with such centers. Therefore, we
must obtain data on persons treated outside of the regional system for comparison
purposes. Thus, efforts should be made to include a sample of nonregional system
persons in any followup sponsored by the Rehabilitation Services Administration.
Either this data should be included in the National Spinal Cord Injury Data Research
Center data base, or a separate study should be financed which would seek out and
study a sample that is representative of the nation.
Studies which assess treatment effects should use random assignment of cases,
and control groups should be employed. The basic principles of accepted research
design should be utilized.
The measures employed in research should include the direct observations of
the behavior under study or instruments which have documented reliability and
criterion validity. Paper and pencil tests and rating scales, if created for the project,
should demonstrate their correlation with the particular behavior under study, on
samples other than the one used in the research.
Multiple levels of measurement should be used whenever possible, especially
when the focus of the study is a psychological trait or emotional reaction.
Longitudinal research should be emphasized because learning to live with a disability
is a dynamic process and not a static event. Furthermore, behavior-environment
units should be the focus of research since evidence suggests that environments may
Methodological Issues
173
account for more variance in behavior than we have recognized. Measurement
systems must be developed which can provide a standardized system for the
assessment of outcomes. With the advent of such systems, there will be greater
opportunity to compare the results of one study with those of another. Thus, two
measurement systems currently being developed need to be examined.
F. Two Approaches to Outcome Measurement.
There are two projects currently in progress which address the issue of outcome
measurement in behavioral terms: the Rehabilitation Indicators Project (Diller,
Fordyce, Jacobs, and Brown, 1977) and the Longitudinal Functional Assessment
System (Willems, 1976b). Each shows promise of advancing the state-of-the-art of
measurement in rehabilitation.
The Rehabilitation Indicators Project (RIP) has focused on developing a
lexicon of behaviors which will define the behavioral domain relevant to
rehabilitation efforts. There are status indicators, such as, employed versus
unemployed, marital status, etc. There are activity pattern indicators, such as,
cleaning house, going to work, telephoning friends. In addition, there are skill
indicators, such as, uses a knife and fork to eat, dresses self, and others.
Environment indicators will be developed to assess features of the person's
environment relevant to function. So far the lexicon includes ten status items, fifty
activity patterns, 450 skill indicators, and the environmental indicators are being
developed.
This lexicon will provide a compendium of specific behaviors which may be the
focus of rehabilitation interventions. A patient or client could be evaluated upon
admission to a program, and behaviors which are problematical can be identified and
goals for treatment specified. Re-evaluation at later points in the treatment will
document changes in the behaviors, and thus, progress can be assessed. Such a
system can be used to evaluate patients and programs, and it is hoped that use of
such a lexicon will provide a methodology for enhancing accountability.
The evaluation of the person will be conducted by interview, according to
present plans (Diller and Brown, 1977); thus the person being evaluated will describe
his behavior, what he does and what he does not do and cannot do. The project
directors appreciate that there is a measurement problem, the validity of self report,
which they have not solved yet. Who conducts the interview has not been
determined and what skill level is necessary to conduct such an evaluation interview
is yet to be determined. The project directors have focused on developing the
lexicon up to now, and they plan to begin the field testing of it in 1978. Therefore,
the utility of this lexicon must be demonstrated through future research.
The Longitudinal Functional Assessment System (LFAS) (Willems, 1976b) has
been developed to document behavioral outcomes of rehabilitation, but it
approaches the problem from an entirely different direction than the RIP does.
Rather than specifying, a priori, which categories of behavior to assess, the LFAS
monitors directly whatever the person does in this everyday routine and then
translates this behavior into quantitative assessments of performance.
STANDARDS
FOR
REHABILITATION FACILITIES
SURVEY CHECKLIST
(RESIDENTIAL FACILITIES)
Texas Rehabilitation Commission
Facilities Section
310 Jefferson Building
1600 West 38th Street
Austin, Texas 78731
1
I. GENERAL INFORMATION
COMMENTS
A. Type of Facility
1. Is this a transitional facility?
2. Is therapeutic group living available?
3. Does the client engage in meaningful vocational or
pre-vocational activities outside the house part of
the day and participate in planned activities within
the facility during the remaining hours?
4. Is there a home-like atmosphere?
5. What disability groups are served?
6. What is the capacity of the house (minimum of ten
1909
Instatille
clients ideal, maximum should be large enough to
remain comfortable yet remain a, "home-like
Tot
20192
эсвирова
atmosphere")?
199 to 1991 этвир:
(0a) vixta storts el .0
a.
Beds
(Male)
el !991 atsupa (08) virigie TO 200
sigition
1001 guigaafe efgats
b. Beds (Female)
leabivibut not wolls syewode bas
off
B. Physical Plant
(i)
980
bns
$98010
193EV
(I)
Jang[
16
stedi
($)
19
dose
101
1.1. Is the physical premises:
a. House - rented or owned which is appropriate
in size for a halfway house program?
1133n
inoibsm
b. Apartment or group of apartments which are
appropriate in size?
00
Lique bie dealt
C. Group facility - such as YMCA, neighborhood
latto
seund
9:11
houses, or etc?
Expired
62 IsnolisM .5
annevA
do th .V ESI
atoni
jI
lets? евкой . ₫
88 C XOS .0 .4
797
-2-
COMMENTS
2. Does the facility meet all local requirements
promulgated by the fire and building departments, zoning
authority, multiple dwelling ordinances, and other
municipal authorities?
a. Certificate from fire inspector?
b. Certificate from city or county health inspector?
C. Certificate from city or county building inspector?
3. Is there adequate heat, light, and ventilation in all
rooms including hallways, bathrooms, dining areas,
and activity rooms?
4. Is there sufficient general storage space?
5. Is there adequate space for general activities?
6. Is there sixty (60) square feet of space per occupant in
multiple sleeping rooms or eighty (80) square feet in
single sleeping rooms?
7. Do toilets, bathtubs, and showers allow for individual
privacy?
8. Is there at least one (1) water closet and one (1)
lavatory for each eight (8) residents?
C. Safety
1. Has a medical affiliation been arranged?
2. Are first aid supplies convenient to residents?
3. Has the house obtained safety information from:
a. National Safety Council
425 N. Michigan Avenue
Chicago, Illinois
b. Texas Safety Association
P. 0. Box 3138
Austin, Texas
Fil
A
-3-
COMMENTS
C. Texas State Department of Health
1100 West 49th Street
Austin, Texas
d. Other
4. Is a procedure outlined for notifying authorities in
case of an emergency?
5. Is there an organized safety committee with scheduled
meetings at least quarterly and adequate records of
these meetings?
D. Records and Reports
1. Are all records kept under lock and key?
2. Are records so placed so that only staff have access
to them?
3. Are appropriate measures taken to insure the con-
fidentiality of all records?
4. Does the house provide a progress report (Addendum A)
monthly to the Texas Rehabilitation Commission
counselor prior to approval of the monthly voucher?
5. Is a current Addendum B on file with the Texas
Rehabilitation Commission?
6. Are clients assessed according to the Standards?
E. Program Evaluation
1. Is there a written plan for program evaluation?
F. Other
1. How is transportation provided to and from work?
2. How is transportation provided to and from halfway
house activities?
3. Is the average time of residency for each client in
accordance with the following:
-4-
COMMENTS
a. Mentally Retarded (12 months)
b. Mentally Restored (6 months)
C. Alcoholic (3 months)
d. Drug Abuse (6 months)
e. Other (12 months)
FEE
:
-5-
II. STAFF REQUIREMENTS
COMMENTS
A. Director - Does the director have:
1. A bachelor's degree in health administration, vocational
counseling, psychology, sociology, education, business
administration, or some other related field and three
(3) years experience in a responsible and administrative
position; or
2. Complete formal graduate education in one of the above
fields; or
3. Two (2) years experience and training related to the
disability served, which in the opinion of the survey
team qualifies the indívidual for the position.
B. Personal/Social Adjustment Trainer and/or Work Orientation
Trainer - Does the trainer have:
1. A bachelor's degree in a related field; or
2. Two (2) years experience and training related to the
disability served which in the opinion of the survey
team qualifies the individual for the position?
3. Do volunteer trainers meet the above requirements?
C. House Parent (s)
1. Do the house parents have sufficient understanding and
appreciation of the nature and behavior of the type of
client served to assure that his relations to such
clients contribute positively to their welfare?
-6-
III. Services Offered
COMMENTS
A. Room
1. Do the bedrooms allow space for a bed, dresser, closet,
table, and chair without crowding?
2. Is there one or more living rooms (activity room) which
will seat ten people comfortably and still allow room
enough for articles such as a television, radio,
books, etc.?
3. Are there one or more offices in which private inter-
viewing and counseling can take place?
4. Is the dining room large enough to accommodate all
residents in one setting?
5. Is space allowed for cabinets, dish closets, and other
kitchen items in the dining area or kitchen?
B. Board
1. Is a balanced diet of three meals per day provided?
2. Does the menu meet the State Department of Public
Health requirements?
3. Are provisions made for meals away from the house?
C. Supervised Living
1. Is 24-hour supervision available?
2. Are residents checked for:
a. Appropriate dress?
b. Personal hygiene?
C. Appropriate manners?
d. Adherence to house rules?
e. Carrying out housekeeping duties?
3. Are resident's whereabouts known INFORMATION all times?
A
1975
-7-
COMMENTS
D. Personal and Social Adjustment Training
1. Is there a formalized program in writing?
2. Does this program show ways of helping the client obtain
socially acceptable skills?
3. Does this program show ways of helping the client become
gainfully employed?
4. Is the client's reaction to his disability stressed?
5. Is the client's reaction to his education stressed?
6. Is the client's reaction to his vocational experiences
stressed?
7. Is the client's reaction to his social experiences
stressed?
8. Is the client's reaction to his future adjustments
stressed?
9. Is a systematic savings plan developed for each client?
10. Is a person employed for the purpose of conducting
personal and social adjustment?
11. Is the trainer available to individual clients?
fir
12. Is the trainer available for staffings?
13. Is a minimum of five hours per week devoted to personal
and social adjustment training for each client?
14. Is at least three hours per week of personal and social
adjustment done in a formalized session?
15. Is the personal and social adjustment for each client
documented?
E. Work Orientation
1. Is the program documented?
2. Does it deal with the psychological demands of a work
setting?
-8-
COMMENTS
3. Does it deal with the social demands of a work setting?
4. Does it include job placement?
5. Is job placement documented?
6. Does their program assist the client in experiencing
an employer-employee relationship while in a
productive environment?
7. Does it help the client adapt to work situations rather
than job skills?
8. Does the staff work closely with the client's employer
to identify and correct problem areas?
9. Check the methods used to carry out this service:
a. Individual counseling?
b. Group counseling?
C. Classroom lectures?
d. Other
10. Is there at least one (1) hour per week of formalized
training?
11. 'Are placement efforts being made during the first sixty
(60) days of training?
REMAD-BAYTOWN
FEB 5 - :
FEB
RECEIVED
-9-
IV. RESULTS OF SURVEY
COMMENTS
A. Certified Programs
1. CLASS I
2. CLASS II
3. CLASS III
4. CLASS IV
B. Temporary Classification
Recommended resurvey on
( days).
Deficient in the following areas:
1.
2.
3.
4.
Recommended Technical Assistance in the areas of:
1.
2.
3.
4.
C. Other Action:
MAY/JUNE 1976
Journal of
REHABILITATION
ndicapped
Parking
Affirmative Action
...
go through the front door
of the employment office
independently and
name the specific job.
KO
National
Rehabilitation
Association
3585647 S
TX
MR LEX
05.7612 J
*
9667 MEADOWVALE
FRIEDEN
HOUSTON
TX 77042
Editorial
Affirmative Action-Do We Have It?
Cornelius L. Williams
President-Elect, National Rehabilitation Association
Contained in the body of this Journal are articles relating
who are aware that "ability counts" and, therefore, welcome
to Section 503 of the Rehabilitation Act of 1973. Section 503
applications from persons who are handicapped.
requires that employers who have a contract with an agency
It seems obvious that the law and regulations were
of the federal government shall, under certain conditions,
changed without giving a fair trial to the original plans. The
take action to employ applicants who are handicapped.
law was enacted and the original regulations, which many
Regulations promulgated under this act by the Department
thought fell far short of the need, were in effect at a time when
of Labor, the designated enforcement agency, and published
all employment was at one of its lowest ebbs. Few people
in June 1974, do not spell out specifically enforcement and
working in any capacity were being employed during this
penalty procedures with the same emphasis as other EEO
period. Therefore, it is incumbent upon us to demand that
programs.
the planners go back to the drawing boards and come up
It was recently reported in the Wall Street Journal that
with a program that does not continue to relegate handi-
several major industries are very much opposed to the en-
capped people to a position less than equal in employment
forcement of Section 503. Developing an Affirmative Action
practices, if this is the only solution.
plan created an undue hardship, it was claimed. These
arguments and others may have affected the provisions of
Regardless of the regulations, there still remains a statute
which implies, at least, that discrimination in hiring or ad-
new regulations published on April 16, 1976.
vancing in employment because of a handicapping condition
The new regulations do not contain effective enforcement
procedures. A major change in the regulations eliminates the
is prohibited.
certification provisions by State Vocational Rehabilitation
The door for handicapped individuals to enter employment
agencies. Rather-"Guides to Evaluation of Permanent
in most businesses and industry may not be wide open, but
Improvement," developed by the American Medical Asso-
certainly it is cracked. The burden of proof may be on the
ciation, are now determinants of a handicapping condition.
handicapped individual and his/her advocates (NRA
There are those who say that nonaggressive type legis-
members and others), but with imagination, ingenuity and
lation will go further to increase the number employed than
determination, qualified applicants can be given an oppor-
laws and procedures that contain a threatening element. This
tunity to enter the world of work in places where they were
argument contends that friendly dialogues can lead to a
formerly excluded. Meaningful dialogues can open many
pleasant atmosphere that will have a more far-reaching effect
doors. Section 503 is not now a tool that can complete the
than the threat of a penalty. That thesis continues by pro-
job without a lot of lubrication. We in NRA can furnish that
posing that education is a necessary first step. Employers
grease, if we will, until a more reliable instrument can be
are not really aware of how valuable an untapped resource
secured. The Commission on Consumer Involvement and the
is available to them. Those who follow this line of reasoning
Consumer Council of this Association should give top priority
are convinced that when employers are assured of getting
to reviewing this problem and reporting to the membership
a well-qualified worker who is of no danger to himself or
the unmet needs in this field. If amending, modifying or
others, the demand will be greater than the supply. Evidence
changing the law is needed, then we in NRA must provide
is presented to prove this point by citing many employers
the leadership to insure this is accomplished.
2
JOURNAL OF REHABILITATION
JOURNAL OF REHABILITATION
May-June, 1976
Vol. 42, No. 3
STAFF
The JOURNAL OF REHABILITATION is the official publication of the Na-
tional Rehabilitation Association, a private nonprofit corporation dedicat-
Editor
Betty Winkler Roberts
ed to the rehabilitation and well-being of handicapped persons. Orga-
nized in 1925, the Association welcomes to its membership profession-
Editorial Assistant
Jan
Wasilewski
al workers in all phases of rehabilitation-state and federal rehabilita-
tion employees; physicians; nurses; psychologists; occupational, physi-
cal, and speech therapists; social workers; hospital and rehabilitation
facility personnel; specialists for the blind, the deaf, the crippled-and
others who desire to express in this way their interest in the problems of
handicapped people.
Membership dues are $20.00 a year; associate membership, $12.50; student member-
ship, $7.50. Also offered are sustaining and life memberships, and memberships for or-
ganizations. All include a subscription to the official magazine and to the NEWSLETTER,
ASSOCIATION OFFICERS
published in alternate months. Single copies of the JOURNAL, $2.00.
President
Treasurer
August W. Gehrke
Carl Hansen
Division of Vocational
Rehabilitation Counselor
Rehabilitation
Education Program
FEATURES
550 Cedar St.
Education Bldg. 306
802 Capitol Square
University of Texas
Bldg.
Austin, Texas 78712
St. Paul, Minn. 55101
2
Affirmative Action-Do We Have It?
President-Elect
Executive Director
Cornelius L. Williams
Diane S. Roupe
Cornelius L. Williams
Division of Vocational
Rehabilitation
14
Suite 220,
Section 503 Conference: A New Day For Handicapped People
929½ Fourth Ave.
Sue Maloney
Huntington, West Va.
25701
20
Affirmative Action-A Tool For Linking Rehabilitation and the Business
Community
Sheila H. Akabas
BOARD OF DIRECTORS
E. Russell Baxter
Norman Kelley
24
Rehabilitation's Great Partnership
Milton Cohen
J.B. McElwee
Gwen Countryman
Shelton McLelland
James S. Peters, // and Seymour J. Mund
Henry S. Couvillon
Michael Oliverio
Frances A. Curtiss
Yoji Ozaki
28
Bill F. Gardner
Bob Roberts
Breaking the Competitive Employment Barrier for Blind People
August W. Gehrke
Ed Rose
Charles H. Wacker
Lowell E. Green
Mary Smith
Carl E. Hansen
Arnold Sax
Vernon Hawkins
32
Oswald Sykes
The Special Child
Betty Hedgeman
Evelyne Villines
Sandra Wiggin
Judy Heumann
Bonnie Watson
George F. Hickman
Cornelius L. Williams
George Hudson
Henry Williams
34
Human Service Scale: A New Measure For Evaluation
Kenneth W. Reagles and Alfred J. Butler
39
Experimental Rigor in Rehabilitation Research: Fact or Fantasy?
Paul Wehman
The JOURNAL OF REHABILITATION is the only professional
DEPARTMENTS
magazine concerned with the rehabilitation field in general. It
is published bimonthly by the National Rehabilitation Associa-
tion (1522 K St., N.W., Washington, D.C. 20005) January,
March, May, July, September, November. The subscription
5, 13 Books In Review
9, 13 Rehabilitation News
price of $2 a year to members is deducted from annual dues.
Price to nonmembers in United States and possessions,
$10.00; Other Americas and Canada, and foreign countries,
7 Industry Introduces
11, 38 Employment Exchange
$12.00. Second class postage paid at Washington, D.C. and
additional mailing entry. Views expressed in Journal articles
are those of the authors and do not necessarily coincide with
45 Authors' Biographies
official NRA policy. Acceptance of advertisements in the
Journal does not imply NRA endorsement of the products or
services advertised.
©
National Rehabilitation Association, 1976
MAY-JUNE, 1976
3
Onthefloor.
Inthefloor.
Leakproof.
Overly puts therapy pools where others don't.
This new modular design demonstrates one of the many
your roof. Ramps, stairs, railings are available. Heat-
advantages of Overly welded aluminum therapy pools:
ing and water treatment equipment can also be
versatility. It was designed to be installed on the floor
supplied, as well as a variety of patient-lifting and
of an existing building (so sections had to fit through a
transfer equipment.
doorway) and is used in an innovative teaching and
Other Overly therapy pool advantages include low
therapy program for retarded children. Like all Overly
maintenance and ease of disinfection. And they're
therapy pools, it is warranted leakproof from defects
vacuum-tested for leaks after installation.
in materials and workmanship.
Send for our warranty, and for more infor-
Overly can design, fabricate and
mation on our many therapy pool capa-
install any type of aluminum or stainless
overly MANUFACTURING CO
bilities, see us in Sweet's or write Overly
steel therapy pool you need, in a new
Manufacturing Company, 574 W. Otterman
building, an existing building, or on
Street, Greensburg, Pa. 15601.
DOES WHAT OTHERS DON'T.
books in review
Legal Aspects of Mental Retardation
Work settings represented by the
A Manual of Electrotherapy by Wil-
(A Search for Reliability) by Rob-
participants were industry, hospi-
liam J. Shriber. Lea and Febiger,
ert Henley Woody, Ph.D. Charles
tals, universities, and government
Philadelphia, Pa., Publisher. Re-
C. Thomas, Publisher. Reviewed
agencies.
viewed by B. G. Johnson, The
by Perry L. Hall, Rehabilitation
The purpose of job stress re-
Rehabilitation Center, University
Education, Wright State Univer-
search (Margolis, B. K. & Kroes,
of Arizona, Tucson, Arizona. 271
sity, Dayton, Ohio.
W. H.) is to identify "stressors" and
pages.
The responsibility of society to
to relate them to specific manifes-
The reviewer of this publication is
mentally retarded people has be-
tations of "strain." Perhaps such re-
a rehabilitation educator, with spe-
come a matter of legal concern in
search will lead to more appropriate
cial emphasis upon graduate re-
recent times. The right to education
selection of workers according to
habilitation counselor education.
question which was examined in the
the nature of stress intrinsic to par-
Consequently, the remarks below
courts in Pennsylvania in 1970
ticular jobs and characteristics of
are biased toward the general edu-
started a trend. The trend is becom-
individual workers. This may lead to
cational area of nonmedically edu-
ing generalized to the degree that
a better understanding of causes of
cated professional rehabilitation
all disabled individuals are becom-
performance decrement and im-
personnel. This may prove quite
ing aware of their right to equal pro-
provement of worker health and
beneficial for many readers in that
tection under the law.
safety. Among industrial physicians
it is an objective opinion by some-
This short informative volume
there is not total agreement in the
one outside of physical therapy or
use of the terms "stress" and
focuses on the right of the indi-
physical medicine.
vidual to competent professional
"strain." Generally, it appears that
William J. Shriber, the author,
these concepts have been borrowed
expert testimony. The book ex-
holds both an M.A. and an M.D. de-
from engineering and applied rather
amines the question of "what hap-
gree. He is assistant professor of
straightforwardly to the phenome-
pens to the mentally retarded ac-
Medicine, Harvard Medical School;
cused of committing a crime?" The
non of the human organism in a
Chief of Physical Medicine, Beth
book brings up the issue of lack of
work context. "Stress" pertains to
Israel Hospital; and lecturer in
knowledge about mental retardation
any sources of pressure external to
Electrotherapy, Simmons College
the person, but confined in this con-
on the part of judges, attorneys, and
Boston, Massachusetts. This is the
text to pressure generated by the
expert witnesses such as psychia-
fourth edition of the text which Dr.
work environment and role functions
trists and the cumulative effect it
Shriber states is the outgrowth of a
has on justice for mentally retarded
of a particular worker. "Strain" per-
work by Richard Kovacs in 1932.
tains to the accommodation of the
people. The book does an excellent
The publication by Kovacs was writ-
job of presenting the problem. The
organism to strain or the effects of
ten chiefly for physicians.
stress in the worker.
use of more actual example cases
The present text is directed to-
would have added a great deal to
Kahn elaborated on three sources
ward physical therapists but is also
the presentation. This book is well
of stress and cited research evi-
for use by those physicians who de-
referenced, demonstrating up-to-
dence related to each. These are
sire more information about electro-
date research on the part of the
role conflict, role ambiguity, and
therapy. The reviewer believes the
author. This publication should be-
role overload. Role conflict involves
manual also offers an excellent
come part of a course required for
two or more incompatible demands
overview for nonmedically educated
special educators, school psycholo-
on the worker. Role ambiguity indi-
rehabilitation professionals.
gists and other persons who could
cates a lack of structure or need
In this latter regard the first two
become involved as expert wit-
for more information than the
chapters provide an example. Chap-
nesses in court.
worker has in order to perform the
ter One gives a readable and easy
job adequately. Role overload per-
to follow introduction to and sum-
tains to job demands or expecta-
mary of the various types of electro-
tions exceeding capacity to pro-
therapy. Included are direct heat
duce. This breakdown of sources of
Occupational Stress edited by A.
methods, ultraviolet radiation, direct
stress has been somewhat accepted
McLean. Charles C. Thomas, Pub-
current, low frequency currents and
and used as independent variables
ultrasound.
lisher. Reviewed by C. D. Auven-
in several studies cited by the
shine, College of Education, Uni-
Chapter Two provides a brief,
author.
versity of Kentucky, Lexington,
well-conceived history of electro-
Kentucky.
This book should be a valuable
therapy. It is not overdone and, as
contribution to industrial medicine
is most of the book, quite easy to
Most contributors to this book
and allied health specialties. It rep-
read. Chapter Two sets the stage
were physicians; however, other
resents a serious effort to better
for the remaining six parts and their
specialists were represented includ-
conceptualize and articulate the
fifteen chapters. Many of the follow-
ing counseling, labor relations, nurs-
heretofore nebulous concepts of
ing chapters are quite technical.
ing, personnel, psychology, rehabili-
"stress and strain" associated with
Basic theory is presented and a step
tation, social work, and sociology.
worker roles and environment.
(Continued on Page 13)
MAY-JUNE, 1976
5
A
Beltone Aid
kept me from being
a drop-out."
-ORALIA MORAN
(A TRUE STORY OF
HEARING REHABILITATION)
Oralia Moran
can't say enough
about the help she has had from
Beltone Dealer Peggy Mayhall and the
Vocational Rehabilitation Commission of the
Texas Education Agency.
Back in 1958 when she was first starting high school, Oralia
had trouble hearing her teachers; and her counselor,
Mr. D. D. Steele, sent her to Peggy Mayhall, the authorized
Beltone Dealer in Austin.
Tests revealed that Oralia had a 60dB
loss in both ears. But there was little money
for hearing aids in the Moran family.
So, Mrs. Mayhall went to work, and with
the help of the Capital City Kiwanis Club,
Oralia was fitted with an aid.
She finished high school and-thanks to the
VR people-went on to business school.
Today, Oralia wears binaurals and works
as a secretary. As she puts it: "Being a
secretary is nice work, and thanks to
Beltone hearing aids, I am a secretary.
Without them, I couldn't take dictation,
answer the telephone or receive clients
in our office."
MORAL: When you work with a Beltone Hearing Aid Specialist, nice
things happen for the hearing-handicapped. Which is why we invite you to call on
one for help with any of your clients.
Beltone
WHEN A HEARING
AID WILL HELP
BELTONE ELECTRONICS CORPORATION-4201 W. Victoria St., Chicago, Illinois 60646
6
JOURNAL OF REHABILITATION
industry introduces
A new battery-op-
cardiovascular disorders such as aneurisms, heart en-
erated, electro-car-
largements, and thickening of heart walls; fetal and
dioscope, the Cardio
maternal anatomy during normal and abnormal preg-
Miniscope, has re-
nancy; and a broad variety of gynecologocal disorders
cently been devel-
and possible birth defects.
oped by Vitalograph
The scanner is called VR-3 Phased Array Ultrasono-
Limited, and literally
graph. Clinical evaluation of the VR-3 began earlier
"fits the physician's
this year, when Varian provided a prototype unit to a
pocket."
large teaching hospital in California. Commercial de-
The Cardio Miniscope with integrated electrodes
liveries are expected to begin in 1976.
measures only 4.5x11x18 cm. and weighs 790 gm. It
is the most compact unit of its type on the world
The VR-3 uses an array of 32 miniature transducers,
market.
combined into a single transducer head. The ultra-
The miniature cardioscope is simply placed on a
sonic beam is aimed electronically and can sweep
patient's chest to provide an instant ECG. No elec-
through a scanning angle of over 80° while the trans-
trodes are attached to the patient, no power lines are
ducer head remains stationary. The small size of the
plugged in, thus saving time when seconds may be
transducer allows its use for imaging the adult heart
precious in making a diagnosis.
through the narrow space between two adjacent ribs.
For more information contact Vitalograph Medical
At the same time, the transducer can be used else-
Instrumentation, 8347 Quivira Road, Lenexa, Kansas
where on the body with great speed and ease.
66215.
For further information contact: Varian Radiation
Division, 611 Hansen Way, Palo Alto, California 94303.
A bedside station
featuring true duplex
voice communica-
A new concept in pro-
tions has recently
viding greater mobility and
a more useful life for
been developed by
American Zettler,
thousands of disabled per-
Inc. Unlike systems
sons is represented by the
using push-to-talk
LEM power chair. Invented
buttons or voice ac-
and currently manufac-
tuated switches, the
tured in Italy, the device
American Zettler Patient Station permits continuous,
is designed for use by
natural, and uninterrupted speech between patient
persons whose independ-
and nurse. There is no need for the patient to reposition
ence of physical move-
himself or even look in the direction of the bedside
ment has been temporarily
station. The ultra-sensitive microphone picks up the
or permanently impaired.
faintest voice levels from anywhere in the room. Inter-
The chair requires little physical exertion to operate.
ruptions due to accidental operation of a switch are
One of its patented key features is the handicapped
eliminated.
person's ability to rotate manually a full 360 degrees
The new Patient Station includes an ultra-sensitive
by using a circular member of the strong, chrome-
microphone, speaker, nurse-call button, privacy light,
tubed frame. The user requires no outside object, such
and call cord. Optionally, the station may be obtained
as a brace, to help the wheelchair start moving, or as
with controls for television, radio, lights, draperies,
a guide in changing direction. A disabled person can
and even the door.
move easily through a room filled with furniture, nar-
For further technical information and prices, contact:
row doors and corridors, and can use standard ele-
Hospital Systems Manager, American Zettler, Inc.,
vators in moving from floor to floor. Speed can be
16881 Hale Avenue, Irvine, California 92714.
carefully regulated from a standstill up to 6.2 miles
per hour.
The LEM power chair is fully approved by medical
An advanced ultrasonic scanner for use in medical
and rehabilitation authorities in Western Europe and
research and diagnosis has been developed by Varian
is completing similar evaluation by such experts in
Associates. The new instrument will allow physicians
the United States. Its price compares favorably with
to observe a patient's internal organs and their move-
the manually operated wheelchairs now in use by the
ments by translating reflected high-frequency sound
majority of handicapped people. Purchase of the LEM
waves into visual images. It provides continuous dy-
power chair and service is being made possible by
namic images, showing the motion of an organ while
French Italian Marketing Corporation.
it is occurring.
For further information contact Richard Wilcox, Wil-
This instrument will bring new refinement to studies
COX & Co., 59 East 54th St., New York, N.Y. 10022.
of real and artificial valves functioning in the heart;
Telephone (212) 758-8120.
MAY-JUNE, 1976
7
What kind of
job should
he have?
Should he be a mason, a plumber,
a clerk, a cook? Singer's Vocational
Evaluation System helps him and
you find out. Whatever his abilities and
special problems, this system with its
job sampling stations will help you
better assess his interests, attitudes
and abilities without a total depen-
dence on pencil and paper testing. The
stations give him opportunities for
hands- on sampling of many careers.
And at the same time give you mea-
surements of his mental and physical
aptitudes. A follow up picture interest
screening technique confirms these
findings.
With this innovative System, you can
deal with his particular needs so
that he can make the transition back
into the world of work and become
a productive, independent citizen. For
the complete story on Singer's Voca-
tional Evaluation System, contact
Singer Career Systems.
SINGER
EDUCATION DIVISION
SINGER CAREER SYSTEMS, 80 Commerce Drive,
Rochester, N.Y. 14623/(716) 334-8080
8
JOURNAL OF REHABILITATION
rehabilitation news
Synthetic Drug Evaluated
answer in hard copy so it can be
ample, if left untreated, can result
referred to again and again.
in complications such as stroke,
Testing of a new synthetic non-
The basis for the service is an
heart failure, and other cardiovascu-
narcotic pain-relieving drug, not yet
acoustic telephone coupler (TTY)
lar events. The system involves a
available to the public but approved
used in conjunction with a teletype-
telephone hook-up to a computer
by the FDA for evaluation, has be-
writer. The electronics for the de-
that can calculate in seconds a pa-
gun at Massachusetts Rehabilita-
vice were designed in the early
tient's susceptibility to cardiovascu-
tion Hospital in Boston.
1920's but were adapted for use by
lar complications.
Hospital officials anticipate that
deaf people in 1964. No special wire
CARDIO-DIAL was prepared in
studies of the drug, which is
networks are required for the sys-
cooperation with the National High
generically identified as butorpha-
tem. The deaf student simply sets
Blood Pressure Education Program,
nol tartrate, will lead to substantial
his telephone receiver into the
National Heart and Lung Institute,
progress in treating many types of
acoustic telecoupler. A light will
and the National Institutes of Health.
diseases and put an end to U. S.
come on to indicate power; another
The "risk analysis" supplied by
dependence on the foreign supply
light will come on to indicate a dial
CARDIO-DIAL is based on data from
of substances required for the man-
tone. When all systems are "go," the
the well-known Framingham Study,
ufacture of narcotic pain relievers
student types out his message on
an extensive investigation of cardio-
such as morphine.
the teletypewriter, and the message
vascular disease begun 25 years
The research will be financed
is automatically transmitted to the
ago in Massachusetts. Comparisons
through a grant to Massachusetts
other end.
with other studies in this country
Rehabilitation Hospital (MRH) from
Currently there are over 12,000
tend to corroborate the Framingham
Bristol Laboratories, a division of
TTY stations available throughout
findings. Using the data from the
Bristol-Myers, the pharmaceutical
the United States and Canada, in-
Framingham Study, CARDIO-DIAL
cluding hundreds available through
can generate almost nine million in-
manufacturer which developed the
drug.
organizations serving the deaf. Pri-
dividual "risk" combinations.
Allan Kliman, director of Hema-
mary use of the TTY systems has
tology at MRH and head of the
been for emergency communica-
research team which will be exam-
tions, as many cities have a direct
ining the drug, says it is capable
tie-in with police and fire depart-
of high-level pain relief in small
ments. Some cities have volunteer
Fellowships Announced
doses without the respiratory sys-
answering services for the deaf.
tem-depressing effects sometimes
The equipment has also been used
The Mary E. Switzer Memorial
seen with narcotics such as mor-
extensively for social communica-
Committee of the Professional Con-
phine and meperidine.
tions from one deaf person to an-
cerns Commission of the National
other.
Rehabilitation Association has an-
nounced that two fellowships will
be presented this fall at the NRA
Conference scheduled for Sept-
Direct Contact for Deaf
ember 18-22.
International Correspondence
Schools (ICS) has inaugurated a
Computer Aids Diagnosis
The fellowships, each in the
"Dial-A-Question" service for deaf
amount of $2,500, will be given to
A physician anywhere in the U.S.
persons, enabling deaf students
will soon be able to pick up his
graduate level students or post-
throughout the United States to
doctoral candidates for study in the
telephone, dial a toll-free number
communicate directly with their in-
areas of business and management,
which will connect him with a com-
structors in Scranton, Pa. ICS is the
thus demonstrating their applica-
puter in New Jersey, and within sec-
first independent study, degree-
tion to the challenges in the field
onds tell a patient sitting in his of-
granting institution to offer such a
of rehabilitation. The fellowships
fice his probable risk of developing
service for deaf students on a na-
cardiovascular disease in the next
will be awarded every year, using
tional scale, according to Robert S.
different topics which will be se-
eight years.
Mudd, national director of ICS' Vo-
lected by the committee.
Called "CARDIO-DIAL," an acro-
cational Rehabilitation Division.
nym for "Cardiovascular Disease
When a deaf student enrolled in
Risk Direct Information Access
The candidates must be currently
an ICS program dials a toll-free long
employed in rehabilitation with a
Line," the computerized system was
distance number, he will be put in
minimum of five to ten years ex-
developed by CIBA Pharmaceutical
contact with a person specially
perience. They must have demon-
Company as an aid to physicians
trained to receive the message on a
strated management skills from
in treating patients with high blood
teletypewriter. After the answer is
three to five years. The fellowship
pressure and other risk factors of
obtained, it will be transmitted back
heart disease who need to under-
may be short-term or long-term, but
to the student through the same
must be completed within the ca-
stand the seriousness of their con-
system, giving the student his
dition. High blood pressure, for ex-
(Continued on Page 13)
MAY-JUNE, 1976
9
Rehabilitation's Real Goal:
Enriched Accomplishments
As enriching as it is, there's more to be gained from rehabilitation
than self-support alone.
Accepting and managing family responsibilities, contributing to
community affairs, attaining personal fulfillment
all this is
open to the handicapped through the operation of automatic
vending machines.
Automatic vending is a proven producer for the physically
handicapped, including the blind, in state after state across
the country. Most often, when manual vending stands are
supplemented by vending machines, average weekly earnings
double. More earned take-home pay gives more confidence and
status to the handicapped citizen.
You will get complete information on how the Rowe vending
program for the handicapped works by sending in this coupon
today. It's an important first step in providing even more than
self-support.
Mr. Arnold Cohen, Vice President
Department JR
Rowe International, Inc.
75 Troy Hills Road
Rowe®
Whippany, NJ 07981
I would like to have complete information about Rowe's rehabilitation pro-
gram for the handicapped.
Name
Phone #
ROWE
international,
Title
inc.
Organization
Street
A SUBSIDIARY OF
TRIA NGLE INDUSTRIES, INC.
City
State
Zip
employment exchange
CLINICAL PSYCHOLOGIST-For State of Kansas
Program Director-Work activities cntr. for
Vocational Rehabilitation Center in Salina,
Kansas. Requires Ph.D. in Clinical Psychology,
M.R. adults. All aspects of admin., public rel.,
and ability to evaluate and counsel clients.
contract procurement, and grant writing. Min.
NEW REGIONAL
Salary Range $14,148 to $17,964. Contact
req. M.A. or equiv. in related field. Salary
negotiable. Send resume to: Roundup Enter-
COMPREHENSIVE
Harry Shimpe, Administrator, Vocational Reha-
bilitation Center, Salina, Kansas 67401. Phone
prises, 1833 East "A" Street, Torrington, Wyo.
82240
REHABILITATION CENTER
(913) 827-9350. An equal opportunity employer.
Serving adult deaf, blind and
other handicapped. Staff needed
for deaf program, July 1976, Bos-
ton area; Social Worker, Social
Work Asst., Psychometrist, Edu-
cational Specialist, Communica-
VOCATIONAL
tions Specialist, Vocational
HOME ARTS
Counselor, Adjustment Coun-
EVALUATOR
selors, Work Evaluator, Job
COORDINATOR
Master's in Vocational Evaluation, or
Placement Specialist, Residence
a Master's in a related field with one
Supervisor, Resident Trainer.
year's experience in V.E., or a Bache-
Master's degree in home economics,
Vita: Dr. Richard E. Thompson,
lor's in a related field with three
Director of Services for the Deaf,
education or related area. Ten month
The Protestant Guild for the
years' experience. Complete voca-
tional evaluations for clients of all
position in school program for train-
Blind, Inc., 456 Belmont St.,
disabilities, with the greatest number
Watertown, Ma. 02172.
able retarded students, grades K-12.
being legally blind. Ability to speak
Spanish helpful but not required.
Salary beginning $10,800. Send cre-
Salary based on experience. Please
dentials and letter of application to:
send resume to:
Bill Winkley, Executive Director
Mr. Daniel Berridge
El Paso County Association for
Director of Educational Services
the Blind
Murray Ridge Center
100 Dunne Avenue
9750 S. Murray Ridge Road
Best Wishes
El Paso, Texas 79905
(915) 532-4495
Elyria, Ohio 44035
to
KENTUCKY
VOCATIONAL EVALUATOR
NEEDED
SOCIAL WORKERS
&
Occupational Development Center
Vocational training center/Sheltered
FOR ISRAEL
workshop
Opportunity to Develop Own Program
ISRAEL-Social Work positions avail-
TENNESSEE
Qualifications: Ability to relate to
able in Israel-case workers-group
staff and clients, use of work sam-
workers and community-development
ples and situational assessment, re-
personnel. MSW degree required.
NRA CHAPTERS
port writing, establish OJE's, knowl-
Also positions in Rehabilitation
edge of labor market and job re-
quirements, participation in staffings,
Counseling or Vocational Guidance
use of psychological testing.
for which MA degree or equivalent is
Experience: Minimum 3 years as
required. Living quarters and seven
chief evaluator with some supervi-
to nine months work-study orienta-
sory experience. Prefer M.A. in voca-
tion and language course prior to
tional evaluation or related field or
placement. For further information,
Bachelors with equivalent experience.
contact:
SNELL'S
Salary: $11,000-$15,000
Sydney Gale, Park Square Building-
Send resume to:
Suite 450, 31 St. James Avenue,
LIMBS & BRACES, INC.
Gary K. Wilder, Executive Director,
Occupational Development Center
Boston, Mass. 02116
400 N East Street
Bloomington, Illinois 61701
MAY-JUNE, 1976
11
Sue Maloney
"Section 503 Conference-
A New Day For Handicapped People"
In a unique conference recently held in Pittsburgh,
Pa., corporate leaders spoke on Section 503 of the
Rehabilitation Act of 1973. This was the first major
conference where the rehabilitation community heard
the employer views on hiring disabled people. Person-
nel from large corporations offered suggestions on
how placement specialists could capitalize on the em-
ployment opportunities created by Section 503.
Pittsburgh, the third largest corporate headquarters
in the country, following New York and Chicago, was
an appropriate meeting ground. Out of Fortune's 500,
16 corporations are headquartered in the Steel City.
Participating in the panel discussion on the economic implications of hiring
These companies make decisions in Pittsburgh which
the handicapped are (left to right) Patrick Greene, AFL-CIO; Terry Tyree,
have hiring implications throughout the United States.
Peoples Gas; Myrtle McDowell, Rockwell; Bertram Dinman, M.D. Alcoa.
What are the economic implications of hiring the
ing and improved relations between industry and reha-
disabled? What are the mutual responsibilities of in-
bilitation. The last five guidelines, he asked the reha-
dustry and the rehabilitation community under Sec-
bilitation community to write.
tion 503? These topics were explored in workshops,
panel discussions, and speeches. Registrants came
A panel discussion on the economic implications of
from 16 different states for the two-day conference
hiring a new employee followed. The panel included
on March 9 and 10.
the medical director of Alcoa, the director of com-
munity services for the AFL-CIO, an employee rela-
tions manager from Peoples Gas, and the personnel
Opening the conference was Leonard Weitzman,
president and chief executive officer of the Vocational
manager of Rockwell International.
Rehabilitation Center, sponsor of the event. Founded
in 1927, VRC is a private, nonprofit center which eval-
The medical director requested complete medical
uates, trains, and places in jobs, people with mental
disclosure from an applicant. This would not preclude
and physical disabilities. This United Way agency
employment, he assured the audience, but the client
serves about 2,500 persons a year and places about
would be placed in a job where his disability would
not be a safety hazard.
500 people.
Weitzman, who is also national president of the
Kicking off the second session was Richard Shep-
Association for Rehabilitation Facilities, introduced
pard, liaison officer, state relations, President's Com-
R. R. Wingard, vice-president for Human Resources for
mittee on Employment of the Handicapped. "Because
the Koppers Company. "Affirmative action has become
503 does not have the 'big stick' provisions of other
a buzz word without any clear definition," states
EEO legislation, it is less likely to impact on employers
Wingard. He outlined guidelines for better understand-
(Continued on page 17)
14
JOURNAL OF REHABILITATION
Affirmative Action Under Section 503: "A Foot in the Door"*
As advocates for employers and our handicapped clients, we can cooperate in a number of ways that
will make 503 pay off:
1. We must be willing to spend more time on job sites doing job analyses and projecting employment
needs. The telephone is the primary tool of most placement specialists and counselors. Today, the
economy dictates a need for more face-to-face contact in order to compete for jobs. Also, the severely
disabled clients we serve cannot be placed from an office chair. If you want favorable response from
employers, be prepared to visit them frequently-not to "bug" them but to offer assistance. Another
way of putting it is, "It's better to have the soles of your shoes wear out than the seat of your pants."
Counselors, placement personnel, and trainers must all learn the techniques of simple job analysis,
skills that many of us do not possess today. Good selective placement is dependent upon such skills.
An essential ingredient of good job development is looking ahead for future employment possibilities.
An employment "crystal ball" can only be maintained by continued communication with potential em-
ployers.
2. We must make our training more job related. How many of you believe that most of our vocational re-
habilitation training efforts result in placements related to that training? It is a challenge that I believe
we can meet through more extensive use of on-the-job training. One of the greatest problems in voca-
tional rehabilitation's use of on-the-job training in the past has been the unwillingness of many em-
ployer/trainers to pay off with a job at the end of a client's training. Affirmative Action should greatly
increase the possibilities of pay offs in jobs. Our employment crystal ball must also be used if our
training is to be responsive to employers' needs.
3. We must use modern placement technology such as the "job bank" effectively and develop our own
devices for responding quickly to "job orders." The major complaint we hear from employers all over
the country is that they have called their local vocational rehabilitation offices and rehabilitation fa-
cilities and received no response to their request for handicapped workers. I believe in many instances
that the job-ready clients are there. However, most vocational rehabilitation agencies are so decentral-
ized, even in urban areas, that effective communication resulting in quick response to job opportuni-
ties is almost impossible. Perhaps the answer is a centralized data bank of job-ready clients.
A major problem is getting people to use the technology that is available. In the vocational rehabilita-
tion agency in which I worked, I would estimate that less than five percent of counselors and place-
ment specialists use the job bank. What is most distressing is that the viewers are located in key vo-
cational rehabilitation offices and job bank training is readily available.
I realize that facilities have special problems in responding to employers' needs. In most cases the
facilities are serving severely disabled clients and cannot readily match job-ready clients to incoming
calls. However, when the facility's placement specialist cannot readily respond to an employer's re-
quest, the specialist should arrange an on-the-job site visit. One objective of such a visit should be
job modification.
4. We must provide routine follow-up services. Not only does such service increase our clients' chances
of successful job adjustment, but it frequently pays off in additional jobs.
5. We must sell employers on the unique services that vocational rehabilitation has to offer. Where else
can an employer turn for employees who have received indepth diagnostic services, training, voca-
tional and personal adjustment counseling, etc.? Such services should include technical assistance
in how to best make "reasonable accommodations" for handicapped employees.
Two weeks ago one of the largest retail firms in the country wrote our Committee detailing their ex-
penses thus far in making "reasonable accommodations." For six handicapped telephone sales per-
sonnel, six cassette tape recorders were purchased at a total cost of $300. For two dozen disabled
employees who take catalog orders, desks were lowered, doors were widened, and grab bars were
installed in lavatories. For each employee, modification costs ranged from $0-$800. Two dozen service
technicians who use wheelchairs were accommodated for $300-$600 each. An IBM typewriter with a
shield to assist a clerk with cerebral palsy was rented at the standard fee. This firm purchased a large
number of telephones with amplifiers for employees with hearing difficulties at a cost of $18.00 per
installation and 65¢ per month rental. I could go on and on, but the point I'm trying to make is that
"reasonable accommodation" need not be very costly. The Veterans and Handicapped Operations
Division, U.S. Department of Labor, has estimated that less than five percent of handicapped workers
need special on-the-job accommodations.
6. We must provide college training at both the graduate and undergraduate levels in the selective place-
ment process. The mandate to increase services to severely disabled individuals and the complexity
of "Affirmative Action" requirements call for us to finally take steps to better train counselors and
sity! placement personnel. Our Committee has been pushing for such training for years. Today, it is a neces-
*-Excerpts from speech delivered by Dick Sheppard in Pittsburgh, Pennsylvania, March 10, 1976.
MAY-JUNE, 1976
15
Guidelines for Effective Action Between
Agencies and Corporations
R. R. Wingard
clearly definable and reasonably at-
Industry has been dealing with the
Vice-President for
tainable objective can be estab-
problems of some handicapped
Human Resources
lished. Objectives cannot be so
people for a long time. These are
Koppers Company
broad as to overcome all pragmatic
people who perhaps have had the
approaches to achieving them. Now
social skills and the financial re-
In my Guidelines for Effective Ac-
it is not my objective here today to
sources to make direct application
tion between Agencies and Corpo-
define your objectives for you, as I
to employment. These are people
rations, number one is: "Don't stand
certainly know that you are capa-
who are employees of the corpora-
in your own way." That's altogether
ble of doing that, and your confer-
tion and, through accident or ill-
too easy I think-and certainly a
ence will be addressing that task.
ness, on or off the job, have be-
common failing of all of us who are
But I suggest that if you seek effec-
come handicapped, and subse-
too anxious and excited and con-
tive action, then the objectives must
quently rehabilitated and reassigned
cerned with our work to become too
be concise; they must be under-
to appropriate work. So, we have
personally involved in the task. It is
standable; and they must be rea-
some familiarity with the kinds of
certainly a failing that I have, and
sonably attainable within some time
problems with which we must deal.
I do not mean that we can separate
frame.
