Running head: ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN

Assistive Technology Fabrication for Individuals with Chronic Back Pain Corinne Trenholm Touro University, Nevada

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN

Back pain is one of the most common medical problems in the United States. It is reported that one-fourth of U.S adults experience at least one day of back pain in a three month period (National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 2010). Low back pain (LBP) is the most common type of back pain which occurs in the lumbar region consisting of the five lumbar vertebrae (National Institute of Neurological Disorders and Stroke (NINDS), 2011). Pain is typically felt just below the bottom of the ribs down to the tailbone. It is estimated that 80% of Americans experience LBP in their lifetime. LBP is the second leading cause of individuals missing work and is the fifth most frequent cause of hospitalization (Healthy People, 2012). According to Grangaard (2006) LBP resolves in 90% of individuals within six weeks and in 12 weeks for another five percent. For those experiencing LBP for three or more months, this is considered chronic back pain (CBP). CBP can persist for months, years, or the duration of ones life (NINDS, 2012). According to Healthy People (2012) two to eight percent of individuals suffer from CBP. Americans spend at least $50 billion each year on LBP and 90% of the total spending is for the treatment of CBP (Healthy People, 2012). Although those suffering from CBP may not be able to identify the root cause for their pain, CBP may persist due to infections, tumors, mechanical problems, injuries, or acquired conditions and diseases (NIAMS, 2010). CBP is a debilitating condition that negatively affects daily activities, routines, and role performances. It not only affects ones physical abilities but also impacts ones psychological state. Through the use of adaptive technology, individuals with CBP can increase their functional capabilities. This allows individuals to engage in meaningful occupations restoring their overall well-being (Fisher, Emerson, Firpo, Ptak, Wonn & Bartolacci, 2007). Literature Review When comparing the qualitative study by Vroman, Warner, & Chamberlain (2009) and the qualitative study completed by Fisher et al. (2007), they equally identified that CBP interferes with

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN participation in meaningful occupations due to psychological problems and physical limitations. The qualitative study completed by Fisher et al. (2007) looked at the lived experiences of individuals suffering from chronic pain. Although this study looked at individuals suffering from various types of

chronic pain, the majority of participants in the study have CBP. The study completed by Vroman et al. (2009) looked at narratives from participants with acute and chronic low back pain to evaluate their lived experiences. Psychological Impact In both studies the participants communicated emotional stress. Feelings of sadness, depression, frustration, and anger were among some of the emotions that were expressed by the participants. One gentleman with CBP said, It hurts all the time and you have nothing to be happy about (Fisher et al., 2007, p. 297). A women suffering from CBP from a herniated disc expressed her frustration with not being able to complete tasks and stating that her pain limits her from doing what she wants (Fisher et al., 2007). In the study completed by Vroman et al. (2009) a woman stated, Not knowing the reason for my pain is extremely stressful and frustrating. This makes me angry and I feel it alters my personality to a degree (p. 979). Other emotional responses included feelings of being overwhelmed, anxiety, fear, and guilt. According to Fisher et al. (2007) individuals with chronic pain often discover the true strength of their relationships with family, friends, coworkers, and health care providers. Some individuals in the study found their relationships to be strong and sustaining. Others however, reported that their relationships declined due to the presence and challenges of their pain. One woman with chronic LBP stated, Because I cant do activities or tours my husband gets disgusted because I cant keep up with him (Vroman et al., 2009, p. 980). Although the majority of participants in the study completed by Fisher et al. (2007) expressed that they can rely on their families for physical and emotional support, many participants in both studies expressed their lack of support from friends, co-workers, and medical

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN

professionals. Participants in both studies expressed that others dont understand the severity of their pain and one cant truly understand their pain without experiencing it for themselves. A service worker with chronic LBP said, Its hard to understand others pain if you havent gone through it too. (Fisher et al., 2007, p. 296) A young man with LBP has been ridiculed by his friends for engaging in exercise that help reduce his back pain (Fisher et al., 2007). One gentleman explained that his back pain hasnt decreased and his employment hasnt been supportive of this pain (Vroman et al., 2009). Feelings of being misunderstood and frustrated with the medical community were apparent in each article. Many participants feel that their doctors dont take their pain seriously and they are frustrated with the lack of treatment and/or innovative approaches. Physical Limitations According to Vroman et al. (2009) the most common reason that individuals with chronic LBP seek treatment is due to their physical limitations in everyday activities. Limitations range from person to person. Pain can impact the simplest tasks such as dressing to more complex tasks such as work and role performance. Not only does pain interfere with tasks that are needed to engage in daily function but also those that are associated with leisure and enjoyment. After reviewing the articles, several areas of occupation were identified as being impacted by CBP. These include ADLs, IADLs, work, leisure, and social participation. For those experiencing pain all the time no matter what they are engaging in, simple ADL tasks are impacted. These tasks include dressing, showering, grooming, and eating. Toileting can also be impacted. One woman discussed that her chronic LBP radiates down to both of her legs and feet and at times causes numbness. This numbness in turn causes incontinence of stool and urine (Vroman et al., 2009). Due to the severity of pain individuals may also become immobile, causing difficulties with functional mobility in their home and community (Vroman et al., 2009).

