Assistive Technology in Traumatic Brain Injury

Kurt L. Johnson and Mark Harniss

GENERAL PRINCIPLES

Assistive Technologies (AT) may serve important roles in rehabilitation, community living, education, and employment for people who have survived traumatic brain injuries (TBIs). AT is defined in the AT Act of 2004 as, “… any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities (29 U.S.C. Sec 2202(2)),” and includes, “any service that directly assists an individual with a disability in the selection, acquisition, or use of an AT device.” So AT can include a wide range of high-tech and low-tech devices and services. Variations on this definition of AT are found in federal laws related to vocational rehabilitation and special education and are relevant in terms of funding AT.

For AT to be adapted successfully, it is important that the user be actively involved in making decisions about AT selection. Not only should the needs of the individual with TBI be considered, but also the needs and preferences of family members or care givers; the “unit” of consideration should be the dyad or even family [1]. Other key considerations are the cognitive and motor prerequisites for use of AT, fatigue, access to technical assistance and even repair after the AT is deployed, and obviously funding is a major issue.

AT needs should be evaluated at differing stages of recovery, ranging from inpatient rehabilitation to outpatient rehabilitation to community re-entry to long-term living. Not only do individual needs change, but options for funding the AT change as well.

In considering AT solutions, we strongly recommend an interdisciplinary approach. Without careful consideration, AT can actually decrease performance on targeted tasks. Thinking through the AT carefully with the interdisciplinary team and individual with TBI is crucial. For example, in considering compensatory strategies in the workplace for memory deficits, a speech pathologist and rehabilitation counselor might consider the advantages and disadvantages of low-tech solutions such as memory books versus more complex AT systems including electronic calendaring.

FUNCTIONAL DOMAINS AND AT

Mobility

Many people who have survived TBI may require mobility aids. We will not discuss these here since the topic is addressed elsewhere (see Chapter 31).

Navigation

People with TBI may have difficulty navigating independently [2]. There are systems in place in many larger communities to provide training in using public transportation, door to door transit, and other options, which people with TBI may use to navigate independently. GPS on hand-held devices may be useful, although some people with TBI find the map interfaces to be too complex and difficult to use in community navigation [3]. Some GPS devices, including those on some smart phones, give voice output related to upcoming landmarks that may be more useful. It is important to not have individuals relying on systems such as looking at screens while walking, which may put them at risk for missing important environmental events and/or cues.

Caregiver Assurance

Some caregivers may be willing to negotiate more community independence for people with TBI if there is a way that they can monitor individuals’ locations. Although there are clearly ethical and privacy issues associated with this, we have found that people with TBI are often willing to agree to this, especially if they can turn off the tracking devices. There are a number of commercial systems available, many of which use a standard mobile phone as a location device. Consideration of a backup plan in case the device is lost or loses power is critical; a plan should be in place to assure a way for an individual to “call for help.”

Taking Notes

For students in K-12 or postsecondary education, or employees, taking notes is often critical. Unfortunately, because of difficulties with divided attention, people with TBI often say that they cannot take notes and listen at the same time and that they have difficulty taking notes because they cannot discern the salient points in real time. One option is to audio-record lectures or meetings, but audio recordings themselves require a lot of effort to review. A low-tech option is to request a note taker as a reasonable accommodation in class, but even with this, individuals often want to be able to annotate as they go. One option that has been very useful for a number of individuals is the Livescribe®. This system uses a pen to record audio and sync it with handwritten notes. The individual can take very general notes, and then when reviewing the notes, can listen to audio playback corresponding to the time the notes were taken.

Memory Aids

Sometimes the “old way” is the “best way,” and memory books ranging from calendars to daily planners to more complex paper and pencil systems have been successfully used for years. The disadvantages of these systems are that users may misplace or lose them, forget to record events or tasks, forget to check the memory book, or may create information overload by inserting numerous “yellow stickies,” loose pieces of paper, and so on, so that they are overwhelmed. Electronic devices such as smart phones, tablets, alpha pagers, and computers may be useful. Using electronic devices is easiest for people who already have experience with them since less new learning is required. It is important to fit the use of any memory device into the day to day routine of the individual, and to the extent possible, the context of their memory needs. Key considerations are:

1. What functions does it perform? Calendar, task list, phone, text, e-mail?

2. Is the visual display easily readable? Is it too cluttered or distracting?

3. Is there speech output?

4. Is the keyboard/text entry usable?

5. Is there voice to text input?

6. Is it compatible with what other family members, friends, or others use at home or at work?

7. How difficult is it to learn to use?

8. Is it redundant—that is, is there back up in case it gets lost, is not charged, or breaks?

9. Is there technical assistance when the user runs into problems?

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