But, in reality, we are not com-
ourselves from our work-far from
pletely free to do anything we would
it. But I think we have to under-
wish to do in this area. I know as a
stand that the failure of an idea or
My third guideline is to "under-
stand the team." This conference,
practical matter in our corporation
a program does not always mean a
as I understand it, is part of an
that we already spend so much time
failure of you or me as an indi-
vidual, and the same is true of suc-
attempt for a mutual understanding
and effort in complying with the
cess. Maybe I can illustrate this
by all members of this team-that
forms involved from regulations that
is labor, business and professional
we are seriously hampered in our
guideline with a few statistics. The
groups in the rehabilitation field,
effort to get through to the sub-
average American, as you know,
and of course, the government. I
stance of the law and to deal effec-
lives to age seventy. He or she
spends twenty-three years sleeping,
applaud this effort. It is badly
tively with the true problems.
eleven years working, six years eat-
needed by all the players. At the
ing, five and a half years washing
risk of some duplication at your
I urge you to listen to guideline
and dressing, eight years being
later seminars and meetings, let me
number five. "Don't play the num-
amused or entertained, including
give you my impressions of a few
bers game." You are probably all
television, three years talking, only
priorities on the list of understand-
all thoroughly familiar with the
nine months listening, and forty-two
ing the business members of the
Affirmative Action plans as they are
and a third years, ninety percent of
team, which I am daring to repre-
presently constituted under regula-
one's waking life, thinking about
sent. First, and I sincerely hope I
tions covering nondiscrimination in
one's self. I am absolutely con-
am not appearing to be trite, I would
employment of minorities and fe-
vinced that the most serious failing
ask for a clear understanding of
males. My own company has some
in dealing with people, centers
the works of the corporation. Ac-
250 separate Affirmative Action
around the fact that so many of
cording to employment fact, most
plans. My point is that all the plans
our efforts are self-oriented rather
of our society does not understand
finally boil down to a set of num-
than group-oriented. As a first step
the corporate mission. It might be
bers which everyone can monitor
then, we must get ourselves out of
useful to some of you to know that
and measure quite easily, and so
we, and the corporations, often
our own way, and then we can per-
the numbers game begins. Believe
need and often welcome help in the
haps focus on the next guideline.
me, the numbers game does not
conduct of our activities. We need,
work. Everybody loses. No one quite
however, help with understanding.
Guideline number two is "under-
understands the difference between
We find ourselves often beseiged
standing the objective." We all
a goal, a quota, and a target, and
with helpers, all with good inten-
know that there is nothing more
yet they all have very different
tions but sometimes misinformed,
exasperating to handle than a solu-
meanings in the rapidly evolving
or occasionally, not informed at all.
tion in search of a problem. You
language of Affirmative Action. In a
professionals in vocational rehabili-
dispute over the numbers and how
tation and its application to the
The fourth guideline I have listed
they are arrived at, again we sub-
business world are certainly under-
is to "examine the trade-offs." Now
stitute form for substance. The real
taking a solemn and complex task.
you may feel that trade-off is a
objectives of the plans are over-
At this conference, I know you will
rather crude way of saying "be
looked. We have made a serious
be dealing with many of the prac-
willing to compromise." Well, some-
mistake. I personally believe Affirm-
tical problems involved in your
times a compromise is involved
ative Action in any area, including
work, and I shall touch on my own
when objectives have become un-
handicapped people, can succeed
views of some of those problems in
realistic, but my real point here is
only if it shifts its emphasis away
a later guideline. But I would hope
that we must seek some answers
from equality of results, and places
as a group, interacting with the
together to some very real prob-
the emphasis squarely upon equality
other involved groups, that some
lems in the area of your concern.
of opportunity.
16
JOURNAL OF REHABILITATION
Approximately 150 rehabilitation profes-
sionals attended the luncheon.
in a way that will develop great resistance. As a matter
of fact I am optimistic enough to believe that 503 will
be welcomed by many employers," said Sheppard. He
Transitional employment proved to be the most
listed six guidelines for the rehabilitation person to
advantageous model for the client, the placement
use in gaining cooperation with prospective employers.
counselor, and the employer. In light of Affirmative
Action obligations, T.E. identifies the qualified dis-
In a workshop on communications, an industrial
abled person, modifies procedures and facilities to
psychologist for Westinghouse, Inc., pointed out strate-
accept various clients into T.E., and provides coopera-
gies for making contacts. 1. Concentrate on one com-
tive and innovative programming between employers
pany at a time. Research them, approach proper per-
and rehabilitation facilities.
sonnel, and maintain contact with your target firm.
2. Match the individual to the job environment as well
as to the job duties. 3. Prepare the client to work with
the other employers in a smooth co-worker relation-
ship. 4. Understand the pecking order in a business.
Tell your client to whom he should talk first, the plant
manager or the foreman.
A second workshop explored how rehabilitation can
cope with the termination process. 1. The termination
process is basically the same for large and small firms,
based on a warning system involving three or four
steps. The larger the company, the more formal the
process. 2. Termination is not an irreversible process.
Mediate between the client and the employer. Do
remedial work outside the job. If termination is in-
evitable, comply graciously. 3. Maintain rapport with
company personnel at all cost. Placement has to be
concerned with the long run, even if it means a coun-
selor has to suggest termination for a client.
A workshop entitled "Techniques for Integrating the
Client Into the Work Force" examined the strengths
and weaknesses of three placement models. 1. Stand-
ard selection placement. 2. On-the-job training, wage
subsidies. 3. Transitional employment (T.E.).
Andrew S. Adams, Commissioner of the Rehabilitation Services Administra-
tion, was keynote speaker at the Section 503 conference luncheon.
MAY-JUNE, 1976
17
Richard Sheppard (left) listens to
speakers at luncheon.
R. R. Wingard from Koppers Company
stresses sending qualified handi-
capped persons to corporations.
This workshop focused on the realities of a T.E.
Conference 503*
experience based on the findings of the Federal Home
Pittsburgh, Pa.
Loan Bank in Pittsburgh. Acting as a transitional em-
March 10, 1976
ployer, the bank hired seven persons with epilepsy
from a VRC research and demonstration project. This
Affirmative Action is not a new concept. But the
resulted in fulltime employment for five of the seven.
Rehabilitation Act of 1973 put some teeth in it.
Despite Affirmative Action and all we do for dis-
abled people, our group is in the lowest level of
Andrew S. Adams, Commissioner of Rehabilitation
employment in the country. Only 81,000 handicapped
Services for the Department of Health, Education and
persons are in the work force. This is an 18 percent
Welfare addressed the luncheon audience of over 150
decrease over last year.
rehabilitation professionals from various agencies. He
Thirty thousand job titles are listed in the De-
described his personal experiences as a client in a
partment of Labor Occupational Manual for handi-
California rehabilitation center. "I wanted to play ball,
capped people. Our big challenge is not to add job
but they told me to embroider," he exclaimed.
possibilities, but to expand training opportunities
Dr. Adams rejoiced that the day has finally arrived for
across the board to industry, business and govern-
the client to find new doors open to him through legis-
ment. We have got to take advantage of public
lation.
schools, junior colleges, more on-the-job training
and setting up training agents. We can train handi-
"Rehabilitation must begin immediately," he stressed.
capped people for many more jobs than we do now.
"It should begin in the hospital or as soon as possible
The law says we must give priority to the more
to help the person over his initial fears and depres-
severely disabled. This is a challenge. Out of the
sion." Planning for the future cannot start early enough,
total number of disabled persons we find jobs for,
according to the Commissioner. VRC presented Dr.
36 percent are severely disabled. This year our
Adams with a brass and walnut plaque inscribed "for
target is 38 percent.
outstanding service to the handicapped of America."
We are putting emphasis on the placement spe-
cialist as a job in itself. This professional is a
The Section 503 Conference in Pittsburgh demon-
matchmaker, providing marriages between handi-
strated that labor and industry leaders are willing to
capped persons and jobs. He must work with in-
meet and dialogue with the rehabilitation community
dustry and analyze clients. Growth on the job and
for the mutual benefit of both. Affirmative Action can
the follow-up aspect of job placement are also
be an effective tool to bring these two sectors closer
important.
together.
*
A new day is dawning for disabled people. These
Excerpts from speech by Dr. Andrew S. Adams, U.S. Commissioner
of Rehabilitation Services, Department of Health, Education and
horizons must be broached by qualified applicants and
Welfare
researched by informed placement counselors.
18
JOURNAL OF REHABILITATION
CHARLES C THOMAS
PUBLISHER
ORTHOPEDIC MEDICINE: A New Approach to Vertebral
UNDERSTANDING YOUR NEW LIFE WITH DIALYSIS:
Manipulations (2nd Ptg.) by Robert Maigne, Hotel Dieu
A Patient Guide for Physical and Psychological Adjustment
Hospital, Paris, France. Translated and edited by W. T.
to Maintenance Dialysis by Edith T. Oberley and Terry D.
Liberson. A system of vertebral manipulations are inte-
Oberley, both of Univ. of Wisconsin, Madison. Forewords
grated by the author into the general field of contemporary
by Francesco del Greco and Eli A. Friedman. This
medicine. Techniques and maneuvers of relaxation, mobili-
composite picture of vital technical, physical, psychological
zation and manipulation are described and illustrated by
and philosophical material on understanding life with
superb photographs and didactic diagrams. A large portion
dialysis is written for patients, their families and profes-
of the book is devoted to methods of examining patients
sionals in the field. Chapters deal with the subjects of
with painful spine or upper and lower extremities. Chapters
kidney failure, the workings of human and artificial
concerning functional anatomy and pathophysiology of the
kidneys, physical and psychological preparation for dialysis,
spine and related structures have been included as well as a
chronic medical conditions, diet and medication, rehabilita-
lucid description of the most frequent clinical conditions
tion, home vs. in-service dialysis, and transplantation vs.
seen by practitioners. '76, 456 pp., 519 il., $22.75
dialysis. '75, 160 pp., 26 il., 2 tables, cloth-$12.50,
paper-$7.95
WORKSHOP MANAGEMENT: A Behavioral and Systems
Approach by Douglas B. Simpson, California State Univ.,
UNDERSTANDING AND LIVING WITH BRAIN DAM-
Fresno, and Philip M. Podsakoff, Indiana Univ., Blooming-
AGE by Patrick E. Logue, Duke Univ. Medical Center,
ton. This interdisciplinary approach to the theory and
Durham, North Carolina. In clear language, this text
practice of managing rehabilitation facilities relies heavily
explains the behavioral effects, thinking changes and
upon behavioral research findings and current innovative
emotional consequences that may frighten and bewilder the
management styles. The structure and functions of manage-
brain damaged patient and his family. Primary emphasis is
rial efficiency and effectiveness are discussed from the
on conceptual understanding, possible useful procedures
viewpoint of both practitioner and student. The book
and sources of help. A checklist table of contents will be
translates theory and research findings into operational
particularly helpful to the physician in enabling him to
terms, stresses a behavioral-systems approach toward man-
mark those chapters dealing with special conditions charac-
aging human resources, and reviews and assesses environ-
teristic of individual patients. '75, 116 pp., cloth-$8.50,
mental constraints which will face the workshop manager
paper-$5.75
of the future. '75, 152 pp., 20 il., 3 tables, $12.95
ANATOMIC GUIDE FOR THE ELECTROMYOG-
RESTORATIVE NURSING IN A GENERAL HOSPITAL
RAPHER: The Limbs by Edward F. Delagi, Aldo Perotto,
by Ruth Schickedanz, Tucson Medical Center, and Pamela
John Iazzetti and Daniel Morrison, all of Albert Einstein
D. Mayhall, Pima Community College, both of Tucson,
College of Medicine, New York. Foreword by Arthur S.
Arizona. The restorative nursing program as defined and
Abramson. A product of detailed dissections by the
outlined in this text is one of the most effective means of
authors, this simple book serves as an aid in the diagnostic
utilizing a broad range of restorative services to respond to
procedure of electromyography. Emphasis is on placement
the needs of many chronically ill and disabled individuals.
of needle electrodes for maximum use in diagnosing
The program brings the restorative care concept into focus
neuromuscular disorders. Anatomical data concerning the
in the earliest and most critical period of patient care and
limbs is organized for easy use. Muscles accessible to the
continues to focus on activating the patient even after
examiner are placed in regional categories, and a brief
discharge from the hospital. The book will serve as a basis
anatomical description and diagram are provided for each
for in-service educational programs, seminars, workshops
muscle. Special requirements for the procedure are listed
and career ladder training for nursing auxillary and hospital
which include position of patient, point of electrode
staffs. '75, 232 pp., 78 il., 3 tables, cloth-$14.75, paper-
insertion and possible errors. '75, 224 pp., 106 il., $6.50,
$10.95
paper
COUNSELING AND REHABILITATING THE CANCER
PHYSICAL THERAPY PROCEDURES: Selected Tech-
PATIENT edited by Richard E. Hardy, Virginia Common-
niques (2nd Ed., 2nd Ptg.) by Ann H. Downer, Ohio State
wealth Univ., Richmond, and John G. Cull, Virginia
Univ., Columbus. Several techniques have been added in
Commonwealth Univ., Fishersville. (7 Contributors) Mate-
this Second Edition and extensive revision has been made
rials in this book include psychoanalytic, psychological and
of many of the procedures. New illustrations provide
other rehabilitation approaches in working with the cancer
visibility to positioning, draping and application of certain
patient as well as a wide variety of case study and narrative
units. A step-by-step procedure is described for the tech-
material which describes in detail various types of tech-
niques of superficial and deep heat, cold, electrical stimula-
niques which are used by rehabilitation counselors, psychol-
tion and testing, ultraviolet, traction and many miscella-
ogists and others who are concerned with the rehabilitation
neous treatments from preparation of the area to termina-
of the individual with cancer. This book will help in dealing
tion of treatment. "This book achieves its stated goal of
with the characteristic problems of persons who have had
filling the need for a clear, concise manual on some of the
to deal with cancer through their own resources. '75, 164
procedures utilized in physical therapy."- Physical Ther-
pp., $11.50
apy. '75, 228 pp., 27 il., $8.75
Orders with remittance sent, on approval, postpaid
301-327 East Lawrence Avenue
Springfield
Illinois
62717
MAY-JUNE, 1976
19
In the last few decades consid-
erable attention has been focused
upon those who are deprived of, or
face limited employment oppor-
tunities because of, racial, sex
and/or age discrimination. Now, at
last, the protection afforded others
has been extended to the physically
and mentally disabled. Section 503
of the Federal Rehabilitation Act of
1973 mandates an Affirmative Ac-
tion policy for disabled people,
which involves all companies with
annual federal contracts greater
than $2,500. In addition, many states
have incorporated disabled people
among those groups against whom
discrimination is illegal under the
provision of their human rights leg-
islation. While the passage of legis-
lation to affirm the rights of people
with disabilities to equal employ-
ment opportunity is a groundbreak-
Affirmative Action - -
ing "first step," the question of
how to turn this newly created cli-
mate of receptivity into positive
action remains under discussion.
This point was, in fact, a question
A tool for linking
faced by the Industrial Social Wel-
fare Center after the passage of the
rehabilitation and the
legislation.
business community
The Center located at the Co-
lumbia University School of Social
Work is funded, in part, as a Re-
gional Rehabilitation Research In-
stitute by a grant from the Reha-
bilitation Services Administration.¹
Sheila H. Akabas
Its mandate is to study the condi-
tions under which trade unions and
corporate management influence
the maintenance at work, and the
integration into the labor force of
those people who are physically
disabled and emotionally ill. A ma-
jor thrust of the Institute has been
to carry out research, training and
demonstration efforts designed to
promote linkage between industrial
parties and the rehabilitation com-
munity.
Stationed at the portals of both
the world of work and the world of
social agencies, it is often possible
to note the lack of fruitful inter-
action between these two worlds.
This observation suggests the over-
20
JOURNAL OF REHABILITATION
whelming need for communication
capped for a long time. At the very
with the problems that business
between these two systems. In the
least, companies have learned
might face in implementation, each
fall of 1974 as we talked with cor-
through the years to find or make
workshop would bring together rep-
porate staff charged with imple-
jobs for employees who have be-
resentatives from government, busi-
mentation of the Affirmative Action
come incapacitated through work.
ness and the rehabilitation com-
legislation, it was clear that they
It was deemed desirable for com-
munity. The goals of the workshops
required more information, and that
panies with pioneering employment
were to inform companies of their
they now had a reason to com-
efforts to share their experience.
responsibilities under the laws and
municate with the rehabilitation
How did they establish programs?
afford an opportunity for business
field. The new laws presented both
What worked, and what didn't work?
and the rehabilitation profession to
the reason and the opportunity for
In addition, information was neces-
come together to resolve the di-
interaction. Center staff made a de-
sary on procedure. Attention should
lemmas they faced in what was, for
termination to run a conference,
focus on
many, a totally new area of Affirma-
"Moving Your Company Into Affirm-
tive Action. Each sector would learn
ative Action for the Disabled."
1. How can a firm begin to move
how it could be more helpful to
2. What is the role of various
the other. Rehabilitation specialists
The New York Chamber of Com-
departments
might give on-the-spot guidance to
merce and Industry independently
company personnel who raised
arrived at the same conclusion from
3. What are the specific legal re-
fears of dealing with the handi-
contact with its membership. The
quirements.
capped in certain work situations.
Chamber, representing a member-
ship of approximately 2,500 which
The Chamber was very anxious
The Chamber assumed primary
includes many of the nation's major
to develop a tone that would not
responsibility for publicity by send-
corporate enterprises, is spokes-
be viewed as "preaching" by the
ing a mailing to all member firms.
man for the larger business com-
business attendees, but rather would
They also recruited business repre-
munity. It has adopted a role of not
permit informal give and take. This
sentatives as speakers. Other speak-
only responding to membership
concern is worthy of note. The
ers and resource personnel from
need but also of bringing before
Chamber's representatives were
rehabilitation agencies were re-
its constituents issues it deems of
consistent in insisting that a pro-
cruited by the Center. A price
importance.² It maintains commu-
gram for employment of handi-
structure which provided declining
nication with a diverse membership
capped people could not be pegged
charges for each successive repre-
of large and small firms through
to humanitarian instincts, an ap-
sentative of a given firm was uti-
newsletters, an extensive commit-
proach often utilized by rehabilita-
lized to encourage companies to
tee structure, short-term training,
tion specialists. The rationale rather
send a team incorporating repre-
and specialized workshops. A repre-
was that Affirmative Action is the
sentatives of various functional
sentative of the Center and the
law of the land, and every firm
departments. The Conference was
Chamber, meeting to explore areas
seeks to create an image of itself
a "sell-out." An overflow crowd of
of mutual interest, quickly identi-
as a paragon of compliance.
almost 200 in attendance repre-
fied Affirmative Action as such an
sented 97 firms and 11 rehabilita-
issue. The Chamber seemed an
Planners agreed that the Con-
tion facilities. The predominant
ideal partner with which to develop
ference should support the past
mood of the day was notetaking,
a conference on Affirmative Ac-
efforts of business while honestly
questioning, discussing. After the
tion; therefore an agreement was
admitting that more could and would
conference a follow-up survey
made to co-sponsor a meeting.
have to be done. Specific informa-
was conducted among participants
tion would be conveyed in a morn-
which, together with the day's pro-
Planning a Conference
ing devoted to review of legisla-
ceedings, provided illumination of
tion and regulations by public repre-
the status and future road for Affirm-
In joint meetings, between the
sentatives, and to sharing of past
ative Action for the Disabled in
Chamber and the Center, a meeting
the business world.
experience by Chamber members.
format was evolved. It was assumed
The afternoon would provide "how-
that American business would
to" workshops for those responsible
An Overview of the Situation
choose to comply with the legisla-
for personnel, recruitment, medical
Out of these efforts grew our
tive mandate. There was recogni-
policy, training, insurance and bene-
firm conviction that Affirmative Ac-
tion that a body of experience ex-
fits, and for writing an Affirmative
tion for the Disabled is a powerful
isted; many corporations have been
Action plan. Within the framework
job promotion device which opens,
involved in employing the handi-
of a practical approach to dealing
to the rehabilitation community,
MAY-JUNE, 1976
21
many previously closed doors. It
The regulations ³ utilize govern-
Further, it is our contention that
became clear that existing Affirma-
ment contracts to encourage busi-
the number of jobs open to the
tive Action programs for women
ness to develop nondiscriminatory
disabled will increase, despite the
and minorities had laid the ground-
policies. This process has a greater
present tremendous economic con-
work for the disabled. The experi-
impact on the large firm than the
straint. At the very least, compa-
ence of noncompliance in other
small one, the multisite corporation
nies will be more amenable to
areas had been sufficiently painful
than the single location company.
maintaining physically and emo-
and expensive for management to
Thus, a large number of jobs come
tionally disabled persons at work.
be ready, at least tentatively, to
into the nondiscrimination system.
But we believe there will be an
consider an employment policy for
The postconference survey, for ex-
absolute increase in hiring as re-
handicapped people. Further,
ample, found that the 200 attendees
cruitment plans develop. The fol-
mechanisms are in place to apply
represented firms employing over
low-up survey confirmed that most
to this new issue. There is a group
a million workers in approximately
companies are just beginning their
of employees in many major cor-
a thousand worksites.
efforts in this area. Less than 20
porations (usually identified as
percent of the conferees came from
equal employment officers) who
With numbers come diversity.
firms with definitive plans in place.
have career commitments to work-
The law establishes the employer's
All others fall into a pool of great
ing on Affirmative Action and who
obligation to hire "qualified" appli-
potential as can be seen in Table
welcome expansion to new popu-
cants. But the more jobs and the
1, below.
lations as an opportunity to in-
greater diversity, the more likely
crease their organizational turf. But
any particular applicant will fit into
the wish cannot be taken for the act
some "slot." As one conference
What Are the Concerns of
Corporate Managers?
here, for it also became clear that
participant noted, "If you have a
an abysmal lack of information ex-
big enough population or extensive
There can be little question but
isted in the corporate world which
enough unit in which work can be
that the law is on the side of peo-
immobilized many businesses from
redistributed, you can accommo-
ple with handicaps. Affirmative Ac-
developing a plan to hire the dis-
date a person with almost any
tion has placed their employment
abled. Further, any movement in
handicap."
on the corporate agenda and raised
relation to the disabled would in-
the issue to prominence in man-
volve departments and policies
In short, a review of the list of
agement consciousness. No longer
hitherto outside Affirmative Action
companies represented at the con-
do these handicapped people have
procedures, e.g. medical units and
ference confirms a conclusion that
to wait for a tight labor market to
insurance benefit administrators.
Affirmative Action establishes the
gain access to a job. Given the
Finally, new roles for rehabilitation
preconditions for this "mainstream-
potential, the concerns expressed
agencies and practitioners were
ing" of the disabled worker into
and problems identified by busi-
suggested by the needs identified
the primary labor force, a process
ness representatives could become
by business.
which, it was suggested earlier, had
barriers to fulfillment.
been frequently impossible before
Affirmative Action As A
the new legislation.
At both the Conference and in
Job Promotion Device
It has long been the contention
of the rehabilitation field that there
should not be "disabled jobs" but
rather just people and occupations.
TABLE 1
Any job, for example, requiring a
great degree of verbal communi-
Status of Company's Affirmative Action Plan
cation is probably not desirable for
At Time of Conference Attendance
a deaf person, but neither should
Already had an Affirmative Action Plan for Disabled People
18%
all deaf workers be made key punch
Already in the process of developing an Affirmative Action Plan for
operators. This basic principle is
Disabled People
44%
now an established requirement of
law. All jobs are open to disabled
Saw attendance at the Conference as a first step in developing an
Affirmative Action Plan for Disabled People
20%
people because denial of employ-
ment, under law, must be based on
Did not fall into the category mandated by legislation to devise an
a demonstrable inability to perform
Affirmative Action Plan for Disabled People
18%
a job.
22
JOURNAL OF REHABILITATION
the follow-up survey, respondents
cedures for monitoring and chang-
How that need is responded to will
revealed uncertainty and seemingly
ing policy; and of kinds of degrees
be all important. During the confer-
insatiable desires for further infor-
of accommodation.
ence planning stage, the Chamber
mation. One business representative
consistently reminded us of busi-
noted, "There has been very little
There is serious interest at the
nesses' antipathy to being "talked
opportunity for education of the
highest level of business. But am-
at" or "told how." Rehabilitation
people who train and employ. We
biguities in the guidelines and gov-
experts will have to abandon rhet-
didn't know in which jobs to hire
ernment expectations are both
oric and be ready to serve these
the handicapped; we need some-
frustrating and immobilizing. There
new consumer clients.
one around not to give us a list but
remain gaps in information which
to help us think about restructuring.
warrant research attention, e.g.
The interaction between the
I was surprised to learn that there
actuarial costs or confidentiality
were blind typists; I couldn't under-
human-oriented system of rehabili-
and hidden disability. The need for
stand how a blind typist would
tation and the authority-oriented
refined information is pervasive. All
know when she was making a mis-
production system of American
these realities suggest new roles
business is bound to cause some
take. The explanation was that
for rehabilitation practitioners and
someone else has the job of proof-
strains. The rehabilitation practi-
their agencies if Affirmative Action
tioner will have to change his own
ing typed material. The job of typist
is truly to take hold.
knowledge base, so that he is more
wasn't restructured in my head to
expert on the nature of the business
include this idea. I have to change
my mentality."
New Roles for the
world, its organizations, structure,
Field of Rehabilitation
roles of different departments, and
style of work. Perhaps most signifi-
The industrial representatives
Employers can be expected to
cant, improved understanding of the
identified a score of issues on which
look to the rehabilitation agent for
insurance and benefit issue will help
they lack information. They were
1. Information (on a host of is-
overcome this favorite of all "cop-
1. The variety of disabling condi-
sues outlined above)
outs" in relation to hiring.⁴
tions and their impact
2. Job candidates
Further, the rehabilitation agent
2. The rehabilitation process and
3. Evaluation and suggested work
must also prepare his handicapped
the nature and use of assistive
activities for those with ob-
applicant differently. First, the range
devices
vious disabilities
of alternative employment possibili-
ties may be viewed as expanded,
3. The nature of architectural bar-
4. Help in retraining those who,
necessitating, perhaps, new train-
riers and possible remedies
because of illness are no
ing choices. In addition, a job can-
longer able to cope with pre-
didate should
4. Job restructuring techniques
vious assignments
and other methods of accom-
5. Funding of major expenses in-
1. Be informed of his rights under
modation
law
curred in hiring a particular
5. Sources of assistance for a
disabled individual (e.g. medi-
2. Be aware of the components
company.
cal care, tools)
in a job and able to suggest
There appeared to be equal con-
6. Training of corporate staff
adaptations.
sistency in the issues business rep-
concerning behavior toward,
resentatives identify as requiring
and appropriate expectations
Affirmative Action establishes the
resolution if Affirmative Action for
of, a disabled employee.
conditions for linkage. The reha-
disabled people is to become a
bilitation counselor and other prac-
fact. Every workshop session spoke
All of this will bring the field of re-
titioners will have to mobilize that
of training of supervisory staff and
habilitation in much closer contact
potential and turn it into desirable
a variety of other personnel who
with the world of business than
and desired jobs. A real dialogue
need to be involved; of insurance
ever before.
must be established in which each
and benefit issues; of concerns of
placement can be viewed as an
confidentiality juxtaposed against
With Affirmative Action under
opportunity to bring the parties to-
the reality that the law's protection
way, it is the business community,
gether, working on new solutions
is only granted those who identify
not the job applicant who comes
to individual and generic problems.
themselves as handicapped; of pro-
in need to the rehabilitation agency.
(Continued on Page 42)
MAY-JUNE, 1976
23
Rehabilitation's
great
partnership
James S. Peters, II and Seymour J. Mund
"It's a problem, Jim. Can you
author was appointed director of
broadened the horizon for disabled
help?"
the Connecticut Division of Voca-
people and seemed destined to
tional Rehabilitation. At the time, he
bring the workshop into closer alli-
"If we work together, we can try
had the option of developing a pro-
ance than ever with its sister pro-
to resolve it."
gram of state-operated rehabilita-
grams. The system of federal and
tion facilities or expanding the
state financial support then placed
This phone conversation is a
handful of privately run facilities
in operation reinforced recognition
common occurrence between the
then in operation. Based on Con-
of workshops as an instrument of
director of the Connecticut Voca-
necticut's long history of private
rehabilitation, and implemented this
tional Rehabilitation program and
enterprise and a strong feeling that
acknowledgment through the sev-
directors of the privately owned and
the private sector has an important
eral financial mechanisms enacted
operated nonprofit rehabilitation fa-
role to play in rehabilitation, the
to stimulate and expand vocational
cilities within the state. This part-
director and his staff decided to
rehabilitation facilities, including
nership between the public and pri-
push for expansion and develop-
workshops.
vate sector has been an important
ment of privately run facilities. The
part of the rehabilitation scene for
one state-operated rehabilitation
Vocational rehabilitation workers,
over 20 years, and has proven both
center in New Haven was closed
economical and efficient. It is a
including workshop administrators,
by the governor during this period
positive example of the attitude of
had long recognized the need for
of creative state-private-federal ef-
cooperation for the betterment of
more substantial support for creat-
fort. The director and his staff noted
people with handicaps.
ing additional workshops and reha-
the emerging role that the work-
bilitation centers for the training of
shops and comprehensive rehabili-
more professional staff members,
This combination of private in-
tation centers were playing in voca-
and for the development and re-
itiative with matching government
tional rehabilitation and sought to
finement of rehabilitation tech-
money and technical assistance has
aid them through federal and state
niques. In his health message to
been a major factor in the expan-
financial assistance.
Congress, January 18, 1954, the
sion of services to disabled people
President set an eventual yearly
in the State of Connecticut.
In 1954 a nationwide ferment of
goal for the state-federal program
interest in expanding vocational re-
of 200,000 rehabilitated persons, as
In the late 1950's when DVR pro-
habilitation culminated in the enact-
compared to 61,000 rehabilitations
grams were expanding, the first
ment of legislation which greatly
in fiscal year 1953. At the same
24
JOURNAL OF REHABILITATION
time, the President set the stage
encouraged the directors of facili-
He proceeded to offer recommenda-
for the enactment of the present
ties to apply for the available funds.
tions to alleviate problems within
legislative framework, which is de-
Many did, and the following are ex-
the original intent of the grant and
signed to help vocational rehabili-
amples of how this cooperation was
also in the areas of plant utilization,
tation and other nonprofit agencies
effective:
long-range planning and promotion,
attack all of these problems.¹
and development of the facility.
Written into the Vocational Reha-
Example I
bilitation Act were special programs
A rapidly growing rehabilitation
The facility has implemented
designed for facilities. These pro-
facility found its expansion causing
these recommendations and has
grams include grants for construc-
"growing pains" in several aspects
continued its growth in a more
tion and staffing, technical assis-
of its administrative and operational
systematic and stable way. This has
tance, training, and more recently,
performances. The prime concerns
resulted in an increased availability
the Laird Amendments and third-
were in the areas of time study,
of improved services to handi-
party funding possibilities. As stated
pricing, and recordkeeping proced-
capped people within the area of
in the law:
ures of the workshop.
this facility.
"The Secretary is authorized to
The administrator of the facility
make grants to public or other non-
applied to the Division of Vocational
profit rehabilitation facilities to pay
Rehabilitation for a technical assist-
part of the cost of projects to ana-
ance consultation grant, available
Example II
lyze, improve and increase their
under the federal rehabilitation law.
professional services to the handi-
A comprehensive rehabilitation
This grant was approved and pro-
facility expanded services over a
capped, their business manage-
vided the funding for an expert in
ment, or any part of their opera-
period of years. The subsequent re-
the field, the DVR facilities consult-
tions affecting their capacity to pro-
sult was an increasing need to
ant, to come to the facility, review
vide employment and services for
transport more and more disabled
its practices and problems, and
the handicapped."
clients to and from the facility. The
make recommendations.
patients and clients who are pro-
vided transportation by the rehabili-
Using the above authorization
The consultant found problems in
tation facility are persons who have,
given at that time, Connecticut DVR
the expected areas. However, he
at the time, no other means of
established the Bureau of Commu-
also found other problems directly
transportation and who, because of
nity and Institutional Services and
caused by recent rapid expansion.
the severity of their disabilities, or
Industrial assembly training leads to many similar
jobs in local industry.
MAY-JUNE, 1976
25
Viewed as Charity
she assumed that my mission was fundraising for
Firm C is the divisional headquarters of a major
the blind agency. Firm D, through its nonprofit Foun-
aerospace company, which has business connections
dation, was noted for its significant annual contribu-
around the world. My contact here was spontaneous-
tions to rehabilitation programs all over the country.
right off the street without an appointment. I walked
When I was successful in convincing the community
into the crowded personnel office and asked the re-
relations representative that the purpose of our meet-
ceptionist with whom I might discuss the employment
ing was to seek employment for blind workers, she
of blind workers. It was just before lunch and perhaps
referred me "up" to the industrial relations director,
bad timing, but I was in the neighborhood and did
her top echelon boss.
not want to pass up an opportunity, especially since
I wouldn't be back again for several weeks. The re-
In my discussions with the industrial relations di-
ceptionist's reaction was the usual sympathetic one,
rector, I found that his conversation dwelled on the
which resulted in my being invited to lunch as the
nonprofit Foundation's gifts to handicapped people,
guest of the manager of personnel services for the
and this seemed to compensate for the absence of
division. He was delighted to discuss the matter with
blind people on the payroll. This attitude of fulfilling
me, which we did at length. The problem was that I
the company's obligation to the community through
had to keep trying to bring the conversation down
social outreach prevailed throughout the industries I
from the philosophical level, which he pursued, to the
contacted. I heard, "You see, all our assembly jobs
pragmatic one I chose. Here was a man who stressed
require sight because we're only building prototypes
that he contributed to the annual fundraising drive of
now-short run stuff that requires new setups almost
the blind agency I represented. He was filled with
daily. We're not doing the long production runs any-
anecdotes about the blind kids for whom he volun-
more. Now there's where I might see a possibility for
teered his time and made contributions. But apparent
your blind worker. Why don't you talk with Bud A,
in everything he said was the underlying sense of pity.
our new Affirmative Action officer? He's got a pretty
good handicap program being organized."
The labor market was tight now, "real tight," he
maintained, and his division wasn't doing any hiring.
Even with the sophisticated employment practices
All those people sitting in the lobby when I came, he
of Firm D, blindness could only be comprehended
pointed out, weren't being given the least encourage-
and categorized as, a phase of the "handicapped
ment. If a contract should demand additional man-
worker" framework. Reiterating the facts of equality
power, former employees on extended layoff would
with the sighted employee on the basis of performance,
have first recall privileges. Then we discussed where
independence, safety, short learning curve, efficient
blind persons might fit into the operation of the plant.
travel reliability, and growth potential made only a
Despite my suggestions of positions involving repeti-
superficial impression on the industrial relations direc-
tive assembly, packaging tasks, routine machine op-
tor. The contact wound up as usual, "We will explore
erations, transcription typing, computer programming,
through our Affirmative Action program. Fair enough?
and blueprint reproduction, the manager's acceptance
Let's keep in touch."
of these possibilities seemed lacking. By the end of
the luncheon, it was clear that as a community service,
But as I left the interview, I began to realize that
the division would make a special effort to hire a
the very fact that I came as a representative of blind
blind worker somewhere in the plant. But there was
no commitment to a positive program of hiring; there
was no consideration given to hiring qualified, blind
individuals on a competitive status with their sighted
counterparts.
Foundation Gifts
Firm D was another international organization, based
on the West Coast. It employs approximately 50,000
people in the diversified fields of information process-
ing, retrieval, language translation by machine, and
systems management, plus a wide range of other dis-
ciplines all the way to automotive parts and reserva-
tion networks. My contact here was with the com-
munity relations representative. I was referred to her
initially because, like the vice-president of Firm A,
Only by coming in person independently repre-
senting himself can the blind job seeker compete
equally with his sighted counterparts in present-
ing his qualifications for a specific job.
30
workers may have damaged credibility in establishing
with equal efficiency by blind or sighted workers.
the vocational independence of applicants. I had done
But on the entire assembly line, I was told that there
the leg work that a sighted person would have done
was only one handicapped worker. "But we're going
for himself.
to hire more as soon as we get the openings. The
corporate directive is now to put on ten of these
Not Even a Taster?
handicapped people in every plant." I was with the
industrial relations director, the Affirmative Action
Firm E was a brewery. What can a trained and
officer, and the employment manager. They were all
qualified blind worker do in a brewery? Whatever his
glad that I called at a time when things were slow,
sighted counterparts can, provided vision is not inte-
and they could talk. None of them saw any reason
gral to do the job. But it is difficult to imagine the
why a blind worker or two couldn't be fitted into the
effrontery of this statement when laid on the table in
operation somewhere. They proceeded to tell me
front of the associate employment director of one of
about the seniority problem that had to be faced on
America's largest breweries. The only representation
rehiring temporarily laid off workers. It was a problem
he had of a blind person was in his mind's eye from
I was familiar with by now. This would put off hiring,
a picture he had once seen of a frightened, disheveled
or even consideration for six months. To the question
man trying to find his way through a crowd with a
of why blind employees had never been considered
flailing stick. Even after this image was corrected, I
before, the employment manager simply stated that
got the usual "how-cans" and "what if's" which you
none ever came around. The observation was valid
can field effectively in terms of the facts, but it was
and needed an equally valid counter: "Would you
the old affective domain that wouldn't give in. I
have hired one if he or she had applied?" He was
stressed that no one would be considered by our
not sure. He said that it would have depended on
agency as an applicant for any job who could not
qualifications, present workload, and the job market
compete equally with any other applicant for that job.
at the time. But the occasion had never arisen.
This argument, although patiently listened to, was
unconvincing. The listener could not conceptualize it.
He did not flatly say no but that he would take
"Continued Negotiations"
it under consideration and discuss it with his superiors.
Firm G: There is a tremendous amount of com-
munication between the prospective employer of blind
I suggested that we tour the plant so that I could
persons and the vocational specialist involved in
become familiar with the various operations. The
placement, particularly about job potential and value
response was, "Great idea; we'll do that sometime, but
systems. Continued communication prevents confron-
not now." Always the polite, not quite refusal when
tation and may continue indefinitely, interrupted only
you're probing the unknown. At this point I was too
by the frustration of the specialist, or an inadvertent
frustrated and embarrassed to ask the one obvious
placement. A typical example of this circular argu-
question, "What about the tasters?"
ment was at this national toy manufacturing firm.
Blind, qualified workers could readily perform assem-
"Would You Have-If?"
bly and packaging tasks, but none had ever been hired
or even considered. So long as negotiations con-
In the automotive assembly operation of Firm F,
tinued between the prospective employer and the
many of the repetitive tasks could have been done
specialist (1) no one had to be hired (2) no one would
be hired. In the eyes of the community, the firm was
"negotiating," and the vocational specialist could feel
that he was developing some rapport with the per-
sonnel director, since he had ready access to him.
And while the vocational specialist hammered away
at an opening, the action was lost in the "continued
negotiations" rather than placement.
Walk In and Name the Job
In all the industrial contacts, it was apparent that
the blind person was considered a fragile entity who
must not be exposed to the same work standards
imposed on the sighted world, nor confronted harshly
with verbal criticism. Perhaps, subconsciously, reha-
(Continued on Page 40)
Demonstrating his skill in performing a job effi-
ciently and safely is worth more than the best
build-up that can be given a blind job applicant by
any vocational counselor representing him by
proxy with the employer.
31
The Special child
Sandra Wiggin
When an individual is handicapped, he belongs to
ways an emotionally stable individual may develop
a minority group. The consciousness of being different
severe mental problems resulting from societal pres-
makes many individuals awkward and shy. A visible
sures. He is alone with this pressure and must resolve
or easily detected handicap arouses curiosity in the
it within himself before he can become a self-sus-
general public which results in various behavior. The
taining, independent individual.
handicapped individual is the object of stares, the
Cerebral palsy involves damage to the brain tissue
subject of questions he may not be prepared to answer,
caused by defective development, injury, or disease.
or he might just be ignored and feel invisible.
It is usually caused by insufficient oxygen reaching
When most people do not know how to cope with
the brain of the infant during the birth process. Other
a minority individual, they take the path of least re-
causes are premature birth, incompatible RH blood
sistance and ignore the presence of the individual,
factor, or the infection of the mother with German
thinking the situation will soon go away. For the han-
measles during pregnancy. There are additional
dicapped individual, this brings about a sense of isola-
causes, but none are thought to be contagious nor
tion. He may be completely accepted in his home en-
hereditary.
vironment but, when he meets outside adversity, how
Thirty years ago my mother was having difficult
is he to cope? After he has learned to adapt to his
labor with her first child, requiring prolonged ad-
own physical limitations, society puts even more
ministration of anesthesia. The birth process was
pressure on him by its unthinking reception. This
slowed, and the oxygen supply to the infant was in
problem within itself is enough to provoke maladap-
question. After delivery, the infant slept for three days,
tive behavior.
and there was a question of survival. Both mother
Learning to live with a handicap is a long, drawn
and child survived, and the child seemed normal until
out process. It begins with the attitudes of parents
she began to walk. Then cerebral palsy was detected.
toward their "special child" and the way he is social-
Luckily, slight spasticity was the only problem.
ized within the family structure. When this phase of
Anxiety dominates the lives of parents of special
development is completed, this socialization process
children as these parents consider the future of such
begins to show in his interactions with other people.
children. My normal intelligence gave my parents
I will be dealing specifically with the process of
hope; thus, they could resume their plans for a happy
social maturation or the transition of the slightly cere-
family life. While there was some anxiety about hav-
bral palsied person, from adolescence into the adult
ing another child, three more healthy normal children
world of which he must become a part. He' has no
were born.
mental abnormalities but, at a glance, he may be
labeled a "poor helpless cripple."
Parental Encouragement
In the family circle, I was encouraged to do every-
Illness from Societal Pressure
thing for myself. Sometimes I realize how painful it
As a slightly cerebral palsied individual, I will look
was for my mother to wait for me to perform a small
at these problems from the inside out and point out
menial task when it would have been simple for her
32
JOURNAL OF REHABILITATION
or one of the other children. The love and simple
that my own "self-acceptance" had never been at-
understanding of parents surrounding me taught me
tained. Outwardly, yes, and in the eyes of others it
never to say I can't until it was absolutely necessary.
had. But I had used defense mechanisms that were
As the other children, I was given responsibility and
not holding. I had overlooked the real circumstances
managed the same tasks as they. Riding a bicycle
of my own disability and had fantasied optimism.
was one of my most battering experiences. This was
painful for my parents also but, with that idea of never
All The Way Down
saying I can't, I perfected the task to the surprise of
Personality changes began to take place rapidly.
all around me. Later in life, the same proved true
Insights broadened. It seemed as if I had to be pushed
with learning to drive a car. Again, love set the stand-
all the way down in order to become emotionally se-
ard, and parents determined not to stand in the way
cure. A small office job opened, and while the pay was
of normal childhood development.
not adequate for financial self-sufficiency, my family
agreed to cooperate until I could get the experience I
When the time came to enter school, special
needed. The job situation was difficult, and most of the
schools were not even considered. It was felt that I
workers were handicapped. I was the secretary to a
could perform normally on my own merits. This was
man who was harrassed and ill-tempered. The people
the time I began to notice "being different." The atti-
employed in the plant and their socio-economic level
tudes of people when they first saw me was that of
was upsetting to me. I saw the world of handicapped
pity. In spite of this, I competed anyway and then re-
people as it really is, and it is not the world I had
treated to my home of love and understanding, knowing
read about. Even with distressing working conditions,
that my parents would make everything all right. This
my faith began working for me again. I decided to con-
defense mechanism worked well until I graduated from
duct my own study of these people in the light of dis-
high school and started to college. Away from the pro-
ability, background, and education. This was enlighten-
tection of my middle class home for the first time,
ing because I began to see bitterness, resentment, and
my problems really began.
immaturity as it ran up the socio-economic and educa-
When the adviser in the sociology department tried
to get rid of me by telling me that I did not belong
there, I did not give in, but I did become depressed.
Unsure of my own personality anyway, this was really
a blow, mainly because I had never been able to say
As a slightly cerebral palsied individual, I will
"I can't." With discouragement and a lack of emo-
look at these problems from the inside out and
tional self-sufficiency, I dropped out of college after
point out ways an emotionally stable individual
one semester.
may develop severe mental problems resulting
from societal pressures. He is alone with this pres-
sure and must resolve it within himself before he
"Someone Will Hire You"
can become a self-sustaining, independent indi-
I completed a business course and was prepared
vidual.
to look for a job. Rejection was the emotion that I had
never permitted myself to experience. Life had been
good to me up until this point. Employers never dis-
couraged me; they just never seemed to offer en-
couragement. Someone will give you a good job one
tional scales. This was not only visible in handicapped,
day, I was told repeatedly, but where or who was that
but in so-called normal or average people also. As my
someone? I simply could not persuade them that I
study began, working conditions became more bear-
would take any kind of employment on my own merits.
able because I was gaining SO many new insights. I
Depressed, disturbed, and distraught, I felt all alone
learned to form friendships on different levels. As
in the world in which I had looked forward to compet-
these people came to know me, they developed trust
ing. Family stood close, hurting as I, but not knowing
which was severely lacking. I saw and became in-
how to help or what to say. The family life I had known
volved in a society that I had only read about.
had been centered around Christianity and the church,
but where was the answer I was searching for? Some
Ability was not my problem now. After a year I
employers used the excuse of not having a job that
took a civil service job and felt that my understanding
of people and their problems was an added asset. As
would utilize my ability. At this point, any type of work
would have helped my deflated ego. I was at the point
I am working and attending school in my senior year,
where depression could have easily won, and I could
it is my desire that some of these experiences will
have become a "psychological cripple." Defeated
prove helpful in some service profession. I cannot say
and alone, I faced the faith that had been instilled in
exactly where it will be because my experience has
me. My understanding of Christianity began to change
unfolded in the past in unusual ways. This unfoldment
into a very personal one for me. Suddenly from within,
continues to give me an opportunity to grow without
I recognized a strength and inner peace that was mine
the fear of mental problems. Physical ones will always
alone. Yes, ideals internalized, and I began walking
be with me but, with acceptance, they will eventually
iron out.
on my own emotional feet. The job and other problems
were still there, but they took on a new light. As I
My minority became my majority, giving workable
saw myself in this light, I realized for the first time
alternatives at the time of need.
MAY-JUNE, 1976
33
Kenneth W. Reagles and Alfred S. Butler
The Human Service Scale:
A New Measure For Evaluation
The Human Service Scale is a useful stimulus
at staff meetings. Each professional discipline
is concerned with unique client needs.
Recently the criterion of "reha-
What is needed is a measure that
source is the emphasis which reha-
bilitated" versus "not rehabilitated"
utilizes rehabilitation concepts, not
bilitation programs place upon
has come under increasing scrutiny.
a device either developed for use
"gainful employment" as the out-
Researchers, program evaluators,
in a related field or revised for use
come criterion of primary concern.
consumer groups, program admin-
by rehabilitationists. The present
Current instruments do little to
istrators, and sophisticated legisla-
manuscript reports the development
measure other areas of clients'
tors have begun to ask questions
of such a measurement device. It is
lives, ignoring the importance of
about program effectiveness that
a better measurement tool because
attention to these for successful
are difficult to answer with the
the degree of client change attrib-
rehabilitation; they simply do not
dichotomous measure of outcome
utable to the receipt of rehabilita-
reflect changes that clients may ex-
("rehabilitated" or "not rehabili-
tion services may be measured. The
perience as a result of receiving
tated") that has been used for over
title of this new assessment meas-
rehabilitation services.
50 years.
ure is the Human Service Scale.
The use of "rehabilitated" versus
Previous Efforts Described
Another observation which may
"not rehabilitated" as a measure of
be made of currently available
program success is analogous to
The comprehensive measures
measures of client change is that
having a yardstick with a single di-
which now exist are primarily com-
they do not have underlying theo-
vision in its middle; on the one side
posed of items which are "voca-
retical rationales. Therefore, these
are the "not-rehabilitated" and on
tional" in nature (e.g., work status,
scales (e.g., the Rehabilitation Gain
the other, the "rehabilitated." Such
earnings). This attribute arises from
Scale, the Life Quality Index) ap-
a measurement tool is simplistic
two sources. The first is that many
pear simply to be collections of
and does not allow answers to
scales came from variables which
typically reported outcome varia-
questions concerning the quality of
are recorded on the standard data
bles. Such scales have often been
the rehabilitation, i.e., the nature
form used by vocational rehabilita-
developed after the fact as attempts
and the degree of client change.
tion agencies, the R300. The second
to form summaries of data.
34
JOURNAL OF REHABILITATION
Experts in program evaluation are
be a valuable tool to counselors,
evaluation of how well agencies are
often inhibited in their investiga-
administrators, evaluators, and re-
fulfilling their purpose ought to in-
tions of rehabilitation programs
searchers. In response to the ex-
clude a measure of the extent to
simply because available instru-
pressed needs from different groups
which client needs are met. Mas-
ments and techniques are inade-
of rehabilitation professions, efforts
low's (1954) hierarchy of basic hu-
quate for the task. Efforts to define
began in 1970 at the University of
man needs was selected as the un-
the complex relationships between
Wisconsin Regional Rehabilitation
derlying theoretical rationale for the
problems or needs of clients, pat-
Research Institute (UW-RRRI) which
development of a new measure of
terns of services provided, and reha-
eventually culminated in the pres-
client outcome.
bilibilitation client outcomes, simply
ent Human Service Scale. Much of
cannot proceed in the absence of
the leadership in this effort was pro-
acceptable outcome criteria. This
vided by Dr. Shlomo Kravetz.*
Over 300 multiple choice items
situation is not unique to rehabili-
The following rationale for the de-
were initially generated which re-
tation; it is common to many human
velopment of the scale was pro-
flected the content of Maslow's need
service delivery systems. It appears
posed: If human service agencies
categories - physiological, safety
and security, lovingness and be-
longingness, self-esteem, and self-
actualization. Eliminating some
items and combining others yielded
a preliminary scale of 150 items.
PERSONAL
NEEDS
These were put into scale form and
administered to 1018 individuals in
29 states who had been accepted
for vocational rehabilitation serv-
ices. The demographic characteris-
EMOTIONAL
tics of this group revealed that they
were reasonably representative of
100
clients served by the state-federal
GL
vocational rehabilitation program,¹
so
FAMILY
except that persons with severe vis-
52
ual disorders or mental retardation
were not included.
