ASSISTIVE TECHNOLOGY
Equipment Equipment
CLIENT: 48-year-old Male CONDITION: Amyotrophic Lateral Sclerosis

Freedom through a Single Switch
Pearl Gryfe BSc, OT(c)
CASE HISTORY: Mr. J.L. is a 48-year-old active male, who was a human resources executive, and was diagnosed with Amyotrophic Lateral Sclerosis (ALS) in August of 1996. J.L. lived alone and was generally in good health until July of 1996 when he developed symptoms of twitching in his left hand. Within a year of diagnosis, J.L. was a complete quadriplegic and his speech was unintelligible. The client had 24 hour attendant care and a strong support network of friends; however, he wanted to feel in control of his environment and to communicate his wishes. J.L. was referred to our clinic by his neurologist to determine his assistive technology needs. CLINICAL CONSIDERATIONS: J.L.’s consistent motor access points consisted of four areas: bilateral hip ab/adduction(L2, L3) – manifested through his knees; right foot (L4, L5, S1); Tibialis Anterior, Extensor Hallicis, Gastrocnemius – manifested by dorsi/plantar flexion of the ankle and extension of the great toe, and head movement was intact. It was clear that J.L. had multiple motor points at the time of the initial assessment; however, as the pathology progresses, the OP and other team members have to take into consideration the possibility that those motor points will degenerate and prepare for the possibility of only one switch site. Thus, how and where the switch(es) would be mounted was an issue that needed careful consideration. TREATMENT/APPROACH: After thorough assessment, and extensive equipment trials, the team determined J.L.’s assistive technology prescription. J.L.’s consistent motor access points consisted of four areas: his knees, his big toe, and his head. It was very important to choose appropriate devices that would be flexible to adapt as our client’s needs changed. With regards to seating, a tilt/recline chair was recommended as this chair positions the body in ways to utilize gravity, instead of working against it. The tilt feature allows gravity to pull the hips to the back of the chair and also relieves pressure on the ischials and coccyx. The recline is useful as many people with ALS find breathing easier when they are reclining. Access was an issue as J.L. had lost the use of his hands and extensive equipment trials were undertaken with head (RIM) controls. Given the pathology of the disease, J.L. was anarthric and he required a communication system that would provide flexibility with respect to multiple accessing techniques, so as motor abilities change, adaptations could be made easily. Our team recommended integrating face-face communication with written communication using a portable computer operated with switches at his knees. With regards to environmental controls (ECU), the technologist and ECU specialist undertook to review integrated computer systems and commercially available ECU’s and borrow them for diagnostic assessment. He was given a system to run: TV, VCR, stereo, call bell system, telephone, motorized bed functions, electronic door opener and lights, through one switch. The switches and ECU were mounted on a tubing system with an easily adjustable clamp that allows it to be moved easily to any site (e.g. wheelchair, bed or easy-chair). He operated the device with a switch at his big toe. OUTCOME: The equipment was installed and J.L. and his attendants were trained in its functional use. J.L. was instructed and trained on the use of his wheelchair, ECU, computer, Internet and communication devices. In spite of this devastating disease, our client was able to master his environment and overcome many barriers. Our team of professionals was able to minimize those barriers by turning towards technology. The success of this project was measured subjectively by witnessing the client’s increased independence, self esteem, and communicative interaction. EQUIPMENT: Storm Power Wheelchair with tilt, recline and VSR, ECU control, RIM controller, Avanti Personal Back, Ultimate cushion, and switch mounts, PC compatible notebook (Toshiba Satellite Pro), Soft-Key switch interface, WIVIK - on screen keyboard, WIVOX - speaking software (speech synthesis, WAVE JAMMER - sound card and software, WINDOWS ’95, WordPerfect Version 8, built-in speakers, fax/modem, Internet and CD-ROM drive, TASH Buddy Button, RELAX ECU-infra-red ECU from TASHmodel # 8200, X-10 TRANSCEIVER - radio-frequency-ECU - model# 4158

ACKNOWLEDGEMENTS: The ALS Society of Metropolitan Toronto and Area The Assistive Devices Program The ATC team including M. Gutmann -SLP, S. Laiken Computer Technologist, J. Hogerwaard ECU Specialist The Centralized Equipment Pool; Project (CEPP) The Neuromuscular Clinic -SHSC ABOUT THE AUTHOR: Pearl Gryfe BSc, OT(c) is Clinical Director, Assistive Technologies Unit, Sunnybrook Health Sciences Centre, Toronto, ON.

Publication supported by a grant from Handicaps Mobile Supplies & Repair.

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