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN Not being able to complete IADLs takes away ones independence, roles, and responsibilities.

CBP can affect roles such as child rearing. One gentleman discussed that he feels guilty that he is unable to help with his children due to his pain (Fisher et al., 2007). Another IADL impacted by pain includes household chores. One homemaker discussed that she is no longer able to complete household chores and relies on her husband for help (Fisher et al., 2007). Another woman discussed that not being able to complete household chores takes away her sense of self (Vroman et al., 2009). Community mobility can also be impacted. Another homemaker discussed that not being able to drive impacts her ability to be independent and takes away her freedom (Fisher et al., 2007). One individual discussed that because her pain is so intense, she has become sedentary. This in turn has caused weight gain and lead to an unhealthy lifestyle. Many participants with CBP discussed social participation as being an area of occupation impacted by their pain. In the study completed by Vroman et al. (2009) the negative impact of family engagement was apparent. A 38-year-old mother with chronic LBP stated, I have few real pleasures in life, coaching my boys is top of the list. Not being able to do that, as I want, causes me pain emotionally. My kids are growing and I feel like time is running out and Im missing something (p. 982). Another mother, in the article written by Fisher et al. (2007), discussed that her family went on vacation without her due to her inability to walk for long periods of time. Some participants avoid social activity where others discussed that they have to cancel plans due to their pain. Other social restrictions, that were discussed earlier, include friends not understanding ones pain and not being able to tolerate the challenges of being friends with a person with CBP. Adaptations for Chronic Back Pain According to Fisher et al. individuals with chronic pain have to make temporal, lifestyle, and cognitive adaptations in order to cope with their pain. Individuals participating in the study completed by Vroman et al. also revealed the use of adaptations in order to cope with pain. Some of the

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN adaptations discussed in the study completed by Fisher et al. include shortening the time spent on a task, altering schedules, using energy conservation strategies, delegating chores to others, and using

joint protection strategies by changing positions during tasks and taking breaks. Others discussed the importance of changing the way tasks are completed using assistive devices. Some of the assistive devices discussed by individuals with CBP include using low stools to sit on when reaching or participating in activities near the floor, using reaching sticks, trading in larger vehicles for smaller ones that are easier to get in and out of, using a high stool to sit on during cooking, and using a seat cushion and wheelchair when needed (Vroman et al., 2009). Assistive Technology According to Grangaard (2006) occupational therapy interventions include training in the use of adaptive equipment, task analysis and use of ergonomic design to modify the environment, training in the use of energy conservation, and education in strategies for pain management, stress reduction, and coping. Occupational therapists can be a great resource for individuals suffering from chronic back pain. By assisting with lifestyle modifications and recommending task adaptations, individuals with CBP can improve their occupational performance and reduce negative psychological impact. The following adaptations, taken from Grangaard (2006), can be made to daily occupations to help individuals with CBP. Bathing. Showering may be a better option that bathing as showering allows one to keep their spine in a neutral position. It is also easier to get in and out of a shower thus eliminating unnecessary movements. Keeping items within reach using shower racks and using long-handled sponges and a handheld showerhead also prevents one from bending over, twisting their back, and engaging in unpleasant movements. For those that have decreased pain during sitting, a shower chair can be used. Dressing. During dressing there is a lot of bending over which typically causes increased pain. Individuals can sit or lay down when dressing in order to keep their back straight. Using long-handled

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN dressing aids such as reachers, dressing sticks, and sock aids can also help individuals keep their back straight. Slip on shoes, loose clothing, and prepping clothing prior to dressing that requires twisting such as threading a belt through pants, can also prevent pain during dressing.