SOCIAL NEEDS
ECONOMIC SECURITY
PHYSICAL
The data yielded by the adminis-
tration of these items was returned
VOCATIONAL SELF-ACTUALIZA-
ECONOMIC SELF
to the UW-RRRI where it was sub-
SOCIAL
jected to item and factor analyses
(orthogonal rotation). The factor
structure revealed that seven dis-
TION
tinct need categories were apparent
instead of the five that Maslow had
postulated. The need categories
were given the labels Physiological,
Emotional, Economic Security, Fam-
ily, Social, Economic Self-esteem,
NEEDS
and Vocational Self-actualization
Needs; the labels reflect as closely
as possible their relationship to
Maslow's original need categories
(see Table 1). The number of items
was reduced from 150 to the pres-
Fig. 1-Human Service Scale Profile used to report results.
ent 80 items; only those items with
factor loadings higher than .30 were
imperative that a better measure
exist to meet the unmet needs of a
retained. The technique of Smallest
of rehabilitation outcome be devel-
segment of the population, then an
Space Analysis revealed that the
oped, and it would be desirable for
configuration of the need categories
such a measure to be applicable to
NOTE: This is the first published description of
was not a simple linear hierarchy;
competing human service programs
the Human Service Scale, an instrument devel-
the analysis suggested instead a
oped, in part, by Dr. Kravetz as the basis for a
in order to measure their compara-
doctoral dissertation, Rehabilitatizon Need and
spherical configuration. Later, the
tive effectiveness.
Status: Substance, Structure, and Process, while
spherical arrangement of contigu-
he was a student in Rehabilitation Counseling
Education, Department of Studies in Behavioral
ous need categories was used to
Disabilities, the University of Wisconsin-Madi-
construct a profile for reporting the
Development of the
son. Dr. Kravetz was employed periodically by
Human Service Scale
results of completed Human Serv-
the University of Wisconsin-Regional Rehabilita-
tion Research Institute and his original research
ice Scales (see Figure 1).
Although some of the early meas-
was supervised, in part, by the authors who take
ures were rather unsophisticated,
full responsibility for the content of the present
manuscript. Dr. Kravetz is now an assistant
it was obvious that an instrument
professor, Department of Psychology, Bar Ilan
The technique of reciprocal aver-
which was capable of measuring
University, Ramat Gan, Israel. His dissertation
aging was used to determine the
is No. 74-10250-1974 available from University
comprehensive client change would
Microfilms, Ann Arbor, Michigan.
weights to be given to each item
MAY-JUNE, 1976
35
response category. An estimate of
of the scale with a population of
outcome are appropriate for use of
the content validity was computed
persons with intellectual deficits.
the scale.
as 0.91, considered moderately high
Since the scale is currently scored
for a scale of this type.
by machine, there is a slight delay
(about five days) in determining the
Dealing with the whole person
The Present
results; a self-scoring version would
Human Service Scale
make the results available immedi-
The necessary emphasis upon
A version of the scale which
gainful employment as the primary
ately. An overall caution must be
goal of vocational rehabilitation pro-
could be scored by machine was
given; any claims made about the
grams frequently results in too
much concern on the part of the
counselor with the vocational objec-
TABLE 1
tive. This often results in the neglect
of client problems in other life
Related Maslow Need Categories and
areas, jeopardizing the success of
Hoyt Reliability Coefficients of HSS Subscales
rehabilitation services. Research
has demonstrated that rehabilita-
Hoyt
tion clients who have many prob-
Related Maslow
Reliability
lems have the greatest likelihood of
HSS Subscale Title
Need Category
Coefficient *
failure (i.e., not sustaining them-
selves after the termination of serv-
Physiological Needs
Physiological Needs
0.86
ices). The Human Service Scale
represents a method of sampling a
Emotional-Security Needs
Safety and Security Needs
0.90
broad range of potential client prob-
lems in a number of life areas. The
Economic-Security Needs
Safety and Security Needs
0.69
counselor is alerted to these and
Family Needs
Lovingness and Belongingness
0.84
may deal with them along with the
vocational objective. As a result, the
Social Needs
Lovingness and Belongingness
0.77
likelihood of rehabilitation success
Economic Self-Esteem Needs
Self-Esteem
0.86
should be enhanced.
Vocational Self-Actualization
Self-Actualization
0.97
Problem Check List
* A measure of internal consistency
The utility of the instrument to the
counselor naturally depends upon
his familiarity with it. The scale is
designed and printed. Standardized
scale must be considered as tenta-
viewed by its developers as being
instructions accompany the scale.
tive, pending the results of addition-
potentially helpful in the early
A clerical worker can be instructed
al research about the scale. Persons
stages of the rehabilitation process.
to complete the essential demo-
interested in using the scale for re-
A scale completed at the time of in-
graphic variables which are used
research purposes should make
take into the rehabilitation process
for identification of scoring results
their interest known to the senior
may be used as a problem check
list. The items of the scale which
and for normative purposes. The
author.
Human Service Scale is self-admin-
compose each of the subscales are
made known to the user so that
istered after very brief structuring
Uses of the Scale
relative need satisfaction is re-
and takes approximately 20 minutes
to complete; turn-around time for
Several potential uses of the scale
vealed in detail. The counselor may
scoring is approximately five days.
have emerged which are of impor-
then act upon this information either
The scale-available on a not-for-
tance to program evaluators, admin-
within the counseling context or
profit basis-costs from $1.10 to
istrators, and researchers, as well
that of rehabilitation planning.
$.85 per administration depending
as to the counselor working with
upon the volume of use. Normative
rehabilitation clients. These include
Entree to the
information is available for a variety
the following:
Counseling Relationship
of disability classifications served
by vocational rehabilitation, devel-
Program Evaluation
A completed Human Services
opmental disabilities, and other hu-
Scale Profile (see Figure 1) may be
man service agencies.
The scores for each of the sub-
used as an entree into the coun-
scales that are yielded by the scor-
seling relationship. For example,
ing process may be used to meas-
the counselor might place the pro-
Limitations of the Scale
ure client change. There is evidence
file of scoring results before the
The scale, although having sub-
that the scale is sufficiently sensi-
client and say "We have the re-
stantial potential, is not, however,
tive to reveal subtle changes that
sults from the Human Service Scale,
without limitations. There currently
go unmeasured by previous scales.
and compared to others like you
is no audio recording available for
As such, the Human Service Scale
who have taken the scale before
those with visual disorders. Those
is viewed as a promising dependent
you, it appears that while you have
clients with severe motor difficulties
variable measure for rehabilitation
several areas in which your needs
will need assistance in completing
researchers and as an outcome cri-
are being satisfied, you may have
the scale. The reading level, com-
terion measure for program evalua-
some personal concerns (low emo-
puted to be at the fifth grade level,
tors. Studies of the relationship be-
tional need satisfaction). You may
may serve as a barrier to the use
tween rehabilitation processes and
have some problems at home or
36
JOURNAL OF REHABILITATION
with the family (low family need
tion with an apparent problem of
dividual (and) is developed jointly
satisfaction), as well as feelings
needing glasses or a hearing aid
by the vocational rehabilitation
about your financial circumstances
and job placement, and then via
counselor
and the handicapped
(low economic-security need satis-
the Human Service Scale reveals
individual
(p. 13).⁵ The impor-
faction). Which would you like to
that he has relatively low need sat-
tance of this relative to the use of
talk about first?"
isfaction in the "Emotional Needs"
the Human Service Scale is the
category, it may be cause for con-
emphasis upon the participation of
It is well known that some cli-
cern. The rehabilitation counselor
the client in rehabilitation planning;
ents seem willing to indicate prob-
might decide in light of other evi-
since the scale is completed by the
lems via an impersonal paper-and-
dence such as that gained from an
client, and the results of the scoring
pencil inventory, while the same cli-
interview with the client to obtain
of the scale have potential utility
ents are reluctant to discuss deeply
a basic psychological evaluation.
for rehabilitation planning, the use
personal concerns until after an in-
An employed person who has low
of the scale by rehabilitation agen-
depth counseling relationship has
need satisfaction in the Vocational
cies would satisfy, in part, this
been established. The counselor
Self-Actualization area might bene-
mandate. Not that the scale would
can capitalize on this phenomenon
fit from a vocational evaluation and
supplant presently used methods of
and move more directly toward the
subsequent guidance. The Human
involving clients in the formulation
discussion of potentially sensitive
Service Scale represents not only a
of a rehabilitation plan, but in a
problem areas using the results of
potential screening device for spe-
systematic fashion the scale pro-
the scale as the catalyst.
cial evaluations but-also impor-
vides an opportunity for the client
tantly-documentation of the need
to indicate problems (needs) requir-
for such evaluations.
ing resolution (satisfaction) by re-
habilitative services.
Team Planning of
Rehabilitation Services
Client Involvement in
The Rehabilitation Act of 1973
Related to the preceding use of
Planning Services
also mandates an annual review of
the Human Service Scale is the use
the individual rehabilitation plan
which those who participate in
The Rehabilitation Act of 1973
in order that the client have an
"staffings" may make of the scale.
(PL 93-112, HR 8070) mandates that
opportunity to redevelop its con-
Staffings typically involve a number
an "individualized written rehabili-
tent. The Human Service Scale may
of professionals, each contributing
tation program (is) required
in
be of assistance for this as well.
from his/her particular position of
the case of each handicapped in-
The scale may be administered on
professional expertise. The Human
Service Scale Profile may be used
as the focus for discussing the cli-
ent. The physician is most intimately
familiar with the Physiological
Needs, the psychologist with the
Emotional Needs, the social worker
with the Family and Social Needs
areas, the rehabilitation counselor
with the Economic Security, Eco-
nomic Self-Esteem and Vocational
Self-Actualization Need areas, and
so on. If clients are present at staf-
fings, they may provide reactions to
the discussion concerning relative
need satisfaction.
Screening for
The Human Service Scale involves the
client in the planning of services.
Diagnostic Evaluations
Examinations and evaluations by
specialists are often the most costly
component of the diagnostic evalu-
ation conducted prior to rehabilita-
tion planning. It is imperative that
good decisionmaking occurs in in-
stances where psychological, social,
and vocational evaluations are pre-
scribed. The Human Service Scale
cannot contribute to decisions about
medical matters per se, but the
Administration of the Human Service Scale
scale may be of assistance with de-
takes approximately 15 minutes and can be
cisions concerning, which clients
done individually or in groups.
could benefit from psychological,
social, and other special evalua-
tions. For example, the individual
who comes to vocational rehabilita-
MAY-JUNE, 1976
37
an annual basis to those clients hav-
categories. The Human Service
range of potential client problems,
ing long-term rehabilitation plans.
Scale is viewed as having a poten-
(3) as an entree into the counseling
In this manner, progress towards
tially important contribution toward
relationship, (4) as a technique to
need satisfaction can be deter-
this end since it is a measure of
facilitate team planning of rehabili-
mined; also, changes in the need
client needs.
tation services, (5) as a screening
satisfaction Profile may suggest
tool for deciding about the selection
modification of the service plan. Not
of various diagnostic evaluations,
only can changes be measured from
Potential as a Clinical Tool
(6) as a technique for insuring cli-
the beginning to the end of a reha-
ent involvement in the planning of
bilitation plan, but the scale might
Another important potential use
services, (7) as a device to provide
also be used as a monitoring device
of the Human Service Scale is as a
feedback to professionals about the
of client progress.
"diagnostic" instrument. Although
effectiveness of their services, (8)
only in the formative stage, its use
as a device to identify severely han-
as a diagnostic tool would be based
dicapped people and,(9) as a poten-
Feedback to Counselors
on the following principle: Areas of
tial clinical tool with which predic-
relatively low need satisfaction
As a measure of client change
tions may be made about the pat-
would be translated into needed
the Human Service Scale may be
terns of services clients ought to
services. In anticipation of satisfac-
useful to the rehabilitation coun-
have - for rehabilitation planning
tory predictive validity of the scale
selor. Most counselors enter the
efficiency. The Human Service
field of rehabilitation because of a
from studies now underway, a list of
Scale has, therefore, important po-
commonly available human service
genuine desire to help people. Of-
tential for counselors, clients, super-
resources has been compiled. The
ten, however, many counselors ex-
visors, administrators, program eval-
professional rehabilitationist would
perience a great deal of frustration
uators, and researchers, as well as
because feedback is often infre-
then use the list as a guide to sug-
for those who are responsible for
gested services which, if brought to
quent or absent. An occasional let-
authorizing funding of rehabilitation
bear upon client problems, would
services.
ter from a satisfied client may not
potentially alleviate areas of low
be sufficient reinforcement for the
need satisfaction. It is envisioned
needs of many counselors. The
that the client and counselor would
NOTE: Additional information and specimen
agency or facility that is experienc-
copies of the Human Service Scale are avail-
then agree upon a plan of services;
ing considerable staff turnover may
able from the Rehabilitation Research Institute,
the plan would be implemented and
the University of Wisconsin, 2605 Marsh Lane,
wish to examine whether or not in-
monitored for needed modification,
Madison, WI 53706.
sufficient reinforcement of coun-
and the Human Service Scale would
selors may be a contributing factor
BIBLIOGRAPHY
be readministered upon its comple-
to staff turnover. While not a pana-
tion to measure client change. With
1. Dishart, M. Highlights of National Studies at
cea, there is reason to believe that
90 State VR Agencies by Patterns of Rehabili-
such a model, client types could be
the Human Service Scale, if admin-
tation Services Project. Washington, D.C.: Na-
generated for which alternative pat-
tional Rehabilitation Association. 1965.
istered prior to and following serv-
terns of services with known prob-
2. Gay, D. A., Reagles, K. W., & Wright, G. N.
ices may provide, in part, such re-
"Rehabilitation Client Sustention: A Longitudi-
abilities of success could be
nal Study." Wisconsin Studies in Vocational
inforcement.
matched. The objective would be,
Rehabilitation, Regional Rehabilitation Re-
search Institute, University of Wisconsin. 1971,
of course, to increase the decision-
2, XVI.
making capability of counselors to
3. Guttman, L. "A General Nonmetric Technique
Identifying the
for Finding the Smallest Coordinated Space for
Severely Handicapped
ensure, as far as possible, client
a Configuration of Points." Psychometrika.
success and agency efficiency.
1968, 33, pp. 469-506.
The Rehabilitation Act of 1973
4. Horst, P. "Obtaining a Composite Measure
From a Number of Different Measures of the
has also mandated that severely
Same Attributes." Journal of Psychometrika.
handicapped people will receive
1936, 1, pp. 53-60.
special attention from rehabilitation
Summary
5. Rehabilitation Act of 1973, P.L. 93-112, H.R.
8070. Washington, D.C.: Superintendent of
agencies. There has been, however,
The need for a new measurement
Documents. September 26, 1973.
little agreement and widespread
tool with which rehabilitation client
controversy regarding the best
progress and program evaluation
means for defining who is and is
may be conducted was recognized.
not "severely disabled." Interesting-
It was further recognized that the
ly, they have been defined in terms
instrument must be capable of
of specific disability categories (e.g.
measuring the qualitative impact of
Executive Director for community
cerebral palsy, mental illness, neu-
rehabilitative services, i.e., the na-
based sheltered workshop. Grad-
rological disorders) and functional
ture and degree of client change.
uate training plus 35 years ex-
limitations requiring multiple serv-
With Maslow's hierarchy of basic
ices. However, it has been demon-
human needs as the theoretical ra-
perience in this or related posi-
strated that the severity of disabili-
tionale, the Human Service Scale*
tion preferred. Evidence of man-
ty (i.e., the medical condition) may
was developed. Although still in the
agement ability essential. Salary
not necessarily be related to the
development stage, it is hypothe-
commensurate with background/
patterns of rehabilitation services
sized that client needs for services
provided nor to the prospects for
and need satisfaction attributable
experience. Send resume to:
rehabilitation success. It would
to rehabilitation services may be
Selection Committee, Arizona
seem more reasonable that "severe
measured. In addition, other poten-
Training Center for the Handi-
handicap" be defined in terms of the
tial uses are discussed: (1) use as a
severity of client needs for rehabili-
program evaluation tool, (2) as a
capped, 308 W. Glenn, Tucson,
tation services, rather than in terms
technique for systematically making
Arizona 85705.
of functional limitations or disability
the professional aware of a broad
38
JOURNAL OF REHABILITATION
Experimental Rigor in Rehabilitation Research: Fact or Fantasy?
Paul Wehman,
University of Wisconsin, Madison, Wisconsin
Research programs in rehabilitation frequently are
Only five studies utilizing single-subject design were
of a survey or demonstration nature. The focus of
found.
much rehabilitation research is to predict client suc-
cess, efficacy of different social agencies, and coun-
TABLE 1
selor effectiveness with different handicapped popula-
Classification of Publications (1)(2)
tions. Unfortunately, many rehabilitation programs fail
to provide applied research in which there are planned
experimental manipulations designed to effect behav-
ioral change in clients. Traditional research methodol-
ogy includes correlation, factor analysis, and heavy
Exper.-
Control
Group
Correlation
and
Prediction
Single-
Subject
Designs
Survey
Research
Case
Study
Review
Paper
General
Position
and
Theoretical
reliance on survey data.
Rehabilitation
While it is true that well-controlled experimental/
Literature
1.4
2.1
1.4
13.9
.3
6.3
74.6
control group research is virtually impossible in many
rehabilitation settings due to ethical and logistical
Journal of
Rehabilitation
.2
.4
.2
4.2
.8
.4
93.8
constraints, this is not necessarily so when examining
relevant treatment variables which may influence the
Social and
effectiveness of individual client habilitation programs.
Rehabilitation
One viable alternative to these limitations in experimen-
Record
.2
0
0
6.6
0
0
93.7
tal control is use of single subject designs. With single
Rehabilitation
subject designs, baseline (preprogram) measures of
Counseling
behavior are taken, and then an intervention (planned
Bulletin
11.8
19.6
.4
23.4
0
5.5
39.3
program change) or experimental manipulation is made.
In order to verify experimental effects, a return to
Mean
baseline may be made in which previous experimental
Percentage
3.4
4.4
.5
12.0
.3
4.0
75.3
conditions are withdrawn. Multiple baselines can also
(1) From 1964-1973
be used to assess the efficacy of an independent
(2) Expressed in percentage of journal's major total publica-
variable across different behaviors, situations or
tions over ten-year period
subjects.¹,²
The purpose of this brief report is to review several
It would appear that the present report, highlights
rehabilitation journals and evaluate the present status
two problems in trends and dissemination of rehabili-
of experimental research in rehabilitation as well as
tation research. First, the most commonly read journals
trends over the last decade. Journal selection is based
by counselors are not publishing applied research
on periodicals which have had high readership in reha-
which can be specifically helpful in developing client
bilitation settings over the past ten years.
training programs. Broadly described demonstration
projects are interesting as are human interest stories,
METHOD
but they usually fail to give the practitioner specific
program direction.
Journals Reviewed-Four rehabilitation journals were
Secondly, applied research trends in rehabilitation
reviewed and articles were grouped into several cri-
do not reflect use of single-subject designs. This is
tiques of research method. The four journals were:
unfortunate since this is one approach to program
Rehabilitation Counseling Bulletin, Journal of Rehabili-
evaluation which is most suitable for use in applied
tation, Rehabilitation Literature, and Social and Reha-
settings such as workshops. A major advantage of be-
bilitation Record. Only the major articles in Rehabili-
havioral research is that it examines the effects of in-
tation Counseling Bulletin were reviewed.
dependent variables on measured behaviors, and looks
Time Span — Articles were analyzed over a time
for cause and effect relationships rather than covarying
period of 1964-1973.
relationships. Hence prediction becomes more precise
Grouping Criteria-Each article reviewed was as-
as behavior is determined to be a function of en-
signed to one of the folowing seven categories: (1) ex-
vironmental contingencies.
perimental/control group (2) correlation/factor analy-
The recommendations made here are twofold: 1.
sis (3) single-subject design (4) survey (5) case study
more applied research is required which examines the
(6) review papers (7) general position papers and
variables involved in effective rehabilitation programs,
theoretical reports.
and (2) this research should be directed to Rehabilita-
tion Counseling Bulletin and also to Journal of Applied
RESULTS AND DISCUSSION
Rehabilitation Counseling, a more recent periodical
gaining increased acceptance. The journals reviewed
Results of the literature review revealed Rehabilita-
in this report must also provide more space and em-
tion Counseling Bulletin published the greatest amount
phasis on applied research reports which focus on
of research with over 50 percent of the articles empiri-
specific variables in program development.
cal in nature (see Table 1). The Journal of Rehabilita-
tion and Social and Rehabilitation Record have pub-
References
lished essentially general position papers and theoret-
ical reports as has Rehabilitation Literature.
1. Hall, R. V., Cristler, C., Cranston, S., Tucker, S. "Teachers and Parents
The findings indicate minimal experimental research
as Researchers Using Multiple Baselines." Journal of Applied Behavior
Analysis. 1970, 3, pp. 247-250.
in the four journals reviewed with a preponderance of
2. Kazdin, A. E. "Methodological and Assessment Considerations in Evalu-
survey research, reviews, and general position papers.
ating Reinforcement Programs in Applied Settings." Journal of Applied
Behavior Analysis. 1973, 6, pp. 517-531.
MAY-JUNE, 1976
39
1. Makes employment of the dis-
abled individuals to avoid a "rotten
abled a national priority
life."
Libertyand Iustice
2. Protects those on-the-job who
for All
may become disabled
Footnotes
3. Increases the pool of new job
1. Grant # RSA-15-P-57807/2-02, U.S. Depart-
openings and promotion op-
ment of Health, Education, and Welfare, Reha-
portunities
bilitation Services Administration.
2. For example, upon completion of a survey of
its membership, the Chamber established that
4. Plugs into an existing EEO
there was considerable interest in child care
INCLUDES
system ready and willing to
issues, and a conference was co-sponsored
with the Industrial Center in March 1974, with
deal with the issues
representatives from over 40 companies in
RETARDED CITIZENS
attendance.
5. Brings rehabilitation close to
3. The latest regulations were issued August 29,
National Association for Retarded Citizens
1975, and can be obtained by writing U.S.
the work situation through
Department of Labor, Employment Standards
2709 Ave. E. East, Arlington, Texas 76011
Area Code: (817) 261-4961
mandated recruitment and pro-
Administration, Handicapped Worker Task
Force, 3418 New Department of Labor Build-
motion, both of which require
ing, S.W., Constitution Avenue, Washington,
its expertise
D.C. 20210.
4. For example, New York State Division of Hu-
6. Creates a new political con-
man Rights has interpreted the Flynn Act to
"protect an individual with a disease involving
stituency interested in the dis-
future risk so long as the disease does not
abled
presently interfere with his ability to perform."
Corporations have historically rejected future
risk job applicants on the basis of potential
7. Negates previous excuses by
insurance costs. See "Equal Rights for the
Affirmative Action
telling business "you have to"
Disabled in New York State," Industrial Social
Welfare Center Newsletter, Columbia University
employ the disabled
School of Social Work. Volume 11, No. 1, Feb-
(Continued from Page 23)
ruary 1975, p. 4.
Conclusion
8. Creates increased experience
and information which will
It has been the contention
prove valuable
throughout that the new equal rights
Reference
legislation is a powerful tool offer-
9. Conversely, offers new privacy
1. Ginzberg, Eli, "Forward," in Reubens, Beatrice
ing unparalleled opportunity for
G., The Hard to Employ: European Programs.
to the disabled in that medical
New York, Columbia University Press, 1970,
change. Viewed most optimistically,
officers cannot reveal "hid-
p. XV.
Affirmative Action for the Disabled
den" disabled whom they dis-
cover
10. Encourages the creative in-
LEARN
volvement of disabled people
MEAT CUTTING
as a "consultant" to his own
Electronics
employment situation, since
TRAIN QUICKLY
the employer is mandated to
in 8 short weeks at Toledo
"accommodate"
for a bright future with
Technology
security in the vital meat business. Trained
11. Opens the door to "future
meat men needed. Good pay, full-time jobs,
year-round income, no layoffs.
risk" applicants (those with
deteriorating conditions) who
LEARN BY DOING
Day and Evening School Programs load to
can no longer be rejected out
of hand.
AT NATIONAL
the degree of Associate in Specialized
Students train under actual meat market
Technology.
As Eli Ginzberg, chairman of the
conditions in big, modern, cutting and
National Commission for Manpower
processing rooms and retail department.
Cutting, buying, percentage, pricing, mer-
Policy has observed, "A rich so-
chandising, management. A complete retail
ciety has an obligation to enable
meat education.
PENNA
all who desire to work to
do
so.
These laws are a mild re-
ESTABLISHED 50 YEARS
quirement when posed against those
VTECH
Students come to NATIONAL from every
in other countries. Beatrice Reub-
state in the U.S.A. and foreign countries.
ens notes, "Legal compulsion on
Recognized and endorsed by leaders in the
meat industry. Approved by Ohio State
private and public employers to
Department of Education. G.I. approved. Ac-
provide jobs for the physically or
credited by N.A.T.T.S. Diploma given.
mentally disabled exists in the large
Thousands of successful graduates. Write
for FREE 40-page school catalog.
PENN TECHNICAL INSTITUTE
western European countries."
71-02-0197T
110 NINTH STREET
But minimal as the step may be,
the potential is powerful. It remains
NATIONAL SCHOOL OF
PITTSBURGH, PA. 15222
for the rehabilitation community to
move on the opportunity presented.
MEAT CUTTING, INC.
PHONE 355-0455
As Albert Camus has said, "With-
33-37 N. Superior
Toledo, Ohio 43604
out work, all life goes rotten." The
law increases the chance for dis-
42
JOURNAL OF REHABILITATION
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44
JOURNAL OF REHABILITATION
CLASSIFIED
DIRECTORY
Advertising
authors'
biographies
RATE FOR ONE-LINE DIRECTORY LISTING-$50 PER YEAR-SIX ISSUES
Aids for the Blind
Science for the Blind
221 Rock Hill Road, Bala Cynwyd, Pennsylvania
Kenneth W. Rea-
Art Schools, see also Floral Design Schools
gle, Ph.D., is asso-
ciate professor, Syr-
The Harris School of Advertising Art Battlewood Estates, Hillsboro Pike, Rt. 8, Franklin, Tennessee
acuse University,
Rehabilitation Coun-
selor Education Pro-
Artificial Limbs, Braces, Orthopedic Supplies
gram. Dr. Reagles
was formerly the re-
J. E. Hanger Limb Co.
2220 Fifth Avenue, North, P.O. Box 616, Birmingham, Alabama
search director of
the Regional Reha-
Long's Limb Shop, Inc
1478 Birch St., Denver, Colorado
bilitation Research
J. E. Hanger, Inc
40 Patterson St., N.E., Washington, D.C.
Institute at the University of Wisconsin-
Madison. He is a three-time recipient of
Palm Beach Limb & Brace Inc
2022-24 N. Dixie Hwy. West Palm Beach, Florida
the ARCA Research Award and has pub-
Brownfield's Inc
122 No. 5th St., Boise, Idaho
lished numerous articles, mimeographs,
reports, and books dealing with the
J. E. Hanger, Inc., of Illinois
638 S. Clark St., Chicago, Illinois
evaluation of rehabilitation services.
J. E. Hanger, Inc., of Illinois
1309 Frye Ave., Peoria, Illinois
J. E. Hanger, Inc., of Indiana
416 North Main St., Evansville, Indiana
Alfred J. Butler is
J. E. Hanger, Inc., of Indiana
1332 North Illinois St., Indianapolis, Indiana
currently professor
Paducah Limb & Brace Co.
1398 S. Irvin Cobb Dr., Paducah, Kentucky
of rehabilitation
Snell's
1833 Line Avenue, Shreveport, Louisiana
counseling at the
Boston Artificial Limb Co
44 Middlesex Turnpike, Burlington, Massachusetts
University of Wis-
consin-Madison, De-
E. H. Rowley Co. of Grand Rapids
120 Division Ave., S. Grand Rapids, Michigan
partment of Behav-
Lamberts Limb & Braces
1120 Broad Avenue, Gulfport, Mississippi
ioral Disabilities,
B & H Orthopedic
4073 S. Grand, St. Louis, Missouri
and is the acting
coordinator of the
J. E. Hanger, Inc.
1914 Olive St., St. Louis, Missouri
program. He was
J. E. Hanger, Inc
312 East McMillan St., Springfield, Missouri
formerly the research director of the
Limbset TM for The Above Knee Amputee
30-75 14th St., L.I.C., New York 11102
Regional Rehabilitation Research Insti-
tute at UW-Madison, and has worked as
Missouri Valley Brace Co.
3219 Leavenworth St., Omaha, Nebraska
a psychologist in various institutions for
Carolina Brace Manufacturing
916 S. Kings Drive, P.O. Box 4562, Charlotte, North Carolina
the retarded. His doctoral degree in
J. E. Hanger, Inc.
312 E. McMillan St., Cincinnati, Ohio
human genetics is from the University of
Toronto.
Allied Limb & Brace Co.-Plaze 0. Crow
5924 E. 31st St., Tulsa, Oklahoma
J. E. Hanger, Inc.
527 N. W. 9th St., Oklahoma City, Oklahoma
Lawton Brace & Limb Co., Inc
2724 Gore Blvd., Lawton, Oklahoma
James S. Peters,
Snyder Artificial Limb & Brace Co
1523 South Harvard, Tulsa, Oklahoma
II is associate com-
missioner of Con-
Tulsa Artificial Limb & Brace Co
315 East Ninth Street, Tulsa, Oklahoma
necticut State De-
Modern Limb & Brace Co
3310 Germantown Ave., Philadelphia, Pennsylvania
partment of Educa-
Gaines Correct Shoes
Bennie Dillon Bldg., Nashville, Tennessee
tion and director,
Division of Voca-
Knoxville Orthopedic Appliance Co.
1833 Forest Ave. at 19th St., Knoxville, Tennessee
tional Rehabilitation
Raiford's Shoes
1022 Madison Ave., Memphis, Tennessee
and Disability Deter-
Tri State Limb & Brace Co., Inc
807 Poplar Ave., Memphis, Tennessee
mination. He holds
J. E. Hanger, Inc. of Texas
a Ph.D. degree in
4122 Swiss Ave., Dallas, Texas
clinical-counseling psychology from Pur-
Hedgecock Artificial Limb, Inc
2827 Commerce St., Dallas, Texas
due University, West Lafayette, Indiana,
Lubbock Artificial Limb Company
3813 24th St., Lubbock, Texas
an M.S. degree in clinical psychology
Meyers Brace & Limb Company
from Illinois Institute of Technology,
1710-B Ninth St., Wichita Falls, Texas
Chicago, and an M.A. degree in social
Fitwell Artificial Limb Co
125 W. Third S., Salt Lake City, Utah
psychology from the Hartford Seminary
Thomas G. Powell, Inc
414 West Broad St., Richmond, Virginia
Foundation, Hartford, Connecticut. Dr.
Clarksburg Artificial Limb Co., Inc
Peters has done research in personality
Rt. 3, Box 462, Clarksburg, West Virginia
and rehabilitation. He is the author of
I. P. Boggs Company
1119 Seventh Avenue, Huntington, West Virginia
numerous articles in the field of coun-
Mountain State Artificial Limb Co.
1536 Penn Ave., Fairmont, West Virginia
seling, rehabilitation, and psychology.
Princeton Brace and Limb Co.
He is an adjunct professor of Psychol-
329 Mercer St., Princeton, West Virginia
ogy at the University of Hartford and
Stark Artificial Limb Company
115 S. Penn St., Wheeling, West Virginia
the University of Connecticut.
MAY-JUNE, 1976
45
Seymour J. Mund
Auto, Diesel and Aeronautics Schools
is program develop-
ment and evaluation
Lincoln Technical Institute
7800 Central Ave., Washington, D.C.
specialist for the
Lincoln Technical Institute
Connecticut State
1201 Stadium Drive, Indianapolis, Indiana
Division of Voca-
Lincoln Technical Institute
1326 Walnut St., Des Moines, lowa
tional Rehabilitation.
Lincoln Technical Institute
3200 Wilkens Ave., Baltimore, Maryland
He received his un-
Bailey Technical School
dergraduate degree
3750 Lindell Blvd., St. Louis, Missouri
in industrial arts ed-
Stevinson Auto & Electrical School
2008 Main, Kansas City, Missouri
ucation from the
United Technical Institute, Inc
1301 St. Louis, Springfield, Missouri
University of the State of New York at
Billings Automotive Training Center
Oswego, and his master's degree in
1300 6th Av. N., Billings, Montana
counseling and guidance from Hofstra
Ryder Technical Institute
227 Irving Blvd., Dallas, Texas
University. He is presently pursuing
graduate work at the University of Con-
necticut in the field of media and tech-
nology.
Barber and Beauty Schools and Supplies
Before being promoted to his present
position, he served as a rehabilitation
Eatons Barber & Beauty Training Center
411 West Capital Ave., Little Rock, Arkansas
counselor. In this capacity, he ran a lo-
Indiana Barber College
5536 E. Washington St., Indianapolis, Indiana
cal office for eight years. Prior to that
he was for ten years a teacher and
Collins School of Cosmetology
111 West Chester Ave., Middlesboro, Kentucky
guidance counselor in various school
Flint Institute of Barbering
3214 Flushing Rd., Flint, Michigan
systems.
American Beauty College
2200 25th Ave., Gulfport, Mississippi
Foster's Cosmetology and Barber College
723 Walnut Street, Ripley, Mississippi
Sheila H. Akabas is
Kenneth Shuler's School of Men's Hairstyling 1730 Broad River Road, Columbia, South Carolina
a faculty member of
Nashville Barber College
209 Broadway, Nashville, Tennessee
the Columbia Uni-
versity School of
Wendell's Knoxville School of Beauty
405-409 Union Ave., Knoxville, Tennessee
Social Work and di-
Hamblen Beauty School
133 West Main St., Morristown, Tennessee
rector of the
Mrs. Carter's School of Beauty
804 Seventh St., Wichita Falls, Texas
School's Regional
Roanoke Barber School
Rehabilitation Re-
309 First St., S.E., Roanoke, Virginia
search Institute. Her
Wheeling Barber College, Inc
1107 Main St., Wheeling, West Virginia
prime interest has
West Virginia State School of Cosmetology
624 Ninth Street, Huntington, West Virginia
been to study the conditions under
which trade unions and corporations
participate in the rehabilitation process
and identify the opportunities for link-
age between the world of work and the
Commercial Colleges and Schools
rehabilitation system. An economist by
training, she received her Ph.D. from
Alverson Draughon Business College
P.O. Box 10971, Birmingham, Alabama
New York University. Dr. Akabas is the
Capital City Business College
800 Louisiana St., Little Rock, Arkansas
author of numerous articles and co-
authored Mental Health Care in the
Draughon School of Business
216 West 6th Street, Little Rock, Arkansas
World of Work. She was the former re-
Penny's School of Floral Design
3420 W. Magnolia Blvd., Burbank, California
search director of the Amalgamated
Clothing Workers' Sidney Hillman Health
American Marine Institute, Inc
1445 Skytrooper Rd., Daytona Beach, Florida
Center in New York.
The Sawyer Secretarial School
3630 W. Kennedy Blvd., Tampa, Florida
Boise Secretarial School
1141/2 North 9th St., Boise, Idaho
Paige E. Cook, Jr.,
has worked in the
Indiana Business College
802 North Meridian St., Indianapolis, Indiana
field of rehabilita-
Draughon's Business College
218 North Fifth St., Paducah, Kentucky
tion since 1964,
when he was em-
Kentucky Business College
628 East Main St., Lexington, Kentucky
ployed as a counse-
Owensboro Business College
Box 1524, Owensboro, Kentucky
lor and supervisor
with the State of Illi-
Soule Business College
1410 Jackson Ave., New Orleans, Louisiana
nois Office of Voca-
Ayers School of Business
Townhouse, Shreveport, Louisiana
tional Rehabilitation
in Chicago. He is currently employed as
Strayer College
600 Equitable Bldg. 10 N. Calvert Street, Baltimore, Maryland
a rehabilitation research associate with
Cleary College
2170 Washtenaw Ave., Ypsilanti, Michigan
the Industrial Social Welfare Center of
the Columbia University School of
Missouri Auction School
1600-32 Genesee, Kansas City, Missouri
Social Work. Mr. Cook holds a master's
Miss Vanderschmidt's Secretarial School
4625 Lindell Blvd., St. Louis, Missouri
degree in community organization and
research from the Columbia University
Sanford-Brown Business College
4100 Ashby Road, St. Ann, Missouri
School of Social Work.
Blackwood Business College
1015 N. Walker St., Oklahoma City, Oklahoma
Draughon's School of Business
713 North Broadway, Oklahoma City, Oklahoma
Sue Maloney is public relations di-
Eastern Oklahoma State College
Wilburton, Oklahoma
rector for the Vocational Rehabilitation
Center of Allegheney County in Pitts-
Adelphia Business School
Admore and Philadelphia, Pennsylvania
burgh, Pa. She graduated with honors
McCann School of Business
Corner Maine and Pine St., Mahanoy City, Pennsylvania
from the school of journalism at Syra-
cuse University, New York in 1964. Ms.
Duff's Business Institute
110 Ninth St., Pittsburgh, Pennsylvania
46
JOURNAL OF REHABILITATION
Reading Business Institute, Inc
10th & Penn Streets, Reading, Pennsylvania
Maloney has done freelance work for
Thompson School of Business & Technology
advertising agencies, newspapers and
1253 W. Market St., York, Pennsylvania
magazines in the northeast region.
Bristol Commercial College
8½ Fifth St., Bristol, Tennessee
Draughon's Business College
131 8th Ave. North, Nashville, Tennessee
Sandra Wiggin has
Knoxville Business College
209 W. Church Ave., Knoxville, Tennessee
been employed by
the State of Ala-
Commercial College of Midland & Odessa
2115 E. 8th St., Odessa, Texas
bama Highway De-
Southwest Business College-Court Reporting-Secretarial
7181/2 Broadway, Plainview, Texas
partment for the
past nine years.
Kinman Business University
110 South Howard St., Spokane, Washington
Prior to this, she
Huntington School of Business
worked as a secre-
1007 5th Ave., Huntington, West Virginia
tary in sales in a
workshop situation.
As a cerebral palsy vic-
Drafting Schools and Supplies, see also Technical Colleges
tim from birth, her observations and
study of people at a sheltered workshop
Denver Institute of Technology
2250 South Tejon St., Englewood, Colorado
generated a desire for more education
Hickok-Griswold Technical Institute
in the field of rehabilitation and the
2341 Carnegie Ave., Cleveland, Ohio
study of underlying behavior factors in-
Raymond J. Horn School of Drafting
659 Semmes, Memphis, Tennessee
volved. In 1968 she began working to-
ward her degree by taking evening
courses while working full time during
Drug Companies and Pharmacies
the day. Presently Ms. Wiggins is in-
terested in gaining more experience in
McGehee Brothers Drug Store
working with disabled persons. She
136 Dexter Avenue, Montgomery, Alabama
hopes to earn a master's degree in the
Cate-Gentry Pharmacy, Inc
2623 Chapman Hwy., Knoxville, Tennessee
field of rehabilitation.
Medical Arts Drug Co., Inc
Corner of Main & Locust Sts., Knoxville, Tennessee
Charles H. Wacker,
Jr. is educational
Electrical, Electronics, and Radio Schools, see also Technical Institutes
supervisor of the
Vocational Inde-
Draughon School of Radio & Television
216 West 6th St., Little Rock, Arkansas
pendence Program,
J & H School of Electronics
127 East Boca Raton Road, Boca Raton, Florida
Foundation for the
Junior Blind in Los
United Electronics Institute
3947 Park Drive, Louisville, Kentucky
Angeles, California.
Northwestern Electronics Inst.
3800 Minnehaha Ave., Minneapolis, Minnesota
He is responsible
Stevinson Auto & Electrical School
2008 Main, Kansas City, Missouri
for the development
Hickok-Griswold Technical Institute
and implementation of pre-vocational
2341 Carnegie Ave., Cleveland, Ohio
skill training courses for competitively
Penn Technical Institute
110 9th St., Pittsburgh, Pennsylvania
employable blind adults seeking a re-
Elkins Institute of Radio & Electronics
2727 Inwood Road, Dallas, Texas
turn to mainstream society. Prior to
this, he worked as a writer and training
specialist for industry, organizing and
interpreting programs and objectives for
Hearing Aids
employees and the public. He received
his doctorate from U.C.L.A. in English
Mobile Hearing Aid Center
58 South Conception St., Mobile, Alabama
and Education. Dr. Wacker is author and
Beltone Hearing Service
editor of numerous articles on the socio-
516 Wood, Texarkana, Arkansas
technical implications of man-machine
Beltone Hearing Aid Service
224 Eighth St., Augusta, Georgia
systems. He has developed a course for
Beltone Hearing Aid Service
108 North Market, Ottumwa, Iowa
the Los Angeles public schools on
Upper Penninsula Hearing Aid Service-Arthur Van Kleeck 318 Sheldon Ave., Houghton, Michigan
Money Management For The Blind and
for U.C.L.A. on Social Attitude Toward
Beltone Hearing Service
204 22nd Ave., Meridian, Mississippi
Blindness.
Beltone Hearing Aid Service-Harry Young, Mgr
State Fair Shopping Center, Sedalia, Missouri
Audiphone Incorporated
610 Locust St., St. Louis, Missouri
Robinson Hearing Aid Co., Inc.
806 Olive St., St. Louis, Missouri
Beltone Hearing Service
Dayton, Piqua, & Greenville, Ohio
Beltone Hearing Aid Center
114 West 11th St., Erie, Pennsylvania
BIRTH DEFECTS
Beltone Hearing Aid Service
1200 11th Ave., Altoona, Pennsylvania
Bennett Hearing Aid Center
ARE FOREVER.
1417 E. Third St., Williamsport, Pennsylvania
Qualitone-Telex-Zenith, Cornelius H.A. Center
326 Louisa St., Williamsport, Pennsylvania
UNLESS YOU
Royal Hearing Aid Center
1547 West Clinch, Knoxville, Tennessee
HELP.
Alamo Hearing Aid Service
Lobby, Nix Professional Bldg., San Antonio, Texas
Hearing Aid Services, Inc.
10 South Loudoun St., Winchester, Virginia
MARCH
Waymack Hearing Aid Center, Inc.
Medical Arts Building, Suite 411, Second and Franklin Streets, Richmond, Virginia
OF
Beltone Hearing Aid Center-Clark Allen
2621 E. Clairemont Ave., Eau Claire, Wisconsin
DIMES
Beltone Hearing Aid Service, Inc
9720 W. Bluemound Rd., Milwaukee, Wisconsin
Beltone Hearing Aid Service of Racine
5200 Washington Ave., Racine, Wisconsin
THIS SPACE CONTRIBUTED BY THE PUBLISHER
MAY-JUNE, 1976
47
Communications Aids
Micon Industries
1440 29th Avenue, Oakland, California
There's only one
Medical Laboratory/Dental Technician Training
reason why this
Gradwohl School of Laboratory Technique
3514 Lucas Avenue, Dept. Jr., St. Louis, Missouri
disabled vet
Optical Goods
can't work.
McElhinney & Kirk
103 West 8th Street, Wilmington, Delaware
Mills-Anderson Opticians, Inc
839 Ninth St., N., St. Petersburg, Florida
Allied Optical Co
208 East Polk Street, Tampa, Florida
You won't let him.
Ballard Optical Co
480 Peachtree St., N.E., Atlanta, Georgia
Columbus Optical Dispensary
P.O. Box 1122, Columbus, Georgia
Irby's Optical Dispensary-E.E. Irby
1303 25th Ave., Meridian, Mississippi
Plaza Optical Dispensary
501 7th Street, North, Columbus, Mississippi
University Opticians
701 Locust Ave., Fairmont, West Virginia
Rehabilitation Facilities and Services
F. B. Weinberg-Realistic Face & Body Restorations
Medical Arts Bldg., Baltimore, Maryland
Goodwill Industries Rehabilitation Center
2701 North Cherry St., Winston-Salem, North Carolina
Harmarville Rehabilitation Center, Inc
Guys Run Road, Pittsburgh, Pennsylvania
United Cerebral Palsy of Middle East Tennessee, Inc.
Box 1735, Knoxville, Tennessee
Daniel Arthur Rehabilitation Center
Emory Valley Road, Oak Ridge, Tennessee
Institute of Human Resources of Knoxville
2501 Magnolia Ave., Knoxville, Tennessee
West Texas Rehabilitation Center
4601 Hartford, Abilene, Texas
Texas Rehab. Hospital & Texas Jaycee Ed. & Train. Ctr. (College)
Box 58, Gonzales, Texas
Surgical Supplies, Sickroom Equipment
Meridian Orthopedic Appliances
1909 6th St., Meridian, Mississippi
Unfortunately, there are
Mohlenburg Prosthetics, Inc
3900 La Branch, Houston, Texas
quite a few businessmen who
Technical Colleges and Institutes
are a little hesitant about hiring
ITT Technical Institute
11 S. Lincoln Park Drive, Evansville, Indiana
disabled veterans.
Bailey Technical School
3750 Lindell Blvd., St. Louis, Missouri
But a recent survey by the
United Technical Institute, Inc
1301 St. Louis, Springfield, Missouri
Pont Company showed
Southwest Technical Institute
412 Northwest 5th St., Oklahoma City, Oklahoma
that 91% of the disabled vets
Cooper Institute, Inc
720 No. 5th Avenue, Knoxville, Tennessee
they hired rated average or
National Camera Technical Training Division
2000 West Union, Englewood, Colorado
above average in job perfor-
mance. And 93% rated aver-
Training Courses, Vocational and Trade Schools
age or above average in job
National Camera Technical Training Division
2000 West Union, Englewood, Colorado
stability.
Miami Barber College, Inc
2242 W. Broward Blvd., Ft. Lauderdale, Florida
So if you have a job to give,
Missouri Auction School, Inc
1600-32 Genessee St., Kansas City, Missouri
call the National Alliance of
National School of Meat Cutting
33-37 N. Superior St., Toledo, Ohio
Health Care Training Institute
81 Madison Bldg., Suite 916, Memphis, Tennessee
Businessmen, and give a dis-
Electronic Computer Programming Institute
1515 Magnolia Ave., Knoxville, Tennessee
abled vet a chance, by giving
United Insurance Adjuster School
Weisbarber Road at Casey Dr., Knoxville, Tennessee
him a job.
A man who's able, mature,
Welding Schools
and experienced should end
Colorado School of Welding
1357 West Alameda Ave., Denver, Colorado
up on the payroll.
Kansas City Welding Institute
1927 McGee, Kansas City, Missouri
Not the welfare roll.
St. Louis Welding Institute
3854 Washington Blvd., St. Louis, Missouri
Steeles' Welding School, Inc
116 Walton Ave., Danville, Va. and 1218 N. Blvd., Richmond, Va.
Help America work.
Other Suppliers of Products and Services
Blankinship-Porter Co., Inc.-Jeweler Suppliers 1829 1st Ave., North, Box 877 Birmingham, Alabama
The National
Typewriting Institute-Dvorak One-Hand Typewriters
3109 W. Augusta Ave., Phoenix, Arizona
Stevinson Auto & Electrical School
2008 Main, Kansas City, Missouri
Alliance
Oklahoma Upholstery Supply, Inc
P.O. Box 50186, Tulsa, Oklahoma
of Businessmen
Frank J. Malone & Son, Inc
108 South 40th St., Philadelphia, Pennsylvania
Pennsylvania Prison Society
Philadelphia, Pennsylvania
Mosehart-Schleeter Company
4404 Directors Row, Houston, Texas
Parsley Manufacturing Co., Inc
1570 Washington St. East, Charleston, West Virginia
Valley Tech Workshop-Piano Tun. & Repair Train
1122 W. Wisc. Ave., Appleton, Wisconsin
48
JOURNAL OF REHABILITATION
Cheney and you.
Helping people
help themselves.
Lots of people need help at some time
ment rec room when suddenly his life was
or another. Not because they aren't self-
changed. And just as suddenly, the steps
sufficient. They are, both at work and at
to the basement became an obstacle too
home enjoying their families. But they
great to overcome. Until Cheney. Because
need help because they can't climb stairs.
now a Cheney Wheelchair Lift takes those
And that's where Cheney and you enter
steps just like Joe used to.
the picture.
To these people, and hundreds like
For instance, Carol's illness prevented
them, the Cheney Company has made
her from using the stairs and nearly forced
the difference by providing the oppor-
her to move to a one-story house. But a
tunity for independence, both inside
Cheney Wecolator™ solved her problem
and outside the home. And Cheney and
by allowing her to ride from floor to floor
you can do the same for many more
quickly and comfortably.
handicapped people. For more informa-
When an accident put Bob in a wheel-
tion on Cheney Wecolators, Wheelchair
chair, he thought he'd never drive again.
