Running head: ASSISTIVE TECHOLOGY PAPER

Assistive Technology Paper

Jesse Vallera
Touro University Nevada

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2
CVA Population

A cerebrovascular accident (CVA) is an interruption of blood flow to the brain where the
nerve cells cannot provide oxygen and nutrients. These nerve cells can become damaged or die
within minutes (CDC, 2013). If this occurs then symptoms can emerge in various areas of the
body and include visual impairments, aphasia, cognitive deficits and/or physical impairments.
Often the population can have an increased risk of having additional CVAs. Other risk factors of
CVAs include smoking, obesity, increased cholesterol, lack of exercise, and/or poor diet (CDC,
2013).
This condition can often inhibit occupational performance and interfere with daily
activities that include meaningful and purposeful occupations. Many clients have physical
impairments and present with hypertonia or spasticity that can be localized in the upper
extremities (UE), hands, and lower extremities (LE) (Wolf, 2011). This can pose a challenge in
basic activities of daily living (ADLs) such has bathing, dressing, feeding, and functional
mobility. In addition, other more complex occupations can have an effect in instrumental
activities of daily living (IADLs) such as communication management, driving and community
mobility, and several other areas of occupational performance (American Occupational Therapy
Association [AOTA], 2014).
Driving and community mobility is under the category of IADLs in the Occupational
Therapy Practice Framework (OTPF) (AOTA, 2014). Many occupations can interfere with
driving, however, utilizing a bicycle is a safe and efficient means of having mobility around the
community. If an occupational therapist (OT) would assess a client with a CVA that affects
bicycling, then the OT must look for specific client factors that could potentially enable
occupational performance around the community. It would be difficult to engage in bicycling

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when clients have impairments for neuromusculoskeletal client factors in joint mobility, joint
stability, control of voluntary movement in coordination, and fine and gross motor control
(AOTA, 2014).
If these body functions have hypertonia or spasticity but remain intact, OTs can play an
active role in interventions to remediate, use compensatory strategies, and provide assistive
technologies in the occupation of bicycling. The first assessment is to evaluate a client that is
able to use a cylindrical grasp and have sustained isometric motor control in the UE joints,
specifically the shoulder, elbow, and wrist joints. The OT will use an establish/restore approach
for clients that have had previous experiences with the occupation of bicycling to remediate this
intervention. OTs can use clinical reasoning to identify functional performance to organize
motor behavior (Wolf, 2011). If the OT identified the necessary components for approval, then
the OT will consider compensatory strategies with regard to motor techniques and contextual
training. Education is important to demonstrate motor techniques to safely operate bicycling,
and also the OT must take into consideration the clients physical environment to prevent
injuries.
Description of Client
Wilber is a 50-year-old male who recently had a cerebrovascular accident (CVA). He
has been afflicted with hemiplegia in his right UE. His speech, visual function, and LE function
are intact and he wants to resume his activities to complete community mobility. He works at a
small grocery store and he lives a short distance away. He is married and his wife also works but
they only have one car so Wilber utilizes a bicycle to get to work. The main intervention is to
create a compensatory strategy so that Wilber can resume his regular bicycling routine.

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4
Literature Review

After a CVA there are specific deficits that can present in the UE. When a CVA occurs,
it is important to assess and remediate these areas to preserve residual function. An evidencebased review entitled, Effectiveness of Interventions to Improve Occupational Performance of
People With Motor Impairments After Stroke: An Evidence-Based Review (Nilsen, Gillen, Geller,
Hreha, Osei, & Saleem, 2015) was performed to determine if interventions could make a positive
impact on occupational performance to remediate function. The authors assert that, Evidence
suggests that repetitive task practice (RTP) can improve upper-extremity function, balance
and mobility, and activity and/or participation (Nilsen et. al., 2015). RTP can play a role in
enhancing Wilbers bicycling to complete his occupation. If he can successfully grip the
handlebars and pedal through alternated movements with the UE and LE, then RTP can provide
vestibular and proprioceptive feedback to increase function. The authors collected evidence for
17 studies associated with RTP and 13 studies have positive results favoring RTP and overall
improvement in balance and mobility (Nilsen et. al., 2015).
When repetitive movements occur, Wilber must stabilize the right forearm, wrist, and
hand to have fluid, synergistic movements. In order to have stabilization in the right UE, he
must have significant strength and motor control to safely maneuver the handlebars. A study that
explored stability of the UE was entitled, How Forearm Position Affects Grip Strength
(Richards, Olson, & Palmiter-Thomas, 1996). In chronological order, results of grip strength
were as follows from weakest to strongest: pronation, neutral position, and supination, because
of muscle recruitment by the biceps brachii. The overall score for the grip strength in the
pronation position compared with the neutral position was p<.0001 indicating a significant
difference (Richards, Olson, & Palmiter-Thomas, 1996). The typical grip utilized for