Functional Mobility. When changing positions in bed, individuals should move their body as a whole using a logroll technique. Getting in and out of bed can also be adapted by having individuals keep their back straight and using their abdominal muscles to support their back. Using a side lying position when getting up and lying down is a technique that helps with proper transfers in and out of bed. When lowing to sit in a bed, chair, or toilet, one must keep a neutral spine and their back straight. Grab bars and chair arms can be used to assist in sitting. It is also recommended that chairs be firm, supportive, and an adequate height and individuals get up from sitting every 15-20 minutes to prevent stiffness. Grooming. Grooming at the sink is another activity that requires bending. To help keep the back straight one can bend at the hips or use a golfers lift movement. This movement consists of bending forward and bearing weight through one knee while extending a straight leg back. Placing a foot inside the base cabinet can also reduce strain on the lower back. Sleep. Having a firm, supportive mattress is the first step in helping clients with CBP. Pillows can also be used such as under the knees when laying in supine to reduce lower back strain and in between the knees when side laying to avoid twisting of the lower body. Toileting. Twisting motions are typically used during toileting. To avoid twisting movements one can reach between their legs when cleaning and get off the toilet and turn to the back prior to flushing. One may also choose to face the back of the toilet by straddling it. This provides a wider base of support and the toilet tank can be used to help one stand after toileting. Child Care. Caring for young children often requires bending over and lifting. To eliminate the need to bend, some activities can be performed on an elevated surface. When dressing a child, one can

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN use a changing table or other elevated surface. During bathing, the sink can be used or a portable tub

can be placed on a kitchen counter. When picking up a child, one should bend at their knees, squatting down close to the child, and pick up the child using their legs with a straight back. Finally, when placing a child in or taking a child out of a car seat, a squatting position should be used. Work. It is important for occupational therapists to assess work environments and demands in order to help individuals with CBP. Each persons environment and tasks are unique and by completing an assessment, an occupational therapist can assist with adaptations. Adaptations can include lifting techniques, adapted schedules, equipment and organization, pacing, and setting up workstations with the appropriate computer, chair, and desk height. Driving. Adjusting the driver seat and steering wheel can help keep the back straight and the spine in a neutral position. When getting in and out of the car, one should turn the body as a whole to avoid twisting. If needed, one can adjust the car seat to make this maneuver possible. Like stated earlier, if one will be sitting for an extended period of time, it is important to pull over and get out of the car to avoid stiffness. Home establishment and management. No matter what activity one is completing, all workspaces should be at a comfortable height with the elbows bent at 90 degrees and the back and neck straight. All frequently used materials should be kept within reach. If one needs to bend such as to get materials from a lower shelf or from the dryer, one should squat down and use their legs to lift or use a stool to sit on. One can also use a golfers lift when bending to retrieve higher up items such as from the washing machine. Long-handled equipment such as reachers and sponges can also be used to help with cleaning, organization, and/or retrieval. All home management tasks should adhere to previous strategies of keeping the back straight and the spine in a neutral position. After examining the literature review, it is easy to see how CBP negatively impacts ones overall well-being. The literature review also shows how individuals use adaptations to help them cope and

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN prevent further pain in order to engage in wanted occupations. Grangaard (2006) further introduces

adaptations that are used in various occupations to help clients engage in every day routines. Through activity analysis, evaluation of occupational performance, and determining a clients wants, priorities, and needs, an occupational therapist can use assistive technology to help their clients engage in meaningful occupations.

Assistive Technology Fabrication There are times when an occupational therapist is unable to locate interventions and adaptations from evidence based literature and textbooks to meet their clients needs. In these cases, an occupational therapist must use their clinical reasoning and decision making skills in order to create individualized interventions and/or adaptive equipment that are appropriate for their client. Client Information/Occupational Profile Greg is a 58-year-old male who has been suffering with CBP for ten years. He has been to numerous doctors; however, they havent been able to identify the cause of his pain in order to treat it properly. Greg retired one year ago. Prior to retirement he worked as a butcher. This job required him to lift heavy objects, stand for long periods of time, and bend over at workstations. All of these job requirements put strain on the lower back and could be the cause of his CBP. Greg discussed that over the years he has found ways to cope with his pain and has changed the ways he does things. His adaptive responses enabled him to continue working and currently allow him to engage in desired and needed occupations. There is one occupation however that Greg has a difficult time engaging in. He finds it extremely difficult to care for his dog named Rosie. Device Purpose Greg lives alone and Rosie is his pride and joy. Rosie is on a special diet that requires her to be fed three times per day. Greg discussed that bending over to retrieve Rosies food and water dish as well as return them to the floor causes strain on his lower back and increases his pain. Squatting down