Lifts and Wheelchair Van Lifts, call or
And the business he'd built for himself
write your local distributor. Or contact
would be gone forever, too. But a Cheney
Mike Bruno, (414) 782-1100 at the
Wheelchair Van Lift gave Bob back the
Cheney Company. Either way you'll dis-
freedom he needed.
cover how Cheney and you can help
Joe had just completed building a base-
them help themselves.
helping people help themselves
The CHENEY Company
Dept. JR, 3015 S. 163rd Street, New Berlin, WI 53151. (414) 782-1100
MAY-JUNE, 1976
49
CALENDAR
DIRECTORY OF DISPLAY ADVERTISERS
May 23-26-NRA Mid-Atlantic Re-
American Motorcycle Institute
Inside Back Cover
gion: annual conference. Omni
International Hotel, Norfolk, Vir-
Beltone
6
ginia.
Charles C. Thomas
19
June 1-4-NRA Northeast Region:
Chair-E-Yacht
43
annual conference. Cherry Hill
Hyatt House, Cherry Hill, New
Cheney
49
Jersey.
Clinical Psychologist
11
June 8-10-NRA Southwest Region:
Colorado School of Trades
41
annual conference. Arlington Ho-
tel, Hot Springs, Arkansas.
Executive Director, Arizona
38
Everest & Jennings
44
Sept. 18-22-NRA National Confer-
ence. Diplomat Hotel, Hollywood,
Hanger
Back Cover
Florida.
Home Arts Coordinator
11
June 13-17-National Conference
Garden City Community College
43
on Social Welfare: 103rd annual
forum, Washington, D.C. Contact:
Gallaudet Today
43
NCSW, 22 W. Gay St., Columbus,
George C. Bishop
43
Ohio 43215.
Ken McRight
43
June 13-18-The XIIIth World Con-
Lakeside Manufacturing Inc.
43
gress of Rehabilitation Interna-
tional, Tel Aviv, Israel. Contact:
National Camera
43
Henry B. Stern, Jewish Occupa-
National School of Meat Cutting
42
tional Council, 114 Fifth Ave.,
New York, N.Y. 10011.
Overly Manufacturing Co.
4
Penn Tech
42
June 20-25-INFORMATION 1976:
11th annual conference of the
Program Director
11
Canadian Foundation on Alcohol
Rowe International
10
and Drug Dependencies. Con-
tact: W. J. Gilliland, conference
Seton Nameplate
43
manager, 33 Russell St., Toronto,
Singer Career Systems
8
Canada M5S 251.
Staff-Rehab. Center
11
June 23-26-Alexander Graham Bell
Snell's Limbs & Braces
11
Association for the Deaf: 1976
Southern Illinois University Press
41
convention, Boston, Massachu-
setts. Contact: A. G. Bell Associa-
Social Workers for Israel
11
tion for the Deaf, Inc., 3417 Volta
Taxidermy Training
13
Place, N.W., Washington, D.C.
20007.
Vocational Evaluator-Texas
11
Vocational Evaluator-Illinois
11
July 10-16-American Corrective
Therapy Association: 29th annual
Williamsport Orthopedic
13
convention, Happy Dolphin Inn,
W. T. Hinnant
13
St. Petersburg Beach, Florida.
Xerox
12
Contact: Bruce K. Machin, P.O.
Box 4044, Bay Pines, Fla. 33504.
Wingates Sales Inc.
41
50
JOURNAL OF REHABILITATION
Marine Mechanic Training
AMERICAN MARINE INSTITUTE
EAM
* Jobs are plentiful in the marine
industry but you must be trained
CERTIFIED MECHANIC
* 5 Wk. Outboard Course
* 10 Wk. Stern-Drive Course
* 15 Week Combination
Stern-Drive/Outboard Course
* Rotary Engine Course
AMERICAN MARINE INSTITUTE
PO Box 2628, Daytona Beach
Call Toll Free 1-800-874-0645
Florida, 32015
Fla, Res. Call Collect 1-904-255-0295
IT'S RESULTS THAT COUNT!
AMI has trained Voc. Rehab. Students from 27 states - Our FULL TIME
Placement Office results in a HIGH PLACEMENT PERCENTAGE for Graduates.
Motorcycle Mechanic Training
12 Week Resident Course
INSTITUTE
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* Dynamometer Lab
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CERTIFIED MECHANIC
* Precision Measurements Lab
* Carburetor Lab
* Electrical & Live Engine Labs
* Dedicated Staff of 50
76-1-30
AMERICAN MOTORCYCLE INSTITUTE
PO Box 2628, Daytona Beach
Call Toll Free 1-800-874-0645
Florida, 32015
Fla, Res. Call Collect 1-904-255-0295
Hanger
This booklet has been designed
for those physicians and other
professionals whose practice
OFFERS
includes amputation, post
medical management and relat-
BOOKLET ON
ed services. Limb Prosthetics
gives ready reference for each
AMPUTATIONS
level of amputation as well as
the prosthesis recommended.
Over 115 years of experience
gained by the Hanger organiza-
tion have gone into this care-
fully illustrated booklet. Illus-
trations include amputation for
the lower and upper extremi-
ties, various Hanger prostheses
and methods of suspension,
Limb Prostitutics
post-operative care and prepa-
\
ration for prosthesis, plus
selected photographs showing
the child amputee and training
for the above knee patient.
We believe that you will find
Limb Prosthetics a most useful
booklet and a valuable source
of quick information. To obtain
1 I
your copy, please write or
phone the certified Hanger
facility nearest you.
3rd EDITION
NOW AVAILABLE
New concepts in the current state of the art of prosthetics
Hanger
AUTHORIZED FACILITIES IN THE FOLLOWING CITIES
Albany, GA
Columbus, oH
Miami, FL
Atlanta, GA
Dallas, TE
Mobile, AL
Raleigh, NC
Augusta, GA
Denver, CO
Montgomery, AL
Richmond, VA
Baltimore, MD
Evansville, IN
Montreal, CAN.
Roanoke, VA
Birmingham, AL
Erie, PA
Nashville, TN
Sarasota, FL
Boston, MA
Fayetteville, NC
New Orleans, LA
St. Petersburg, FL
Charleston, SC
Gainesville, FL
New York, NY
Savannah, GA
Charleston, WV
Indianapolis, IN
Oklahoma City, OK
Springfield, MO
Cincinnati, OH
Jacksonville, FL
Orlando, FL
St. Louis, MO
Chicago, IL
Lafayette, LA
Peoria, IL
Tampa, FL
Columbia, SC
Mansfield, oH
Philadelphia, PA
West Palm Beach, FL
Columbus, GA
Marietta, OH
Pittsburgh, PA
Washington, DC
November 1985
Special Issue: Spinal Cord Injury
An OT Program
Reconstructive Hand Surgery
Wheelchair Cushions, Trends
Enhancing Vocational Outcomes
Independent Living
Life Satisfaction and Depression in Older
Spinal Cord-Injured Persons
The American Journal of Occupational Therapy
Volume 39, Number 11
ISSN 0272-9490
G.E.Miller,Inc.
DELTOID-AID ARM COUNTERBALANCE
Immediate patient activity with
progressive therapy
Aids in restoring function
Firm, gentle support to upper
extremities
NEW FEATURE: Adjustable tension
treatment boom
Adaptable for patients of all ages
Rapid positioning
Completely mobile with easy storage
The G.E. MILLER DELTOID-AID ARM COUNTERBALANCE GJ 3710
Provides firm, gentle support of the patient's arms to assure immediate patient activity with full confidence. Therapists
find that it enhances the development of skills in A.D.L.'s diversional activities and vocational training. By eliminating
the effects of gravity, the DELTOID-AID ARM COUNTERBALANCE increases the functional capacity of the forearms
and hands, helps patients to maintain good posture, prevents stretching of weak muscles, helps maintain range of mo-
tion, helps relieve spasticity, relieves and prevents edema.
Superior engineering permits effortless adjustment to patient's needs. Precise counterbalance is accomplished with
weights and springs functioning whisper-smooth on nylon-tired, full ball-bearing pulleys. They operate out of sight in-
side the chrome plated steel tubing from which the GJ 3710 Arm Counterbalance is constructed. The newest addition
adds controlled horizontal resistance or assistance by means of an adjustable knob that also locks the boom in line or
allows it to swing free. The spreader bars are quickly adjustable to any size arm. This unit is adjustable in height and
may be used in a wheelchair or chair. When either horizontal boom is not in use, it folds out of the way. The G.E.
MILLER DELTOID-AID ARM COUNTERBALANCE is completely self-contained with casters for mobility, and floor lock
device for stabilization.
G.E. Miller GJ 3710 Deltoid-Aid comes with ac-
GJ 3710A - Additional Cuffs
each 6.00
cessories: 8 one pound weights, 4 half pound
GJ 3710B - Additional Springs
each 4.30
weights, 8 springs and 4 disposable cuffs.
GJ 3710C - Additional Weights 1 lb.
each 6.00
Total carton weight 67 pounds.
GJ 3710D - Additional Weights - ½ lb.
each 6.00
Price (with standard accessories) $755.00
F.O.B. Yonkers
G.E.Miller, Inc.
484 S. BROADWAY, YONKERS, N.Y. 10705
(212) 549-4850 or (914) 969-4036
WE DO NOT SELL THROUGH AGENTS OR DEALERS
Comfort.
Finally, there's a foam
Dual Density For
Sets You Straight Without
If you want to know more,
cushion made especially for
Double Comfort
Setting You Back
send for our free color brochure
wheelchairs that's lightweight,
Combi's secret is a form
At only $90 suggested retail
explaining how Combi is setting
durable, good-looking, moder-
fitting, contoured seat cushion
for the seat cushion and back-
the standard for Comfort in
ately priced and best of all,
molded of two foam densi-
rest together, the Combi comes
wheelchair seating.
comfortable. It's called the
ties - firm inside for support,
loaded with extras including: a
TM
Combi™ Posture Seating System.
and soft outside for comfort.
non-skid bottom to prevent slid-
Two Cushions Are Better
(Patent Pending). When com-
ing; a built-in leg separator; and
combii Medical
Than One
bined with an adjustable lumbar
washable, breathable, stain-
Unlike other foam cushions,
support backrest, you have a
resistant designer covers in a
the Combi is a seat cushion
seating system that literally
choice of colors.
Posture Seating System
PLUS a backrest that combine
FITS. And because it's scien-
to give you improved seating
tifically contoured, it helps to
Please send me your FREE Combi color brochure
comfort. The Combi promotes
reduce spasticity and supports
against leaning and slumping.
Name
a correct posture, reduces sit-
ting fatigue, and minimizes
The Combi's Tough
Phone
SEND TO:
stress in the lower back.
Built for the long haul, the
Institution/Business
Jay Medical, Ltd.
Combi's life expectancy can be
805 Walnut
measured in years instead of
Boulder, CO 80302
months. To prove it, Jay Medi-
Street
cal backs the Combi with its
City
Tel (800) 648-8282
18 month limited warranty.
State
Zip
© 1984 JAY MEDICAL, LTD.
ROLYAN®
Support
Hemi Arm
you want.
Sling
Comfort
they want.
The Rolyan® Hemi Arm Sling
Sizing to fit each patient
Elasticated clavicle
provides optimal support-and
The Rolyan Hemi Arm Sling is
strap controls humeral
exceptional comfort-for patients
position.
available in four sizes, both left
with shoulder subluxations or other
and right, ensuring optimum fit
injuries to the ligaments and
Elasticated anterior
and patient comfort. Measuring
tendons of the shoulder.
strap regulates degree
the distance from acromion to
of internal rotation.
It provides effective support for the
acromion across the midpoint of
patient's humerus without
the scapulae determines the
Adjustable humeral cuff
restricting circulation in the flaccid
correct size: Small 14" to 18",
provides snug fit
without impeding
arm. The degree of internal and
Medium 18" to 24", Large 24" to
circulation.
external rotation is easily adjusted
28" and Extra Large 28" to 34".
for static or dynamic positioning.
And with the Rolyan Hemi Arm
Rolyan: therapists working
Posterior positioning
Sling, passive and active self-
with therapists
ring allows even weight
range of motion can be effected
distribution of the
At Rolyan, we've been researching
without removing the sling-in
affected arm over
and developing quality orthotic
shoulders and back.
both sitting and standing positions.
materials for over a decade. Our
entire sales and support staff is
Elasticated posterior
Designed for extended wear
made up of experienced
strap regulates degree
of external rotation.
The comfortable fit of the Rolyan
therapists-easily accessible and
Hemi Arm Sling encourages
eager to answer your questions.
extended wearing time which, in
Call us toll-free-1-800-558-8633-
turn, means more effective therapy
for more information about the
ROLYAN
for your patients. The Rolyan Hemi
Rolyan Hemi Arm Sling or any of
MEDICAL PRODUCTS
Arm Sling conforms closely to the
our orthotic products. If you'd like,
humerus and fits unobtrusively
we can also arrange a convenient,
under clothing. Constructed of
personalized in-service with one of
nylon plush and polyester foam, it
our Rolyan representatives.
TM
is machine washable in warm
N93 W14475 Whittaker Way
water and removes easily by
Menomonee Falls, WI 53051
detaching the two anterior straps.
(800) 558-8633 or, in Wisconsin, (414) 251-7840
In Canada (800) 243-1417
A member of the Smith & Nephew Group of Companies
Volume 39
CONTENTS
Number 11
The American Journal of Occupational Therapy
November 1985
(ISSN 0272-9490)
Official Publication of The American
Occupational Therapy Association, Inc.
703
Nationally Speaking-New Perspectives for the Occupational
Editor
Elaine Viseltear
Therapist in the Treatment of Spinal Cord-Injured
616 Tanner Marsh Road
Individuals
Guilford, CT 06437
Susan Lipton Garber, MA, OTR
Managing Editor
FEATURES
Jaclyn Alexander
705 High-Level Quadriplegia: An Occupational Therapy
Editorial Board
Challenge
Pamela A. Lathem, OTR; Theresa L. Gregorio, OTR;
1985-1987
O. Jayne Bowman
Susan Lipton Garber, MA, OTR
Jean C. Deitz
Elaine Ewing Fess
715 Reconstructive Hand Surgery for Quadriplegic-Persons
Anne G. Fisher
Juanita Ainsley, OTR; Christa Voorhees, OTR; Elaine Drake,
Susan L. Garber
OTR
Lisette Kautzmann
Margo Mansfield
722 Wheelchair Cushions for Spinal Cord-Injured Individuals
Wayne P. Pierson
Kathleen Barker Schwartz
Susan Lipton Garber, MA, OTR
Julia M. Van Deusen
726 Enhancing Vocational Outcomes of Spinal Cord-Injured
1984-1986
Persons: The Occupational Therapist's Role
Carole Adler
Margaret Carroll Kanellos, CRC, MEd
Roann Barris
Anne B. Blakeney
734 Independence: The Ultimate Goal of Rehabilitation
Diana P. Burnell
for Spinal Cord-Injured Persons
Judy C. Colditz
Winnie Dunn
Lex Frieden, MA; Jean A. Cole, PhD
Kathy Hoffmann-Grotting
Catherine A. Trombly
740 Correlates of Life Satisfaction and Depression in Middle-Aged
Judith C. Vestal
and Elderly Spinal Cord-Injured Persons
Susan D. Decker, PhD, RN; Richard Schulz, PhD
1983-1985
Adele C. Germain
DEPARTMENTS
Margot C. Howe
Barbara Kleinman
746 Brief or New: Feeding Device for Finger Foods
Susan H. Knox
Melanie Morrison Wiener, OTR
Peggy T. McKnight
David L. Nelson
748
American Occupational Therapy Foundation-AOTA and
Karen C. Oberzan
Mary L. Warren
AOTF Sponsor Small Research Grants Program for Members
750
Book Reviews
Advertising Manager
Janet M. Schmidt
753
Classified Advertising
Production Editor
Sabine J. Beisler
762
Index to Advertisers
Editorial Assistant
Laura L. McKinley
Book Review Editors
Jeanette Bair
Stephanie P. Hoover
© 1985 by The American Occupational Therapy Association, Inc.
This journal is abstracted or indexed by: Behavioral Medicine Abstracts, Cumulative
Indexing to Nursing and Allied Health Literature, Exceptional Child Education Resources,
Editors Emeriti
Excerpta Medica, Inc., Hospital Literature Index, Index Medicus, Institute for Scientific
Charlotte D. Bone
Information, Medline, Psychological Abstracts, Rehabilitation Literature, and Social Sci-
Lucie Murphy Jeffers
ences Citation Index.
The American Journal of Occupational Therapy
The American Occupational Therapy
The American Journal of Occupational
Reprints are not available except to
Association, Inc.
Therapy is an official publication of The
authors of articles published in AJOT.
American Occupational Therapy Associa-
Authors receive a reprint order form and one
tion, Inc. Articles pertain to occupational
Executive Board
complimentary copy of AJOT (per author)
therapy and include new approaches and
routinely.
techniques of practice, the development of
Voting Members
theory, research, and education activities,
Back issues of most issues of AJOT (1979-
Robert K. Bing, President
and professional trends.
1983) can be purchased for $6 per copy,
Elnora M. Gilfoyle, President-Elect
prepaid only: AOTA Distribution Center,
Mary M. Evert, Vice-President
Manuscripts should be submitted to the
1383 Piccard Drive, Rockville, MD 20850.
Editor at the address shown on the Contents
Evelyn G. Jaffe, Secretary
page and follow requirements described in
Sandra L. Laase, Treasurer
Microfilms of complete volumes (Vols. 1-
the Author's Guide published in the January
37) may be obtained from Xerox-University
Sharon T. Sanderson, Speaker, Representa-
and July issues, and in other issues periodi-
Microfilms, 300 North Zeeb Road, Ann
cally. Because one of the objectives of the
tive Assembly
Arbor, Michigan 48106.
AJOT is to be a forum for the free expres-
Jane Rourk, Vice-Speaker, Representative
sion and interchange of ideas, the opinions
Advertising in AJOT is accepted on the
Assembly
and positions stated by contributors are
basis of conformity with the standards of
Linda A. Anderson, Recorder, Representa-
those of the authors and not necessarily
The American Occupational Therapy Associa-
tive Assembly
those of either the editor or the American
tion, Inc. AOTA is not responsible for state-
Cynthia G. Jones, Chair, Committee of State
Occupational Therapy Association, Inc.
ments made by contributors or advertisers in
Association Presidents
its publications. Unless so stated, material in
Mae D. Hightower-Vandamm, Delegate,
Copyright of the journal is held by The
AJOT does not reflect the endorsement,
World Federation of Occupational Ther-
American Occupational Therapy Associa-
official attitude, or position of AJOT's
tion, Inc. (AOTA). Permission must be ob-
apists
Editors, Editorial Board, or The American
tained from AOTA to reproduce or photo-
Occupational Therapy Association, Inc.
Nonvoting Members
copy material appearing in the journal.
James J. Garibaldi, Executive Director, Na-
Reproduction or photocopy of up to one
Subscription to AJOT is included in the
tional Office
copy per student of an AJOT article for
AOTA member's annual fee. Individual
purposes educational is permitted provided
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L. Randy Strickland, Chair, Communica-
that (a) such prints are distributed free of
Canada, Mexico, and foreign. Allow 4 to 6
tions Committee
charge or at cost, (b) permission has been
weeks for delivery of first issue.
Sandra L. Laase, Chair, Fiscal Advisory
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Committee
each copy includes a notice of copyright.
Changes of address: Members are re-
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Permission to use journal material for
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Commissions
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Reprint material must indicate that it is
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ics
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replacement copies will be honored up to 60
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American Occupational Therapy Associa-
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members or subscribers, and up to 90 days
inclusive pagination, and year of publica-
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Madelaine Gray, Deputy Executive Director
tion, as well as title and author(s) of the
Associate Executive Directors
material being reprinted.
The American Journal of Occupational
Therapy is published 12 times a year. Second
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Direct all requests and inquiries regarding
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The American Occupational Therapy Association, Inc.,
1383 Piccard Drive, Rockville, Maryland 20850
Telephone: (301) 948-9626
700 November 1985, Volume 39, Number 11
What Every Splint Material Should
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RESTING
SPLINT
The LMB Wrist-Hand-Finger Orthosis Model #105 is designed to rest the hand
when indicated by arthritis, tendonitis, or following trauma or surgery. It provides
the patient with a quality positioning splint saving the therapist valuable time.
Constructed for optimum fit with malleable ulnar deviation and thumb supports
and adjustable platform, the Wrist-Hand-Finger Orthosis:
can be accurately fitted within minutes
is anatomically designed
is comfortable and light-weight
(less than 4 oz)
has no hard edges
has padding as an integral part
of its construction
provides good ventilation to maintain
healthy skin
has been extensively clinically evaluated
is cost-effective
positions and supports hand, wrist,
thumb and fingers
is washable
is easily adjusted. to individual
requirements.
The LMB Wrist-Hand-Finger. Orthosis Model #105is easily
fitted and adjust requiring no special tools or heat. It is
available. in both. ef tandright hand models n three adult sizes
at $40.00 each. Size: B (small: fits small.lady),-C (medium:
average lady, small man), D (large: average man).
Please remember to indicate size and left or right side when
ordering. All prices F.O.B. San Luis Obispo, California, USA.
For all prepayment orders, LMB pays shipping within the
continental United States.
LMB
HAND REHAB PRODUCTS, Inc.
MB
P.O. Box 1181
San Luis Obispo, CA 93406
(805) 541-3992
NATIONALLY
SPEAKING
New Perspectives
jury slowly evolved into the pres-
for the Occupational
ent concepts of training in activi-
ties of daily living, designing and
Therapist in
fabricating assistive devices,
the Treatment of
strengthening upper extremities,
Spinal Cord-Injured
exploring avocational and voca-
Individuals
tional interests and skills, and pro-
viding mechanisms to promote in-
Susan Lipton Garber
dependence (4, 5). The use of
constructive or functional activity
Traumatic spinal cord injury
to maximize personal indepen-
has a history as old as mankind.
dence and economic self-suffi-
Unlike injuries to the extremities,
ciency was and continues to be the
the complexity of the spinal cord
central philosophy of occupational
injury and the overwhelming loss
therapy in the restoration of phys-
of function present enormous,
ical function (6). The effective re-
often insoluble problems for pa-
habilitation of spinal cord-injured
tients and practitioners alike. As a
patients depends on these tradi-
consequence, few efforts were
tions and identifies new evaluation
made before 1941 to deal with
these conditions or their complica-
Susan Lipton Garber, MA, OTR, is
and treatment efforts in such
tions.
Assistant Director for Research, De-
areas as environmental control
Perhaps the earliest description
partment of Occupational Therapy,
systems, pressure sore prevention
The Institute for Rehabilitation and
programs, and technology and
of spinal cord injury is found in a
Research, Houston, TX 77030. She
adaptive skills training (7). New
5000-year-old papyrus. An Egyp-
is also Assistant Professor, Depart-
challenges include reducing the
tian physician not only character-
ment of Rehabilitation, Baylor Col-
length of hospital stays and devel-
ized the specific symptoms of a
lege of Medicine, Houston, TX
oping community-based programs
complete cervical cord lesion but
77030.
for severely disabled people (8, 9).
also commented on the bleak
These, then, have become the
prognosis of such patients by ad-
spinal cord-injured patients were
province of the modern occupa-
monishing that it is "an ailment
still considered useless cripples (1,
tional therapist.
not to be treated" (1, p 1). This
p 5). Because of the large number
Currently, there are 200,000
attitude persisted for the next
of spinal cord injuries resulting
cases of spinal cord injury in the
4955 years. During World War I,
from World War II, the 1940s
United States, and it is projected
47 to 65% of those who acquired
saw the development of the first
that there will be 7000 to 8000
a spinal cord injury died within a
rehabilitation program for these
new traumatic spinal cord-injured
few weeks or months from uri-
patients. The efforts of such pi-
survivors each year. The mean
nary or respiratory complications
oneers as Guttmann, Monroe,
age of the victims is 28.74 years,
or from the effects of pressure
Rusk, Kessler, and Covalt, as well
and 82% of all patients are male.
sores. The mortality rate for this
as the policies and programs of
Vehicular accidents are responsi-
type of injury for the first three
the United States Veterans
ble for half of all spinal cord inju-
years after injury was 80% (1, p
Administration, resulted in the
ries; 47% of the injuries result in
5). Even within the last hundred
creation of a new philosophy of
paraplegia, and 53% result in
years, while people with other
care for spinal cord-injured peo-
quadriplegia (10-12).
forms of physical disability such as
ple (2, 3).
The state of the art of current
blindness and amputations have
From these beginnings, the role
approaches to the rehabilitation of
benefited from innovative rehabil-
of the occupational therapist in
people with spinal cord injuries is
itation techniques and equipment,
the treatment of spinal cord in-
the focus of this special issue of
The American Journal of Occupational Therapy
703
the American Journal of Occupa-
tation of individuals with spinal
tional therapists on the rehabilita-
tional Therapy. The topics in this
cord injury. The last three articles
tion team, because our specialty
edition are of the immediate con-
of this special issue reflect these
remains one of flexible adaptation
cern and interest to occupational
concerns and their importance to
to patient needs.
therapists and were selected be-
occupational therapists. Kanellos
cause of their relevance to current
ACKNOWLEDGMENTS
reviews the long-term outlook for
issues in occupational therapy
The author dedicates this manuscript to
people with spinal cord injuries,
the memory of Maureen Parker, OTR,
practice. They have been included
with primary emphasis on employ-
whose knowledge, skill, and compassion en-
also because of their relatively
ment opportunities and reentry
abled so many individuals with spinal cord
limited coverage in the occupa-
injury to achieve their highest potential.
into community life. Frieden and
tional therapy literature. In this is-
REFERENCES
Spencer discuss the concept of in-
sue, consideration is given to po-
dependence, a major goal of per-
1. Guttman L: Spinal Cord Injuries. Com-
prehensive Management and Research,
tential new horizons and to the
manently physically disabled peo-
2nd edition. London: Blackwell Scien-
impact that technology is already
ple. Innovative independent living
tific Publications, 1976
having on occupational therapy
programs are now available as al-
2. Monroe D: Cervical cord injuries:
Study of 101 cases. N Engl J Med
practice. Lathem, Gregorio, and
ternatives to traditional custodial
229:919-933, 1943
Garber present detailed descrip-
care.
3. Clifton GL, Donovan WH, Frankowski
tion of a comprehensive program
The effectiveness of rehabilita-
RF: Patterns of care for the patient
with spinal cord injury. Curr Concepts
for rehabilitating the individual
tion efforts can be judged only by
Rehabil Med 2:14-17, 1985
with a high cervical cord injury.
conducting studies that use longi-
4. Mosey AC: Occupational therapy--A
This program provides a distillate
tudinal follow-up of patient func-
historic perspective. Involvement in
the rehabilitation movement-1942-
of their institute's more than 25
tion and self-satisfaction. Decker
1966. Am J Occup Ther 25:234-236,
years of experience in managing
has provided us with an assess-
1971
spinal cord injury, and it incorpo-
ment of the spinal cord-injured
5. Lindberg A: Occupational therapy. In
Rehabilitation of the Severely Disabled,
rates the latest in computer tech-
patient's psychological status, a
WM Jenkins, RM Anderson, WL Die-
nology for the development of
major factor in assessing the out-
trich, Editors. Dubuque: Kendall/
maximum function.
come of the rehabilitation process.
Hunt, 1976
6. Spackman CS: A history of the practice
The lack of upper extremity as-
In summary, these articles are a
of occupational therapy for restoration
sistive devices that are completely
current review of several aspects
of physical function: 1917-1967. Am J
suitable for quadriplegic patients
of modern occupational therapy
Occup Ther 22:67-71, 1968
7. Diasio K: Occupational therapy-A
has brought about new programs,
practice in the context of spinal
historic perspective. The modern
such as reconstructive hand sur-
cord injury.
era-1960-1970. Am J Occup Ther
gery, in which the occupational
Few fields in medicine are
25:237-242, 1971
8. Reilly M: Occupational therapy-A
therapist has an important role.
changing more rapidly than occu-
historic perspective. The moderniza-
This concept, as discussed in de-
pational therapy. The impact of
tion of occupational therapy. Am J Oc-
tail by Ainsley, Voorhees, and
high technology has not yet been
cup Ther 25:243-246, 1971
9. Scott SJ: The medicare prospective
Drake, may provide new hope and
fully realized, but it must be antic-
payment system. Am J Occup Ther
function for some patients.
ipated. It is apparent that systems
38:330-334, 1984
The occurrence of pressure
and devices that maximize func-
10. Young JS, Burns PE, Bowen AM,
McCutchen R: Spinal Cord Injury Sta-
sores and their subsequent man-
tional potential will continue to be
tistics. Phoenix: Good Samaritan Med-
agement continues to be a major
a major concern in the rehabilita-
ical Center, 1982
11. Fine PR, Kuhlemeier KV, Stover SL:
concern for the long-term health
tion of individuals with spinal
Spinal cord injury: An epidemiology
and independence of spinal cord-
cord injuries. With the explosive
perspective. Paraplegia 17:237, 1979
injured people. A rational basis
expansion of electronic technol-
12. Kraus JF, Franti CE, Riggins RS, Rich-
ards D, Borhani NO: Incidence of trau-
for successful therapeutic inter-
ogy, microprocessor-controlled,
matic spinal cord lesions. J. Chronic Dis
vention in this important area is
preprogrammed "smart" devices
28:471-492, 1975
presented.
are now forthcoming in the areas
13. Seplowitz C: Technology and occupa-
Regardless of the effectiveness
of wheelchair mobility, environ-
tional therapy in the rehabilitation of
the bedridden quadriplegic. Am J Occup
of long-term medical manage-
mental control, and vocational
Ther 38:743-747, 1984
ment, improving the quality of life
training (13, 14). The area of
14. Youdin M, Dickey RE, Sell GH, Strat-
ford CD: Instrumentation for the se-
and the degree of function remain
technological innovation will pre-
verely disabled: An update. Model Sys-
the primary focus in the rehabili-
sent the new challenge to occupa-
tems' SCI Digest 2:16-24, 1980.
704 November 1985, Volume 39, Number 11
High-Level Quadriplegia:
An Occupational Therapy
Challenge
(quadriplegia; rehabilitation; skills, living; spinal cord injuries, therapy)
Pamela A. Lathem, Theresa L. Gregorio, Susan Lipton Garber
Rehabilitation of the C₁ to C₄ quad-
T
he National Spinal Cord In-
respiratory or other breathing aids,
riplegic person is a relatively recent
jury Association reports there
c) long-term medical and personal
phenomenon. Few rehabilitation fa-
are currently 500,000 spinal cord-
care needs, and d) limited func-
cilities accept the challenge these pa-
injured individuals in the United
tional recovery expected.
tients present. This paper describes a
States (1) and anticipates 20,000
It is only within the last 15 years
comprehensive occupational therapy
new injuries each year, of which
that many individuals with spinal
program for the C₁ to C₄ quadri-
approximately 50% will suffer
cord injury at the C₁ to C₄ levels
plegic person. It presents the objec-
quadriplegia. Of 3,950 quadri-
survived the initial trauma; those
tives and mechanisms for treating
plegic persons followed by the
who did survive were confined to
these individuals (e.g., range of mo-
Spinal Cord Injury Data Bank be-
intensive care units and acute hos-
tion, strengthening existing muscula-
tween 1975 and 1979, 649 (16%)
pitals. Until recently, rehabilitation
ture, functional activities training,
had injuries of C₁ to C₄ spinal level.
of those individuals was unknown
pressure sore prevention, and equip-
The average age of onset was 29.1
or extremely limited. Few facilities,
ment prescription) and introduces
years (compared with 28.5 for the
private or public, would accept
new approaches to increasing func-
entire spinal cord-injured popula-
them for rehabilitation. There is
tion through current therapeutic and
tion), and males comprised 86% of
little published information that
engineering technological advances.
the population, compared with
addresses the occupational therapy
The quality of life of these patients
82% of the entire spinal cord injury
treatment of the G₁ to C₄ quadri-
may well be determined by their expo-
population (2). Of the high cervical
plegic patient. Therefore, func-
sure to functional activities in occu-
injuries, 50% were the result of
tional activity and the control of
pational therapy.
vehicular accidents. Current emer-
one's environment have only re-
gency medical techniques have en-
abled many of these individuals to
survive the initial trauma.
Pamela A. Lathem, OTR, is a unit
The phrase "high-level quadri-
supervisor, Theresa L. Gregorio,
plegic" describes an individual who
OTR, is a senior staff therapist, and
has sustained an injury to the spinal
Susan L. Garber, MA, OTR, is As-
cord at any segmental level be-
sistant Director for Research; all at
tween the C₁ and C₄ vertebrae. For
the Occupational Therapy Depart-
the purpose of this paper, this term
ment, The Institute for Rehabilita-
refers to those individuals with any
tion and Research, Houston, TX
or all of the following conditions:
77030. Susan Lipton Garber is also
a) diminished or no motor and
Assistant Professor, Department of
sensory innervation below C₁ to C₄,
Rehabilitation, Baylor College of
b) total or partial dependence on
Medicine, Houston, TX 77030.
The American Journal of Occupational Therapy
705
cently been considered part of the
length and expense of hospitaliza-
the use of mouthsticks and con-
rehabilitation program for this spe-
tion, and diagnostic levels were
struction guidelines for them. Al-
cial population.
found in the literature (5, 6), pub-
though the literature is replete
Primary objectives in the reha-
lished material on the rehabilita-
with information that describes
bilitation of C₁ to C₄ quadriplegic
tion and occupational therapy
types of mouthsticks and their uses,
patients include education regard-
treatment of the C₁ to C₄ quadri-
there appears to be no information
ing their care and exposure to
plegic person is limited.
describing a structured program of
functional activities. Because the
Young and Harris (5) studied
mouthstick training or other as-
domain of occupational therapy is
364 people with high-level quad-
pects of occupational therapy treat-
functional activity, occupational
riplegia and found that hospital-
ment for the C₁ to C₄ quadriplegic
therapy is one of the most impor-
ization costs ranged from a mean
patient.
tant health services delivered dur-
expense of $55,000 to $84,000
During the early 1970s, many
ing the rehabilitation process. The
during the initial medical-rehabili-
new electronic assistive devices for
quality of life for C₁ to C₄ quad-
tation period. Of these subjects,
the disabled were developed and
riplegic patients may be deter-
13% had an initial hospital expense
marketed (14, 16). The mass mar-
mined by their experiences with
of over $100,000, and 2% incurred
keting of the microcomputer has
functional activities during reha-
an expense between $100,000 and
made a significant impact on the
bilitation. These activities may be
$200,000. One subject had a
lives of both able-bodied and dis-
transferred then to marketable
$320,000 initial hospital expense.
abled individuals. Vanderheiden
vocational skills and thus to em-
These figures illustrate the high
(17) suggested that microcompu-
ployment. This paper presents
cost of rehabilitation of high-level
ters serve a dual purpose for dis-
an occupational therapist's ap-
quadriplegic patients and further
abled individuals: a) they help in-
proach to and treatment of this
substantiate the need for organized
dividuals perform tasks denied to
special population.
treatment programs to ensure
them due to their disability; and
timely delivery of occupational
b) they can be modified in a way
Review of Literature
therapy services.
that allows the disabled person to
For many years, occupational
The use of mouthstick activities
use all the microcomputer's com-
therapists have been involved with
with the C₁ to C₄ quadriplegic pa-
puting and word-processing pow-
the rehabilitation of individuals
tient is a major component of an
ers. The International Software/
with spinal cord injuries. However,
occupational therapy program.
Hardware Registry (20) is a re-
only within recent years have the
Skills in these activities allow pa-
source developed by Trace Re-
occupational therapist and other
tients to perform otherwise impos-
search and Development Center to
rehabilitation professionals been
sible tasks. According to Jay (7),
help disseminate programs and
challenged to develop effective
people with these levels of spinal
provide adaptations to enable dis-
programs for the rehabilitation of
cord injuries are not commonly
abled individuals to better access
the high-level quadriplegic person.
seen in rehabilitation: centers be-
computers.
Issues such as survival, hospitaliza-
cause of either an early death or
The New York Regional Spinal
tion expense, realistic activities,
too severe of a traumatic injury.
Cord Injury System (NYSCIS) Re-
and technological advances con-
Two major textbooks used in OC-
habilitation Program developed an
tribute to the development and
cupational therapy schools do not
occupational therapy electronics
success of such programs.
address C₁ to C₃ quadriplegic per-
evaluation laboratory (16) to en-
Advances in medicine and engi-
sons, but these books state briefly
sure adequate clinical evaluation of
neering technology have increased
that mouthstick activities may be
technical aids, such as environmen-
the survival rate of the C₁ to C₄
performed by C₄ quadriplegic per-
tal control systems, mobility con-
quadriplegic person (3, 4). How-
sons. The mouthstick activities
trols systems, typewriter control
ever, the costs of treating individ-
mentioned are typing, page turn-
systems, and electric page turners.
uals with these injuries are often
ing, and writing. Additional activi-
Because the high cost of many of
enormous because of major medi-
ties (e.g., painting and playing
these technical devices prohibits
cal complications and the need for
cards, checkers, and chess) are ex-
most occupational therapy depart-
specialized management. Although
plained and illustrated. Functional
ments from having them readily
statistics on etiology, age at onset,
aids references (10, 13) describe
available for patient evaluation, the
706 November 1985, Volume 39, Number 11
published summary findings of the
stability, respiratory function, and
chin-controlled motorized wheel-
NYSCIS Occupational Therapy
the medical concerns of circulation
chair, or to operate an environ-
Electronics Evaluation may be a
and metabolism are the priorities.
mental control unit. In addition to
useful reference for occupational
Once the body systems are stabi-
helping the patient perform range
therapists, vocational counselors,
lized, the rehabilitation team is
of motion exercises of the upper
physiatrists, engineers, and con-
charged with maximizing the pa-
extremities, the occupational ther-
sumers (16). A retrospective study
tient's potential. This is accom-
apist may also provide the patient
conducted at NYSCIS revealed
plished through a comprehensive,
with platform hand orthoses to
that "when the activity patterns of
multidisciplinary program of which
maintain proper hand positioning
users and non-users of an environ-
occupational therapy is a major ele-
and prevent contractures and joint
mental control system were com-
ment. The occupational therapist
deformities.
pared, the users were significantly
continuously interfaces with the
Strengthening and Endurance Ex-
more active, spent more time in
other members of the rehabilita-
ercises. The strength of the inner-
educational activities, and were
tion team, including the physician,
vated muscles is determined, and
performing more independently
physical therapist, respiratory ther-
an exercise program is developed.
than non-users" (16, p 18). The
apist, social worker, nurse, thera-
These muscles may include ster-
same technological advances that
peutic recreational specialist, and
nocleidomastoids, levator scapulae,
helped to save the life of the high-
vocational counselor as well as with
upper trapezius, spinalis muscles,
level quadriplegic person yesterday
special consultants in the orthotics
and splenius muscles. Strengthen-
have the potential to improve the
and rehabilitation engineering de-
ing of the innervated musculature
quality of that life today. Although
partments.
may be accomplished by doing is-
this utilization impact appears to
otonic/isometric exercises or by
be significant, a major difficulty
Initial Phase of Occupational
performing mouthstick activities.
that confronts users of this equip-
Therapy Treament
Progressive Wheelchair Sitting.
ment is a lack of funding for the
The major objectives in the ini-
Progressive wheelchair sitting is
equipment.
tial phase of occupational therapy
initiated when the patient's or-
treatment are a) increasing pas-
thopedic surgeon determines that
Program Description
sive and active ranges of motion,
there is spinal stability. In addition,
The occupational therapy pro-
b) strengthening the innervated
there should be no evidence of is-
gram at The Institute for Rehabil-
musculature and building endur-
chial, sacral, or trochanteric pres-
itation and Research in Houston,
ance, c) initiating a progressive
sure sores. A full-reclining-back
Texas, is based on 25 years of clin-
wheelchair sitting program and
wheelchair is positioned at a 50°
ical experience in the rehabilitation
functional skills, and d) beginning
reclined angle; if the patient is in
of individuals with spinal cord in-
training with advanced technolog-
need of ventilatory support, then
juries. It is rooted in treatment ap-
ical equipment.
the bedside respirator is used. The
proaches developed at a specialty
Range of Motion. Range of mo-
patient usually sits on a foam cush-
hospital for patients with the severe
tion is a major component in the
ion of medium-to-firm stiffness
physical and respiratory effects of
rehabilitation program. Basic rea-
that is 7.5 cm (3 in.) thick. The
polio. This program has changed
sons for passive range of motion
foam allows ease of transfer and
over the years to incorporate the
include the a) prevention of con-
pressure relief. During the initial
latest medical, mobility, and tech-
tractures, b) prevention of joint
sitting sessions, blood pressure is
nological advances. These ad-
pain caused by contractures,
monitored. Hypotension (dizzi-
vances have allowed occupational
c) prevention of joint deformities,
ness) may occur when the patient
therapists to initiate functional pro-
and d) mobility of the joints. Lim-
is transferred from the bed to the
grams for this population. Since
ited joint range of motion may in-
reclined sitting angle. Lack of mus-
1959, 289 individuals with spinal
hibit dressing, transfers, and posi-
cle tone throughout the body may
cord injuries between the levels of
tioning in bed or wheelchair and
cause the blood to "pool" in the
C₁ and C₄ have participated in this
may be painful. Limitation in range
abdomen or lower extremities,
program. During the early phase
of motion of the neck may hinder
thus resulting in decreased blood
of hospitalization following acute
the patient's ability to perform
pressure. An abdominal binder
spinal cord injury, issues of spinal
mouthstick activities, to drive a
and elastic hose are worn to mini-
The American Journal of Occupational Therapy
707
mize this. The wheelchair is tilted
Figure 1
back until the patient's blood pres-
U-shaped foam neck support
sure stabilizes. Blood pressure
readings of 80/60 to 130/80 are
the parameters used to determine
the sitting angle. The reclining an-
gle of the wheelchair is decreased
until blood pressure is within the
parameters mentioned. Portable
respiratory equipment may be
placed on a platform mounted on
the back tilt bars of the wheelchair
so the patient can be mobile for
subsequent sitting sessions.
This progressive wheelchair sit-
ting program is continued until the
patient maintains an adequate
blood pressure reading while sit-
ting at an 80° or 90° angle. If the
C₁ to C₄ quadriplegic patient does
not have innervation of the muscles
that hold his or her head in an
upright position, the angle of the
wheelchair is adjusted appropri-
ately. A U-shaped neck foam sup-
monds, and figure eights). Gross
result in a smooth finish after kiln
port (see Figure 1) may be used to
motor assignments allow the pa-
firing. Because ceramic pieces can
support the patient's head in an
tient to gain a sense of control and
be purchased commercially, the
upright position if he or she is un-
coordination with the paintbrush.
patient may continue this activity
able to do so.
Watercolor and tempera paints are
after discharge from the hospital as
recommended because they dry
an avocation or vocation. The end
Functional Activities Training
quickly, allowing the patient to
product has positive psychological
Functional activities training in-
take the painting home after the
benefits because the patient has a
troduces the C₁ to C₄ quadriplegic
therapy session. Mastery of these
sense of accomplishment when the
person to activities and ways of per-
tasks may take several therapy ses-
project is complete. Some patients
forming those activities that will
sions, depending on (the patient's)
may also smooth the rough edges
maximize his or her abilities. In this
neck strength and endurance.
of the ceramic greenware piece if
program, the functional activities
Large prewriting pattern painting
they have developed sufficient con-
include painting, page turning,
is practiced before an attempt is
trol in using the greenware clean-
playing table games, typing, and
made to paint large alphabet let-
ing tool.
using the microcomputer.
ters. As the patient's lettering skill
Page Turning. Developing page-
Painting. The patient may
improves, he or she is encouraged
turning skills allows the patient to
paint either by holding a mouth-
to decrease the size of the letters.
read for educational or leisure pur-
stick with a paintbrush attached to
Progress is recorded by retaining
poses. The tool used for turning
it or by holding the paintbrush it-
dated photocopies of all paintings
pages is a dowel stick 13 mm (0.5
self in his or her mouth. Initially,
and painting exercises.
in.) in diameter and approximately
the patient paints vertical and hor-
The patient progresses from pa-
35 cm (12 in.) long to which a large
izontal lines across a piece of paper
per to ceramic painting. He or she
pencil eraser is attached on the dis-
positioned and secured to a tilted
selects a simple ceramic piece to
tal end. The eraser provides fric-
table top. Then the patient paints
glaze using a paintbrush mouth-
tion against the page. The proxi-
simple geometric figures (e.g.,
stick. Ceramic glazes may be
mal end has either plastic tubing or
squares, circles, rectangles, dia-
painted on in any manner and still
a dental acrylic U-shaped plate for
708
November 1985, Volume 39, Number 11
the mouthpiece. A book or maga-
Figure 2
zine is placed on a slanted tabletop
Use of birdbeak mouthstick for card playing
or bookstand. The eraser end of
the dowel stick is placed on the
bottom right corner of the right
page of the book. Pressure is ap-
plied in a diagonal direction to-
ward the left to turn the page. This
activity requires frequent practice
to develop skill.
Table Games. Leisure time pur-
suits are an important aspect of
rehabilitation. Patients may be
trained to manipulate various table
game pieces (e.g., playing cards,
dominoes, chessmen, checkers,
backgammon chips, tabletop video
machines, and Hi-Q pegs). Mouth-
sticks such as the "birdbeak" and
"vacuum-wand" as well as conven-
tional dowel mouthsticks are used.
It may be necessary to adapt the
playing pieces so the patient can
manipulate them. A simple adap-
tion is a pipe cleaner wrapped
strength in the neck flexors, exten-
may choose to use the microcom-
around the playing piece with one
sors, and rotators, then the patient
puter (see Figure 3) for teaching
end of the pipe cleaner extending
can use those muscles to move his
mouthstick typing because its keys
upward so it can be picked up with
or her head and, in turn, move the
are easier to depress than electric
a birdbeak mouthstick. Playing
mouthstick to hit the typewriter
typewriter keys and because it is
boards may be adapted to a smaller
keys. If neck musculature strength
easier to edit text. The manner in
scale if neck rotation is limited by
is inadequate, a support system is
which a patient enters data into a
either reduced strength or joint
used to stabilize the head. Then,
microcomputer depends on physi-
range of motion. Small magnetic
the patient can use his or her
cal capacities (e.g., facial, oral, and
travel games are used when the
tongue to move the mouthstick to
neck muscle strength, endurance,
board game must be tilted toward
different positions to hit the de-
and coordination). Conventional
the patient to reach all areas of the
sired keys. The patient is instructed
access to the standard computer
board. Card holders are used to
to depress each successive row of
keyboard may not be feasible;
support the patient's playing cards
the typewriter keys on the key-
therefore, the occupational thera-
(see Figure 2), and a birdbeak
board. The therapist may need to
pist must evaluate and train the
mouthstick is used to grasp the
adjust the position of the type-
patient with the most efficiently
card from the dealer and place it
writer to enable the patient to
used input system. An interface
in a card holder.
reach all keys. If the patient is un-
may be needed; this is a mechanism
Typing. A mouthstick with a
familiar with the keyboard, the
by which an individual has access
large eraser on the end can be used
therapist initiates a teaching pro-
to a machine or other object to
to depress the keys of a typewriter.
cess from a standardized school
accomplish a specific goal (14).
An electric typewriter with a built-
typing book. Accuracy and speed
There are many adaptive interface
in correction unit and return key
of typing may serve as signs of im-
systems commercially available (18,
is recommended. The typewriter
provement in this skill. Typing can
19) that can be used with the Apple
may be tilted toward the patient at
be used by patients as a communi-
II and Apple Ile computer to pro-
an angle where the patient can view
cation as well as a vocational tool.
vide a variety of transparent input
all of the keys. If there is adequate
Microcomputer Use. Therapists
routines. These input routines in+
The American Journal of Occupational Therapy
709
Figure 3
board. The lapboard provides
Mouthstick typing on the microcomputer
trunk support; when made of Plex-
iglas, it allows the patient to ob-
serve the full body and thus com-
pensate for severe sensory depri-
vation. Thoracic side supports may
be ordered to augment stability
and trunk balance. The manual
wheelchair is equipped with swing-
away, detachable footrests, al-
though some patients may request
elevating legrests, which reduce
hypotension or allow them to re-
cline for pressure relief. Each
wheelchair has a safety belt and
chest strap to secure the patient.
Special head positioners have been
fabricated to provide safe and ad-
equate support for patients with C₁
to C₃-level injuries when they
travel in a van. It may be necessary
to equip this wheelchair to accom-
modate respiratory equipment.