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conventional handlebars is in pronation. Wilber would benefit from adaptive handlebars to have
increased strength and stability for a neutral position compared with conventional handlebars that
are in pronation.
Device
Assistive technology (AT) devices can create compensatory strategies to accomplish
occupations in ADLs and IADLs. Many CVAs cause difficulties in the UE that interfere with
occupations. Wolf states that common performance skills problems associated with limited
UE use following stroke and some frequently used assistive devices to compensate for them
(Wolf, 2011, pp. 289). He continues to state that many devices can be adapted using common
materials that can be purchased in hardware stores (Wolf, 2011). To accomplish Wilbers
occupation in community mobility, an AT device can be utilized to create adaptive handlebars so
that he can ride his bicycle to work. Wilber bicycling was impacted by his UE hemiplegia,
spasticity, and limited ROM in the UE joints. Adaptive handlebars would remediate his
occupation using a cylindrical grasp to sustain isometric motor control in the UE joints. A
neutral position would be beneficial to have increased strength and muscle recruitment by the
biceps brachii. (Richards, Olson, & Palmiter-Thomas, 1996). This will provide vestibular and
proprioceptive feedback to improve balance on the bicycle when grasping the device in the
neutral position while starting to pedal. In addition, the client will develop improved alignment
pertaining to performance skills in trunk stability and core strength (AOTA, 2014.) When the
client has suitable alignment in dynamic balance while sitting on the bicycle seat, then repetitive
task practice (RTP) will improve upper-extremity function, balance, and function mobility
(Nilsen et. al., 2015).

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This device will also benefit safety for operating the bicycle and preventing further
injury. If the device was not in place, then the client will either operate the bicycle with only the
left UE or rest on the right forearm but with no grip strength. Wilber would benefit from
adaptive handlebars and compensate to fulfill his community mobility.
Production
The initial device was a vertical grasp using a copper pipe and to attached the handlebars
perpendicularly. The materials purchased were two stainless steel metal clasps, two steel
screws, and a PVC (Polyvinyl Chloride) pipe because it is just as sturdy and less expensive.
All materials were purchased at Lowes hardware store, and the cost was $7.56. In addition, a
bicycle was purchased on Craiglist.com for 20 dollars, but that was not included in the actual
cost of the device.
When attempting to drill the hole, measures were not anticipated and the top bar was
much smaller in diameter then the bottom. Assessment was made to measure the top bar in
diameter. Instead, the design changed using only the top bar to drill a hole vertically. All
material was returned except the PVC pipe because the PVC is in diameter and it is ideal for
the cylindrical grasp. Hex x 6 bolt, HM zinc-flat washer, two fender washers, and a
hex nut was purchased to secure the pipe and bottom screw (see Table 1 for cost analysis). The
bolt was measured without measuring the handlebars and it turned out to be 5. PVC was cut
using a Ryobi compound miter top saw that measured 5. The top bar was drilled with a
cordless drill with drill bit and attached in order for the hex bolt, fender washer, PVC pipe,
fender washer, HM zinc-flat washer, and hex nut on the opposite side of the bar. An openended wrench was applied to the top bolt and a socket wrench was applied to the bottom hex nut
to secure the device. Metal spray paint was applied for aesthetic appearance (See Table 2).

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7
References

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

Domain and process (3rd ed.). American Journal of Occupational Therapy, S1S48.
http://dx.doi.org/10.5014/ajot.2014.682006
Centers of Disease Control and Prevention. (2015). Stroke. Retrieved from:
http://www.cdc.gov/stroke/
Nilsen, D. M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G.T. (2015). Effectiveness
of Interventions to Improve Occupational Performance of People With Motor
Impairments After Stroke: An Evidence-Based Review. American Journal of
Occupational Therapy, 69(1), 1-14. doi: 10.5014/ajot.2015.011965
Richards L.G., Olson B., & Palmiter-Thomas P. (1996). How forearm position affects grip
strength. American Journal of Occupational Therapy, 50(2), 147-147.
doi:10.5014/ajot.50.2.133
Wolf, T. J. & Birkenmeier, R. (2011). Intervention to Increase Performance and Participation
Following Stroke. In C.H. Christiansen & K.M. Matuska, Ways of living: Intervention
strategies to enable participation (4th ed., pp. 281-298). Baltimore, MD: AOTA Press.

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Table 1
Cost Analysis
Materials

Retail Outlet

Quantity

Hex x 6 bolt

Lowes Hardware Store

$0.54

HM zinc-flat washer

Lowes Hardware Store

$0.11

Fender washer

Lowes Hardware Store

$0.12 x 2= $0.24

Hex nut

Lowes Hardware Store

$0.06

PVC pipe

Lowes Hardware Store

$1.65

Total

Price

Subtotal (before tax)

$2.48

Table 2
Adaptive Handlebars
Assistive Technology Device

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Table 3
Comparison to Similar Devices
Device
Rifton
Large
Loop
Handlebars

Purpose

Price

The loop
$200.00
handlebars
can be
used to
rest the
forearm
but a
cylindrical
grasp
must be
used in
pronation.

Website and Picture

Tadpole Adaptive

Retrieved from:
http://tadpoleadaptive.com/media/catalog/product/cache/1/image/
9df78eab33525d08d6e5fb8d27136e95/
h/a/handlebars_cmyk_sharp-wm_1_1_2.jpg