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN and keeping his back straight isnt an option for Greg due to his weight and decreased strength in his legs. In order for Greg to feed his dog without increasing his pain, the Bend Free Pet Feeder was created. These feeders, one for food and one for water, allow Greg to keep his back straight with his

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spine in a neutral position while feeding his dog. The feeders consist of containers that store food and water and use tubing to deliver the food and water to a pets bowl. The food feeder tubing contains a magnet at the end and the water feeder tubing contains hex nuts at the end. These allow the tubing to connect to the magnets placed on the bowl to help steady the tubing and prevent spilling during water valve release and food tipping. These devices were also created to be portable. Greg recently bought a recreational vehicle (RV) and likes to travel with Rosie. By making these devices portable, Greg can continue to prevent back strain while on vacation. Projected User/Group The Bend Free Pet Feeders were created for individuals who suffer from CBP. These devices however, can be used by several populations who are unable to reach the floor for various reasons. As individuals age it gets harder for them to squat and/or bend while holding and/or lifting objects. Individuals who are in wheelchairs may not have the trunk support or the ability to reach the floor. Individuals recovering from surgeries such as hip, knee, or back surgery have to adhere to precautions which would inhibit them from bending and squatting. Other individuals who suffer from degenerative or neuromuscular diseases such as multiple sclerosis may also find it difficult to bend and squat due to decreased energy and muscle strength. The Bend Free Pet Feeders enable individuals to care for their pets without bending, squatting, transferring, and exhausting energy. Current Products Currently there are automatic pet feeders that can be used by individuals suffering from CBP. These feeders are designed in various sizes, styles, and offer different features. Some allow for food and water to be dispensed continually while others allow for portion control. Some of the feeders provide

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN daily feedings while others can last more than a week. These automatic feeders may also require a power supply outlet and/or batteries. The price of an automatic feeder depends on the style and features. Appendix B lists different prices of automatic food and water feeders along with their features. Prototype Uniqueness

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The Bend Free Pet Feeders are unique when compared to automatic pet feeders. The Bend Free Pet Feeders allow individuals to actively engage in caring for their pets on a daily basis. Not only does feeding a pet add structure and routine to ones day, it also helps individuals stay connected to their pets, boosts vitality, and provides pleasure and a sense of self-worth (HELPGUIDE.org, 2012). As seen in Appendix B, most feeders that allow for portion control are expensive and require the use of batteries or electrical hookups. The Bend Free Pet Feeders allow for portion control and do not require the use of electricity, batteries, or timers. This enables the feeders to be low cost and saves money and time. Purchasing batteries and using electricity adds extra costs when using the automatic pet feeders. Individuals also have to spend time purchasing batteries and setting and managing timers. Whenever electronics are involved, there is always the risk of something breaking down or malfunctioning. Electrical problems are also difficult to repair and often require professional help. The Bend Free Pet Feeders do not have electrical issues. They also contain simple, inexpensive parts that can be purchased at a local hardware store and easily replaced by the pet owner. Many automatic feeders are bulky, stationary, and require a large storage area. The Bend Free Pet Feeders are portable, small, and easy to store. Usability The Bend Free Pet Feeders are low tech devices that are light weight and easy to use. Individuals using the pet feeders are able to adjust the amount of water and food they add to the containers which helps them manage the weight they are holding. An individual can also use the

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measurement lines found on the containers when their pets are on food and liquid diets or they can add measured portions of food and water to the containers prior to feeding. The water feeder requires upper extremity bilateral coordination while the food feeder only requires the use of one upper extremity to manipulate the device. Finger manipulation is important for the water feeder as it requires one to adjust the water valve to start and stop the flow of water. Both devices contain a handle that is used to grip and manipulate the containers. Although grip is helpful, individuals can use adaptive responses to hold the containers such as sliding ones fully extended fingers and hand through the grip handles or using their forearms and/or arms with body support. There are four steps required for the food feeder which are 1) fill the container with food or use food that has been stored in the container, 2) align and attach the tubing to the pet bowl, 3) tilt the container to pour the pet food down the tubing, and 4) stop tilting and remove the tubing once the required amount of food is in the bowl. There are four steps involved in the water feeder, with a slightly more complicated step involving a twist valve. These steps include 1) Fill the container with water or use stored water, 2) align and attach the tubing to the pet bowl, 3) twist the valve counterclockwise to allow the water to flow down the tubing, and 4) turn the valve clockwise to stop the flow of water and remove the tubing from the pet bowl. These easy steps require minimal training and individuals can use different positions and grip patterns during use. The Bend Free Pet Feeders are low cost and could easily be made from recycled materials. The total cost for both feeders was $26.52. Appendix A contains a price analysis highlighting materials used and their cost. The Bend Free Pet Feeders low cost and ease of use makes these devices readily accessible for individuals with CBP. The ability for individuals to make their own device with recycled materials further adds accessibility. Conclusion Two to eight percent of individuals in the U.S. suffer from CBP. CBP is a debilitating condition that affects an individuals physical and psychological well-being. Occupational therapists can provide