The occupational therapist, in
clude scanning, Morse code, and
Both manual and motorized
collaboration with the orthotist,
direct selection techniques. These
wheelchairs are considered and
designs this adaptation. The
adaptive interface systems take the
prescribed by occupational thera-
basic manual wheelchair with the
input, manipulate it, then inject the
pists to meet the individual mobil-
above options costs approximately
characters into the computer in
ity needs of each patient. The
$2,000 to $2,500. A manual wheel-
such a way that the computer
wheelchairs described in this sec-
chair is recommended even if the
thinks that they are coming from
tion have been used with C₁ to C₄
person is to receive a power chair.
its own keyboard. In this way, a
quadriplegic persons at The Insti-
It serves as a back-up against pos-
patient can be using a "sip-and-
tute for Rehabilitation and Re-
sible malfunction of the motorized
puff" switch to literally "type" on
search. (This hospital not only spe-
chair, is easier to transport, and is
the keyboard of the computer.
cializes in the treatment of spinal
more compatible in size with most
Mobility. Wheelchair mobility
cord injuries but also is one of few
doorways. Approximately 25 to
provides high-level quadriplegic
centers in the US that accepts high-
50% of high-level quadriplegic per-
persons with one of their most
level quadriplegic persons for re-
sons will receive only a manual
achievable functional activities and
habilitation.)
wheelchair.
also allows them to regain some
The Manual Wheelchair. Rec-
The Power Wheelchair. For this
control over the environment. Dif-
ommended is the semireclining or
group of patients, the most fre-
ferences of opinion exist regarding
full-reclining back model. This
quently prescribed is the semire-
the selection of wheelchair styles,
chair provides the patient with an
clining chin control or sip-and-puff
especially with reference to auto-
adequate high-back, optional head-
wheelchair. The power chair is de-
matic full-reclining back versus a
rest support and allows the patient
signed to accommodate portable
manual reclining back power
to sit upright or at a variety of
respiratory equipment and pro-
wheelchair. Our observations of
angles that best support a position
vides independent mobility with
patients using either type revealed
for head control and function. This
minimal mechanical repairs. Indi-
no differences in skin or medical
wheelchair is usually ordered with
viduals with good head control
complications between the two
a detachable, adjustable desk or
generally prefer a chin control
groups.
full-length armrests and a lap-
wheelchair because it allows them
710 November 1985, Volume 39, Number 11
to use strengthened neck muscula-
dures. The patient is then taught
and fan). It is adaptable to situa-
ture and to have better control.
to verbally direct his or her own
tions that require momentary or
Those patients with poor head con-
care in the areas of body position-
latching operations, such as using
trol usually are able to operate a
ing in the bed and wheelchair,
electric beds, drawing drapes, se-
sip-and-puff control with a modi-
functional equipment placement,
lecting radio and television chan-
fied safety switch. This switch is
and exercise and range of motion
nels, and using an intercom system.
used if the patient loses control of
programs. While the patient is in
Safety features include a loud call
the pneumatic straw-like control
the rehabilitation setting, the en-
signal, an emergency buzzer, a re-
switch. The power wheelchair is
tire team coordinates efforts that
mote control emergency call, and
equipped with the same style arm-
enable the person to develop effec-
the intercom system. These options
rests, footrests, lapboard, side sup-
tive communication skills. The
provide an opportunity for the
ports, and head supports and posi-
therapist helps the patient identify
high-level quadriplegic person to
tioners as is the manual wheelchair.
the most effective way to direct
have some safe, independent time
Costs vary depending on the type
others. Practice and repetition are
alone.
of control ordered. A completely
essential, as are reinforcement and
The ECS also can interface with
adapted power wheelchair for
consistency. For this program to
a microcomputer, resulting in ad-
the high-level quadriplegic person
succeed, the patient must become
ditional areas of control. Micro-
costs $4,500 to $7,500.
an active participant. This occurs
computers can be adapted to op-
When prescribing any wheel-
when the person is allowed to make
erate as a vocational tool in the
chair, it is important to consider
choices in the areas that do not
home and eventually allows the pa-
the patient's living situation, edu-
interfere with medical manage-
tients to control household opera-
cational and vocational potential,
ment. For example, patients may
tions, money management, and
transportation, and maintenance.
be given a choice of functional ac-
home-to-office operations.
The occupational therapist has the
tivities, clothes to wear, and sched-
primary role of informing the pa-
uling. At the time of discharge,
Prevocational Training
tient and the family of options,
many of these individuals have
The physical limitations of peo-
costs, maintenance record, and
been able to direct their care in an
ple with C₁ to C₄ quadriplegia pose
transportability of the wheelchair.
effective and assertive manner.
severe problems in accomplishing
With this information, the patient
Technology. Technology allows
vocational tasks. Activities result-
can become an active participant in
the C₁ to C₄ quadriplegic person to
ing in marketable vocational skills
the selection process.
regain control in some areas of
are integral to occupational ther-
function. There is a variety of
apy treatment. A patient's interest,
Control of Environment
equipment available that allows the
motivation, and intellectual capac-
The most devastating aspect of
patient to mechanically control
ity are important factors in deter-
high-level spinal cord injury is the
parts of the environment, allowing
mining the most effective prevo-
total loss of control. Initially, the
some of the freedom and privacy
cational training methods. The oc-
patient is unable to perform any of
that the patient had before the in-
cupational therapist collaborates
the most basic functional daily tasks
jury. The types of equipment most
with the patient to develop a train-
and is totally dependent on others.
frequently introduced are environ-
ing program that meets the pa-
Not only is the patient unable to
mental control systems (ECS) and
tient's individual needs. Many of
move but, in many cases, he or she
microcomputers. The selection of
the previously described functional
is unable to breathe without help.
the appropriate ECS depends on
activities are prerequisites to the
The primary objective of the re-
range of motion and strength, dis-
achievement of prevocational
habilitation team and most chal-
charge placement, and adaptability
tasks. Activities such as neck
lenging task is to restore areas of
of the equipment. The ECS can be
strengthening and mouthstick ac-
control to the patient. This is ac-
controlled by pneumatic, tongue,
tivities are the preliminary tasks re-
complished through education and
rocking lever, or brow switches.
quired for the carry-over and ap-
the application of technology.
The system may have a built-in
plication of marketable skills.
Education. It is important to
telephone and the capability to
Some of the prevocational train-
educate the patient regarding
manage several simple on/off de-
ing skills developed include typing,
treatment objectives and proce-
vices (e.g., television, lights, rádio,
writing, activating small appliances
The American Journal of Occupational Therapy
711
(e.g., dictaphone and calculator),
for reference. The therapist adapts
the patient in collaboration with
using microcomputers, painting,
the work station to position and
the occupational therapist. Com-
and giving verbal instruction. Al-
stabilize the calculator for optimal
mercially available standard soft-
though some of these activities
use. The therapist develops a pro-
ware packages are used for com-
were discussed earlier, their spe-
gram of assignments for the patient
puter activation practice. These in-
cific relationship to the prevoca-
and observes, evaluates, and docu-
clude word processing packages,
tional situation is discussed here.
ments improved patient skill and
accounting packages, environmen-
Typing. Typing in the prevoca-
accuracy.
tal control programs, music, enter-
tional context is more intense than
Dictaphone/Tape Recorder Use.
tainment, and graphics. Appropri-
during initial functional activities
Some patients are able to record
ate positioning and stabilizing of
training. It is a skill used to com-
their verbal messages by using a
the microcomputer are critical fac-
pose letters and manuscripts and to
dictaphone or tape recorder. The
tors in successful microcomputer
communicate ideas. The therapist
therapist evaluates the various
use. Although work tables for com-
evaluates the patient's knowledge
types of devices available, assessing
puters and other mechanical and
of typing procedures and designs
factors such as activation, position-
electronic equipment are commer-
the program based on this knowl-
ing, and stabilization. The patient
cially available, the therapist often
edge. The typing skills include fa-
practices activating the device by
must modify and adapt the station
miliarity with typewriter key func-
use of a mouthstick or other switch-
to meet individual needs. We pho-
tions, margin and spacing parame-
ing technique. Clarity of voice is
tograph specialized computer
ters, and letter composition. The
important for translating recorded
mounting systems for future ref-
patient is given simple typing as-
communication; therefore, the
erence. Today, because many busi-
signments to practice newly ac-
tape recording sessions provide
nesses use microcomputers, having
quired skills. Typing may be per-
feedback to the patient. A student
this skill makes the patient a more
formed using a mouthstick, pneu-
can use this skill to record class
marketable candidate. Alternative
matic scanning, visual scanning, or
assignments and term papers; a
interfaces may be necessary if tra-
voice activated interface through a
business person can use this skill to
ditional keyboard activation is not
microcomputer.
dictate letters.
possible.
Writing. Mouthstick writing is a
Microcomputer Use.
A micro-
Painting. Art guilds for dis-
task that is practiced primarily for
computer is one of the best modes
abled people have been established
the purpose of developing a legi-
of accomplishing work tasks and
to encourage talented artists to ex-
ble, legal signature. The signature
serves as an adjunct to an ECS. It
hibit and market their art works.
may be the patient's full legal
allows a person to use his or her
Patients are exposed to a variety of
name, initials, or a registered cer-
home as a work station. Learning
painting media, such as watercolor,
tified mark. Mouthstick writing is
to type and to use a microcomputer
oil, or acrylic painting, ceramic and
a difficult, laborious task. Yet, it is
may be accomplished concurrently.
stoneware painting, and acrylic em-
important for the patient to de-
One barrier to computer operation
broidery. Painting may be pursued
velop the ability to sign a legal doc-
is the patient's inability to access
as an avocational activity which has
ument. Various types of writing im-
the standard computer keyboard.
great psychological benefits (see,
plements (e.g., ballpoint pens, felt
Therefore, the therapist evaluates
Figure 4).
tip pens, or pencils) are evaluated
the patient's physical capacities to
Verbal Instruction. The patient
by the patient to determine which
activate the microcomputer. The
is given assignments to verbally di-
is the most effective.
patient may use a mouthstick, an
rect a variety of tasks. For example,
Calculator Use. Desktop or
interfacing scanning system by way
the patient may be asked to give
pocket calculators may be activated
of a pneumatic switch, a brow-
the therapist directions to the hos-
by the use of a mouthstick to cal-
wrinkle switch, a tongue switch, an
pital administrator's office or to
culate mathematical equations, bal-
electromyographic switch, a mer-
give instructions to assemble a sim-
ance checkbooks, complete mathe-
cury switch, or voice activation. Be-
ple woodwork project or prepare a
matic homework assignments, or
cause most microcomputers have
meal. The accomplishment of these
record telephone numbers. Calcu-
training tapes that instruct a person
tasks depends on the accuracy of
lators that record on paper scrolls
on the basic operations of the com-
the patient's verbal instructions.
are used when numbers are needed
puter, these tapes are reviewed by
The therapist provides feedback to
712
November 1985, Volume 39, Number 11
Figure 4
positioning and stabilization of
The patient's local community
Mouthstick painting
equipment is critical to the per-
can often be a great source of funds
formance of vocational tasks.
for equipment. Civic clubs, reli-
Therapists collaborate with reha-
gious affiliations, neighborhoods,
bilitation engineers to design and
and often an entire town will or-
fabricate modified work stations
ganize block parties, garage sales,
that facilitate a patient's optimal
cookouts, and car washes to raise
performance in an occupation.
money for equipment that will in-
tegrate the patient back into his or
Financial Concerns
her community.
ECS, microcomputers, and
power wheelchairs provide patients
Discussion
who have a high-level spinal cord
injury with greater independence
Within the last five years, 75 pa-
and control in life. Unfortunately,
tients with C₁- to C4-level spinal
the cost of these items is high and
cord injury participated in this oc-
is seldom financed through third-
cupational therapy program. Of
party payers. The patient and the
these patients, 4 died before dis-
family have usually exhausted their
charge from the rehabilitation fa-
savings by the time it is appropriate
cility, 62 were discharged to their
to order such equipment. The
homes, and 9 were discharged to
acute care hospitalization for the
nursing homes.
high-level quadriplegic may exceed
Of the survivors, 96% were us-
$114,000 and may be complicated
ing a mouthstick for functional ac-
by essential lifesaving techniques.
tivities at time of discharge. Be-
the patient on clarity and effective-
Therefore, these individuals may
cause of limited finances, only 49%
ness of the instructions. Because
not reach the rehabilitation hospi-
received a power wheelchair, and
many occupations depend mainly
tal until after enormous sums of
only 9% received ECS. Fewer than
on verbal instruction, the refine-
money have been paid. The result
5% received a microcomputer, and
ment of this skill allows the patient
is limited funds for rehabilitation
these were obtained through pri-
to become a more successful can-
services and equipment. Third-
vate funds or were provided by the
didate for occupations such as
party reimbursement agencies do
patient's employer. Special inter-
receptionist, paging operator,
not readily accept the fact that the
face switches, used for emergency
teacher, or psychological or infor-
use of the equipment (e.g., power
power wheelchair braking systems
mation service spokesperson. The
wheelchair, ECS, and even micro-
and/or for microcomputer activa-
C₁ to C₄ quadriplegic person uses
computers) will eventually reduce
tion, were purchased for 7% of this
verbal instruction in vocational
the cost of patient care by allowing
population. The occupational ther-
pursuits and in fulfilling a role con-
the patient more independence, re-
apy program for functional activi-
gruent with family life. Disabled
duced nursing care, and employ-
ties for the high-level quadriplegic
parents will need to instruct their
ment opportunities.
person assisted 16% to return to a
children in various developmental
The occupational therapist and
vocation and 19% to continue or
tasks. The accuracy of the verbal
the rehabilitation team can help
to extend their education in public
direction will be critical to the
the patient find additional financ-
schools and universities.
child's successful achievement of
ing by contacting the state voca-
the tasks.
tional rehabilitation services and
Summary
Modified Work Station Organiza-
local service agencies. Letters of
tion. Employment will be deter-
justification with complete and
The primary purpose of the oc-
mined by prevocational skills ac-
concise information about equip-
cupational therapy program de-
quired and work station adapta-
ment utilization should be sent to
scribed in this paper is the devel-
tion. Information about modified
the patient's insurance company
opment of skills that maximize in-
work station adaptations and the
and other possible contributors.
dependence for C₁ to C₄ quadri-
The American Journal of Occupational Therapy
713
plegic persons. Despite severe
4. Klose KJ, Goldberg ML: Neurological
cal aids used by people with disability.
physical disability and often de-
change following spinal cord injury: An
Am J Occup Ther 37:761-765, 1983
assessment technique and preliminary
creased respiratory function, these
15. Sell GH, Stratford CD, Zimmerman
results. SCI Digest 2(2):35-43, 1980
ME, Youdin M, Milder D: Environ-
individuals often achieve a level of
5. Young JS, Harris RM: High cervical
mental and typewriter control systems
function and control that was im-
(C1-4) spinal cord injury. SCI Digest
for high-level quadriplegic patients:
2(4):7-16, 1980
possible in the previous decades.
Evaluation and prescription. Arch Phys
6. Young JS, Burns PE, Wilt GA: Medical
Med Rehabil 60:246-252, 1979
Occupational therapy, in combi-
charges incurred by the spinal cord
16. Youdin M, Dickey RD, Sell GH, Strat-
nation with medical and engineer-
injured during the first six years follow-
ford CD: Instrumentation for the se-
ing injury. SCI Digest 4(2): 19-34, 1982
ing technology, has had a major
verely disabled: An update. SCI Digest
7. Jay P: An Approach to Occupational Ther-
2(1):16-24, 1980
impact on the rehabilitation of
apy, 3rd edition. London: Butter-
17. Vanderheiden GC: Computers can play
these patients.
worths, 1977
a dual role for disabled individuals. Byte
8. Hopkins HL, Smith HD (eds): Willard
7(9):136, 138-140, 142, 144, 146,
and Spackman's Occupational Therapy,
148, 150, 154, 156, 158-159, 162,
ACKNOWLEDGMENTS
5th edition. Philadelphia: Lippincott,
1982
1978
The authors thank Laurine Battise for
18. Schwejda P, Vanderheiden G: Adap-
9. Trombly CA, Scott AD: Occupational
preparing the manuscript and Gordon Stan-
tive firmware card for the Apple II.
Therapy for Physical Dysfunction. Balti-
ley for doing the illustrations.
Byte 7(9):276, 278, 282, 283, 286, 288,
more: Williams & Wilkins, 1977
291-294, 299, 302, 304, 306, 310,
10. Agerholm M: Equipment for the Dis-
312, 314, 1982
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transparent access to the Apple Ile
1. Carter RE, Donovan WH: 1982 Spinal
11. Hale G: The Source Book for the Disabled.
computer for high spinal cord injured
Cord Center Statistics, Volume 15. Hous-
London: Paddington Press, 1979
individuals. Rehabil Tech Rev 3(2):3-5,
ton: Institute for Rehabilitation and
12. Lowman E, Klinger JL: Aids to Inde-
1984
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pendent Living. New York: McGraw-
20. Vanderheiden GC, Walstead LM (eds):
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Hill, 1969
International Software/Hardware Regis-
(C1-4) spinal cord injury. SCI Digest
13. Robinault IP: Functional Aids for the
try. Madison: University of Wiscon-
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Multiply Handicapped. New York: Har-
sin-Madison, Trace Research and De-
3. Menter RR: Spinal cord injury (beyond
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714
November 1985, Volume 39, Number 11
Reconstructive Hand Surgery for
Quadriplegic Persons
(hand dysfunction, therapy; quadriplegia; tendon transfer)
Juanita Ainsley, Christa Voorhees, Elaine Drake
Reconstructive hand surgery is one
approach to restoring lost hand
W
ith the simple gesture of a
ficult, and surgical attempts often
handshake, the major func-
sabotaged the function that natural
function in quadriplegic patients.
tions of the hand-providing sen-
tenodesis had provided.
This paper describes Craig Hospi-
sation, grip, and human contact-
During the late 1960s and
tal's experience with the two-stage
can be identified. Cervical spinal
1970s, Zancolli (3) developed a sur-
procedure for achieving active grasp
cord injury has a devastating effect
gical procedure with predictable,
and pinch for C₇ spinal cord-in-
on these hand functions because
realistic results that increased hand
jured patients. It describes the hand
varying degrees of paralysis and
function for the C₇ spinal cord-
clinic, patient selection and educa-
loss of sensation result (often per-
injured patient. His work, along
tion, the surgery itself, and postsur-
manently). In a survey of male
with the work of Dr. James House
gical occupational therapy. It also
quadriplegic persons, 75% rated
at the University of Minnesota,
includes follow-up results on all
the restoration of normal function
provided the basis for the hand
patients treated since the program's
of arms and hands as more impor-
program at Craig Hospital devel-
inception.
tant than the return of normal
oped in 1978 with Dr. Charles
bowel and bladder function, nor-
Hamlin, a hand surgeon. Dr. Ham-
mal use of legs, and normal sexual
lin has continued to modify the
function (2).
procedure, referred to as Two-
Methods to reconstruct the
Stage Hand Reconstructive Sur-
quadriplegic person's hand have
gery for Grasp and Pinch, identi-
been of interest for a long time.
fying and using new and improved
Following World War II, the im-
variations (1). This paper describes
provements in the total physical
the occupational therapy program
management of the spinal cord-
used with this procedure.
injured population allowed the ex-
ploration of surgical reconstruc-
The Setting: Hand Clinic
tion for the hand, which included
The hand program ensures op-
bone blocks, joint stabilization, ten-
timum team interaction as the pa-
odeses, and tendon transfers; this
tient is evaluated for and educated
exploration was based in part on
work done for polio patients. The
results were often unsuccessful, re-
Juanita Ainsley, OTR, is Director of
quiring revision and reversal. Also,
Occupational Therapy, and Christa
the daily tasks of the quadriplegic
Voorhees, OTR, and Elaine Drake,
person often were not taken into
OTR, are Senior Supervisors in the
account. For example, joint stabi-
Occupational Therapy Department;
lizations frequently made transfers
all at Craig Hospital, Denver, CO
and propelling the wheelchair dif-
80110.
The American Journal of Occupational Therapy
715
about reconstructive surgical op-
anticipated for themselves. Be-
therapy, and attendant care.) This
tions. Team members include the
cause candidates often hear selec-
figure does not include transpor-
hand surgeon, an attending physi-
tively, the occupational therapist
tation or living expenses for those
cian from the hospital, the director
must encourage them to take as
who do not live locally. While the
of occupational therapy, and the
much time as needed to develop
surgery is considered "elective," in-
occupational therapist specializing
that accurate understanding be-
surance companies usually do
in hand treatment who is responsi-
fore surgery is begun. With input
cover the expenses if they are ed-
ble for the patient. Other attendees
from the entire team, final patient
ucated about the resultant func-
may include a physical therapist,
selection is determined by the phy-
tional gains and the improved qual-
family service counselor, the pa-
sicians, occupational therapist, and
ity of life for these patients.
tient's hospital attending physician,
the patient.
and family members.
Physical Factors
In discussing the surgical options
Emotional Factors
Available passive range of mo-
and revisions for a patient, the
Motivation, tenacity, and the
tion must allow for functional use
hand clinic team considers the pa-
ability to understand the muscle
of the extremity. Mild contrac-
tient's own plans, preferences, ob-
reeducation process are all essen-
tures, however, do not eliminate
jectives, support systems, educa-
tial characteristics in selection be-
patients from surgery. Minimal fin-
tional and vocational commit-
cause they help the patient to get
ger flexion contractures may even
ments, financial resources, and
through the casting period, to ob-
augment the functional outcome.
emotional status. Patients are seen
serve treatment precautions, and
Stretching, casting, or surgical ten-
in the hand clinic postoperatively
to cooperate fully with the therapy
don releases that provide lasting
at intervals throughout the course
program.
results are needed at times to pre-
of hand therapy and continue to be
A candidate's productivity is a
pare a patient for surgery.
seen whenever they return for
factor that can cause lively debate.
For this active transfer, mini-
reevaluation for long-term assess-
Although the candidate's level of
mum strength must be present in
ment of outcome.
independence and educational and
the following muscles: extensor
The advantage of having a team
vocational objectives are weighed,
carpi radialis (longus and brevis)
with a stable and limited group of
the essential issue is whether he or
(ECR-L&B) 5 (normal), pronator
therapists, physicians, and sur-
she has formed realistic personal
teres (PT) 4+ (good plus), bra-
geons is that the opportunity for
goals.
chioradialis (BR) 5 (normal), and
continual dialogue exists. This
Because the casting period essen-
flexor carpi radialis (FCR) 3+ (fair
sharing of surgical and clinical ob-
tially returns the patient to a state
plus). Because the ECR-L tendon
servations and ideas results in con-
of dependency not unlike the time
will be transferred, adequate ECR-
tinual and systematic refinements
immediately following spinal cord
B strength is essential to perform
of the surgery and postsurgical
injury, emotional stability is a ne-
wrist extension. Manual muscle
management.
cessity. To require assistance from
testing cannot accurately differen-
Patient Selection
others for basic care after having
tiate between ECR-L&B strengths.
achieved some measure of inde-
The muscle grade of the FCR is
Candidates for reconstructive
pendence is more trying than most
often an indicator of the strength
hand surgery must be at least one
patients anticipate. The candidate
of the ECR-B. Although the FCR
year post-spinal cord injury and
should also have available atten-
is left intact (i.e., not transferred),
have had neurological stability dur-
dant care and a good support sys-
it is used to provide wrist flexion
ing the past six months. Through
tem of family and friends.
for the extensor phase tenodesis
discussion, primarily with the oc-
action.
cupational therapist, they must
Funding
If spasticity is present, it should
demonstrate accurate understand-
Funding is another factor in se-
not interfere with expected func-
ing of what the surgery will accom-
lection. The 1984 cost of the sur-
tion. Sensation should be adequate
plish and appreciate its limitations
gery is approximately $10,500.
for function. Having diminished
and gains. Candidates' expecta-
(Costs include operating room,
sensation does not rule a patient
tions should be realistic and in
anesthesiologist's and surgeon's
out for surgery because his or her
keeping with the functional goals
fees, electric wheelchair rental,
vision can compensate.
716 November 1985, Volume 39, Number 11
Patient Education
these will affect attendant care are
Figure 1
stressed. Every attempt is made to
Extensor phase
Method
prepare patients to cope with this
Patients need information on all
frustrating time of dependency.
Extensor Communis
aspects of this potential reconstruc-
The therapy program is outlined.
tive hand surgery so they can make
Functional gains and equipment
an informed decision on whether
that may be discarded afer surgery
to have it, and when it is best done
are presented. These gains are con-
and also to cooperate with and fol-
siderable, but it is crucial that the
low through with the treatment
patient understand and accept the
Abductor
Pollicis Longus
Extensor
program afterward. Because so
fact that the hand will not be nor-
Pollicus Longus
much must be covered to educate
mal. Changes in transfer tech-
candidates, all team members are
niques and wheelchair propulsion
involved in the process. The sur-
needed to protect the tendon trans-
geons describe the surgical proce-
fers are illustrated.
dure, the risks, the expected vari-
Patients are told that maximum
lateral pinch (flexor phase). Phase
ation in results, and postsurgical
results are not reached until six
one provides or accentuates the
management. The family service
months to one year after surgery,
hand's inherent tenodesis action.
counselor discusses psychological
that a home program is needed,
When the wrist flexes, the fingers
and financial considerations. Other
and that a surgical revision is a
and thumb extend. Patients who
patients who have had the surgery
possibility. Financial considera-
have enough active finger and
discuss their experiences. The oc-
tions are important. The patient
thumb extension do not need this
cupational therapist brings to-
must understand that this surgery
phase. Phase two uses a strong mus-
gether all of this information in
is elective and that insurance com-
cle to produce a new motion when
elaborate detail to help the patients
panies and other third-party payers
attached to a weak or paralyzed
put all factors in perspective. A
are not obligated to finance it.
muscle. Reduction of almost one
sound and slide show along with
Often this surgery is introduced
muscle grade occurs when the ac-
handouts augment these discus-
long after the third-party payers
tive, transferred muscle is perform-
sions.
have assumed that the major reha-
ing its new motion.
bilitation costs are over. Instead of
Extensor Phase. The extensor
Content
being demanding of the insurance
phase is shown in Figure 1. The
The surgical procedure is re-
company, which would be counter-
extensor pollicis longus (EPL), the
viewed. Names, locations, and ac-
productive, the patient learns how
abductor pollicis longus (APL), and
tions of muscles transferred in the
to sell the procedure, and present
the extensor digitorum communis
surgery and the incision scars are
it in terms of anticipated functional
(EDC) are tenodesed into the ra-
described and demonstrated. It is
gains, increased independence,
dius. An intrinsic procedure to pre-
explained that pain and edema can
and in some cases, new vocational
vent hyperextension of the meta-
be expected following surgery. Pa-
options.
carpophalangeal (MCP) joints, is
tients learn that they will be in the
usually done during the extensor
hospital either one or two days for
Surgical Description
phase. After this phase, a short arm
the surgery, depending on the
cast is applied, which protects the
course of their postoperative re-
The hand occupational therapist
surgical work on the tendon by im-
covery and on the type of anes-
assigned to the patient usually ob-
mobilizing the hand in a functional
thesia selected. They learn that an
serves the surgery to ensure com-
position.
electric wheelchair is needed after
plete familiarity with the proce-
Flexor Phase. The flexor phase
surgery, about the type of casts to
dure and any slight variations that
is shown in Figures 2-4. The ECR-
be applied, and that an overhead
may be involved.
L is sutured into the four tendons
suspension sling is used for treat-
This procedure consists of two
of the flexor digitorum profundus
ment of edema. The type and time
phases: a) tenodesis transfers for
(FDP) for grasp (see Figure 2). BR
of immobilization and restrictions
opening (extensor phase) and b)
(with a free tendon graft for
during convalescence and how
active transfers for gross grasp and
length) is inserted into the abduc-
The American Journal of Occupational Therapy
717
Figure 2
lines. Variations in surgery, pain,
Flexor phase: extensor carpi radialis longus to flexor digitorum profundus (palmar view)
edema, or a patient's difficulty in
learning new motor movements
Extensor Carpi Radialis Longus
can prolong the time.
To Flexor Digitorum Profundus
In preparing the patient for dis-
Palmar View
charge home during the casting pe-
riod, the occupational therapist
makes provisions to elevate the pa-
tient's arm in the overhead suspen-
sion sling and to place the electric
wheelchair drive box on the side of
the uncasted upper extremity, fre-
quently on the nondominant side.
Issuing or loaning adaptive equip-
ment to accommodate these tem-
Extensor Carpi
Flexor Digitorum
porary activities of daily living
Profundus Tendons
(ADL) changes may be indicated.
Radialis Longus
Further, a method of independent
weight shifting is established, and
the date and time for beginning
postsurgical treatment is set.
During the casting period follow-
ing the extensor phase, daily IP
Figure 3
Figure 4
flexion and extension range of mo-
Flexor phase: brachioradialis to ring sublimus
Flexor phase: pronator teres to flexor pollicis
tion is done to ensure a free glide
to abd. pollicis brevis and opponens pollicis
longus (palmar view)
of the FDP to prevent the devel-
Brachioradialis to Ring Sublimus to
Pronator Teres to
opment of binding adhesions.
Abd. Pollicis Brevis and Opponens Pollicis
Flexor Pollicis Longus
After the patient has had four
Palmar View
weeks in cast, the cast and stitches
Abd. Pollicis Brevis
are removed. Daily water soaks are
Opponens Pollicis
Brachioradialis
followed by petrissage; this slow,
circular massage is performed by
Split ring
the finger pads to the scar and ad-
Sublimus
Tendon
Flexor Pollicis
jacent tissue to stimulate circula-
Palmar Fascial
Longus
tion and help break down adhe-
Pulley
Pronator Teres
sions. The volar portion of the re-
moved bivalved cast becomes the
temporary splint, protecting
against marked wrist flexion and
(MCP) extension until a low tem-
tor pollicis brevis (APB) and oppo-
Therapeutic Considerations
perature thermoplastic splint is
nens pollicis (OP) (see Figure 3) for
made.
thumb opposition. The PT is trans-
Therapy time lines are presented
Range of motion is resumed to
ferred to the paralyzed flexor pol-
in Figures 5 and 6 and delineate
all upper extremity joints, keeping
licis longus (FPL) tendon (see Fig-
postsurgical management for each
the following factors in mind. The
ure 4) for thumb flexion. After this
phase. They serve only as guide-
position in which the joints are
phase, a full arm cast is applied,
lines and are individualized for
casted is the position of protection
which immobilizes the upper ex-
each patient; some parts require
to the transfer. Further ranging in
tremity in 90% of elbow flexion, in
more time than others. The treat-
these directions is indicated, once
about 30% of wrist flexion, and in
ment program should not progress
out of the cast. Motions opposite to
functional finger flexion.
faster than is suggested in the time
these must be progressed slowly
718 November 1985, Volume 39, Number 11
Figure 5
Craig Hospital tendon transfer surgery: extensor phase suggested treatment program
Weeks
Activity
0
1
2
3
4
5
6
7
8
Surgery
Casting and ROM
Limited activity
Elevation
IP flexion and extension to all fingers
Treatment
Cast/stitch removal
Splinting and elevation
Water soaks and petrissage
ROM (passive, active, active assistive to all UE joints; IP flexion and extension to all
fingers)
Strengthening (emphasizing wrist extension)
Light ADL (feeding, grooming, hygiene, UE dressing)
Gradual increase time out of splints
Teach protective methods of transferring with splint
Discharge
ROM (as indicated)
Strengthening (all muscles, emphasizing wrist flexion & extension)
Increase ADL skills [LE dressing, pushing manual wheelchair, transfers (use splints with heavy activity)]
Discontinue splints, plan flexor phase surgery
and cautiously to prevent over-
gram is established for all muscles
lows in the second week of treat-
stretching or pulling out of the su-
to be used as motors in the next
ment with adaptive equipment
tured tendon and to prevent pain.
phase, emphasizing wrist extension
(e.g., built-up handles on eating
Full wrist extension with MCP and
because the ECR-L will be trans-
utensils and universal cuffs), which
interphalangeal (IP) flexion is eas-
ferred in the second surgical phase.
is discarded following the second
ily achieved. Gradual progression
Wrist flexion, which powers the ex-
surgical phase. Before discharge,
into wrist flexion with MCP exten-
tensor tenodesis, is also strength-
patients are instructed on how to
sion begins. A strengthening pro-
ened. The resumption of ADLs fol-
increase range of motion and
Figure 6
Craig Hospital tendon transfer surgery: flexor phase suggested treatment program
Weeks
Activity
0
1
2
3
4
5
6
7
8
Surgery
Casting
Limited activity
Elevation
Treatment
Cast/stitch removal
Splinting and elevation
Water soaks, petrissage, ultra sound (with Dr. order)
ROM (passive, active, active assistive to all UE joints)
Muscle reeducation (manual, EMG, Electrical Stim. with Dr. order)
Strengthening (all UE motors)
Light ADL and fine coordination (limit to 2 lb of resistance)
Gradually increase functional activities beyond 2 lb of resistance
Splinting only for transfers and pushing wheelchair
Review transfers and w/c propulsion with splint
Dischärge
ROM
Strengthening
Increase ADL skills
The American Journal of Occupational Therapy 719
strength and ADL skills are re-
and if strengthening is needed.
into a car (making it possible for
viewed. All heavy activity, trans-
The patient proceeds from active
some individuals to drive a car in-
fers, and wheelchair propulsion are
assistive motions to active and re-
stead of a van). In terms of im-
accomplished with the protection
sistive ones in a graduated fashion.
proved self-image, patients enjoyed
of the splint for two additional
As long as the protective splint is
the renewed ability to shake hands.
weeks.
in place, other upper extremity ex-
Patients made gains in home-
Two months after the first sur-
ercises (e.g. the use of wall pulleys)
making and other ADLs such as
gery, the flexor phase is scheduled.
can be performed safely. The ECR-
managing electrical plugs, turning
The treatment for the flexor phase
B now singly must perform full
on and adjusting televisions, using
follows three weeks in cast. The
wrist extension. Once voluntary
knives, managing pots on the stove,
standard cast and stitches are then
contraction of transferred muscles
peeling and chopping vegetables,
removed. Dorsal protection is
is obtained, light ADL and fine
opening the refrigerator, holding
needed against over-extension of
coordination activities begin, lim-
glasses, cups, and pitchers, washing
wrist and fingers. Continuous ele-
iting resistance to 2 pounds of
dishes, and opening soda cans.
vation is critical because trauma to
pinch. At first, activities include
They also had the increased ability
intermuscular tissues is more ex-
writing, hygiene activities, and
to cook, clean house, and do the
tensive in this procedure. Again,
feeding. The resistance (beyond 2
laundry.
the volar portion of the bivalved
pounds) and the time involved in
Avocationally and vocationally,
cast is used as a protective splint
the activity are gradually increased
patients became able to handle the
until another thermoplastic or plas-
in the third and fourth treatment
phone, write with different types
ter one is made. Water soaks,
weeks to include such activities as
of pens (and with enough force to
which help relieve pain, can be
cutting meat, picking up books, lift-
handle carbon paper), pick up fire-
more frequent in this phase. Range
ing pots, and managing wheelchair
wood, throw a ball, use scissors, use
of motion is initiated in all upper
parts.
a paint brush, use hand and electric
extremity joints. When a trans-
tools, and shoot a bow and arrow.
ferred muscle crosses two joints,
Follow-up Results
Patients could pick up very small
each joint is carried separately
Program analysis was compiled
things, large objects, and heavy ob-
through a range of motion, while
in the spring of 1984 on all 23
jects. The array of functional gains
the other is stabilized and posi-
patients who underwent this pro-
that these 23 patients experienced
tioned to create slack on the ten-
cedure. In five of the more recent
is quite impressive.
don. The transferred muscle is pro-
cases, however, the information
The major equipment items dis-
tected by the therapist's correctly
was obtained less than one year
carded by these patients included
placing the hand when ranging,
after surgery, but changes can OC-
the wrist-driven flexor hinge hand
stretching, or strengthening it. Ex-
cur up to one year. Patients were
brace, universal cuff, dressing
ercise is stopped if pain occurs, and
surveyed about their experience
loops, button hooks, pegs for push-
the hand is allowed to rest until the
and were asked to identify their
ing wheelchair, and wheelchair
pain subsides.
gains, complications, and satisfac-
brake extensions. These are signif-
The muscle reeducation process
tion.
icant gains in themselves in terms
is extensive with the flexor phase.
Of the 23 patients, 21 were sat-
of convenience and appearance.
Therefore, this treatment is more
isfied with their gains and were
Surgical results can change over
time consuming than is the exten-
glad they had had the surgery. Sig-
time, depending on how the hand
sor phase treatment. Three new
nificant gains were achieved in self-
is used spontaneously. For exam-
movements must be isolated, pro-
care and in reducing attendant
ple, an individual who habitually
gressing to combinations of new
care needs. Making transfers,
hooks his thumb around the wheel-
motions. Reeducation is done us-
dressing, managing leg bag connec-
chair push handles could loosen or
ing visual and tactile cues, electro-
tions, gripping wheelchair rims,
stretch the thumb into extension,
myographic feedback, and manual
and taking armrests and footrests
thus weakening the pinch. Con-
assistance. On occasion, the sur-
off wheelchairs all became easier
versely, the determined and fre-
geon may order electrical stimula-
for the patients. One potential cost-
quent appropriate use of a hand
tion, if contraction of the rerouted
saving gain is the patient's in-
can result in continued strength-
muscle is not obtained volitionally
creased ability to pull a wheelchair
ening beyond the period of one
720 November 1985, Volume 39, Number 11
year. Surgical revisions are some-
long. and ring fingers to release
Conclusion
times necessary. They are consid-
flexor tightening, and f) arthrod-
While the physical, financial, and
ered a natural and successful step
esis of DIP of ring finger (because
emotional demands are great with
in the program when accomplished
of tightening).
reconstructive hand surgery, most
in a timely fashion.
Grasp strength now averages 13
patients with spinal cord injury feel
Of the two dissatisfied patients,
pounds and pinch averages 5
it is all worthwhile. The cumulative
one's long thumb extensor was
pounds (excluding the one patient
experience of a stable group of sur-
stretched so his thumb rested in his
who plans to reattach the FPL).
geons and therapists, discreet pa-
palm. He has so far refused what
Before surgery, grasp and pinch
tient selection, and patient educa-
should be a successful revision. In
had no measurable strength at all.
tion make the outcome of this two-
the other case, the EDC tendons
Quantitative and qualitative in-
stage reconstructive procedure
pulled out of their insertion in the
formation is important for pro-
predictable. Also, continued access
radius, and the patient waited one
gram evaluation. However, indi-
to the patient is desirable, to mon-
year before returning to have it
vidual expectations and responses
itor postsurgical changes, suggest
revised. Her fingers had con-
preclude any meaningful correla-
home programs, and perform re-
tracted in flexion during that time,
tion between objective measures of
and thus fusion of PIPs and DIPs
visions early and avoid unnecessary
outcome and patient satisfaction.
complications.
was necessary. Her only active
The importance of various func-
This surgical procedure is a wel-
grasp motion is at the MCPs. It is
tions achieved differ from one per-
come alternative to many spinal
functional but not optimally so.
son to another. One patient might
cord-injured patients, restoring
Of the remaining 21 patients
be delighted at a relatively weak
some lost hand function and inde-
with "successful" results, two are
outcome because he or she is able
pendence and offering them new
awaiting surgical revisions. One
to perform something of vital im-
has contractures of DIPs, which
options that affect many areas of
portance to him or her, whereas
their lives.
could be fused if he chooses to have
another patient with a stronger
this done. Another needs to have
outcome might feel less enthusiasm
REFERENCES
the FPL reattached.
because he or she anticipated
Other revisions, all relatively
more.
1. Ainsley J, Hamlin C, Drake E: The
simple, were completed with suc-
The cost-effectiveness of this re-
Craig Hospital Hand Clinic: A team
approach. Spinal Cord Injury Digest
cessful results and included the fol-
constructive hand surgery needs to
Winter, 1981
lowing: a) tightening of EDC,
be studied to identify how and to
2. Hanson RW, Franklin WR: Sexual loss
b) tenodesis of FPL (because ac-
in relation to other functional losses for
what extent the functional gains
spinal cord injured males. Arch Phys
tive transfer had not provided
decrease the cost of attendant care.
Med Rehabil 57:291-293, 1976
enough force) c) release of adhe-
This might be increasingly impor-
3. Zancolli E: Surgery for the quadriplegic
sions, d) insertion of pins in fingers
tant in justifying the surgery to
hand with active, strong wrist extension
preserved. Clin Orthop Rel Res
and thumb, e) flexor tenolysis of
third-party payers.
112:101-113, 1975
The American Journal of Occupational Therapy
721
Wheelchair Cushions for
Spinal Cord-Injured Individuals
(decubitus ulcer, therapy; equipment, therapeutic; pressure; evaluation;
wheelchairs)
Susan Lipton Garber
Pressure sore prevention is a major
W
heelchair cushions are fre-
clinical method of evaluating them.
objective in the rehabilitation of indi-
quently prescribed during
Although some investigators who
viduals with spinal cord injury.
the rehabilitation of individuals
studied the effect of pressure on
Wheelchair cushions are frequently
with paraplegia and quadriplegia
tissue developed instruments to
prescribed to relieve pressure and re-
secondary to spinal cord injury.
measure pressure at the interface
duce the risk of pressure sores in this
The primary purpose of these
of the buttocks and the various
population. In this study, 251 sub-
cushions is to relieve pressure un-
wheelchair cushions, few of these
jects with paraplegia and quadriple-
der the person seated in a wheel-
instruments were usable in the clin-
gia were evaluated to decide which
chair and ultimately to reduce the
ical environment (2, 9). Therefore,
wheelchair cushions were suitable.
risk of pressure sores. During the
clinicians in hospitals and rehabili-
Criteria for the comparative evalua-
last 25 years, many investigators
tation centers developed their own
tion of cushions included not only
have attempted to identify the one
preferences without the benefit of
magnitude and distribution of pres-
wheelchair cushion or material that
scientific evidence.
sure but also factors such as wheel-
would effectively reduce pressure
In recent years, many new
chair compatibility, ease of transfer,
for all individuals with physical dis-
wheelchair cushions have been de-
activities, and independence. Al-
abilities, especially those with
veloped for use by individuals who
though the Roho cushion was pre-
spinal cord injury (1-5). However,
have spinal cord injury and other
scribed most frequently, it was not
it has been determined that no sin-
neurological and musculoskeletal
recommended for all subjects. This
gle device is effective for all people
disorders. These cushions include
study provides additional evidence
and that individual evaluation is
new and improved types of poly-
that no single cushion is optimal for
essential (6-8).
urethane foam, air cushions of
all people with spinal cord injury.
Before 1970, the selection of
various designs, gel cushions of un-
Rather, objective measurements and
wheelchair cushions was usually an
determined contents, and combi-
clinical judgments are essential ele-
arbitrary decision based on the re-
nations of these materials. In addi-
ments of a complete evaluation.
habilitation or medical team's fa-
tion, clinically useful tools for the
miliarity with and the availability
evaluation of the pressure exerted
of these devices. Such devices in-
cluded primarily foams and gels,
although some air cushions were
Susan Lipton Garber, MA, OTR, is
also available. In many hospitals,
Assistant Director, Department of
patients were seated on air rings or
Occupational Therapy, The Institute
"doughnuts" with the hope that
for Rehabilitation and Research,
they would not develop pressure
Houston, TX 77030. She is also As-
sores. Very little was known about
sistant Professor, Department of Re-
the usefulness or effectiveness of
habilitation, Baylor College of Medi-
these devices because there was no
cine, Houston, TX 77030.
722
November 1985, Volume 39, Number 11
on the different cushions have
for the clinical evaluation of more
The selection of currently avail-
been developed (6, 10). These two
than 800 patients. It is discussed in
able wheelchair cushions was deter-
factors have made it possible for
detail elsewhere (6-8, 11). (The
mined by evaluating each subject
occupational therapists to individ-
PEP is now commercially available
on a maximum of seven cushions.
ualize the prescription of these de-
as the Texas Interface Pressure
The cushions were divided into
vices for people with physical disa-
Evaluator (TIPE) through TK Ap-
three major categories: airfilled
bilities.
plied Technology, 11915 Meadow
(Bye Bye Decubiti and Roho), flo-
This paper discusses the evalua-
Trail Lane, Stafford, TX 77477.)
tation (Aqua Seat and Stryker Gel),
tion and prescription of wheelchair
and Foam (Stainless Comfy Hard
cushions for 251 individuals with
Procedures
Foam and Temper Foam) models
spinal cord injury. Although the
The PEP was used to evaluate
(12). The remaining cushion (the
primary factors determining selec-
the magnitude and overall distri-
Jay) is a combination of foam and
tion of the cushion were the mag-
bution of pressure each subject ex-
flotation materials.
nitude of pressure and the distri-
erted while seated in his or her own
bution pattern of the pressure be-
wheelchair or one that closely re-
Results
tween the patient's buttocks and
sembled it in style and size. The
the wheelchair cushion, other fac-
two main objective criteria for
In this study, the Roho produced
tors are also discussed.
cushion selection were a) the mag-
the greatest pressure reduction in
nitude and location of maximum
the majority of subjects. In fact,
Methodology
and ischial pressure, and b) the
Roho cushions were prescribed as
Subjects
overall distribution of pressure.
often as were all other cushions
Subjects consisted of 251 indi-
The sensing pad of the PEP was
combined and were equally effec-
viduals who had sustained a spinal
placed between the subject and the
tive in both males and females (see
cord injury. They were males (N =
cushion being evaluated. Maxi-
Table 1). The second most fre-
207) and females (N = 44) whose
mum pressure was identified as the
quently prescribed cushion, the
injuries resulted in paraplegia (N =
pressure, measured in millimeters
Stainless Comfy Hard Foam, was
145) and quadriplegia (N = 106).
of mercury (mm/Hg), at which the
optimal in only 18% of the subjects.
All subjects were referred to occu-
first light on the readout display
There was no substantial differ-
pational therapy for a wheelchair
became illuminated. Anatomic lo-
ence in the effectiveness of this
cushion evaluation because of a) a
cation of maximum pressure, a
cushion with respect to male or
prior history of pressure sores, b)
bony prominence or soft tissue, was
female subjects. The Jay and Bye
an existing sore, or c) the need to
determined by palpation. The
Bye Decubiti cushions were pre-
correct a pressure sore following
large-matrix design of the sensing
scribed for 14% and 10% of the
surgery.
pad enabled the investigator to de-
subjects, respectively. Again, no
termine the overall pattern of pres-
significant differences were found
Instrument
sure distribution.
with respect to male and female
The instrument used to measure
pressure at the interface of the but-
tocks and the wheelchair cushions
Table 1
was the Pressure Evaluation Pad
Distribution of Wheelchair Cushions Among Subjects Studied (N = 251)
(PEP). This device was designed
Males
Females
Total
and developed specifically to indi-
Cushion Prescribed
N
vidualize the prescription of wheel-
%
N
%
N
%
chair cushions. It was the first clin-
Aqua Seat
5
2
4
9
9
4
Bye Bye Decubiti
18
9
6
14
24
10
ically useful large-matrix pressure-
Jay
30
14
6
14
36
14
monitoring system that permitted
Roho
103
50
24
55
127
51
quantification of pressure in large
Stainless Comfy Hard Foam
38
18
7
16
45
18
Stryker Gel
6
3
1
2
7
3
numbers of physically disabled peo-
Temper Foam
5
2
3
7
8
3
ple who sat on a variety of wheel-
Miscellaneous
3
1
0
0
3
1
chair cushions. Since 1973, the
Totals
207
44
251
PEP has been used in research and
The American Journal of Occupational Therapy
723
Table 2
This study demonstrates that pa-
Distribution of Wheelchair Cushions in the Paraplegic Subpopulation (N = 145)
tients who develop pressure sore
Males
Females
Total
complications while using polyure-
Cushion Prescribed
N
%
N
%
N
%
thane foam cushions are best
Aqua Seat
2
2
2
8
4
3
treated with an alternate pressure
Bye Bye Decubiti
8
7
3
12
11
8
relief cushion. Indeed, 82% of all
Jay
23
19
5
19
28
19
patients in the present investiga-
Roho
55
46
10
38
65
45
tion were best treated with a cush-
Stainless Comfy Hard Foam
24
20
4
15
28
19
Stryker Gel
4
3
0
0
4
3
ion other than the polyurethane
Temper Foam
1
1
2
8
3
2
foam type. Of the various cushions
Miscellaneous
2
2
0
0
2
1
tested, the Roho appeared to be
Totals
119
26
145
optimal in over 50% of the pa-
tients. The basis for this is not com-
pletely clear.
Factors other than pressure en-
ter into the successful prescription
subjects. The remaining cushions
Discussion
of an effective pressure-relief de-
were prescribed infrequently.
vice. Tables 2 and 3 show a re-
There were some differences,
Subjects were referred to occu-
duced rate of prescription of Roho
however, between prescription pat-
pation therapy for a wheelchair
cushions in paraplegic subjects and
terns for paraplegic and quadri-
cushion evaluation because of pre-
an increased use of the Jay and
plegic subjects (see Tables 2 and 3).
vious or existing pressure sore
Stainless cushions in this group. Al-
Approximately 22% more quadri-
problems. In earlier studies that
though Roho cushions provide ex-
plegic subjects received Rohos than
used unselected patient popula-
cellent pressure relief, they do not
did paraplegic subjects. In contrast,
tions, polyurethane foam cushions
provide lateral stability or maneu-
the Jay cushion was prescribed
were the most effective in reducing
verability in some subjects because
170% more frequently for para-
pressure. In fact, during the early
of the cushion's height and convex
plegic than for quadriplegic sub-
phases of rehabilitation, most sub-
surface. In paraplegic patients who
jects. No major differences in cush-
jects were given foam cushions.
have considerable mobility, sensa-
ion efficacy was evident for males
The foam, a 7.5-cm (3-in.) block of
tions of decreased stability and im-
or females within the paraplegic or
firm polyurethane, enabled the
paired transferability were com-
quadriplegic subpopulations. Simi-
subject to achieve- vertical toler-
monly noted in tests using Roho
lar frequencies were noted in the
ance while distributing pressure,
cushions. These sensations were
prescription of the other cushions
develop transfer skills, and increase
not reported by patients using the
studied in both subpopulations.
sitting tolerance.
Jay and Stainless cushions. Further-
more, many paraplegic subjects
tend to use lightweight, more ma-
neuverable wheelchairs, which may
have a reduced compatibility with
Table 3
the Roho cushion. On the other
Distribution of Wheelchair Cushions in the Quadriplegic Subpopulation (N = 106)
Males
Females
Total
hand, most quadriplegic persons
must be secured to their chairs with
Cushion Prescribed
N
%
N
%
N
%
seatbelts and lapboards. These at-
Aqua Seat
3
3
1
6
4
4
tachments compensate for the re-
Bye Bye Decubiti
10
11
1
6
11
10
Jay
6
7
1
6
7
7
duced stability of the Roho cushion
Roho
48
55
10
55
58
55
and thus require heavier-duty
Stainless Comfy Hard Foam
13
15
3
16
16
15
wheelchairs.
Stryker Gel
2
2
1
6
3
3
Temper Foam
4
5
1
6
5
5
The aspects of clinical judgment
Miscellaneous
1
1
0
0
1
1
must weigh heavily in the creation
of a successful cushion prescrip-
Totals
88
18
106
tion. Neither objective criteria,
724
November 1985, Volume 39, Number 11
such as pressure measurement, nor
termine wheelchair cushion pre-
Stauffer ES: Comparison of pressure
distribution qualities in seat cushions.
clinical judgment alone can be as
scription patterns. Although no
Bull Proc Res 10:129-143, 1971
effective as both together. Never-
differences in cushion selection be-
4. Cochran GVB, Slater G: Experimental
theless, the data demonstrate that
tween male and female subjects
evaluation of wheelchair cushions: Re-
no single cushion is uniformly ideal
were noted, there were differences
port of a pilot study. Bull Pros Res 10-
20:29-61, 1973
for all subjects. Therefore, this
between paraplegic and quadri-
5. Souther SG, Carr SD, Vistnes LM:
study provides additional evidence
plegic subjects. No single cushion
Wheelchair cushions to reduce pres-
that individualized prescription of
was identified as ideal for all sub-
sure under bony prominences. Arch
Phys Med Rehabil 55:460-464, 1974
pressure relief devices must be
jects, regardless of diagnosis or sex.
6. Garber SL, Krouskop TA, Carter RE:
done using objective criteria, such
In many rehabilitation facilities,
A system for clinically evaluating
as that provided by such instru-
wheelchair pressure relief cushions. Am
the occupational therapist is re-
J Occup Ther 32:565-570, 1978
ments as the PEP, in combination
sponsible for the prescription of
7. Garber SL, Krouskop TA: Body build
with clinical assessments.
pressure relief devices for individ-
and its relationship to pressure distri-
These data also suggest that
bution in the seated wheelchair patient.
uals with spinal cord injuries. This
Arch Phys Med Rehabil 63:17-20, 1982
reevaluation of patients is essential
study demonstrates that both ob-
8. Krouskop TA, Noble P, Garber SL,
to adequately treat pressure sores
jective evaluation data and careful
Spencer WA: The effectiveness of pre-
once they have developed. Fur-
clinical judgment must be the bases
ventive management in reducing the
occurrence of pressure sores. J Rehabil
thermore, periodic reevaluation
therapists should use for this indi-
Res Dev 20:74-83, 1983
may be necessary to prevent the
vidualized cushion prescription.
9. Bush CA: Study of pressure on skin
development of pressure sores.
under ischial tuberosities and thighs
during sitting. Arch Phys Med Rehabil
The prescriptions may not be
REFERENCES
46:202-213, 1969
static; changes may be necessitated
10. Rogers JE: Program for prevention of
by a patient's alteration of life-
tissue breakdown, in Annual Reports of
1. Kosiak M, Kubecek WG, Olson M,
Progress REC at Rancho Los Amigos Hos-
style, body build, or activity pat-
Kottke FJ: Evaluation of pressure as a
pital, USC. Downey, CA, 1974, pp 50-
tern.
factor in the production of ischial ul-
51
cers. Arch Phys Med Rehabil 39:623-
11. Garber SL, Campion L, Krouskop TA:
629, 1958
Trochanteric pressure in spinal cord
Summary
2. Houle PJ: Evaluation of seat devices
injury. Arch Phys Med Rehabil 63:549-
designed to prevent ischemic ulcers in
552, 1982
Patients with a history of tissue
paraplegic patients. Arch Phys Med Re-
12. Garber SL: A classification of wheel-
habil 50:587-594, 1969
chair seating. Am J Occup Ther 10:652-
breakdown were evaluated to de-
3. Mooney V, Einbund MJ, Rogers JE,
654, 1979
The American Journal of Occupational Therapy
725
Enhancing Vocational Outcomes
of Spinal Cord-Injured Persons:
The Occupational Therapist's Role
(rehabilitation, vocational; services, occupational therapy; work)
Margaret Carrol Kanellos
Because work is a core element of our
ioral and environmental options
physical, social, and psychological
available to the individual, and suc-
H
istorically, the rehabilitation
movement in the United
survival, the significance of work for
cessful performance of job-related
States has been virtually synony-
spinal cord-injured persons is no
tasks in a supportive setting. The in-
mous with vocational rehabilita-
less than it is for able-bodied per-
teraction between the occupational
tion. The predominant criterion
sons. To develop expectations of a
therapist, the vocational rehabilita-
for judging "success" in rehabilita-
productive life-style, vocational plan-
tion specialist, and the employer
tion involves the entry or restora-
ning must be initiated early in the
should be characterized by clear,
tion of the handicapped individual
rehabilitation process, with the occu-
nontechnical communication, an un-
to the world of work. Indeed, the
pational therapist contributing sig-
derstanding of what functional activ-
goal of competitive employment is
nificantly to the initial and ongoing
ities the patient actually does (rather
not simply one that the state-fed-
functional and prevocational assess-
than what the person can do), a will-
eral rehabilitation system imposes
ment. Interaction between the thera-
ingness to try creative solutions to
on its participants, but it is also one
pist and the spinal cord-injured
environmental and performance
that is highly valued by disabled
person can promote the experience of
problems, and a recognition of the
persons as well (1). Neff (1) said,
control over environment, a feeling
employer's need for quantity and
"We live in a strongly work-ori-
of responsibility for success of the re-
quality of production. All these com-
ented society, in which the ability
habilitation process, the ability to
bined reduces the potential for fail-
to perform remunerated employ-
solve functional problems outside of
ure on the job and enhances the like-
ment is not only virtually a sine qua
the rehabilitation environment, an
lihood of achieving the highest possi-
non of full citizenship, but has been
understanding of the range of behav-
ble level of vocational potential.
internalized by most of us as the
indispensable requirement for be-
coming an autonomous and inde-
pendent adult" (p 111).
Persons with spinal cord injury
appear to value work similarly be-
fore and after their injuries (2).
However, the ability of our current
rehabilitation system to move
Margaret Carrol Kanellos, CRC,
MEd, is a rehabilitation counselor
and Director of Vocational Services,
The Institute for Rehabilitation and
Research, Houston, TX 77225.
726 November 1985, Volume 39, Number 11
spinal cord-injured persons with
comes for persons with spinal cord
4. Does the occupational thera-
work-oriented values and goals
injury. Even so, Trieschmann (7),
pist consider innovative and non-
into competitive employment has
in her review of the literature, con-
traditional vocational options that
been disappointing. Studies report
cluded that if success is defined as
may be available to the individual
that post-injury employment varies
employment, we have not been
with spinal injury and work actively
from 20% to 85%, depending on
very successful.
with other rehabilitation team
the definition of "employment."
The vocational potential of the
members to explore the feasibility
Weidman and Freehafer (3), who
spinal cord-injured person de-
of those options?
define the "vocational mode" as
pends mostly on his or her ability
5. Does the occupational thera-
worker, homemaker, or student,
to analyze and solve problems, plan
pist translate functional capabilities
found a 48.3% "positive vocational
and execute the plan, apply skills
into lay terminology in such a way
mode," which is similar to the 49%
and technologies, engage the phys-
that vocational counselors and
reported by the National Spinal
ical and social environment, and
other members of the rehabilita-
Cord Injury Data Research Center.
maintain health and physical capa-
tion team can make informed judg-
However, of the 145 persons they
bilities. While the occupational
ments relative to vocational op-
studied with spinal cord injury,
therapist's role in the restoration
tions?
21% were working as homemakers
of physical function contributes
The ability to affirmatively an-
and 12% as students. Studying pa-
significantly to the ultimate out-
swer these five questions will, to a
tients eight years after injury,
come of rehabilitation, it can also
large degree, provide some mea-
Goldberg and Freed (4) found 15
have important cognitive, emo-
sure of assurance that the occupa-
of 29 persons in the competitive
tional, and social impacts. Whether
tional therapy program contributes
labor market, 1 person a student,
the traditional role of the occupa-
to vocational outcomes. Closer in-
1 person retired and 17 people un-
tional therapist facilitates the vo-
spection of the five questions re-
employed. Siegel (5), in a survey of
cational rehabilitation of the spinal
veals what are essentially five key
persons with quadriplegia, found
cord-injured person is, however, a
issues that can be reduced to short
34% in competitive employment,
subject deserving of critical inspec-
descriptors and examined in
2% as homemakers, 47% in school,
tion. Some of the questions that
greater depth. These five issues
and 17% unemployed. Finally, a
should be asked relative to occu-
are:
study by Jellinek and Harvey (6)
pational therapy services and vo-
long-range planning,
revealed an employment rate of
cational rehabilitation include the
therapeutic behaviors,
19% for spinal cord-injured per-
following:
involvement of family and com-
sons considered able to benefit
1. Is the occupational therapy
munity,
from vocational/educational ser-
plan developed with comprehen-
consideration of all options, and
vices after they had participated in
sive vocational goals in mind as well
appropriate follow-through.
a medical rehabilitation inpatient
as discrete functional objectives?
program without on-site voca-
2. Does the occupational thera-
Principles
tional/educational services. Place-
pist consciously engage in behav-
ment rates increased to 75% when
Long-Range Planning
iors and activities that foster real-
on-site
vocational/educational
istic vocational expectations rather
The examination of these five
services were provided. The con-
than contribute to the spinal cord-
issues can logically begin with long-
fusing inconsistencies in research
injured person's feelings of help-
range planning. The value of long-
results seem to be a function of the
lessness and diminished sense of
range vocational planning in reha-
wide variety of criteria for success
self-worth?
bilitation has only recently been
(work, school, homemaking) and
3. Does the occupational thera-
recognized. Athelstan (8) stated,
the composition of the sample
pist actively engage family, friends,
"Vocational planning seems most
group (persons able to benefit from
and community support systems in
likely to succeed if it starts early
vocational services, all spinal cord-
the therapy program through ed-
and sustains some momentum
injured patients, persons with
ucation and counseling relative to
throughout the rehabilitation pro-
quadriplegia). These inconsisten-
realistic functional expectations
cess" (p 181). Vocational planning
cies also point to a need for a hard-
and problem-solving functional dif-
needs to be initiated at the outset
nosed analysis of employment out-
ficulties?
of the rehabilitation program.
The American Journal of Occupational Therapy 727
Some rehabilitation practitioners
tion, environments, resources, and
ronment. By providing opportuni-
would have us defer vocational
understanding of impairment are
ties for the hospitalized person to
planning until after the restorative
sure to change, the plan must be
exercise some control over the en-
phase of treatment is completed.
flexible and alterable as the reha-
vironment, especially those factors
As an example, a position paper on
bilitation program progresses.
that provide the potential for pain
the role of occupational therapy in
or pleasure, an occupational ther-
the vocational rehabilitation pro-
Therapeutic Behaviors
apist is in a key position to posi-
cess states, "Once the restorative
With the long-range vocational
tively affect the individual's early
phase of treatment has been com-
plan as a guide, the therapist's ap-
motivation, cognition, and emo-
pleted, the need for prevocational
plication of therapeutic behaviors
tional adjustment. While the ther-
assessment of clients with residual
implements the program. The
apeutic experience itself may be
disabilities is considered" (9, p
term therapeutic behaviors was cho-
part of the solution, Wool and oth-
882). Planning the restorative pro-
sen because it can be interpreted
ers (12) have suggested that confi-
gram without considering long-
in several ways. The most obvious
dence training through positive
range outcomes and developing a
interpretation of the term refers to
practice or rehearsal experiences
therapeutic plan that is designed to
the traditional activities the occu-
before exposure to physically or
achieve these outcomes is suspect
pational therapist engages in to re-
emotionally taxing real-life chal-
both conceptually and practically.
store function (e.g., teaching activ-
lenges develops confidence and ex-
Prevocational assessment should
ities of daily living, prescription of
pectation of success.
begin at the outset of the rehabili-
adaptive equipment, etc.). Another
Locus of control is another fac-
tation program and should logi-
interpretation of the term refers to
tor to assess and include in the
cally develop into vocational plan-
the way in which the therapist in-
therapist's development of the
ning, programming, and follow-
teracts with the patient and the in-
therapeutic program. The differ-
through. Long-range vocational
fluence, often unintended, that
ences between people who exhibit
planning is not an easy task. Athel-
these interactions may have on the
behaviors consistent with external
stan (8) cited factors that confound
patient.
locus of control and those who
the planning process, including un-
Taylor (10), in writing about the
exhibit behaviors consistent with
certain medical prognosis, changes
way that occupational therapists in-
internal locus of control are signif-
in financial status or family ar-
teract with persons having spinal
icant and present different prob-
rangements, financial disincen-
cord injury, said,
lems for the therapist. The exter-
tives, or other aspects of the spinal
Therapists may not be communicating
nal locus of control person may not
cord-injured person's life. Often
with patients what they perceive the
assume an active role in directing
the patient is resistant to planning.
goals of the treatment to be or they
the therapeutic program. This al-
"Some patients resist planning as a
may not be acting upon the feedback
from patients regarding their wants
lows the therapist to plan and di-
way of denying the reality of their
and goals. If it is assumed that active
rect the rehabilitation process, thus
disability. However, plans are
patient involvement in treatment is de-
reinforcing the patients' feelings of
needed to guide the treatment pro-
sirable, effective communication be-
helplessness.
gram and to establish some land-
tween therapists and patients is vital. (p
The spinal cord-injured person
marks for measuring progress aside
29)
with an internal locus of control
from physical restoration". (8, p
Failure to actively engage the pa-
can present quite a different prob-
181). Counselors and therapists
tient in the therapeutic program
lem for the therapist who is unpre-
must acknowledge the individual's
can encourage the progression of
pared for the independent, self-di-
desire and even determination to
what Seligman (11), Trieschmann
rected behavior that is characteris-
return to work with his or her pre-
(7), and others have referred to as
tic of these individuals. Albrecht
vious physical capabilities, and a
"learned helplessness."
and Higgins (13) emphasized that
positive, practical approach to the
The theory of learned helpless-
patients who do not adopt the tra-
future can often engage the person
ness states that unless the person
ditional sick role can be proble-
in an interim plan for return to
who has experienced trauma be-
matic, saying, "After extensive
work that entails the use of a wheel-
gins to control the events around
observation of staff conferences, it
chair and deals with barriers. Be-
him or her, the person may cease
became apparent that medical re-
cause the patient's physical func-
making efforts to control the envi-
habilitation staff do not seem pre-
728 November 1985, Volume 39, Number 11
pared to accept these new patient
that person to consistently perform
people who use a wheelchair for
roles and therefore judge some of
that task or activity in the home or
mobility. The obvious "desk" and
these independent patients to be
other environment. The therapist
"bench work" type of occupations
uncooperative and not to have
should be actively involved in de-
come to mind. Jobs traditionally
completed the staff's conception of
termining whether home, work, or
requiring the ability to stand, walk,
the rehabilitation program" (p 44).
another environment is conducive
or use certain upper extremity
The therapist's challenge is to rec-
to the patient's performance of dis-
functions are often ruled out even
ognize the willingness and ability
crete tasks and functions and, if
before they are thoroughly exam-
of the patient to assume an active
not, what alternatives are available
ined with respect to the patient.
role in the therapeutic program
for dealing with the problem. As
This unconscious vocational selec-
and to develop a therapeutic plan
Trieschmann (7) stated, "Rehabili-
tion process may also be accom-
that takes into account differences
tation is the process of learning to
panied by the immediate supposi-
between individuals. The goal is to
live with one's disability in one's
tion that the patient will require
provide as many opportunities for
own environment" (p 20). And be-
additional education or vocational
direct control over the hospital en-
cause rehabilitation is also behavior
training to reenter the job market.
vironment and rehabilitation out-
change, what should merit the
These preconceived notions, en-
comes as possible. By setting goals,
therapist's attention in the final
trenched over time, have signifi-
choosing therapeutic activities, set-
analysis is what the patient actually
cantly impaired the ability of many
ting schedules, ordering priorities,
does rather than what he or she
professionals to seek creative and
and monitoring progress toward
can do.
innovative solutions to the injured
objectives, spinal cord-injured per-
If the patient either cannot or
person's vocational problems.
sons can practice the skills they
chooses not to perform certain be-
In exploring creative and inno-
need to succeed in the world of
haviors "in one's own environ-
vative solutions to the employment
work.
ment," then those behaviors, al-
problem, the role of assessment
though they may be documented
cannot be overemphasized. Proper
Involvement of Family and
in a progress note, do not serve his
assessment requires the involve-
Community
or her rehabilitation. Most occu-
ment of the full rehabilitation
The third issue, involvement of
pational therapists have faced peo-
team, with the patient and voca-
family and community, has re-
ple who have declined the use of
tional specialists assuming key
ceived considerable attention in
adaptive equipment. In such a case,
roles. Hightower-Vandamm (14),
the rehabilitation literature, but it
the occupational therapist should
commenting on the changed role
continues to receive inadequate at-
identify and teach alternate strate-
of the occupational therapist in vo-
tention from many rehabilitation
gies for solving problems related to
cational evaluation and rehabilita-
professionals. Often the interac-
that function. The therapist plays
tion, noted that the therapist's con-
tion with the patient's family (or
a pivotal role in environmental as-
tribution is now more specialized
rehabilitation counselor) is per-
sessment and should work with the
and functionally oriented.
ceived as the responsibility of the
patient's family, friends, and em-
medical social worker or psycholo-
ployers to develop strategies for
In looking at the role of occupational
therapy in vocational evaluation and
gist and is avoided or accorded
living in an environment that may
rehabilitation, it is apparent that the
minimal attention by other clinical
be less than optimal in terms of
occupational therapist no longer holds
specialists. Only by working di-
functional accommodation.
the major role as vocational evaluator,
rectly with family members can the
since this role has been taken over by
occupational therapist ensure that
Consideration of All Options
the persons especially trained in voca-
Perhaps the most significant of
tional evaluation and the professional
they have a clear understanding of
vocational specialist. The occupational
the patient's functional capabilities.
the key issues is the fourth, consid-
therapist, however, does have a role in
Intrinsic to this understanding is
eration of all options. Through a
the vocational evaluation of physically
the notion that, although the pa-
process of unplanned standardiza-
and mentally handicapped clients
tient may be functionally capable
tion, there has come to be an infor-
through the provision of a physical and
functional evaluation and a sensori-
of performing a certain task or ac-
mal protocol that limits one's
motor evaluation, when indicated, and
tivity in the rehabilitation setting,
thinking with respect to the voca-
through the management of a sustain-
it may be unreasonable to expect
tional opportunities available to
ing evaluation program (p 633).
The American Journal of Occupational Therapy
729
A vocational counselor's analysis
nate that, in some respects, we
community in some productive
of the patient's transferrable voca-
beome prisoners of our experi-
(i.e., vocationally satisfying) capac-
tional skills and an investigation of
ence. Because rehabilitation
ity, then the summative evaluation
the application of these skills to the
professionals have, through edu-
of this success is fairly easy to com-
world of work can be of special
cation and experience, developed
plete.
value to the occupational therapist,
a repertoire of solutions to com-
The formative evaluation of the
although it may not readily be
mon or recurring problems, it is
rehabilitation process is more im-
available in some settings. The
often difficult to escape from the
portant to success and more diffi-
counselor's assessment should in-
trap of relying on the convenient
cult to perform. What is required
corporate the patient's educational
or proven path to success. True
is a) ongoing performance assess-
and work history, testing results (if
creative problem solving requires
ment that takes into account the
available), the observations and
both open-mindedness and work.
changes in the spinal cord-injured
judgments of the members of
Solutions to difficult problems do
person's medical, psychological,
the interdisciplinary rehabilitation
not emerge fully developed and
and social situation; b) frequent
team, current occupational status;
ready to put into place; they re-
and critical examination of the
and the realities and resources of
quire time for development, test-
therapeutic regimen to determine
the workplace. Without a voca-
ing, and implementation. In a work
appropriateness and suitability to
tional counselor's assessment, the
environment where time is often
his or her needs at a given point
therapist may stimulate an individ-
the most costly commodity, it is
and time; and c) constant monitor-
ualized approach to the assessment
often more expedient to look for
ing of the communication style and
of vocational options by asking the
the readily available solution.
network to ensure that all key peo-
following questions: Can the pa-
ple, including the patient, rehabil-
tient return to his or her former
Follow-Through
itation professionals, family, and
job? If so, what needs to be done
Addressing the first four issues,
appropriate community members,
to facilitate the return? Can the
no matter how effectively, can fail
are informed and involved to the
patient return to work for his or
to produce desired results if the
extent necessary for optimal re-
her employer in a similar or modi-
fifth issue, appropriate follow-
sults. Without follow-through, vo-à
fied job? Do new technologies have
through, receives inadequate at-
cational rehabilitation becomes ar
the potential of replacing critical
tention. There is a natural ten-
lock-step process that is unrespon-1
job functions that the spinal cord-
dency to perceive follow-through
sive to change in the individual, the
injured person cannot perform? If
as something associated with the
environment, or the other partici-
not, what would the patient like to
finishing or ending of a process.
pants in the process, including re-
do? Is his or her vocational prefer-
This is not the case in vocational
habilitation professionals and
ence one that is reasonable in light
rehabilitation. Follow-through is a
members of the family and com-
of functional capabilities and eco-
continuous process that involves
munity. With the proper amount
nomic and social realities? If the
ongoing assessment, modification,
and timing of follow-through, the
vocational preference is not rea-
and further planning and imple-
process is flexible and fosters crea-
sonable, what alternatives are avail-
mentation. Because, rehabilitation
tive approaches to problem solving
able, and will one of these alterna-
is an evolving process, it is falla-
and vocational planning:
tives be acceptable to the patient?
cious to assume that success or fail-
Finally, have we exhausted all pos-
ure can be judged by taking a mea-
Discussion: Occupational
sible alternatives and looked be-
surement at one point in time and
Therapy Interventions
yond the typical options in explor-
developing plans based on that
ing this issue?
static measurement.
Expectations
Some of these questions may be
Educators use the terms forma-
With these five issues in mind, it
difficult to answer. Trieschmann
tive evaluation and summative eval-
is worth examining the role that
(7) noted the common tendency to
uation to differentiate between
the occupational therapist can play
think of all the possible reasons
process assessment and product as-
in the vocational rehabilitation
why a solution will not work and
sessment. If it is assumed that the
process. The most basic yet signif-
stressed the need to generate
successful end product in rehabili-
icant contribution that any mem-
"ideas in profusion." It is unfortu-
tation is the patient's return to the
ber of the rehabilitation team can
730 November 1985, Volume 39, Number 11
make to a positive vocational out-
workplace: quantity (total output
tional therapist also contributes to
come is the expectation of return
of the worker) and quality (mea-
successful vocational outcomes.
to employment. Study after study
sure of acceptability of the unit of
Knowing that the quadriplegic per-
reaffirms the validity of the Pyg-
work). These constructs should re-
son can operate devices such as a
malion Principle; however, we who
main in the consciousness of the
push-button telephone, stapler, or
work with spinal cord-injured per-
therapist who translates the pa-
copy machine may be more helpful
sons sometimes fail to apply the
tient's performance in therapy into
to the rehabilitation counselor than
concept for fear of encouraging
vocationally relevant data. It is not
knowing the degree of wrist exten-
false hopes. Trieschmann (7) ad-
enough that the patient simply
sion, the number of repetitions lift-
monished that, "We need to con-
demonstrate the ability to perform
ing a weight, or the pounds of pre-
sider each person to be a candidate
a behavior in the context of the
hension. Resources to bridge the
for some job, and we must assess
rehabilitation hospital. To include
communication gaps that often
the person's strengths using multi-
it in the patient's behavioral rep-
separate professional groups are
ple evaluation strategies, psycho-
ertoire, the task must be per-
available. For example, The Selected
logical tests and behavior samples"
formed such that the speed or
Characteristics of Occupations De-
(p 124).
quantity of the behavior and the
fined in the Dictionary of Occupa-
quality of the output allow the pa-
Assessment
tional Titles, (16), a standard refer-
tient to be productive at some level.
ence of all professions that relate
Initial and ongoing functional as-
The occupational therapist who
to the world of work, defines six
sessment is an essential task of the
works with spinal cord-injured
categories of physical activities re-
occupational therapist. In this re-
persons can also create an aware-
quired of a worker in a job and
gard, the occupational therapist is
ness of critical work behaviors on
further breaks down the physical
responsible for assessing a) mobil-
the part of the patient and assess
demands into five degrees in fairly
ity, b) upper extremity and hand
the individual's performance of
specific terms. Another publica-
function, c) coordination, d) speed
those behaviors as part of partici-
tion, Physical Demands Job Analysis:
of motor rèsponse, e) strength and
pation in regularly scheduled ther-
A New Approach (17), breaks down
endurance, f) ability to bend, lift,
apy. Stolov and Hooks (15) have
the job task into detailed, precisely
reach, handle, and feel, and g) spa-
identified 14 examples of work be-
defined physical requirements.
tial limits of work activity. The con-
havior critical to job success; all of
tributions of the occupational ther-
which can be observed by the ther-
Therapeutic Activities
apist in the initial assessment of
apist in the routine therapy pro-
In addition to the important role
these vocational parameters are
gram. However, the expertise of
that occupational therapists play in
certainly important. However, of
the occupational therapist is of par-
the assessment process, they also
equal importance is the ongoing
ticular value when evaluating fac-
have significant therapeutic re-
role of the occupational therapist
tors such as endurance (ability to
sponsibilities. In many cases, the
in documenting change and re-
sustain activity for the period of a
therapeutic program is designed
porting changes to the patient and
day, week, or month) and vitality
with the express purpose of en-
other rehabilitation team mem-
(whether performance levels sus-
hancing motor skills but without
bers. Communication between the
tain or deteriorate over time); pro-
regard for the importance of those
patient and the various members
duction consistency (whether the
motor skills as they relate to voca-
of the rehabilitation team should
worker's output varies from unit to
tional competence. People with
be frequent and clear. As capa-
unit); work methods (organization
spinal cord injury may find them-
bilities increase (or in some cases
of tools and materials); supervision
selves doing leather work or ce-
decrease), the patient and those
requirements; and personal hy-
ramics when their vocational goals
people involved in implementing a
giene, grooming, and dressing.
are focused on electronics work or
vocational program must be kept
By using clear, precise, non-
computer careers. Although the
informed.
technical lay terminology to de-
therapeutic program was designed
Stolov and Hooks (15), in their
scribe the patient's performance to
to strengthen upper extremity
discussion of prevocational evalua-
the vocational rehabilitation coun-
muscles, alternate activities might
tion, pointed out the two factors
selor applying this information to
have been identified that produced
that most affect success in the
the world of work, the occupa-
similar results and also accelerated
The American Journal of Occupational Therapy
731
progress toward vocational goals.
occupational therapist must manip-
gories of rehabilitation profession-
Furthermore, the self-esteem that
ulate the environment to better ac-
als (e.g., vocational specialists and
can come from learning new skills
commodate the patient. This ma-
counselors) has led to a diminution
and engaging in activities per-
nipulation can take the form of
of the role that occupational ther-
ceived as productive and contrib-
designing modifications in the
apists play in vocational rehabilita-
uting to society is a benefit that is,
workplace or prescribing adaptive
tion. It should not be assumed,
although difficult to measure from
equipment that can help the pa-
however, that the occupational
a quantitative perspective, of un-
tient perform prescribed task and
therapist's role in vocational reha-
deniable value.
function in a particular job. Of
bilitation has diminished in propor-
From a behavioral perspective,
even greater importance is the
tion to the percentage of the pro-
the occupational therapist can cre-
teaching of creative problem-solv-
cess for which they were and are
ate opportunities for the spinal
ing approaches so that the patient
responsible. Because rehabilitation
cord-injured person to experience
can assess environmental obstacles
services to provide a more compre-
success, gain control over the en-
and develop solutions on his or her
hensive program to the spinal
vironment, and avoid developing
own.
cord-injured person have ex-
behaviors associated with learned
panded, the sophistication of vo-
helplessness. For example, confi-
Conclusion
cational evaluation and vocational
dence training (positive practice or
The occupational therapist
rehabilitation services has in-
rehearsal experiences prior to ex-
brings to vocational rehabilitation
creased dramatically. It would be
posure to physically or emotionally
unique knowledge and skills that
erroneous to conclude that occu-
taxing real-life challenges) may
can potentially enhance vocational
pational therapists could assume
counteract the forces promoting
outcomes. Failure to involve the
the added assessment and service
learned helplessness in the individ-
occupational therapist in prevoca-
delivery demands that came with
ual who has sustained the trauma
tional and vocational programming
expansion of services. What has de-
of spinal cord injury (12). Devel-
to a substantive degree detracts sig-
veloped is a situation in which the
oping a gradual hierarchy of steps
nificantly from the likelihood of
knowledge and skills of the occu-
that bridge the gap to difficult ac-
achieving desired outcomes. The
pational therapist complement the
tivities is a similar approach (18).
occupational therapist's involve-
knowledge and skills of other mem-
Also, by analyzing activities in
ment is needed in prevocational
bers of the rehabilitation team (in
which the patient was previously
stages with respect to the expecta-
general) and vocational specialists
engaged, the therapist can help
tion of productivity, the develop-
(in particular), all to the ultimate
him or her gain access to rein-
ment of good work habits, the
benefit of the spinal cord-injured
forcers as expeditiously as possible.
practice of personal hygiene, which
person. However, this complemen-
Other techniques involve the ex-
will enhance the likelihood of ac-
tary process will not automatically
tinction of disability-inappropriate
ceptance in the work setting, the
occur. A conscious effort must be
behaviors, the selection of rein-
refinement of writing and other
made by the occupational therapist
forcers, to increase desired behav-
motor skills to a degree that they
to be actively involved in voca-
iors, modeling, the use of perform-
are applicable in the work setting,
tional rehabilitation, just as other
ance graphs to monitor progress,
and the provision of other ancillary
team members must remain cog-
and the evaluation of progress in
skills, such as driver training, which
nizant of the contributions that OC-
terms of environmental and patient
improve the likelihood of securing
cupational therapists can make.
changes (19).
employment. The occupational
To quote from the American
The person with spinal cord in-
therapist's role in actually securing
Occupational Therapy Associa-
jury is confronted by an environ-
employment includes evaluating
tion's AD Hoc Committee of the
ment that offers substantial bar-
and recommending changes in the
Commission on Practice: "Occu-
riers to employment. Machines are
work environment and prescrib-
pational therapy is based upon
designed for people who have use
ing, fitting, and instructing in the
the fundamental belief that en-
of upper and lower extremities.
use of job-specific, adaptive equip-
gagement in purposeful activity
Work stations are generally de-
ment.
(occupation), including both the in-
signed with little regard for wheel-
In summary, the emergence
terpersonal and environmental di-
chairs or other equipment. The
since World War II of new cate-
mensions, may prevent or reme-
732
November 1985, Volume 39, Number 11
diate dysfunction and elicit maxi-
2. Goldberg RT, Freed MM: Vocational
sion, Development and Death. San Fran-
mum performance in the work role
adjustment, interests, work values, and
cisco: Freeman, 1975
career plans of persons with spinal cord
12. Wool RN, Siegel D, Fine PR: Task
adaptation" (9, p 881).
injuries. Scand J Rehabil Med 5:3-11,
performance in spinal cord injury: Ef-
When services are provided on
1973
fect of helplessness training. Arch Phys
the basis of narrowly focused func-
3. Weidman CD, Freehafer AA: Voca-
Med Rehabil 18:36-45, 1977
tional outcome in patients with spinal
13. Albrecht G, Higgins P: Rehabilitation
tional objectives and do not take
cord injury. J Rehabil 47:63-65, 1981
success: The interrelationships of mul-
into account the broader goals,
4. Goldberg RT, Freed MM: Vocational
tiple criteria. J Health Soc Behav 18:36-
both with respect to vocational out-
development of spinal cord injured pa-
45, 1977
tients: An 8-year follow-up. Arch Phys
14. Hightower-Vandamm MD: The role of
comes and general quality of life,
Med Rehabil 63:207-210, 1982
occupational therapy in vocational
optimal results are not likely to be
5. Siegel MS: the vocational potential of
evaluation, Part 2. Am J Occup Ther
achieved. A true collaborative ef-
the quadriplegic. Med Clin North Am
35:631-633, 1981
53:713-718, 1969
15. Stolov WC, Hooks DL: Prevocational
fort that actively engages the OC-
6. Jellinek HM, Harvey RF: Vocational/
evaluation. In Krusen's Handbook of
cupational therapist in planning
educational services in a medical reha-
Physical Medicine and Rehabilitation, FJ
and implementing the vocational
bilitation facility: Outcomes in spinal
Kottke, GK Stillwell, JS Lehmann, Ed-
cord and brain injured patients. Arch
itors. Philadelphia: Saunders, 1982, pp
program results in reduced trial
Phys Med Rehabil 63:87-88, 1982
190-198
and error in identifying vocational
7. Trieschmann RB: Spinal Cord Injuries:
16. The Selected Characteristics of Occupa-
options, clarification of functional
Psychological, Social and Vocational Ad-
tions Defined in the Dictionary of Occu-
strengths and weaknesses, and en-
justment. New York: Pergamon, 1980
pational Titles. Washington, DC: US
8. Athelstan GT: Vocational assessment
Dept of Labor publication No 1980 0-
hanced likelihood of achieving the
and management. In Krusen's Hand-
301-764. Employment and Training
highest possible level of vocational
book of Physical Medicine and Rehabili-
Administration, 1981
potential. These, ultimately are the
tation, 3rd edition, FJ Kottke, GK Still-
17. Lytel RB, Botterbusch KF: Physical De-
well, JF Lehmann, Editors. Philadel-
mands Job Analysis: A New Approach.
goals of the rehabilitation process.
phia: Saunders, 1982, PP 163-189
Menomonie, WI: Materials Develop-
9. Ad Hoc Committee of the Commission
ment Center, 1981
18. National Institute of Handicapped Re-
REFERENCES
on Practice: The role of occupational
search: Adjusting to disability-Les-
therapy in the vocational rehabilitation
sons from spinal cord injury research.
process. Am J Occup Ther 34:881-883,
Rehabil Brief 11:1-4, 1979
1. Neff WS: Rehabilitation and work. In
1980
19. Fordyce WE: Behavioral methods in
Rehabilitation Psychology, WS Neff, Ed-
10. Taylor D: Treatment goals for quadri-
rehabilitation. In Rehabilitation Psychol-
itor. Washington, DC: American Psy-
plegic and paraplegic patients. Am J
ogy, WS Neff, Editor. Washington, DC:
chological Association, 1971, pp 109-
Occup Ther 28:22-29, 1974
American Psychological Association,
142
11. Seligman M: Helplessness: On Depres-
1971, PP 74-108
The American Journal of Occupational Therapy
733
Independence: The Ultimate Goal
of Rehabilitation for
Spinal Cord-Injured Persons
(consumer participation; independent living; rehabilitation; role,
occupational; spinal cord injuries)
Lex Frieden, Jean A. Cole
During the late 1960s and early
services necessary to expand the
T
he question is often asked,
1970s, a new concept related to re-
range of living options for disabled
"What are the long-term
habilitation and improvements in
people beyond those traditionally
goals of spinal cord-injured indi-
quality of life began to emerge and be
available in most communities.
viduals after rehabilitation?" The
expressed by people with spinal cord
The role of occupational therapists
answer is, more likely than not,
injuries and other disabilities. This
in the independent living stage of the
that the goals of spinal cord-in-
concept, independent living, is the
rehabilitation process can be similar
jured individuals are generally the
foundation of the independent living
in some respects to their role during
same as those for anyone else. Most
movement, which has helped to over-
earlier phases of medical rehabilita-
people want to have a family, a
come the barriers to a higher quality
tion. However, the definition of inde-
home, a car, a job, and recreational
of life for disabled people. Of the
pendence as a "mind process" leads
opportunities.
many organizations and programs
to considerable expansion of the ther-
In the past, some rehabilitation
set up to provide support for dis-
apist's role beyond the focus on phys-
professionals, friends, and family
abled people living in the community,
ical skills, which are usually key
members have discouraged people
the independent living program
priorities during medical rehabilita-
with spinal cord injuries from
seems to be comparatively successful
tion. Occupational therapists typi-
adopting or seeking these goals.
at facilitating independence by peo-
cally possess knowledge and skills
ple with spinal cord injuries. Inde-
that equip them well for assisting
pendent living programs provide the
clients in the independent living
Lex Frieden, MA, is Executive Direc-
kind of community-based support
stage of the rehabilitation process.
tor, National Council on the Handi-
capped, Washington, DC 20591. At
the time of this study he was Director,
Independent Living Research Utili-
zation Project, The Institute for Re-
habilitation and Research, Houston,
TX, and Assistant Professor of Reha-
bilitation at Baylor College of Medi-
cine, Houston, TX.
Jean A. Cole, PhD, is a master's
candidate, School of Occupational
Therapy, Texas Woman's University;
she also is Assistant Professor of Re-
habilitation at Baylor College of
Medicine, Houston, TX, 77030.
734 November 1985, Volume 39, Number 11
The injured people were led to
open to the general public. They
toward people with disabilities and
believe that such goals were un-
rejected the notion, often ex-
of disabled people toward them-
realistic and that they should be
pressed by professionals, that they
selves. Perhaps most important, it
satisfied and happy to be alive. Lit-
should be confined to institutional
led to new opportunities for se-
tle hope was given for spinal cord-
care. They rejected the assumption
verely disabled people, including
injured people to achieve near-nor-
that they had fewer rights than
those with spinal cord injuries, to
mal lives; in fact, the general pub-
nondisabled people, and they re-
seek independence, to enjoy the
lic's expectations of life for spinal
jected the idea that government's
benefits of their labors, and to en-
cord-injured people could be
obligation to them was limited by
joy the high standards and quality
weighed on a different scale of nor-
their disability.
of life that society offers (2).
mality than was their own. What
These people began to assert
As a result of the independent
was considered a normal life-style
themselves in public forums. They
living movement and the changes
for the general population was not
organized and formed lobbying
that have occurred during the past
considered normal for people with
groups. They claimed equal rights
few years, people with spinal cord
spinal cord injury. As a result of
as citizens to public services like
injury may now realistically seek
these attitudes, many spinal cord-
transportation, housing, educa-
goals that were once limited to
injured people adopted restricted
tion, and employment and de-
nondisabled people. In fact, the
goals and lowered their expecta-
manded to vote. Although most of
limits imposed by spinal cord injury
tions.
these rights were not denied inten-
may be less important in determin-
During the late 1960s and early
tionally or directly, they were in-
ing the achievement of a person's
1970s, a new concept related to
directly denied by virtue of the fact
goals than are certain other demo-
rehabilitation and improvements in
that most of the public services and
graphic and socioeconomic varia-
quality of life began to emerge and
the public offices and polls were
bles not related to the disability.
was expressed by people with spinal
inaccessible to them.
Many disabled people now go di-
cord injuries and other disabilities.
From the concept of indepen-
rectly from the rehabilitation cen-
This concept is called independent
dence, a movement emerged to
ter to independent living arrange-
living and is defined as follows:
overcome the barriers to a higher
ments in the community. Others
Control over one's life based on the
quality of life for disabled people.
do so after a temporary respite with
choice of acceptable options that mini-
Called the independent living
their families, and still others do so
mize reliance on others in making de-
movement, it is defined as follows:
after participating in extended vo-
cisions and in performing everyday ac-
tivities. This includes managing one's
The process of translating into reality
cational rehabilitation or transi-
affairs, participating in day-to-day life
the theory that, given appropriate sup-
tional living programs.
portive services, accessible environ-
in the community, fulfilling a range of
social roles, and making decisions that
ments, and pertinent information and
lead to self-determination and the min-
skills, severely disabled individuals may
Overcoming Barriers
imization of physical or psychological
actively participate in all aspects of so-
The principal barriers to achiev-
ciety (1).
dependence upon others (1).
ing goals of independence that
This movement was joined by
spinal cord-injured people face
At first, it was a reaction to
disabled people, their family mem-
may be categorized into three
repression. Some disabled people
bers, friends, and neighbors, reha-
groups: environmental, personal,
felt their lives were unnecessarily
bilitation professionals, politicians,
and economic. Environmental bar-
restricted by their disabilities.
opinion leaders, policy makers, and
riers are independent of and often
They acknowledged that the bar-
people throughout society. The
beyond immediate control of the
riers to goals of independence that
movement led to new laws that as-
individual (e.g., curbs, steps, and
exist for everyone were compli-
serted equality and protected the
narrow doorways). Environmental
cated by disability, but they be-
rights of disabled people. It led to
barriers may also be the societal
lieved the barriers could be over-
new or adapted accommodations,
attitudes that project disabled peo-
come. They felt that supportive
making housing, transportation,
ple as incapable and pathetic. Per-
programs could be established and
public places, schools, and job sites
sonal barriers relate directly to in-
environmental accommodations
accessible to people with disabili-
dividuals and, more likely than not,
made, that would allow them to
ties. It also led to new, more posi-
can be affected by them. Examples
have opportunities and seek goals
tive attitudes by the general public
of such barriers include negative
The American Journal of Occupational Therapy
735
attitudes, low self-esteem, feelings
couragement, and self-control, in
would include a nationalized health
of dependence, unreasonable inse-
addition to simply the passage of
insurance program, a nationwide
curity, unwillingness to take risks,
time, may be instrumental in the
attendant care or home health care
preoccupations with cure, the ina-
resolution of personal barriers. On
program, or a nationwide system
bility to organize and plan, poor
a broader scale, positive attitudes
for purchase and distribution of
self-image, and unnecessarily lim-
and expectations of the general
equipment and devices for disabled
ited expectations and goals. Eco-
public, and positive portrayals of
people.
nomic barriers relate to an inability
spinal cord-injured persons by the
to purchase needed equipment,
mass media, would be helpful.
supplies, and services. Economic
Economic barriers may be not
Role of Independent Living
barriers may confound a person's
only the most difficult to overcome
Programs
ability to overcome both environ-
but also the most important, be-
Of the many organizations and
mental and personal barriers be-
cause they can affect solutions to
programs set up to provide support
cause they restrict the range of pos-
the other two types of barriers. Ob-
for severely disabled people living
sible solutions.
viously, spinal cord-injured people
in the community, one new type of
There are more solutions now
who are independently wealthy or
than ever before to overcoming the
whose families have substantial
program seems to be compara-
tively successful at facilitating in-
barriers to independence, includ-
means are not as likely to be bound
dependence by people with spinal
ing purchasing or making adaptive
by economic barriers as are others.
cord injuries. This is the indepen-
equipment and devices. For exam-
However, the vast majority of peo-
dent living program, which is de-
ple, high-level quadriplegic per-
ple who are disabled must depend
fined as:
sons may purchase electrically pow-
on private or public insurance, pri-
ered wheelchairs that are con-
vate or public aid, and their own
A community-based program which
trolled by either making slight
abilities to work and earn money.
has substantial consumer involvement,
movements of the chin or by sip-
Independence costs more for
provides directly or coordinates indi-
rectly through referral those services
ping and püffing into a straw. So-
spinal cord-injured people than
necessary to assist severely disabled in-
phisticated remote-control devices
for nondisabled people because in
dividuals to increase self-determination
and primitive robots are also avail-
addition to normal expenses (e.g.,
and to minimize unnecessary depen-
able. In addition, there are
housing, transportation, food,
dence on others. Services that an in-
broader, more systematic solu-
clothing, and routine medical
dependent living program must pro-
vide or coordinate through referral are
tions, such as the mandated use of
care), they have expenses for adap-
housing, attendant care, readers and/
mass transportation vehicles made
tive equipment, medical supplies,
or interpreters; and information about
accessible by widening doorways,
and attendant care. The economic
goods and services relevant to inde-
expanding seating areas, and in-
barriers to independence for spinal
pendent living. Other services that are
stalling ramps or lifts. This also
cord-injured people are frequently
either provided or coordinated by in-
dependent living programs include
includes community-wide efforts to
complicated by the fact that to be
transportation provision or registry,
install ramps on curbs and provide
independent, most people need a
peer counseling, advocacy or political
access to both public and private
job, but to have a job, one must be
action, independent living skills train-
buildings.
reasonably independent.
ing, equipment maintenance and re-
With respect to personal bar-
Examples of solutions to over-
pair, and social-recreational services.
Note that custodial care facilities and
riers, there are several possible so-
coming economic barriers include
primary medical care facilities are spe-
lutions. Rehabilitation counselors,
housing subsidies to help pay for
cifically excluded from the definition
psychologists, social workers, and
housing, vocational rehabilitation
of an independent living program (1).
other professional human service
agency grants or subsidies to help
providers may help a client analyze
pay for educational or work-re-
Independent living programs
and overcome these barriers. Peer
lated expenses, welfare or human
typically are unique among those
counselors may share informa-
service agency subsidies to help pay
programs serving spinal cord-in-
tion, serve as role models, and pro-
for attendant care expenses, and
jured people in the community
vide support. Family members
work income or Social Security Dis-
because they are generally run
and friends may give encourage-
ability Insurance payments to
by or managed in large part by
ment and support. Finally, a
cover the balance of other ex-
consumers-the disabled people
client's self-determination, self-en-
penses. More general solutions
themselves. They are also unique
736 November 1985, Volume 39, Number 11
because they usually serve a cross-
disabled people from comparatively
Role of the Occupational
disability population, and they
dependent living situations to compar-
often organize their services
atively independent living situations.
Therapist
The primary service provided by these
In 1981, the American Occupa-
around a peer support model, as
programs is skill training in such areas
tional Therapy Association
opposed to one of professional in-
as attendant management, financial
adopted an official position paper
tervention or treatment. Perhaps
management, consumer affairs, mobil-
that emphasizes the congruences
most important of all, they often
ity, educational-vocational opportuni-
ties, medical needs, living arrange-
between principles and practices of
provide a broad range of services,
ments, social skills, time management,
occupational therapy and the field
including housing referral, atten-
functional skills, sexuality and so forth.
of independent living. The discus-
dant care referral, information
Additional services may be provided.
sion here is intended to provide
about goods and services provided
Transitional programs are usually goal-
more specific ideas on how thera-
by other agencies, peer counseling,
oriented and/or time-linked (1).
pists might operationalize these
transportation, equipment repair,
It has proven to be exceptionally
general concepts in specific ways to
independent living skills training,
effective in helping spinal cord-
help disabled people live indepen-
and advocacy (3). Independent
injured individuals acquire the in-
dently (5).
living programs tend to focus on
formation and skills they need to
The role of occupational thera-
solving problems caused by the en-
successfully establish an indepen-
pists in the independent living
vironment and the person's inter-
dent life-style following rehabilita-
stage of the rehabilitation process
action with the environment as
tion. Transitional programs pro-
can be similar in some respects to
opposed to the usual approach
vide instruction in areas of mobil-
their role during earlier phases of
in rehabilitation of focusing on
ity, medical self-care, financial
medical rehabilitation. Important
problems associated with the indi-
management, attendant care, hous-
therapist functions in both phases
vidual and his or her specific dis-
ing, sexuality, and social skills
include teaching clients adaptive
abling condition.
among others. More important,
techniques, helping them acquire
Since the independent living
these programs encourage individ-
and learn to use equipment, and
movement began in the early
uals to make decisions for them-
providing consultation on physical
1970s, nearly 200 independent liv-
selves and to be responsible for
modifications of home or work en-
ing programs have been estab-
their own lives. Examples of tran-
vironments. These approaches
lished. Programs are now located
sitional independent living pro-
may be useful in all of the major
in every state, and together they
grams that are effectively serving
occupational domains of the per-
are annually serving more than
spinal cord-injured individuals are
son's life, including work, leisure
20,000 severely disabled people,
being operated by several regional
activities, and self-care. Beyond the
many of whom have spinal cord
spinal cord injury centers, includ-
functions of occupational thera-
injuries. According to the Registry
ing the Institute for Rehabilitation
pists that are most evident in ear-
of Independent Living Programs
and Research, Rancho de Lós Ami-
lier phases of medical rehabilita-
maintained by the Independent
gos, and Craig Rehabilitation Insti-
tion, there are several additional
Living Research Utilization
tute.
ways in which they can be helpful
(ILRU) project in Houston, more
For people with spinal cord in-
to clients at the independent living
than 90% of these programs serve
juries, independent living pro-
stage of their rehabilitation. These
people with spinal cord injuries (4).
grams may provide the kind of
are examined in terms of the dis-
As a matter of fact, most of the
community-based support services
tinctions established above be-
early leaders in the independent
necessary to expand the range of
tween personal, environmental,
living movement were people with
living options beyond those tradi-
and economic barriers to inde-
spinal cord injuries, and today
tionally available in most commu-
pendence that severely physically
many programs are managed by
nities. These people have already
disabled people face.
people with such injuries.
demonstrated that, given appropri-
In helping clients deal with per-
A particular type of independent
ate support services, they can live
sonal barriers to independent liv-
living program, the transitional
comparatively independently in
ing, it is extremely important that
program, is defined as follows:
the community outside of their
we recognize the definition of in-
An independent living program that
parents' homes, nursing homes,
dependence that is fundamental to
facilitates the movement of severely
and other institutions.
the independent living movement.