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN valuable services for individuals with CBP in order to help them engage in needed and meaningful occupations. Occupational therapists can assist in client education related to proper body mechanics

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and compensatory strategies. Occupational therapists can also help individuals obtain proper adaptive equipment. Although there are current evidence based interventions and adaptive equipment devices on the market for individuals with CBP, there is always a need to use clinical reasoning skills to individualize a clients goals and interventions. In Gregs case, using proper body mechanics and recommended compensatory strategies were not suitable. This prompted a need to adapt how Greg cares for his pet. Using the PEOP model, an occupational profile was created and examined in order to create an adaptive device that meets Gregs needs. The Bend Free Pet Feeders allow Greg to stand while feeding his dog which prevents low back strain and pain. The feeders are also portable which will allow Greg to continue to use the devices while on vacation. It is exciting to know that the Bend Free Pet Feeder will enable Greg to engage in a desired and meaningful occupation that will enhance his quality of life.

ASSISTIVE TECHNOLOGY FABRICATION FOR INDIVIDUALS WITH CHRONIC BACK PAIN References

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Fisher, G., Emerson, L., Firpo, C., Ptak, J., Wonn, J., & Bartolacci, G. (2007). Chronic pain and occupation: An exploration of the lived experiences. American Journal of Occupational Therapu, 61(3), 290-302. Grangaard, L. (2006). Low back pain. In H.M. Pendleton & W. Schultz-Krohn (Eds.), Pedrettis occupational therapy: Practice skills for physical dysfunction (6th ed., pp. 1036-1055). St. Louis, MO: Mosby Elsevier. Healthy People. (2012, May). Arthritis, osteoporosis, and chronic back conditions. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=3 HELPGUIDE.org. (2012, February). The therapeutic benefits of pets. Retrieved from http://www.helpguide.org/life/pets.htm National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2010, July). Back pain. Retrieved from http://www.niams.nih.gov/Health_Info/Back_Pain/default.asp National Institute of Neurological Disorders and Stroke. (2011, December). Low back pain fact sheet. Retrieved from http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm National Institute of Neurological Disorders and Stroke (2012, May). NINDS chronic pain information page. Retrieved from http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm Vroman, K., Warner, R., & Chamberlain, K. (2009). Now let me tell you in my own words: Narratives of acute and chronic low back pain. Disability and Rehabilitation, 31(12), 976-987.

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Appendix A Bend Free Pet Feeder Price Analysis Dog Feeder Pitcher Hose *Magnets *Wire Total: Water Feeder Pitcher Tube Brass Coupling Plastic Valve O-Ring Hex Nut X2 *Adhesive Caulk Total: Feeders Grand Total Double Feeding Dish Magnets *Super Glue Total: Feeders & Accessory Grand Total $ 1.97 $ 5.00 $ 2.70 $ 3.00 $ 12.67 $ 1.97 $ .96 $ 2.37 $ 4.70 $ .59 $ .28 $ 2.98 $ 13.85 $ 26.52 $ .99 $ 2.73 $ .99 $ 4.71

Dog Bowl Accessory

$ 31.23

*This cost represents the total cost of material although only a portion of the material was required for construction of the product.

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Appendix B Competing Devices: Automatic Dog Feeders Name PetSafe Healthy Pet Food Station Dog Bowl Designer Pet Eatery In-Wall Pet Bowl with Waterline Petmate Replendish Stainless Steel Waterer for Pets Petmate Le Bistro Portion Control Feeder Top Paw Water Fountain for Dogs Features Provides food No portion control 3 sizes Provides water No portion control Allows for waterline hookup Provides water No portion control Provides Food Portion Control Batteries required Provides water No portion control Electrical cord Price $ 24.99-34.99

$164.99

$ 39.99

$94.99

$44.99