The American Journal of Occupational Therapy 737
Heumann (6), in a classic mono-
indicates that these skills are often
sonal barriers to independence, OC-
graph in the literature of the inde-
more effectively taught through
cupational therapists can play im-
pendent living movement, suc-
experiential learning on field trips
portant roles as teachers of skills of
cinctly stated the following defini-
or through other activities in actual
self-direction and as counselors or
tion. "To us, independence does
community settings (8).
advisers who help clients analyze
not mean doing things physically
Occupational therapists possess a
their life-styles in terms of concrete
alone. It means being able to make
theoretical framework, which may
activity patterns.
independent decisions. It is a mind
enable them to help clients analyze
Occupational therapists can also
process not contingent upon a 'nor-
their life-styles in terms of the re-
help clients deal with environmen-
mal' body" (p 1). This definition of
lationship between activities and
tal barriers to independence.
independence as a "mind process"
roles and to understand how what
Traditionally, therapists have
leads to considerable expansion of
they do shapes who they are. The
helped people deal with such bar-
the therapist's potential role be-
concepts of occupational behavior
riers in their immediate home or
yond the focus on physical skills
theory are useful a) in considering
work surroundings by recommend-
which are usually key priorities
how activity competencies are com-
ing space modifications, rearrange-
during medical rehabilitation.
bined into social roles for a given
ment of furnishings, the use of
The implications of the inde-
client, and b) in helping the client
ramps or curb-cuts, and the use of
pendent living philosophy to the
recognize that loss of specific com-
adaptive tools and equipment that
practice of occupational therapy
petencies need not mean that he or
can compensate for inconvenient
dictates that the therapist's princi-
she must withdraw from associated
features of environmental design.
pal role be one of support in help-
roles if substitute activity compe-
The independent living movement
ing the client learn to solve prob-
tencies can be acquired. For ex-
challenges occupational therapists
lems related to his or her inter-
ample, this approach can help a
to think of the environment much
action with the environment as
client realize that he can be a good
more broadly, at the level of the
opposed to directing therapeutic
father, although he personally does
neighborhood or perhaps the com-
activities designed to restore cer-
not show his child how to play base-
munity. At this level, the environ-
tain of the client's abilities. This is
ball, or a good husband, although
ment can be thought of as an array
not to say that restorative activities
he does not mow the lawn or make
of opportunities and resources ac-
are not important but that there is
home repairs. This point may seem
cessible to the individual, but they
sometimes far too much emphasis
self-evident, but experience with a
must be within the mobility sphere
placed on changing the person as
large number of independently liv-
of the individual. Using an envi-
opposed to helping the person
ing clients indicates that they often
ronmental frame of reference, a
adapt to the circumstances and
feel they must give up present or
therapist might help a spinal cord-
change the environment.
future roles because they lack spe-
injured person choose an apart-
The theoretical literature and
cific activity competencies usually
ment in a neighborhood that has a
professional training of occupa-
associated with the role.
grocery store, bank, pharmacy,
tional therapists equips them well
Because occupational therapists
recreational facilities, and oppor-
to teach clients specific skills of self-
have a background in activity anal-
tunities for social interaction
direction. These skills include cre-
ysis and because they are aware of
within range of an electric wheel-
ative problem solving, crisis man-
the importance of "doing" for a
chair. The therapist might also
agement, sequential planning,
sense of competence and control,
help the person analyze the deci-
communicating effectively, identi-
they can often provide counseling
sion to move to a new community
fying resources, setting priorities,
about role issues in much more
that offers more job options, better
comparing choices, making com-
concrete terms than can counselors
support services, or a milder cli-
mitments, assessing risks, and mak-
with other backgrounds. The ap-
mate.
ing decisions (7). Such skills are
peal to many handicapped people
Occupational therapists can also
usually taught by working through
of a practical and concrete ap-
act as advocates for changes in the
hypothetical examples. However,
proach to life planning is demon-
environment. For example, they
several years of experience in the
strated by the great popularity of
might join and become active in an
New Options Transitional Living
peer counseling in consumer-run
organization whose purpose is to
Project at the Institute for Reha-
independent living programs.
assure accessible transportation for
bilitation and Research in Houston
Thus, to help overcome the per-
disabled people, or they might de-
738
November 1985, Volume 39, Number 11
velop a new attendant training and
ing involved in organizations such
may serve as vital allies to disabled
referral program for the commu-
as local, state, or national consumer
people seeking the goals of inde-
nity.
coalitions, independent living pro-
pendence.
Economic barriers to indepen-
grams, or Governors' Committees
dence often seem to be outside the
for Employment of the Handi-
ACKNOWLEDGMENTS
realm of the occupational therapist
capped.
L. Frieden and J. A. Cole, formerly re-
because they arise from basic fam-
search director and project director, respec-
ily circumstances and from public
tively, of the New Options transitional living
Summary
project at the Institute for Rehabilitation
policy and formal benefit systems
and Research (TIRR), acknowledge the
established by the government or
Occupational therapists typically
many meaningful ideas and experiences that
large organizations (e.g., insurance
possess knowledge and skills that
were shared with them by former New Op-
tions staff members and participants and
companies). However, at the level
equip them well for helping clients
which contributed to the substance of this
of the individual, therapists can
in the independent living stage of
article. This project was supported in part
help disabled people learn to use
the rehabilitation process. With
by a grant to Baylor College of Medicine
and TIRR (RT-4) from the Department of
the support services and benefit
their holistic perspective of the in-
Education, National Institute for Handi-
programs available to facilitate in-
dividual within an environment,
capped Research (No. G008300044). For
dependence. Also, by using reim-
with a view that emphasizes effec-
further information related to independent
living, write ILRU, PO Box 20095, Hous-
bursement-oriented terminology
tive functioning in broad domains
ton, TX 77225. ILRU is a national center
(9), therapists can help clients de-
of work, play, and self-care occu-
for information, training, and technical as-
velop maximum available benefits
pations, and with their preponder-
sistance for independent living. Its goal is to
improve the spread and use of results of
coverage and assistance. For ex-
ant emphasis on activities and
research programs and demonstration proj-
ample, occupational therapists may
"doing" rather than cognitive or
ects in the area of independent living.
write prescriptions for needed
intellectual approaches, occupa-
equipment giving carefully de-
tional therapists can provide a form
REFERENCES
tailed justification of its therapeutic
of assistance that is practical and
1. Frieden L, Richards L, Cole J, Bailey
benefits; this will substantially in-
concrete. They can help clients
D: ILRU Source Book. Houston: Inde-
crease the probability of insurance
change their lives in clearly visible
pendent Living Research Utilization
sponsorship of the purchase. Ther-
ways. As professionals who typi-
Project, 1979
2. Frieden L: Independent living in the
apists can also teach clients to use
cally practice creative problem
US and implications for other coun-
informal helping networks and as-
solving using common sense and
tries. Rehabil World 6(3):10-14, 1981
sistance exchanges, which can min-
everyday objects rather than highly
3. Frieden L: Independent living program
models. Rehabil Lit 4:169-173, 1980
imize the need for direct financial
specialized medical or therapeutic
4. Frieden L, and Veerkamp E: Indepen-
expenditures. An in-kind exchange
equipment, occupational therapists
dent Living Program Registry. Houston:
might be, for example, a relation-
can help clients learn to overcome
Independent Living Research Utiliza-
tion Project, 1984
ship between a physically disabled
barriers and develop solutions to
5. American Occupational Therapy As-
person and an individual with men-
problems that are workable within
sociation: Official position paper on OC-
tal retardation or an emotional dis-
a community context of everyday
cupational therapy's role in indepen-
dent or alternative living situations. Am
ability in which physical attendant
life. Finally, because of their back-
J Occup Ther 35:812-814, 1981
services provided by the mentally
ground of study and involvement
6. Pflueger S: Independent Living. Wash-
impaired person are exchanged for
in psychiatric practice, occupa-
ington, DC: Institute for Research Uti-
lization, 1977
help with self-direction provided
tional therapists have the broad
7. Cole J: Skills training. In Independent
by the physically disabled person.
theoretical framework necessary to
Living for Physically Disabled People,
On a broader level, occupational
consider independence as a mind
Crewe and Zola, Editors. San Fran-
cisco: Jossey-Bass, 1983
therapists can become knowledge-
process that emphasizes self-direc-
8. Cole J, Sperry J, Board M, Frieden L:
able about public policy issues that
tion and choices. By applying the
New Options. Houston: Institute for Re-
affect economic barriers to the in-
independent living philosophy to
habilitation and Research, 1979
dependence of disabled people.
9. Uniform Terminology for Reporting Oc-
the practice of occupational ther-
cupational Therapy Services and Occu-
They can make positive contribu-
apy and by appropriately expand-
pational Therapy Product Output Report-
tions to improve opportunities for
ing the scope of their knowledge
ing System (adopted by the Representa-
the disabled population by becom-
tive Assembly). Rockville, MD: AOTA,
and skills, occupational therapists
April 1979
The American Journal of Occupational Therapy
739
Correlates of Life Satisfaction
and Depression in Middle-Aged
and Elderly Spinal Cord-Injured
Persons
(quality of life, social perception, social support, spinal cord injuries)
Susan D. Decker, Richard Schulz
Advances in health care science al-
levels of social support, and judged
low more people with spinal cord in-
their health status to be good. These
T
he individuals most at risk for
incurring spinal cord injury
juries to live to old age. The purpose
people also viewed their disability
are teen-aged and young adult
of this study was to determine those
more favorably, tended to have
males, and the increased longevity
factors that contribute to the well-
higher incomes and more education,
of this population has resulted in
being of middle-aged and elderly
were employed, and were more reli-
an ever-increasing number of mid-
spinal cord-injured people. One
gious than those indicating lower lev-
dle-aged and elderly spinal cord-
hundred spinal cord-injured people,
els of well-being. The severity of the
injured persons (1). In the past two
ranging in age from 40 to 73 years,
spinal cord injury was not correlated
decades, we have learned much
completed an extensive structured in-
highly with subjective well-being, al-
about the attitudes, feelings, and
terview. In general, respondents re-
though there was a tendency for. those
coping mechanisms of spinal cord-
ported a degree of well-being on the
with greater disability to report lower
injured people soon after the in-
same measures of satisfaction and
levels of well-being. People who were
jury has occurred, but little re-
depression that was slightly lower
younger, who incurred their disabil-
search exists long after the event
than that of similarly aged nondisa-
ity at a younger age, and who
has occurred. The purpose of this
bled people. Pearson correlations in-
blamed themselves and felt they
study was to identify those factors
dicated that people experiencing high
could have avoided the injury also
that contribute to the psychological
levels of well-being reported high lev-
tended to report higher levels of well-
well-being and life satisfaction of
els of perceived control, had higher
being.
middle-aged and elderly people
with spinal cord injuries at least five
years after injury.
Susan D. Decker, PhD, RN, is Asso-
ciate Professor of Community and
Mental Health Nursing, School of
Nursing, University of Portland,
Portland, OR 97203.
Richard Schulz, PhD, is Associate
Professor of Psychiatry and Director
of Gerontology, University of Pitts-
burgh, Pittsburgh, PA 15260.
740
November 1985, Volume 39, Number 11
Adjustment to Spinal Cord
Instrumental support was viewed
on. In a more active way, this can
Injury
as the provision of tangible aid,
be accomplished by fostering posi-
People who sustain a severe
such as financial assistance, trans-
tive self-attributions and encour-
spinal cord injury face numerous
portation, or help in carrying out
aging direct action through state-
adaptation demands. In addition to
activities of daily living. Cognitive
ments such as, "Keep on trying,
having problems associated with
support was defined as the com-
you've never been a quitter." Sup-
loss of mobility and sensation, the
munication of information that
port people may also foster a per-
spinal cord-injured person under-
helps the individual to negotiate his
ception of control by helping the
goes tremendous psychological
or her world. It ranged from the
injured person to appraise the sit-
stresses (2). Spinal cord injury rep-
specific "how to" variety to more
uation as less threatening and one
resents a threat to life, self-concept,
subtle types of information ena-
that can be coped with. They can
social position, job, and love rela-
bling the person to appraise the
provide information for the in-
tionships. In a society where disa-
appropriateness of his or her feel-
jured person to use in active prob-
bility is frequently accorded a neg-
ings, beliefs, attitudes, and goals.
lem-solving strategies, and they can
ative status, individuals must com-
Affective support was viewed as the
help the injured person realign his
bat misconceptions that devalue
communication of direct positive
or her values in accordance with
them as human beings. As the in-
affect (i.e., the receiving of feed-
remaining assets. Thus, the family
jured person grows older, his or
back that the person is loved, re-
and significant others are crucial in
her loss of health, income, and sig-
spected, and belongs). To more
providing the injured person an
nificant others may pose additional
fully understand how social sup-
emotional climate conducive to the
adaptation demands.
port mechanisms facilitate coping
perception of control and positive
In their review of the extensive
and satisfaction with life, a social-
view of self.
literature on psychological adjust-
psychological perspective, learned
Because little research has fo-
ment of disabled people, DeLoach
helplessness, was also examined.
cused on the well-being of middle-
and Greer (3) suggested that the
The theory of learned helpless-
aged and elderly people with spinal
way in which a person interprets a
ness (15, 16) says that when indi-
cord injuries, the first question
disability influences adjustment to
viduals are exposed to uncontrol-
posed in this study was, "What is
the negative event. In particular,
lable outcomes, they develop ex-
the degree of life satisfaction and
they concluded that people who
pectations that future outcomes
depression?" The second question
are severely disabled don't neces-
will also be uncontrollable. This in
was, "What factors are correlated
sarily experience lower life satisfac-
turn leads to the motivational, cog-
with life satisfaction and depres-
tion than do able-bodied people be-
nitive, and emotional deficits asso-
sion?" In particular, how important
cause they can redefine situations
ciated with helplessness and
are social support and feelings of
and adopt a value system that al-
depression. The learned helpless-
control in facilitating long-term ad-
lows them to feel good about them-
ness theory suggests that social sup-
justment to spinal cord injury?
selves.
port may facilitate coping with se-
Although many factors are re-
vere disability by fostering a per-
Methods
lated to successful adjustment to
ception of control and feelings of
spinal cord injury, the literature
competence. Because the spinal
Respondents
(1-8) suggests that social support is
cord-injured person has lost so
The sample consisted of 100
crucial in enabling the injured per-
much control over his or her body
spinal cord-injured people living
son to make physical, social, and
and environment, issues of com-
in noninstitutional community set-
cognitive life changes. Therefore,
petence and control are very im-
tings. To be included in the sample
one focus of this study was to ex-
portant.
the person had to have paraplegia
amine the role of social support in
Support people may help the in-
or quadriplegia, be 40 years of age
facilitating the long-term adjust-
jured person regain or increase his
or older, have no progressively de-
ment of paralyzed individuals.
or her perception of control over
teriorating disease, have had five
Based on a number of studies (9-
the psychosocial and physical envi-
years or more since the injury oc-
14), social support was conceptual-
ronment in a variety of ways, such
curred, and be willing to partici-
ized as consisting of instrumental,
as assuring the individual that they
pate. Subjects were located
affective, and cognitive support.
are available and can be counted
through agencies that have contact
The American Journal of Occupational Therapy 741
with spinal cord-injured people in
the 11 items. Scores on this scale
tion. Scores on this scale range
the Pacific Northwest. A total of
could range from 0 (no support) to
from 0 to 60, with 60 being the
106 individuals were approached
275 (high support on all items from
most depressed response. Radloff
as possible participants. Four per-
five persons). Reliability analysis of
(19) reports that the internal con-
sons declined, and two persons
this scale indicated a Cronbach's
sistency (Cronbach's alpha = .85),
were excluded from the sample be-
alpha of .70. In addition to obtain-
split-halves reliability = .77), test-
cause they had a deteriorating dis-
ing a scale score for social support,
retest reliability (r = .54), and va-
ease condition. The respondents
subjects were asked to indicate on
lidity of the scale are high, and
were all Caucasian and were pre-
Likert-type scales how satisfied
correlations between the CES-D
dominantly (90%) male. The age
they were with the overall quality
and age, social class, and gender
of subjects ranged between 40 and
and quantity of the social support
are minimal. Reliability analysis of
73 years, with a mean age of 56
they received.
the scale in this study of spinal
years. The subjects' ages at time of
The Perceived Control Scale was
cord-injured persons resulted in a
injury ranged between 12 and 68
composed of five Likert-type items
Cronbach's alpha of .83.
years, with a mean age of 35 years.
with a potential score range of 5 to
Procedure
The causes of spinal cord injury
25. Subjects indicated to what ex-
corresponded closely to national
tent they felt able to achieve or
Structured interviews (approx. 1
statistics on causes of injury (1).
obtain what was important to them,
hour each) were conducted over a
Subjects were classified as follows:
to make their interactions with
nine-month period by two skilled
paraplegia, incomplete (40%); par-
people end up the way they ex-
psychiatric nurses. Interviewers
aplegia, complete (27%); quadri-
pected, to count on themselves to
asked participants to verbally re-
plegia, incomplete (29%); and
cope successfully when stressed,
spond to the items on the question-
quadriplegia, complete (4%).
and to solve problems in their lives
naire and to the outcome measures
and to what degree they perceived
of life satisfaction and depression.
Instruments
the good things that happened to
Each respondent thus answered the
Data were collected using a ques-
them were the result of their own
same questions in the same order.
tionnaire designed for this study
actions. The Cronbach's alpha for
Data Analysis
and two established instruments
this scale was .81, indicating a rel-
for measuring life satisfaction and
atively high degree of internal con-
All computer-assisted data anal-
depression. The major categories
sistency.
ysis was conducted using the Statis-
of data collected were demo-
The Life Satisfaction Index-A
tical Package for the Social Sci-
graphic, health, disability percep-
(LSIA-A) is an 18-item self-report
ences (20) and the SPSS Update
tion, social support, perceived con-
scale designed to measure subjec-
(21). Statistical approaches in-
trol, and life satisfaction and
tive psychological well-being (17).
cluded descriptive techniques,
depression. Health was measured
Scores on this scale range from 0
Pearson correlation analyses, and
by a Likert-type item that indicated
to 18, with 18 being the most pos-
reliability analyses.
the subject's perception of general
itive response. Intercorrelations
Results
health status. Scales were con-
have been demonstrated between
structed from the items on the
the LSIA-A and other measures of
Degree of Life Satisfaction and
questionnaire to measure social
life satisfaction (e.g., LSIA, .989;
Depression
support and perceived control.
LSIZ, .952; Philadelphia Geriatric
Scores for this sample on the
The Social Support Scale was
Center Morale Scale, .779; and Ca-
LSIA-A ranged from 0 to 18, with
composed of 11 Likert-type items
van, .799) (18). Reliability analysis
a mean score of 10.76, a mode of
measuring instrumental, affective,
of the LSIA-A in this study of
9.0, and a median of 10.88. These
and cognitive support. Subjects
spinal cord-injured people re-
scores were compared with those
were asked to name up to five per-
sulted in a Cronbach's alpha of .76.
reported by Harris and Associates
sons who were important sources
The Center for Epidemiologic
(22) who used the LSIA-A (N =
of help, support, or guidance.
Studies Depression Scale (CES-D)
4,254). The scores of the spinal
After identifying these persons,
is a 20-item self-report scale de-
cord-injured sample do reflect
subjects were asked to indicate how
signed to measure depression
lower levels of life satisfaction than
much each person helped them on
symptoms in the general popula-
do the scores reported for nondis-
742 November 1985, Volume 39, Number 11
abled people (65+ years, mean
Table 1
score 12.2) and the general adult
Major Correlates of Two Measures of Subjective Well-being
public (mean score 13.2) as re-
LSIA-A
CES-D
r
ported by Harris and Associates.
Perceived control
.52
Perceived control
-.56
Over 50% of the spinal cord-in-
Satisfaction with amount of social
.51
Perceived health
-.49
jured people in this study gave re-
contact
Perceived health
.47
Satisfaction with amount of social
-.45
sponses indicating dissatisfaction
contact
on 5 of the 18 items on the LSIA-
Social support (instrumental, cog-
.45
Satisfaction with quality of social
-.44
A. Responses included the follow-
nitive, affective support)
contact
Satisfaction with quality of social
.42
ing: that they were not as happy
contact
now as when they were younger
Disability perception
.40
(66%), that these were not the best
Positive meaning of disability
.37
Education
.36
years of their lives (73%), that their
Assistance with activities of daily
-.35
lives could be happier than they are
living
now (78%), that they would change
Employed
.33
their past if they could (63%), and
See text for abbreviations and definitions. For all correlations, p<.001.
that the lot of the average person
is getting worse, not better (51%).
The reasons subjects gave for some
others, and pain. Subjects were also
have more education, were em-
of these responses were related to
asked to identify fears about the
ployed, and required less assistance
their disability; for example, some
future. The fear of having an in-
with activities of daily living.
volunteered the information that
adequate income was most fre-
The severity of the spinal cord
the part of their past they would
quently mentioned (32%), fol-
injury was not correlated highly
change would be their injury.
lowed by fear of deteriorating
with perceived well-being, al-
Using the CES-D, subjects were
health, dependency on others, los-
though there was a tendency for
asked to indicate how often they
ing others and loneliness, death,
those with greater disabilities to re-
had felt or behaved in particular
going to a nursing home, and pain.
port lower levels of well-being.
ways during the past week. Scores
People who were younger and who
ranged from 0 to 37, with a mean
Correlates of Life Satisfaction and
had incurred their disability at a
score of 9.74 and a median of 7.5.
Depression
younger age also tended to report
The mean score of the spinal cord-
Many variables considered in this
higher levels of well-being, as did
injured sample was similar to the
study showed a positive correlation
those who blamed themselves and
mean (9.25) of a probability sample
with the measures of subjective
felt they could have avoided incur-
of 2,514 persons from a general
well-being. Those independent
ring the disability. Although cor-
adult population in a study con-
variables with a Pearson correla-
relations were low, people who had
ducted by Radloff (19). The simi-
tion coefficient of r = .3 or higher
higher incomes and were more re-
larity in scores between the spinal
are shown in descending order of
ligious also tended to report
cord-injured sample and the gen-
significance in Table 1. The varia-
greater well-being.
eral population suggests that the
bles accounting for the greatest
disabled group is not particularly
amount of variance in the outcome
Discussion
at risk of depression.
measures are perceived control, so-
In general, the spinal cord-in-
In addition to the scales measur-
cial support measures, and per-
jured people in this study reported
ing life satisfaction and depression,
ceived health. It is interesting that
a level of well-being that was only
several individual questions rele-
the highest correlate of depression
slightly lower than that reported in
vant to well-being were asked. The
is perceived control. This is con-
studies of nondisabled people on
most frequent response to the
sistent with the learned helpless-
the same measures of life satisfac-
question, "What are the major dif-
ness theory of depression (15, 16).
tion and depression. Despite phys-
ficulties in your life at this time?"
In addition to the variables already
ical disability, the majority of par-
was dependency and immobility
noted, people reporting higher lev-
ticipants in this study appeared able
(38%), followed by health prob-
els of well-being viewed their disa-
to form a perception of life and self
lems, finances, relationships with
bility more favorably, tended to
that was relatively positive. Those
The American Journal of Occupational Therapy
743
reporting high life satisfaction per-
their lives. The ability to attribute
makes those with spinal cord inju-
ceived a high degree of control
positive meaning or purpose to a
ries vulnerable to the potential loss
over their lives, were very satisfied
disability most probably enhances
of these supports. Spouses, in par-
with the quantity and quality of
a perception of control over how
ticular, provided much emótional,
social support they received, and
one feels about one's self and one's
physical, and home maintenance
perceived their overall health sta-
life situation (i.e., you are not
support. It was the impression of
tus as good. They could see positive
doomed to feel miserable because
the interviewers that many of the
meaning in their disability and did
of the disability; you have a choice
respondents would have numerous
not view their disability as the
of how to feel). When a severe in-
coping problems if they lost a
worst thing that could happen to
jury is incurred, it is often per-
spouse. Unfortunately, as this pop-
them.
ceived as a close brush with death,
ulation ages, as divorce becomes
Respondents viewed their disa-
accompanied by a clear realization
more socially acceptable, and as
bilities in the following ways: as the
of human vulnerability. Thus, a se-
more women enter the workforce,
worst or almost the worst thing that
vere trauma may make a person
it is possible that spouses will be less
could happen (54%), as neither the
stop and think what life is really
available for support.
worst nor the best (41%), and as
about and thus lead to dramatic
It was interesting that being em-
the best or almost the best thing
value and attitude changes.
ployed showed a significant posi-
that could happen to them (5%). It
As noted in Table 1, the percep-
tive correlation with life satisfac-
is relatively easy to imagine how a
tion of control was the variable
tion, whereas income showed only
respondent would perceive paraly-
most highly correlated with life sat-
a slight positive correlation. This
sis as the "worst thing that could
isfaction and the absence of depres-
suggests that employment, regard-
happen," but what about those who
sion. With a potential score of 25
less of financial remuneration, may
said it was "the best thing that
on the control scale, the mean and
have a positive influence on life
could happen"? Perhaps the re-
median scores for this sample were
satisfaction. Most of the respon-
sponse of one such person gives
19.0 and 19.7. It might be ex-
dents in this study (74%) were un-
some insight into this question:
pected that spinal cord-injured
employed, which indicates that at-
"Before, I was drifting; since then
people would perceive. dependence
tention could be directed toward
I have gone to school and my out-
on others and lack of control over
factors associated with this high
look on life has changed drastically
their lives. But this was not true for
rate of unemployment. Those em-
toward the positive."
the sample in general; however,
ployed identified a variety of oc-
A large number of respondents
among people experiencing the
cupations, and one-half of those
(64%) said there has been some
most severe injuries (quadriplegia,
employed were professionals. This
purpose of positive meaning in
complete), the perception of con-
may indicate a high degree of ca-
their disability. The most fre-
trol was lower.
reer commitment among profes-
quently mentioned types of mean-
As expected, social support was
sional people or that professional
ing were those related to personal
positively correlated with life satis-
jobs frequently do not require a
growth, such as "an increased
faction. With a potential social sup-
large degree of physical mobility.
awareness of self," "becoming a
port scale score of 275, the scores
Among those working, job satisfac-
better person," "value change,"
in this sample ranged from 0 (no
tion was very high.
and "seeing other people as more
support) to 247, with a mean of
Respondents were low users of
important." It appears that over
92.9, a mode of 49.0, and a median
community services and agencies.
time, many people with spinal cord
of 83.5. Of particular, significance
Most (85%) said they never used
injuries go through a process of
is the small number of support peo-
any community services or agen-
reorganizing their values and per-
ple named by many respondents.
cies. Others (6%) reported using
ceptions of themselves to cope with
The mean number of support peo-
services and agencies once a week
their new status as a disabled per-
ple identified was 2.3, the mode
or more; these people tended to be
son. This reorganization process
1.0, and the median 1.9. The larg-
older or more severely disabled. As
most likely entails a search for pos-
est number of respondents (41%)
this population ages, however, it
itive meaning or purpose in their
named only one support person,
is possible that more of them will
disability so they can accept and
which was usually a spouse. The
require community assistance.
integrate this new element into
small number of support people
Therefore, a thorough assessment
744 November 1985, Volume 39, Number 11
of the needs of this population and
and family members reorganize
4. Roessler R, Bolton B: Psychosocial Ad-
the factors that may influence use
their value systems in ways that
justment to Disability. Baltimore: Uni-
of services (e.g., availability, ac-
versity Park Press, 1978
emphasize remaining assets.
5. Frielich M: Vocational and avocational
ceptability, accessibility, cost, types
Among health team members,
adjustment: A followup study of dis-
of services provided) is indicated
the occupational therapist has long
charged paraplegic and quadriplegic
before investing resources in pro-
veterans. Dissertation Abstracts Interna-
had a tradition of helping disabled
tional, 37:7682-A 1977 (University Mi-
grams.
people focus on ways to use their
crofilms No. DBJ77-13461)
remaining physical, intellectual,
6. Guttman L: Spinal Cord Injuries-Com-
Implications for Occupational
and psychosocial assets, rather than
prehensive Management and Research.
Therapy
Oxford, UK: Blackwell Scientific Pub-
concentrating on lost abilities.
lications, 1976
This study identifies some of the
Spinal cord-injured people need
7. Kemp B, Vash C: Productivity after
factors related to the well-being of
not only physical rehabilitation but
injury in a sample of spinal cord injured
people with spinal cord injuries. An
persons: a pilot study. J Chron Dis
also help in adjusting psychologi-
24:259-275, 1971
understanding of these factors pro-
cally and socially to their injuries.
8. Rogers J, Figone J: Psychosocial param-
vides direction for the occupational
In the long run, the occupational
eters in treating the person with quad-
therapist in the assessment of risk
riplegia. Am J Occup Ther 33:432-439,
factors and in interventions with
therapist's interventions in helping
1979
the injured person perceive control
9. Brandt P, Weinert C: The PRQ-A
individual patients and population
social support measure. Nurs Res
over the physical and psychosocial
aggregates. Perhaps the finding of
30:277-280, 1981
environment may be central to sub-
10. Caplan G: Support Systems and Commu-
most interest to the occupational
sequent life satisfaction.
nity Mental Health. New York: Behav-
therapist, is that the perception of
ioral Publications, 1974
This study examines the well-
control was the variable most
11. Cobb S: Social support as a moderator
being of people with spinal cord
of life stress. Psychosom Med 38:300-
strongly associated with well-being.
injuries at only one point in their
314, 1976
A central aim of occupational ther-
lives. Of value would be a longitu-
12. Cronenwett L, Kunst-Wilson W: Stress,
apy is to help people achieve a max-
social support, and the transition to
dinal study of such people from the
fatherhood. Nurs Res 30:196-201,
imum degree of wellness and pro-
time of injury throughout their
1981
ductivity and maintain a sense of
independence and control. The
lives. Such a study would shed light
13. Hirsch BJ: Natural support systems and
coping with major life changes. Am J
on the relationship between the oc-
Community Psychol 8:153-166, 1980
therapist works toward this goal in
cupational therapist's interventions
14. Norbeck J, Lindsey A, Carrieri V: The
many ways. In addition to teaching
and the patient's long-term adjust-
development of an instrument to mea-
the patient and family ways of man-
sure social support. Nurs Res 30:264-
ment to disability. However, in the
269, 1981
aging activities of daily living, the
absence of such data, occupational
15. Abramson LY, Seligman EP, Teasdale
occupational therapist should help
therapists can use correlational
JD: Learned helplessness in humans:
the injured person and his or her
Critique and reformulation. J Abnorm
data from studies such as this one
Psychol 87:49-74, 1978
family make the psychological and
to plan and evaluate approaches to
16. Seligman ML: Helplessness: On Depres-
social changes that will have a long-
the care of people with spinal cord
sion, Development and Death. San Fran-
term impact on well-being.
cisco: Freeman, 1975
injuries.
17. Adams D: Analysis of a life satisfaction
For example, the therapist may
index. J Gerontol 24:470-474, 1969
help spinal cord-injured people be-
ACKNOWLEDGMENTS
18. Lohmann N: Correlation of life satis-
come aware of the importance of
faction, morale and adjustment mea-
This work was supported by the Ameri-
sures. J Gerontol 32:73-75, 1977
social support and develop the
can Association for Retired Persons Andrus
19. Radloff L: The CES-D scale: A self-
skills necessary to build and main-
Foundation.
report depression scale for research in
tain a support system. The thera-
REFERENCES
the general population. Appl Psychol
Measurement 1:385-401, 1977
pist may work with family members
1. Trieschmann RB: Spinal Cord Injuries:
20. Nie N, Hull C, Jenkins J, Steinbrenner
to help them reinforce a positive
Psychological, Social and Vocational Ad-
K, Bent D: Statistical Package for the
self-image and foster feelings of
justment. New York: Pergamon, 1980
Social Sciences, 2nd edition. New York:
2. Vargo JW: Some psychosocial effects of
McGraw-Hill, 1975
competence and control in the in-
physical disability. Am J Occup Ther
21. Hull C, Nie N: SPSS Update. New York:
jured person. By projecting a fa-
32:31-34, 1978
McGraw-Hill, 1979
vorable view of "life after injury,"
3. DeLoach C, Greer B: Adjustment to Se-
22. Harris L & Associates. The Myth and
vere Physical Disability, A Metamorphosis.
the therapist helps injured people
Reality of Aging in America. Washington,
New York: McGraw-Hill, 1981
DC: National Council on Aging, 1975
The American Journal of Occupational Therapy
745
Brief or New: Feeding Device for
Finger Foods
Melanie Morrison Wiener
O
ccupational therapists fre-
20 cm (8 in.) from the surface using
Figure 1
quently prescribe, design,
external rotation and right lateral
Upper extremity feeding device
and fabricate adaptive equipment
trunk flexion. Hypertonicity in his
that helps spinal cord-injured in-
biceps helped to maintain his elbow
dividuals increase their indepen-
in a partially flexed position. With
dent living skills. Traditional de-
his arm in this position, he had
vices that assist the C₄ to C₇ spinal
sufficient strength in his abdominal
cord-injured quadriplegic person
muscles to flex his trunk the dis-
in self-feeding include the ball
tance necessary to allow his mouth
bearing feeder, monosuspension
to reach his hand during feeding.
sling, reciprocal orthosis, universal
Initial attempts at' self-feeding
cuff, foam built-up utensil handles,
with traditional devices were frus-
and custom-fabricated splints.
trated by the patient's lack of use
Those devices available commer-
of a spoon or fork. Eating, in his
cially and those commonly con-
rural Mexican culture consisted of
structed by occupational therapists
rolling food by hand into a flour
do not always match an individual's
tortilla, which was then brought to
eating preferences and habits be-
the mouth.
cause of cultural or socioeconomic
The device constructed for this
factors. This paper describes a fin-
patient to promote independent
ger food device designed for a 25-
self-feeding consisted of a cylinder
year-old Mexican-American male
of Polyform (Rolyan Manufactur-
with syringomyelia.
ing Co., PO Box 555, Menomonee
Syringomyelia is the presence of
Falls, WI) which was closed at the
abnormal liquid-filled cavities in
base and open at the top, attached
the following items are needed:
to his dominant or more functional
Polyform splinting material, Pre-
the spinal cord (1). In this case, the
patient's resulting disability resem-
hand by a strip of Polyform (see
Bond splinting adhesive (Johnson
& Johnson, Sherman, TX), and a
bled incomplete C₄ level quadriple-
Figure 1). The device was placed
hydroculator or other container to
gia. His manual muscle test re-
on the patient's hand, and a stuffed
vealed the following muscle grades:
tortilla was inserted. He could now
heat water, scissors, and a pair of
tongs. The following pieces are cut
G+ bilateral shoulder elevation
independently bring the tortilla to
his mouth and bite off the end (see
from the Polyform sheet: a rectan-
and depression; F+ shoulder inter-
gle 15 X 13 cm (57/8 X 5½ in.), a
nal rotation; P- external rotation,
Figure 2). Using his teeth, he could
pull the tortilla far enough out of
strip 22 X 3.5 cm (85/8 X 1³/₈ in.),
flexion, and abduction; and F ad-
and a circle 6 cm (2% in.) in diam-
duction and extension. In addition,
the device to take the next bite.
eter. The length of the strip de-
he had right F forearm pronation
There was enough friction be-
and G- wrist extension. All other
tween the food and the device to
upper extremity motions were
allow the food to remain in place
trace or zero. Functionally, he was
once partially extracted.
Melanie Morrison Wiener, OTR, is
able to place his right elbow on the
Senior Occupational Therapist, The
Construction
surface of a table or on the armrest
Institute for Rehabilitation and Re-
of his wheelchair and lift his hand
To construct the feeding device,
search, Houston, TX 77030.
746
November 1985, Volume 39, Number 11
Figure 2
Figure 3
Figure 4
Subject eating with feeding device
Diagrams of cylinder
Subject holding feeding device with strip at-
tached
A
B
A, cylinder made from rolled rectangular
piece (13 cm long, 4 cm diam.). B, cylinder
with circular piece attached.
tight enough to remain in place
pends on the size of the patient's
during self-feeding. After the pa-
hand. A piece of stockinette pro-
tient has worn the device for 15 to
tects the patient's hand from the
across the palm of the hand, with
20 minutes, his or her hand should
heat of the splinting material.
the enclosed end protruding from
be monitored for pressure areas
the ulnar side. If the patient has
Procedure
and the device modified accord-
active wrist extensors to create
ingly.
The water in the hydroculator is
even a weak tenodesis grasp of the
heated to 65°C (150°F). The rec-
cylinder, this gives the therapist an
Implications for Use
tangle is placed in the water for 20
idea of the most functional position
seconds or until it is very flexible.
of the cylinder (see Figure 4).
This feeding device is applicable
It is then rolled along the width
Once softened, one end of the
for handicapped people of any
and overlapped approximately 2
Polyform strip is attached to the
background. It can be modified to
cm (3/4 in.), where it is glued with
open end of the cylinder, wrapped
accommodate finger foods such as
the adhesive (see Figure 3A). This
around the dorsum of the hand,
hot dogs, pita sandwiches, or ice
creates a cylinder 13 cm (5½ in.)
and attached to the base of the
cream cones, foods that are other-
long and 4 cm (1½ in.) in diameter.
cylinder. This creates an opening
wise difficult, if not impossible, for
The circular piece is heated and
for the hand (see Figure 3). The
most quadriplegic persons to grasp.
placed over one end of the cylin-
strip should be positioned directly
ACKNOWLEDGMENTS
der. The edges of the circular piece
proximal to the metacarpophalan-
The author thanks Susan Garber, MA,
are folded up around the base of
geal (MP) joints to avoid pressure
OTR, for her assistance and Rich, her hus-
the cylinder on the outside and
over bony prominences.
band, for his helpful feedback.
glued in place using adhesive (see
When the material has hard-
REFERENCE
Figure 3B).
ened, the therapist should make
While the patient wears the
sure the feeding device can slip eas-
1. Dorland WAN: Dorland's Dictionary,
stockinette, the cylinder is placed
25th edition. Philadelphia: Saunders,
ily on and off the hand but still be
1974, 1532.
The American Journal of Occupational Therapy
747
THE
FOUNDATION
AOTA and AOTF
Table 1
Sponsor Small
Pattern of Proposals by Subject Matter (fiscal year 1984-85, through May 1985)
Number
$ Amount
Number
$ Amount
Research Grants
Subject
Requested
Requested
Funded
Funded
Program for Members
Activity
1
$1,100
0
0
Administration
4
5,377
2
$4,370
Basic science
0
0
0
0
Developmental Disabilities
4
8,941
4
8,785
The American Occupational
Education
2
6,933
0
0
Therapy Association and the
Gerontology
2
6,382
0
0
American Occupational Therapy
Mental Health
0
0
0
0
Physical disabilities
2
9,726
0
0
Foundation jointly support a small
Sensory integration
2
8,881
0
0
research grants program for
Theory
0
0
0
0
members of AOTA. This pro-
Total
17
$47,268
6
$13,155
gram is administered by the Re-
search Advisory Council under a
process established by the coun-
Table 2
cil's Grants Review Committee.
Pattern of Proposals by Fiscal Year
Research proposals were received
Number
$ Amount
Number
$ Amount
semiannually through 1984 and
Fiscal Year
Submitted
Requested
Funded
Awarded
are currently accepted for review
1978-79
36
$ 88,451
17
$ 34,065
on a quarterly basis.
1979-80
18
35,975
7
13,696
1980-81
44
105,685
12
26,138
Grants are limited to $5,000,
1981-82
28
61,574
12
23,185
and each study should be com-
1982-83
32
90,275
10
20,148
pleted within 12 months. Grant-
1983-84
24
69,048
5
12,945
1984-85*
17
47,268
6
13,155
ees agree to submit their final re-
Total
199
$498,276
69
$143,332
ports in the form of a manuscript
to the professional journal of their
through May 1985
choice. For a complete listing of
grants funded and their current
status, please send $3 (to cover
the costs of duplication and post-
Studies on the testing and de-
The 199 studies submitted have
age) to the Office of Professional
velopment of standardized instru-
sought a total of $498,276.
Research, AOTF.
ments for either clinical or re-
Through May 1985 AOTA and
Through May 1985, a total of
search purposes;
AOTF have supported these re-
199 grant proposals have been
Clinical studies well
search grants with funds totalling
submitted; approximately 12 of
grounded in theory;
$143,332. AOTA funds are
them were resubmissions (i.e.,
Studies concerning occupa-
budgeted at $15,000 each year.
they were revised in accordance
tional therapy education; and
AOTF uses money from its "Spe-
with grant reviewers' recommen-
Studies to test or develop
cial Projects, Unrestricted" fund
dations). Revision does not guar-
models of health care delivery.
and from smaller funds contrib-
antee funding, but it often im-
Of special interest are a) re-
uted specifically to be used for re-
proves the proposal significantly,
search studies that examine activi-
search purposes.
and many proposals are funded in
ties or occupations with regard to
Tables 1 and 2 document the
their second cycle.
normal or dysfunctional life con--
pattern of grant proposals submit-
Priorities for funding grants are
ditions and b) studies that advance
ted and funded since the incep-
established by the Research Advi-
the knowledge base of the profes-
tion of the program in 1979.
sory Council. Current priorities
sion by contributing to the devel-
include the following.
opment and testing of theory.
748
November 1985, Volume 39, Number 11
You'll Love the City Sights in
Minneapolis
HEALTH AND
TECHNOLOGY
PARTNERSHIP FOR THE FUTURE
The American Occupational Therapy Association's 66th Annual Conference
April 20-23, 1986 Minneapolis, Minnesota
The American Journal of Occupational Therapy 749
BOOK
REVIEWS
To Provide Safe Passage: The
forget this is to forget ultimately
The chapters on neurological
Humanistic Aspects of Medicine,
what we are."
changes, cardiovascular aging,
Pauline L. Rabin, MD, and David
This reviewer found this book
and pulmonary rehabilitation are
Rabin, MD, Editors. Philosophical
to be exciting and challenging. I
excellent references for new grad-
Library, Inc., 200 West 57th
would recommend it to any thera-
uates or practitioners with a lim-
Street, New York, NY 10019,
pist working with the terminally
ited background in gerontology.
258 pp (1985).
ill, chronically disabled, or a
Similarly, the chapter on oncology
professional colleague who is
provides a fairly thorough picture
This book is a collection of
chronically ill. The chapters are
of how cancers affect the elderly,
twenty essays by patients, family
particularly demonstrative of is-
emphasizing the benefits of restor-
members and physicians whose
sues that raise consciousness. It
ative programs including occu-
lives have been touched by severe
was with pleasure that I reviewed
pational therapy as well as the
illness. When all medical technol-
this book, and I recommend it to
frequent benefit of supportive
ogy and human knowledge cannot
occupational therapists.
programs. A chapter is devoted to
save a life, the caregiver can pro-
Kathy Hoffman-Grotting, OTR
stress management with recom-
vide "safe passage," meaning the
mendations for setting up treat-
support and ready availability of
Aging: The Health Care Chal-
ment protocols. Significant atten-
physicians to their patient until
lenge, Carole Bernstein Lewis,
tion is also devoted to a review of
death. This implies "a mutual con-
RPT, MSG, MPA, PhD, Editor.
drug concepts and common drug
fidence and trust
that allows
F.A. Davis Company, 1915 Arch
therapy including the most com-
the sick to feel that all that could
Street, Philadelphia, PA 19103,
mon types of medications pre-
be done to save had been done,
386 pp (1985).
scribed and purchased over the
and that the anxiety would be di-
counter. Further chapters deal
minished even unto death."
Carole Bernstein Lewis presents
with research, economic consider-
There are chapters that focus
information and data on aging in-
ation of rehabilitation, and the so-
on how difficult it is for health
cluding approaches to treatment
cial and political ramifications of
care professionals to deal with an
and management of common
the current health care system.
ill colleague. Other chapters sug-
problems, research, and social and
Despite the multidisciplinary ap-
gest practical guidelines for physi-
psychological implications for our
proach, the text's focus is clearly
cians and other health care profes-
aging society. Contributors to the
on physical therapy intervention
sionals whose patients deal with
book include professionals in
and appears targeted to the physi-
acute grief, intractable pain and
speech pathology, occupational
cal therapy audience. Neverthe-
terminal illness.
therapy, physical therapy, physical
less, occupational therapists look-
In the last chapter, the author
education and recreation, phar-
ing for a basic text that addresses
attempts to make sense of the loss
macology, and researchers of
the whole gamut of physical, psy-
of a friend and provides a respect-
adult health and development.
chological, social and political is-
ful reflection of the value of
Two chapters were written by
sues will find this book readable,
"play" and humor as a means of
occupational therapists. These
well organized, and a good addi-
reaffirming the vitality and exu-
provide information on the var-
tion to any professional or per-
berance of life. One of the au-
ious ADL instruments and the
sonal library. Therapists will find
thors, Richard Zaner, states that,
losses of strength, endurance and
the material well organized with
"Cure is care, and the finest medi-
joint mobility that can hinder
bibliographies included after each
cine for an afflicted human being
function, plus visual, auditory,
chapter, and a lengthy index for
must always include that endorse-
gustatory, olfactory changes, with
easy reference.
ment of human life by play and its
brief discussion of kinesthesis,
Beverly P. Horowitz, MS, OTR
inherently caring presence. To
touch or tactile sensibility.
750
November 1985, Volume 39, Number 11
A
Productivity
MOVING?
Systems Guide
PRODICTIVITY
for
STSTEMS GUIDE
FOR
OCCIPATIONAL
Occupational
THERAPY
Attach your address label
Therapy
from current issue
here.
Examines ways OTs can
document to determine
productivity and show
Member/Subscriber-moving? Let us know as early as possible
how data is used to de-
and by the 15th of the month, so that AJOT and OT News will
velop proposals for addi-
reach you uninterrupted at your new destination. Attach the
tional staffing/report
mailing label from a current issue and mail it with your new
department activities. Ex-
address to: AOTA Membership or Subscriptions Department,
amples of ways to docu-
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ment productivity, including AOTA's Product Output
NEW ADDRESS:
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examples from 21 contributors. Other sections include
Name
Address
productivity ranges excerpted from the AOTA Member
City/State
Zip
Data Survey and 2 surveys that yield productivity data.
Includes bibliography and glossary of terms. Health care
consulting firms listed in appendix.
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Edited by Jeanette Bair and Carol H. Gwin.
National Office staff prefers to contact members during the day,
when they are working. If you recently changed jobs, please
Soft cover,
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GUIDELINES
At last, a complete workbook that takes you step-by-step
through the entire process of planning a successful workshop
from the general planning committee to specifics such as
FOR PLANNING
location, date, & facilities; from general correspondence to
the development of brochures or pamphlets; from the finan-
A WORKSHOP
cial to the audiovisual; from the registration to the evaluation
It's all here. And there's room on each page for your own
personal plans in conjunction with the guidelines.
by Shelley Stowers, M.S., OTR
Marlys M. Mitchell, Ph.D., OTR
in conjunction with the
Division of Professional
Development AOTA
ORDER YOUR COPY TODAY!
Please send me
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(Non-members) prepaid. Please make checks payable to AOTA.
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The American Journal of Occupational Therapy 751
An AOTA Product
Occupational
Therapy Manpower:
BIOFEEDBACK
A Plan for Progress
STRATEGIES
A report of the Ad Hoc Commission on
Occupational Therapy Manpower of the
American Occupational Therapy Association
Textbook and 6 Videocassettes
Drawing on a broad range of social, health
by Abby Abildness, M.S., OTR
care, economic, political, and educational
perspectives, this report represents a com-
Biofeedback Strategies Textbook, (1982). #BP-14
Gives therapists the information they need to become
prehensive profile of the occupational thera-
competent in incorporating biofeedback into clinical
py profession in the 1980s:
practice and teaching curricula. It explains biofeed-
back apparatus, procedures, and theory that relate
An invaluable resource guide and reference
directly to primary prevention and rehabilitation of
tool, Occupational Therapy Manpower pro-
psychological and physiological disorders. A self-
vides data on demographic and employ-
contained teaching package divided into six training
sessions, the textbook includes specially extracted
ment characteristics, geographic distribution
literature that relates to occupational and physical
of manpower, and trends in education, prac-
therapy. Use the text alone or combine it with the
tice, certification, and licensure.
AOTA's six Biofeedback Strategies Videocassettes,
which are designed to augment each session.
84 pp. Soft cover. Illustrated.
(160 pp)
$19 member
$7.00/AOTA members; $9.00/nonmembers.
$25 nonmember
Biofeedback Strategies Videocassettes (1981).
Order from AOTA Products
Piccard Drive
aoia
The AOTA offers six 3/4-inch color videotaped in-
struction sessions prepared for use in education pro-
Rockville, MD 20850
gams or in inservice staff training. Each casette, which
reinforces a training session of the Blofeedback Strate-
gles Textbook, incorporates instrumentation methods
and behavioral treatment strategies and their applica-
An Insightful, Practical
tion to oT research and clinical practice. Each cassette
may be ordered individually, by title, or in the complete
Exploration of the Role of
package of six.
Learning In All Forms of Therapy
Single Cassette Price
I. The Learning Process (25 min.) #V-31
Offering a broad theoretical perspective
II. Instrumentation and Activity Analysis (35 min.)
#V-32
drawn from basic neurosciences and
III. Positive Reconditioning of Neurological Injuries
psychology, Therapy as Learning by Richard K.
(21 min.) #V-33
Schwartz presents a clear and comprehensive
IV. Counterconditioning Pain and Vascular Disorders
overview of the nature of the learning process
(33 min.) #V-34
and its important implications for both thera-
V. Counterconditioning Cardiovascular Disorders
(30 min.) #V-35
pist and client.
VI. Occupational Behavior-Application and Justifi-
Filled with practical suggestions for using
cation (24 min.) #V-36
Purchase
$80 member $110 nonmember
learning to improve
Rental*
$30 member $ 45 nonmember
the quality of thera-
py, this book is
Complete Package #V-30
a valuable and
Purchase price includes 6 videocassettes and 1 copy
necessary addition
Therapy
of Biofeedback Strategies Textbook. (Textbook not
included with rental.)
to the therapist's
as
Purchase
$450 member $575 nonmember
professional library
Learning
Rental*
$150 member $260 nonmember
139 pp. Soft cover. Illustrated
Specify title when ordering individual videocassette.
$17.00/AOTA members;
Rre hard N hanrt:
*Rental price is for five working days. Please reserve 30 days in
$21.00 nommembers.
advance and indicate date cassette is required.
Order from:
Send check or purchase order to
AOTA Products
AOTA Products
1383 Piccard Drive
1383 Piccard Drive
Rockville, MD 20850
Rockville, MD 20850
752 November 1985, Volume 39, Number 11
CLASSIFIED
ADVERTISING
California
send resume to Whitley Rehabilitative Ser-
our modern and progressive acute care hos-
vices, Incorporated, 13910 Fivay Road, Suite
pital for a full-time staff Occupational Thera-
TWO POSITIONS-Occupational Therapist
9, Hudson, FL 33567, or call (813) 868-6800
pist. Varied case load includes stroke, head
($1,830-2,268); Graduate Occupational.
for additional information.
injury, DD, arthritic, COPD, geriatric and car-
Therapist ($1,735). Challenging new OT po-
dial patients. Will also include evaluation and
sitions with Riverside County Mental Health
* Illinois
treatment of a wide variety of developmental
Dept. w/diverse patient load. OT requires
and neurologically impaired children. Back-
current AOTA registration; no exp. needed.
REGISTERED OCCUPATIONAL THERA-
ground in SI and NDT preferred. New grad-
Graduate OT must meet AOTA requirements
PIST-Full or part time to service severe and
uates considered. Position offers excellent
and provide verification of filing for AOTA
profoundly handicapped students in a school
working environment. If interested please
registration. Exc. fringe benefits, career po-
setting. Salary commensurate with education
write or call collect: Joe DePalantino, Person-
tential and professional working environ-
and experience. Send detailed resume to:
nel, Cary Medical Center, Van Buren Road,
ment. Salary commensurate with experience.
Curt E. Clouse, Kankakee Area Special Ed-
Caribou, ME 04736, (207) 498-3111, Ext.
Liberal benefits package; attractive So. Calif.
ucation Cooperative, RR #7, Box 339-A,
233. Equal Opportunity Employer.
location with ideal year-round climate; many
Kankakee, IL 60901, (815) 939-3651.
rural and metropolitan cultural and recrea-
tional attractions. Call for immediate consid-
* Maryland
eration. Positions open and available until
* lowa
filled. COUNTY OF RIVERSIDE PERSON-
OCCUPATIONAL THERAPIST-Position
OCCUPATIONAL THERAPIST-Special 67-
NEL DEPT., 4080 Lemon Street, Room 109,
available in 240-bed JCAH-accredited acute
bed pediatric hospital for children requiring
Riverside, CA 92501-3664, (714) 787-6125.
care referral center for northeast lowa. Ser-
post acute and rehabilitative care has open-
EOE. AA. M/F/H.
vices provided to 20-bed skilled nursing unit,
ings for 1 Sr. Staff oT resp. for evaluation
rehabilitation patients, satellite contracts,
and treatment of inpatients and outpatients
SUPERVISOR/STAFF THERAPISTS-
nursing homes and home health care. Com-
and involvement with interdisciplinary team
White Memorial Medical Center, a 377-bed
petitive salary and benefits including health,
and 1 Staff oT to work with 50% inpatients
university affiliated teaching hospital, has
disability, prescription drug and life insurance
and 50% Home Health Agency patients. Cur-
openings for qualified Occupational Thera-
programs. Paid time off program and Well-
rent MD licensure, national certification and
pists. SUPERVISOR-For outpatient clinic.
ness Center. Previous experience preferred.
1 year exp. in peds. Good salary and benefits
Individual should have a strong background
New graduate considered. The Waterloo/Ce-
program and educational opportunities for
in hand therapy and some basic knowledge
dar Falls area has a population of 135,000
growth offered. For immediate consideration,
in arthritis, work evaluations and hemiplegia.
and has many community, sports and leisure
please send resume to: Mr. Stephen J. Cut-
STAFF THERAPISTS-Full-time positions to
activities. The area has an excellent school
ler, Personnel Director, MT. WASHINGTON
work in Rehab Unit. One year of previous
system including the University of Northern
PEDIATRIC HOSPITAL, INC., 1708 W. Rog-
experience preferred. New grads considered.
lowa and Wartburg College. For further infor-
ers Avenue, Baltimore, MD 21209, or call
White Memorial offers an outstanding bene-
mation, call collect or write the Personnel
collect, (301) 578-8600, Ext. 245. EOE.
fits package. Interested candidates, please
Department: Allen Memorial Hospital, 1825
contact Alicia Rivera, OTR, Director of Oc-
Logan Avenue, Waterloo, IA 50703, (319)
cupational Therapy, or send resume to:
235-3630.
WHITE MEMORIAL MEDICAL CENTER,
Classified
1720 Brooklyn Ave., Los Angeles, CA 90033,
(213) 268-5000, Ext. 1511. EOE.
Kentucky
Advertising Rates
DIRECTOR OF OCCUPATIONAL THER-
Classified advertisements accepted for
CERTIFIED OCCUPATIONAL THERAPY
APY/OCCUPATIONAL THERAPIST-Im-
positions available and positions wanted
ASSISTANT-Full time to work in the warm
mediate openings in our JCAH-accredited
at $8.00 per line averaging 40 characters
sunny San Diego area in a new innovative
158-bed adult psychiatric facility and 50-bed
and spaces.
30-bed adolescent psychiatric hospital. Sal-
adult MR facility for full- and part-time posi-
Display classified advertising rates are
ary commensurate with experience. To apply
tions. Excellent opportunities for profes-
½ page at $420, and 1/4 page $355. A
send resume or phone: Doug Braun, Rancho
sional growth in our soon-to-be completed
one-time typesetting charge of $60 (1/2-
Park Hospital, 109 E. Chase Ave., El Cajon,
new hospital and activities building. Interdis-
page) or $40 (1/4-page) will be added to
CA 92020, (619) 579-1666.
ciplinary team approach to patient treat-
the display rate.
ment. Director position requires 3 years'
Copy must be double-spaced and re-
* Florida
experience with degree and must be regis-
ceived on the 15th of the month, 45
tered with The American Occupational Ther-
days before publication date of the first
OTRs & COTAs-Positions available in var-
apy Association. Supervisory experience
of the month. For example, copy for the
ious locations with growing rehabilitation
desired. Staff positions require degree in
January issue is due November 15th.
agency. Work involves treatment of physical
Occupational Therapy and must be regis-
dysfunctions in a geriatric population in hos-
tered by AOTA within 6 months of employ-
Purchase order, requisition, or voucher
pitals and nursing homes. The positions in-
ment. Will consider new graduates for staff
must accompany the advertisement.
volve working as part of a complete rehabili-
positions. Competitive salary and fringe
Cancellations: $1.00 per line typesetting
tation team with speech therapists and phys-
benefits. Contact: Personnel Department,
fee charged for ads cancelled between
ical therapists and includes program devel-
Central State Hospital, Lakeland Road,
15th and 22nd of month. No cancella-
opment. Our company offers top salaries and
Louisville, KY 40223, (502) 245-4121, Ext.
tions accepted after the 22nd of the
a comprehensive benefit package. Please
381. Equal Opportunity Employer. M/F/H.
month. Advertisers will be invoiced the
full amount.
* Maine
AJOT reserves the right to change copy
*State names showing asterisks (*) des-
to conform with the style and format
OCCUPATIONAL THERAPIST, REGIS-
ignate those states that require licensure.
established by the Editors.
TERED-We have an immediate opening in
The American Journal of Occupational Therapy 753
CLINICAL EDUCATION COORDINATOR,
accredited acute care hospital in brand-new
tion, Pleasant Valley Way, West Orange, NJ
HAND CENTER-The Raymond M. Curtis
facility. Community of 75,000 and home of
07052, (201) 731-3600, Ext. 206.
Hand Rehabilitation Center seeks an OT to
University of Montana. Excellent salary/ben-
provide clinical education services for staff.
efits. Qualified applicants apply: St. Patrick
Interacts with PT counterpart and is respon-
Hospital, Personnel Dept., PO Box 4587,
* New Mexico
sible for coordinating teaching programs, li-
Missoula, MT 59806, (406) 721-9640.
aison work with affiliating universities, super-
oT POSITIONS-The Albuquerque Public
vising student programs and providing OC-
School System is accepting applications for
cupational therapy for our patients. Prefer
* Nebraska
Occupational Therapist positions. Interested
individuals should submit a letter of interest,
someone with previous experience in hand
OCCUPATIONAL THERAPIST-For VA
therapy. Those interested please contact Liz
an updated resume, and the names and ad-
Cooney, Human Resources, at (301) 554-
Medical Center, Lincoln. Salary commensu-
dresses of three individuals who may be con-
2035 (collect), or Dale Eckhaus, Chief, Hand
rate with experience. Benefits include Fed-
tacted as references. Send materials to Ra-
eral retirement, health and life insurance, sick
OT at (301) 554-2774. The Union Memorial
quel Reedy, APS Personnel Dept., PO Box
leave and vacation leave. For further infor-
Hospital, 201 E. University Parkway, Balti-
25704, Albuquerque, NM 87125. An Equal
more, MD 21218.
mation contact Marilyn Rooney, Personnel
Opportunity Employer.
Service, VA Medical Center, 600 South 70th
Street, Lincoln, NE 68510, (402) 489-3802,
Missouri
Ext. 330. An Equal Opportunity Employer.
* New York
OTRs-Modern, suburban, 644-bed teach-
REGISTERED OCCUPATIONAL THERA-
PIST-Immediate opening in progressive fa-
New Jersey
ing hospital seeks full-time, part-time and per
diem registered and eligible-for-licensure
cility for the mentally retarded and develop-
OCCUPATIONAL THERAPISTS-We offer
OTs. Opportunity for career oriented Chief,
mentally disabled. Located near Kansas City
area and scenic Missouri Ozarks region.
the best. Dynamic physical rehabilitation set-
Supervisors and Staff Therapists to revitalize
ting provides opportunity to expand clinical
Psychiatric OT Program as part of a multidis-
Competitive salary and benefit package. Ex-
skills through inpatient and outpatient treat-
ciplinary team. Staff positions also available
cellent opportunities for advancement. Con-
ment of spinal cord injury, brain injury, CVA,
in physical dysfunction. Competitive salary
tact Personnel Analyst, Nevada Habilitation
Center, Nevada, MO 64772, (417) 667-
burns and amputees. Existing Spinal Cord
with excellent benefit package. Contact: Mar-
7833, Ext. 425. Equal Opportunity Employer.
Regional Center, Brain Trauma Special Care
ion Miller, Chief OT, Dept. of Physical Med.
Unit and Cognitive Remediation Program al-
& Rehab., Nassau County Medical Center,
low professional specialization. We offer ex-
2201 Hempstead Turnpike; East Meadow,
perienced OTRs and new graduates an ex-
NY 11554, (516) 542-2533.
* Montana
cellent salary and benefits package including
OTR-Challenging position involving a varied
4 weeks' vacation, dental/optical coverage,
FACULTY POSITION-Ten-month tenure
case load including: neuro, orthopedic, acute
tuition reimbursement and extensive contin-
track position at Utica College of Syracuse
care, geriatric, cardiac and mental health pa-
uing education. Please call or send resume
University beginning Spring 1986. Area of
tients. Experience in physical dysfunction
to Robert S. Geller, Vice President, Human
teaching primarily in psychosocial dysfunc-
and mental health preferred. 213-bed JCAH-
Resources, Kessler Institute for Rehabilita-
tion. Qualifications: OTR with Master's de-
OCCUPATIONAL
NRH
THERAPISTS
NATIONAL
REHABILITATION
A challenging opportunity exists for innovative
HOSPITAL
individuals to assist in the expansion of services in a
comprehensive acute care hospital, serving both
inpatients and outpatients. Experiences are available
The Choice of Extraordinary
in burn care, all aspects of rehabilitation,
Professionals.
orthopedics, general acute hospital care, and the
newborn intensive care unit, with an opportunity to
Once in a great while, an opportunity comes
assist with an estabilshed psychiatric milieu
along that allows you to make a real differ-
program.
ence in peoples' lives, while you make great
Located in Anchorage, Alaska, Providence Hospital is
strides in your career.
a 303 bed acute care facility currently undergoing
This is one of those opportunities. The
expansion. A city of 250,000, Anchorage enjoys a
National Rehabilitation Hospital is now open
moderate climate, offers a variety of cultural and
in Washington, D.C. A 160-bed, private, not-
educational opportunities, and is the hub of Alaska's
for-profit facility, NRH will be setting a new
commerce and industry. Excellent salary and
standard of excellence in rehabilitation. We
benefits provided; relocation assistance available.
need your skills, your expertise, and your
Send resume to: Judy Samples, Personnel
dedication.
Assistant, Providence Hospital, Pouch 6604,
For complete details and an application call
Anchorage, Alaska 99502. Equal Opportunity
or write Elizabeth V. Collard, Recruitment/
Employer.
Employment (202) 877-1715.
National Rehabilitation Hospital
SISTERS OF
106 Irving St., N.W.
Suite 101
PROVIDENCE
Washington, D.C. 20010
An Equal Opportunity Employer
SERVING THE WEST SINCE 1856
A Member of the Washington
Healthcare Corporation
754 November 1985, Volume 39, Number 11
gree. Previous clinical and academic experi-
mensurate with experience. Excellent dental
who can work with rehab, acute med/surg
ence necessary. Rank is dependent upon
and medical benefits. Must be AOTA certified
and outpatients are preferred. One person
experience. Salary competitive. Liberal fringe
and have at least 2 years' experience in
should have hand experience. Need COTA
benefits, tuition remission for dependents.
psychiatric and/or substance abuse treat-
to be involved in our Therapeutic Activities
Deadline December 1, 1985. Send letter of
ment. Send resume to: Lenore Pless,
program. Providence is a 168-bed hospital
application and resume to: Richard C. Wright,
Forsyth-Stokes Mental Health Center, 725
located in southern Oregon's Rogue River
MS, OTR, Director of Occupational Therapy,
Highland Ave., Winston-Salem, NC 27101.
valley. Our city of 40,000 is surrounded by
Health Sciences Division, Utica College of
rivers, lakes, mountains and forests. South-
Syracuse University, Burrstone Road, Utica,
OTRs-Needed for comprehensive outpa-
ern Oregon State College and the Oregon
NY 13502, (315) 792-3059. AA/EOE.
tient rehab facility in eastern NC. Background
Shakespearean Festival are located in nearby
in general rehab and/or hands desirable. Ad-
Ashland. Contact Personnel Office, Provi-
CERTIFIED OCCUPATIONAL THERAPY
ditional positions also available in psychiatry
dence Hospital, 1111 Crater Lake Avenue,
ASSISTANT-The Glens Falls Hospital has
or pediatrics. OTR income to $35,000; COTA
Medford, OR 97504, (503) 776-5078. Equal
an immediate opening for a full-time COTA in
needed-income to $20,000. Contact Mike
Opportunity Employer.
our expanding and dynamic Phys. Dys./Re-
Hillis, OTR, Rt. 1, Box 40, Stantonsburg, NC
hab Occupational Therapy Department. The
27883, (919) 238-3336.
FULL-TIME STAFF OCCUPATIONAL THER-
position involves providing services in our
APISTS (REGISTERED) & CERTIFIED OC-
acute care facility and in an area nursing
CUPATIONAL THERAPY ASSISTANT-Im-
home. The Glens Falls Hospital is a modern
* Ohio
mediate openings to work in a dynamic mul-
440-bed general hospital located in upstate
tiprogram Occupational Department. Acute
New York. The hospital is also located in a
LICENSED OCCUPATIONAL THERAPIST-
care hospital with Rehab Unit; full inpatient
year-round resort area with a wealth of cul-
Position available for Licensed Occupational
and outpatient services. Interdisciplinary
tural opportunities. This position offers an
Therapist at a state operated 380-bed psy-
team approach is a priority. Occupational
excellent starting salary and a comprehen-
chiatric hospital. Excellent fringe benefits;
Therapy Department has continuing educa-
sive benefit package. For further information
hours are flexible, part time or full time. Send
tion budget. Staff is made up of 8 full-time
contact: Edmund T. Capezzuti, Personnel
resume to: H. W. Johng, MD, Medical Direc-
OTRs, 2 COTAs and 2 Physiatrists. Salary
Director, Glens Falls Hospital, 100 Park
tor, or W. J. Roberts, Director of Personnel,
commensurate with experience; excellent
Street, Glens Falls, NY 12801.
Massillon State Hospital, PO Box 540, Mas-
benefits. Salem, the capital city of Oregon, is
sillon, OH 44648, or call (216) 833-3135.
situated in the center of the beautiful Willa-
EEO Employer. M/F/H.
mette Valley, approximately halfway between
* North Carolina
Portland and Eugene. We are a city of over
120,000 people that offers excellent educa-
OCCUPATIONAL THERAPIST II-To direct
*
Oregon
tional and cultural opportunities. Mountain
activity therapy service for a 28-bed inpatient
and ocean recreational facilities are all within
program for adults having psychiatric or sub-
OCCUPATIONAL THERAPISTS/COTA-
1 hour's driving time. Please contact: Salem
stance abuse disorders in an innovative com-
Providence Hospital's CARF accredited Re-
Hospital, Employment Office, PO Box 14001,
munity mental health center. Position super-
habilitation Services Department has 3 full-
Salem, OR 97309, (503) 370-5184 (collect)
vises an OTR, recreational therapist and 2
time positions available in its Occupational
between 10 am-4 pm, Monday through
aides. Salary range $18,752-28,309 com-
Therapy Department. Experienced OTRs
Friday, EOE.
Therapists for
INSTITUTE
DIRECTOR
Head Injury Treatment Program
OF CHICAGO
O. T. EDUCATION
The Center at Manatee Springs, a new 120-bed head injury
treatment facility, is seeking several individuals with back-
A challenging position within the Rehabilitation Institute of
grounds in occupational therapy to serve as cognitive therapists
Chicago's Education and Training Center which will provide a
and therapy supervisors. Applicants will be evaluated for their
unique opportunity for a creative occupational therapist to: (a)
willingness and capabilities to learn new assessment, treatment
conceptualize and coordinate continuing education courses
planning and patient management approaches, to adopt unu-
which draw a national audience, (b) develop audio-visual and
sually broad therapeutic responsibilities and nontraditional roles,
written educational materials, (c) have administrative responsi-
and to help design and develop therapy procedures.
bility for student and staff development programs within the
For staff positions, experience with neurologic injuries is not
Occupational Therapy Department, and (d) directly interact
required, although special attention will be given to applicants
with the 50 professional staff in the Occupational Therapy
with acute or long-term head trauma rehabilitation, psychiatric
Department regarding educational, clinical and research pro-
and/or sensory integration training and experience. For associ-
grams. Opportunity to teach in continuing education courses
ate team leader and team leader positions, prior specialized
and to pursue available clinical or research interests. Applicant
program experience is required.
should have a minimum of five years' clinical experience; some
Excellent salaries, benefits, training, research opportunities
of which occurred in a rehabilitation setting. A Master's Degree
and growth potential are offered. Our facility is located in a
in a related area is required with a background in education
southern Florida Gulf Coast beach community a short distance
desirable. The 176-bed Institute has a broad education and
from Sarasota and from the Tampa-St. Petersburg metropolitan
research focus. It is located in a modern building on the down-
area.
town lakeside campus of Northwestern University. Competitive
salary and benefit plan, including tuition reimbursement. Posi-
Please send statement of interests, resume and references
tion available immediately. Interested applicants should send a
to:
resume to:
Larry E. Schutz, PhD, Clinical Director
Shari Intagliata, OTR/L
Director, Occupational Therapy Department
The Center at Manatee Springs
5627 9th Street East
Rehabilitation Institute of Chicago
345 E. Superior St.
Bradenton, FL 33507
Chicago, IL 60611
E.O.E.
The American Journal of Occupational Therapy 755
*
Pennsylvania
pital, 1001 S. George St., York, PA 17405,
Medicine, Nursing and Allied Health. The
(717) 771-2327 (CALL COLLECT). A MEDI-
School of Allied Health, in addition to Occu-
OCCUPATIONAL THERAPIST-Full-time
CAL CENTER THAT CARES. AN EQUAL
pational Therapy, offers Physical Therapy
position available for a Director of Occupa-
OPPORTUNITY EMPLOYER.
and Medical Technology with other disci-
tional Therapy in a 700-bed psychiatric hos-
plines being considered. Lubbock, Texas, a
pital. The opportunity presents a unique chal-
*
regional service community of 200,000 peo-
lenge for developing new and innovative pro-
Tennessee
ple is supported by higher education, energy,
grams for adult patients. Must be registered
REGISTERED OCCUPATIONAL THERA-
agriculture and small industry. The city offers
and eligible for Pennsylvania licensure. At-
PIST-Full-time position in psychiatric hos-
southern hospitality with a Southwest flavor
tractive salary with excellent fringe benefits.
pital and center. OTR to work as a member
in a Sun Belt environment. Requirements of
Send resume to: Director, Social Rehabilita-
tive Services, Danville State Hospital, PO
of a multidisciplinary team providing treat-
the position are earned doctorate in a related
Box 700, Danville, PA 17821-0700 or call
ment to adults in both inpatient and partial
field, 5 years of experience in each of the
(717) 275-7216, EOE.
hospitalization programs. Competitive salary
following areas: higher education, Occupa-
and benefits. Near Knoxville and the Great
tional Therapy clinical practice and adminis-
Smoky Mountains. Send resume to Linda C.
tration. Candidate must show evidence of
DIRECTOR OF OCCUPATIONAL THER-
Daniels, PhD, Coordinator Day Treatment/
successful involvement in professional af-
APY-Woodville State Hospital has an im-
Activity Programs, Ridgeview Psychiatric
fairs, grant writing and research and qualified
mediate opening for an OTR with 5 years'
Hospital and Center, 240 W. Tyrone Road,
to be licensed in the State of Texas. Duties
professional experience, including 3 years as
Oak Ridge, TN 37830, (615) 482-1076.
and responsibilities are those traditionally ex-
an OTR. State salary and benefits. Located
pected of a curriculum chairperson with the
on I-79 south of Pittsburgh. An Equal Oppor-
added challenge of nurturing and building a
tunity Employer looking for the right talented
*
Texas
relatively new program that includes a faculty
and creative person. Call or send resume to:
practice component. The position is offered
Woodville State Hospital, Attention Person-
CHIEF OCCUPATIONAL THERAPIST-To
as a 12-month tenure track appointment.
nel Office, Carnegie, PA 15106, (412) 279-
head department in large medical center in
Salary is competitive and negotiable depend-
2000.
south Texas. Interesting case load of children
ing on qualifications. Applications will be ac-
and adults. Comprehensive program. Out-
cepted until January 15, 1986. Send resume
CLINICAL SUPERVISOR-Immediate open-
patients only. Attractive salary. Call Mr.
and names, addresses and telephone num-
ing for a Clinical Supervisor in a 592-bed
Schafer collect at (512) 722-2431 or write
bers of 3 references to: Ted James, OTR,
acute care teaching medical center in south-
Cowl Rehab Center, PO Box 1620, Laredo,
MA, FAOTA, Associate Professor, Chairper-
central Pennsylvania. Established physical
TX 78041.
son Search Committee, Department of Oc-
disabilities service treats inpatients and out-
cupational Therapy, School of Allied Health,
patients. Special programs of the Occupa-
OCCUPATIONAL THERAPY CURRICULUM
Texas Tech University Health Sciences Cen-
tional Therapy Service include sensory inte-
CHAIRPERSON-Acreative, challenging po-
ter, Lubbock, TX 79430, (806) 743-3242.
gration therapy, neurodevelopmental ther-
sition is available in a newly accredited curric-
TTUHSC is an Equal Employment Opportu-
apy, self-care training, perceptual-motor
ulum due to the appointment of present
nity/Affirmative Action Employer.
training and splint fabrication. Potential for
Chairperson as Dean of the School of Allied
program expansion. Interested applicants
Health. Occupational Therapy is housed in a
please contact Beverly A. Malloy, York Hos-
medical/academic complex with Schools of
Hand Therapist
M
NewMediCo Associates, Inc.
BATON ROUGE GENERAL
MEDICAL CENTER
HEAD INJURY
A 482-bed, private, not-for-profit acute care regional
REHABILITATION
referral center. Known for its "centers of excellence" in
neurosciences, heart, cancer and burn care. Opportunity
for new or experienced therapists to join department of
CENTERS
seven Occupational Therapists with a variety of clinical
expertise in orthopedics, burn, neurology, pediatrics,
SNF and injured worker program. Hand program con-
OCCUPATIONAL THERAPISTS
sists of acute traumatic and chronic hand injuries and
other upper extremity problems. Individual should also
COTA's
have interest in program development, clinical research
Challenging positions are available within our specialized re-
and student education.
habilitation head injury programs. These openings offer the
opportunity for creative input and sharing of ideas as a member of
Excellent salary and benefit program including liberal
our interdisciplinary team. Responsibilities include diagnostic
evaluation, treatment, program development and comprehensive
continuing education opportunities. Range $25,000-
patient management. Previous experience with a neurological
32,500. For more information call Mr. Joseph M. Mor-
population desired but will consider new graduates.
ette, Administrative Director, Physical Medicine, (504)
Positions currently available in New England, Upstate New
381-6520 or send resume to: Baton Rouge General Med-
York, Michigan, and Arkansas.
ical Center, PO Box 2511, Baton Rouge, LA 70821.
If you enjoy challenge and wish to work in this exciting area-of
rehabilitation, we are fully prepared to meet your needs for
growth and development while offering excellent salaries, edu-
THE
cational reimbursement and a comprehensive, fully paid benefits
package.
GENERAL
Please send resume to Director of Staff Recruitment, New
Medico Head Injury Program, 150 Lincoln St., Boston,
MA 02111.
An Equal Opportunity Employer
A Facility of the General Health System
756 November 1985, Volume 39, Number 11
Vermont
pational therapy program providing student
Box 112, Berryville, VA 22611, or call (703)
affiliation. Virginia Baptist Hospital is a full-
955-2400. EOE.
OTR-Full-time position available for enthu-
service nationally accredited 313-bed hospi-
siastic therapist with experience or interest
tal located in a lovely residential section at
OTR-Challenging OTR position available to
in preschool and school-based OT. Further
the foot of the Blue Ridge Mountains conven-
work with acute, chronic and geriatric men-
clinical opportunities available in inpatient
ient to many summer, winter and historic
tally ill. Vast opportunity for program devel-
physical medicine rehabilitation and psychi-
resorts. Salaries are current and competitive,
opment, research, training, supervisory ex-
atric interdisciplinary programs. Competitive
and we provide an excellent benefit program.
perience and liaison with transitional com-
salary and fringe benefits. New graduate con-
Submit resume to Lauralyn W. Martin, Direc-
munity programs. Independence and flexibil-
sidered. For more information, contact:
tor, Personnel, Virginia Baptist Hospital,
ity to "make your job," as well as strong
Wendy Wood, OTR, Chief of Occupational
3300 Rivermont Avenue, Lynchburg, VA
collaborative efforts within interdisciplinary
Therapy, Mt. Ascutney Hospital and Health
24503, (804) 522-4516.
team structures. New graduates or experi-
Center, RR 1, Box 6, Windsor, VT 05089,
enced welcomed. Competitive salary. Excel-
(802) 674-6711. An Equal Opportunity Em-
OCCUPATIONAL THERAPIST-Riverside
lent state benefits. Located in historic colonial
ployer.
Hospital, in Newport News, Virginia, is cur-
Williamsburg, VA. Prefer registration with
rently seeking an AOTA registered or eligible
AOTA. Please submit resume to: Barbara J.
CHIEF OCCUPATIONAL THERAPIST-
therapist to work in the psychiatric section of
Walsh, Personnel Office, Eastern State Hos-
Challenging position in 180-bed acute care
our Occupational Therapy Department. Our
pital, Drawer A, Williamsburg, VA 23187 or
hospital located in central Vermont. BSOT
growing department provides an excellent
call (804) 253-4020.
and registration required along with 2-3
opportunity for both professional and per-
years' clinical experience. Management skills
sonal growth. The geographic location of Riv-
required and some experience preferred.
erside provides a mild climate with proximity
* Washington
Competitive salary and benefits. Submit re-
to historic Williamsburg and to the resort area
OTR-For therapeutic preschool with emo-
sume including salary requirements to: Per-
of Virginia Beach. Interested candidates may
sonnel Department, Central Vermont Hospi-
tionally disturbed & developmentally delayed.
submit a resume and salary history to Jane
Multidisciplinary team. SI certified. Previous
tal, Box 547, Barre, VT 05641, (802) 229-
L. Jacobsen, Personnel Coordinator, Person-
pediatric experience. Salary: DOE. Send re-
9121, Ext. 184. An Equal Opportunity- Em-
nel Department, Riverside Hospital, 500 J.
ployer.
sume to: Valley Cities Mental Health Center,
Clyde Morris Blvd.; Newport News, VA
Children's Day Treatment, 2704 I Street, NE,
23601. Equal Opportunity Employer.
Auburn, WA 98002. EOE.
Virginia
OCCUPATIONAL THERAPIST/COTA-Im-
OCCUPATIONAL THERAPIST-VIRGINIA
mediate opening for full-time OTR or COTA
* West Virginia
BAPTIST HOSPITAL has an excellent oppor-
in private residential school setting for chil-
PROGRAM DIRECTOR-Development of in-
tunity for an Occupational Therapist on our
dren with autistic and autistic-like behaviors.
patient programs for mentally ill; develop-
Acute Rehabilitation Unit. Must be registered
Therapist should have general interest in sen-
ment of staff training; challenging position for
or registry eligible. Recently opened addition
sorimotor programming and parent-teacher
creative person with ability to work indepen-
includes new Occupational Therapy Depart-
education. 12-month school program. Con-
dently. Opportunity to demonstrate clinical
ment with latest facilities. Established occu-
tact Personnel Office, Grafton School, PO
and administrative skills. Graduation from an
DIRECTOR OF PT/OT/REC THERAPY
Opportunity to Function as Pediatric Staff Specialist
The Children's Mercy Hospital in Kansas City is a 167-bed acute care
facility dedicated to the special needs of pediatric patients. As Director
Occupational Therapists
of PT/OT and REC Therapy you will report to the Assistant Admin-
istratór and take full responsibility for designing and shaping activities,
RehabCare a total commitment to caring.
policies and procedures for an extensive range of state-of-the-art
RehabCare Corporation provides comprehensive team-oriented physical
health care therapies. Administrative duties include budget prepara-
rehabilitation programs for hospitals nationwide. Our interdisciplinary
team of rehab professionals are dedicated to providing quality care for
tion and attendance at management meetings, and development of
patients suffering from strokes, head and spinal cord injuries and
Quality Assurance programs. Selected candidate will also act as
degenerative diseases. Our intensive in-patient programs focus on max-
Clinical Instructor for PT students and Advisor to Staff Occupational
imizing abilities with individualized therapy and goal oriented pro-
Therapist and/or Recreation Therapist.
grams for both patients and family.
Minimum qualifications for consideration include:
OCCUPATIONAL THERAPISTS -
Must
be
graduate
of
an
accredited occupational therapy program with current AOTA certifica-
Graduation from approved School of Occupational Therapy
tion required, and state licensed as necessary. Minimum 2 years clini-
Licensed in the State of Missouri
cal and supervisory experience preferred: Will assess patient activities
At least 3 years management experience
and conduct OT programs for patients with neurological and ortho-
Must have N.D.T.
pedic dysfunction. Opportunity to-work closely with other professionals
Majority of clinical experience in hospitals with pediatric care facili-
in the fields of nursing, social work, psychology, PT and speech.
ties.
COTAs - Must be graduate of a nationally approved occupational
Membership in A.O.T.A.
therapy. assistant program and hold AOTA certification. Will assist OC-
Excellent communications and interpersonal skills
cupational therapists in providing care for patients.
High career advancement potential with a young, growing company.
Selected candidate can expect an outstanding salary and compre-
Chance to create new rehabilitation programs. Opportunity to relocate
hensive benefits package, plus relocation to Kansas City, one of
throughout the country if desired. Please call or send confidential
America's most "liveable" cities in terms of professional and educa-
resume to:
tional opportunities. Please send your resume in confidence to:
Personnel Specialist
Dorene Shipley, Employment Manager, CHILDREN'S MERCY
HOSPITAL, Twenty-Fourth At Gillham Road, Kansas City, MO
RehabCare®
64108.
The
RehabCare Corporation
CHILDREN'S
1299 Clayton Road West
Suite 200N
Ballwin, MO 63011
(314) 391-1271
Mercy Hospital
An Equal Opportunity Employer
We are an equal opportunity employer, m/f.
The American Journal of Occupational Therapy 757
accredited college or university with a certif-
Evanston, WY 82930, (307) 789-3464.
COME SUN WITH US-Many positions avail-
icate from an approved school of occupa-
Equal Opportunity Employer.
able in Texas and throughout the southwest,
tional therapy and registered with AOTA. Ex-
south, and southeast. Fee paid by employer.
cellent benefits. Located in beautiful moun-
OTR-Needed for outpatient rehabilitation
Contact Jim Dryden, Southern Medical Re-
tain area close to hiking, fishing, white water,
mid-January 1986. Types, of cases served
cruiters, 121 Del Mar, Corpus Christi, TX
etc. Send resume to: Rein Valdov, Adminis-
are spinal cord and brain injury, stroke, or-
78404. Call (512) 888-8116. Toll free: 1-
trator, Weston Hospital, Drawer 1127, Wes-
thopedic disabilities, cerebral palsy, multiple
800-531-3104, in Texas 1-800-242-3363.
ton, WV 26452.
sclerosis, arthritis, etc. Salary, health insur-
ance, vacation plus sick leave. Contact:
Douglas L. Warnock, Executive Director,
Wisconsin
Gottsche Rehabilitation Center, Hot Springs
OCCUPATIONAL THERAPISTS-Dynamic
State Park, PO Box 790, Thermopolis, WY
positions are now available in a variety of
82443, (307) 864-2147.
locations in Wisconsin. Opportunities abound
in tapping the resources of this state's largest
United States
rehabilitation agency, including having ac-
cess to a diversified network of therapy staff.
NEW GRADUATES, DIRECTORS, AND
New and experienced therapists have the
STAFF-Relocate nationwide or choose
potential for program development and re-
from local positions. All fees are employer
search in individual specialty areas. Our com-
paid and all inquiries are held in strict confi-
prehensive compensation package is flexible
dence. Call 1-800-792-3504 Ext. 425 or
to meet individual needs. For specific infor-
send your resume to Hugh Teweles, CPC,
mation or an interview appointment contact:
Director of Health Care Services, Dunhill of
Jody Garber, OTR, Therapy Associates, Inc.,
Milwaukee, 735 North Water Street, Milwau-
1515 W. Mequon Rd., Mequon, WI 53092,
kee, WI 53202.
(414) 241-4240.
TIME FOR A MOVE? TELL US WHERE!--
All contacts confidential and at no cost to
Wyoming
you! Our Consultants specialize in staff, su-
OCCUPATIONAL THERAPIST, REGIS-
pervisory and director positions nationwide
in both OT and PT. Send resume to Health
TERED-Psychiatric oriented OTR for state
Care Search, 3383 Vineville, Macon, GA
position listed as Evaluation Developmental
31204. Call (800) 841-6381. Georgia, (912)
Therapy Specialist I. Salary range effective
474-9400.
July 1, 1985: $20,071-23,274 annually, com-
mensurate with experience. Contact: Person-
nel, Wyoming State Hospital, PO Box 177,
OCCUPATIONAL
New Hampshire
THERAPISTS
OCCUPATIONAL
Allied Services has excellent oppor-
THERAPIST
tunities for staff therapists in our oc-
Modern, progressive 92-bed acute care
cupational therapy departments serv-
hospital seeks a dependable
ing 2 Rehabilitation Hospitals. The
independent registered or registry
90-bed George T. Walters Institute lo-
eligible occupational therapist.
Caseload includes, but is not limited to,
cated in Scranton, PA, and the 86-bed
orthopedics, neurologic, psychiatric
John Heinz Institute located in
and home care patients. Competitive
Wilkes-Barre, PA, offer professional
salary and fringe benefits package
growth in a multidiscipline setting.
combined with the exceptional
recreational opportunities of the White
Generous salary and benefit package.
Mountains.
If interested, send resume or call col-
If interested contact Personnel
lect:
Department,
Employment Manager
ANDROSCOGGIN VALLEY
ALLIED SERVICES
HOSPITAL
475 Morgan Highway
59 Page Hill Road,
PO Box 1103
Berlin, NH 03570
Scranton, PA 18501
(603) 752-2200, Ext. 204
dh
An equal opportunity employer
(717) 348-1348
758 November. 1985, Volume 39, Number 11
MANAGER OF
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
POSITIONS
Jefferson Hospital currently has a challeng-
ing professional position for an experienced
Occupational Therapist to provide supervi-
sion of progressive inpatient and outpatient
Fresno Community Hospital is a facility of Community
Occupational Therapy Department. An inter-
Hospitals of Central California which is a progressive
disciplinary team approach for a case load
diversified multi-hospital system located in the heart of
that-includes the Psychiatric, Physical Reha-
the San Joaquin Valley. The Corporation's 6 facilities
bilitation, Acute and Long Term Care areas.
have a total of 950 beds and 2,800 employees.
The successful candidate will have Bache-
lor's Degree, current Occupational Therapy
registration and proven management experi-
ence. Prior JCAH experience preferred.
Occupational Therapists
Please send resume or call:
Excellent opportunity for an Occupational Therapist to
Recruitment Retention Coordinator
participate in a multidisciplinary team setting as part of
SOUTH HILLS HEALTH SYSTEM
an outpatient head injury rehabilitation program. Re-
1800 West Street
sponsibilities include assessment and therapy of adoles-
Homestead, PA 15120
cent and adult brain-injured population, with emphasis
(412) 464-6121
on fine and gross motor skills, sensory integration, inde-
pendent living and community reorientation skills. In-
dividual will work closely with Recreation Therapist to
coordinate activities in the program's residential facility.
South Hills
Must be able to work evenings and weekends. Candidates
should possess Bachelor's degree and appropriate regis-
Health System
tration. Certification in sensory integration therapy is
desired.
We are also currently looking for Occupational Thera-
pists to work within our Rehabilitation Department.
Move your career to
the Texas Medical Center.
Occupational Therapy Manager
One of the nation's leading teaching, research
Immediate opening for a Manager in the Occupational
and tertiary care facilities, Hermann Hospital
Therapy Department. Individual will provide manage-
offers an opportunity for the progressive thera-
ment direction to 30 staff members within Occupational
pist to excel. Although trauma and critical care
and Recreation Therapy. These areas are part of a 66-
are our specialties, we provide a highly challeng-
ing and diverse caseload.
bed JCAH and CARF accredited (DRG exempt) rehab
Hermann psychiatric therapists receive
unit encompassed in a 458-bed acute care hospital. Suc-
blanket referrals and provide goal-directed
cessful candidate will be a Registered Occupational Ther-
rather than diversional treatment. Our Physical
apist with a minimum of 3 years' supervisory experience
Disabilities Division is divided into sections of
in a medium to large Rehab Department. Financial/
neuro, burns, pediatrics, hands/ortho and med/
budgetary background a definite plus.
surg. Both areas allow you creative input and
sharing of ideas as a member of our interdisci-
plinary team.
We offer a competitive salary, benefits package and relo-
Qualified candidates (eligible for Texas licen-
cation assistance. For immediate consideration, send
sure) should contact the Department of Human
Resources, Hermann Hospital. 1203 Ross Ster-
your resume in confidence to:
ling Avenue, Houston, Texas 77030. Or call (713)
797-4473 collect.
Art Calderon
Personnel Department
Fresno Community Hospital
HERMANN
PO Box 1232
HOSPITAL
Fresno, CA 93715
1203 Ross Sterling Avenue
Houston, Texas 77030
Affiliated/The University of Texas Medical
School at Houston. We are an equal
opportunity employer, m/f/h.
The American Journal of Occupational Therapy 759
The Rehabilitation Institute of Virginia
Opening in January 1986
The Rehabilitation Institute of Virginia is a new, regional, 75-bed
intermediate rehabilitation hospital located on the beautiful
Hampton Roads waterfront in Newport News, Virginia.
The opening of this facility presents an excellent opportunity to
join in the challenges and rewards of rehabilitative therapy.
Openings exist for Occupational Therapy Director, Staff
Therapists, and Assistant positions.
This ground floor opportunity offers the following: an inter-
disciplinary team approach to patient care
good patient/therapist
ratios
excellent patient education opportunities
inpatient and
outpatient settings.
If you are interested in more information, call collect or send
resume to:
Ms. Phyllis A. Corker
Employee Relations Manager
Personnel Department
Riverside Hospital
500 J. Clyde Morris Blvd.
Newport News, VA 23601
Phone: (804) 599-2025
Equal Opportunity Employer
1207
MOBERG
760 November 1985, Volume 39, Number 11
Occupational
Therapist
Occupational Therapist
McKay-Dee Hospital
America Is Number One
Ogden, Utah
Thanks to Our Veterans
The McKay-Dee Hospital is a 370-bed Teaching
Hospital with a tradition of providing excellent patient
care to the Ogden area.
A Staff Therapist position is available in our dynamic
The Veterans Administration needs
26-bed rehabilitation facility and comprehensive out-
patient program.
Occupational Therapists. Our goal is
You will be working with a wide variety of physical
to provide the nation's veterans with
disabilities in NICU through Geriatrics. You must be
registered or registry eligible in the State of Utah.
the best medical care available.
The Therapist functions as an integral member of a
multidisciplinary team.
We offer excellent benefits and a salary commensu-
Find out what the VA has to offer you.
rate with experience. Ogden offers abundant cultural
Call us toll-free at 800/368-6008
and recreational facilities, excellent schools, and is an
attractive place to live and work. Housing is afford-
able. Please send resume to:
(800/552-3045 in Virginia) and talk
McKay-Dee Hospital
to us about current employment
Stewart Rehabilitation Center
Sandy Bybee
opportunities.
Human Resources
3939 Harrison Boulevard
Veterans
Ogden, Utah 84409.
(801) 625-2060
Administration
Equal Opportunity Employer
An Equal Opportunity Employer
The University of British Columbia
School of Rehabilitation Medicine
OCCUPATIONAL
FACULTY POSITIONS
THERAPIST
Applications are invited for tenure track positions at
Seeking Occupational Therapist to work with
the rank of Assistant Professor in the Divisions of Physical
Spinal Cord Injury Model Program. Bachelor's
Therapy and Occupational Therapy at the University of
degree in oT with AOTA Registration is required.
British Columbia. Candidates must be eligible for mem-
1 to 3 year Clinical Spinal Cord Injury experience
bership in the Canadian Physiotherapy Association or the
and/or 3 to 5 years experience in Independent
Canadian Association of Occupational Therapists, have
Living Programming at a Center for Independent
Living are important qualifications. Masters'
a doctoral degree, strong research accomplishments, and
field experience related to one or more of the following
degree in OT or related health service profession.
group and individual counseling experience and
areas: Physical Therapy-néurosciences, adult and pe-
excellent interpersonal skills will be helpful.
diatric neurology, kinesiology and exercise physiology;
Occupational Therapy-adult and pediatric neurology,
This position is a good opportunity to develop an
rehabilitation technology, vocational rehabilitation and
innovative Occupational Therapy program. and to
mental health.
collaborate clinical practice with community
Academic leadership qualities desirable. Salary will be
based Center for Independent Living service.
commensurate with qualifications and experience. In ac-
Individuals with personal experience with
cordance with Canadian immigration requirements, prior-
disability are encouraged to apply. Send resume
ity will be given to Canadian citizens and permanent
to Employment Representative. University of
residents of Canada.
Michigan Medical Center. N18A05. 300 N. Ingalls.
Deadline for submission of applications is January
Box 50. Ann Arbor. MI 48109.
1, 1986. Application, curriculum vitae and the names of
3 references should be submitted to: The Director, School
of Rehabilitation Medicine, The University of British Co-
UNIVERSITY
lumbia, T106 Third Floor, Acute Care Unit, HSCH, 2211
OF
MEDICAL
Wesbrook Mall, Vancouver, British Columbia, V6T 1W5,
MICHIGAN
CENTER
CANADA. Telephone: (604) 228-7414
A Non-Discriminatory. Affirmative Action Employer
The American Journal of Occupational Therapy 761
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762 November 1985, Volume 39, Number 11
CHARLES C THOMAS
PUBLISHER
New!
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the emotionally handicapped, receives close attention in
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The American Journal of Occupational' Therapy 763
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You take control.
Introducing a new standard of excellence in lightweight mobility. The Rolls 500 ATS by Invacare.
For more information, call or write Invacare Corporation, 899 Cleveland Street, P.O. Box 4028,
INVACHRE
Elyria, Ohio 44036-2125 U.S.A. Phone: 800/321-5715. In Ohio: 800/362-7415. Telex: 6873185 I CARE UW.
The POSTURE-CARE ® System:
Custom Fitting for
Pediatrics to Adults.
New! Theradyne's Posture-Care® System now includes
Pediatric and Junior sizes-making it the most versatile
therapeutic seating system on the market. With our wide range of
custom positioning aids, Posture-Care is the ideal starting point
for the full spectrum of patient needs-from pediatrics to adults,
from moderately to severely involved.
Our newest prescription wheelchairs, like our classic adult
model, provide safe, comfortable therapeutic seating. And
because our positioning aids offer a wide range of adjustability,
patients can be fitted in one visit-saving the time and cost
of one-of-a-kind special orders. All modular Posture-Care
components are maintained in stock by Theradyne.
Only Posture-Care offers all this in one system:
Heavy-duty frames
Sealed-bearing wheels and casters
Posturethane® upholstery-self-skinning. flame-
retardant, impervious to water, non-cracking, non-
peeling, easy-to-clean
Adjustable-height arms
Standard or recliner models
Posture-Care: the custom fit is built in
not added on. Call or write for free brochure.
theradune
THERADYNE CORPORATION
21730 Hanover Avenue
Lakeville, MN 55044
(612) 469-4404
Toll-free (800) 328-4014
© 1985 Theradyne Corporation
Fred Sammons, Inc. is working
hard to make your
job easier.
At Fred Sammons, Inc., helping you meet the needs
of your patients is our only concern. In 1985, for
example, we introduced our Orthopaedic Catalog
to provide a single source for fast and efficient
ordering of a specialized group of products. Each
year, through our catalogs and supplements, we
bring you a range of new and innovative products,
representing the latest state-of-the-art technology
products you've asked us for.
In addition, Fred Sammons, Inc. community
consultants from coast to coast conduct numerous
splinting workshops-comprehensive learning
experiences for the beginner or the more advanced.
In 1985, we also introduced a west coast distribu-
tion center and faster order processing. Finally, we
offered a 10% discount on telephone or mail orders
of $250 or more.
The best is yet
to come!
Watch for Fred Sammons, Inc. in 1986. We will
be continuing our "Commitment to Excellence"
and you
with exciting new products and
important services to make your job a little easier.
To experience the Fred Sammons, Inc. difference
yourself, order from us today. Call toll-free
1 800 323-5547 (in Illinois, 1 800 942-2129).
FRED SAMMONS, INC.
BeOK!
A
BiSSE!!
HEALTHCARE
COMPANY
Commeticat
to Excellence
BOX 32, BROOKFIELD, IL 60513-0032
The American Journal of
Occupational Therapy
1383 Piccard Drive
Rockville, Maryland 20850
019940