Accelerating Adoption of Assistive Technology to Reduce Physical Strain among Family Caregivers of the Chronically Disabled Elderly Living at Home. Appendix A. Annotated Bibliography Figures and Tables


FIGURE A-1. Literature Review Flow Diagram
PubMed/Medline Database Search
Abstracts/Titles Screened
Citations excluded within reason
(Irrelevant, laborator studies)
Potentially relevant articles retrieved for more detailed evaluation
Full-text articles excluded
(Irrelevant, laboratory studies)
Relevant Articles
Total articles included in analysis
Additional articles identified through review of reference lists of cited studies and other sources

TABLE A-1. PubMed/MEDLINE Search Strategy and Results
Search Concept Search String* Results (hits):
Original Search
Results (hits):
Search Update
1 Caregivers/ care settings "Caregivers"[MeSH] OR caregiver*[tiab] OR "Home Health Aides"[MeSH] OR "home health aide*"[tiab] OR "home health worker*"[tiab] OR "home nursing"[MeSH] OR Health Personnel[MeSH] OR "Nurses' Aides"[Mesh] OR "long-term care"[MeSH] OR "Skilled Nursing Facilities"[Mesh] OR "Nursing Staff"[Mesh] OR "Home Care Services"[Mesh] OR "Assisted Living Facilities"[Mesh] 372,857 390,224
2 Physical strain stress[tiab] OR strain[tiab] OR injury[tiab] OR injuries[tiab] OR "low-back pain"[MeSH] OR "back pain"[MeSH] OR "Moving and Lifting Patients/adverse effects"[Mesh] OR "Transportation of Patients/adverse effects"[Mesh] OR "Fatigue"[Mesh] OR "Cumulative Trauma Disorders"[Mesh] OR "Physical Exertion"[Mesh] OR "physical burden" 1,017,601 1,089,348
3 Assistive technology "self-help devices"[MeSH] OR "self-help devices"[tiab] OR "assistive technology"[tiab] OR "assistive technologies"[tiab] OR "Protective devices"[MeSH] OR "adaptive equipment"[tiab] OR "adaptive technology"[tiab] 34,182 35,901
4 Home modifications "Home modifications"[tiab] OR "Environment Design"[Mesh] OR "environmental modification" OR "environmental home modification" OR "home environmental modification" 2,776 3,138
5 Physical strain prevention "Back Injuries/prevention and control"[Mesh] OR "Accidents, Occupational/prevention and control"[Mesh] OR "physical morbidity" 5,478 5,746
6   Set 1 AND Set 2 AND Set 3 258 9 Limits: English, Publication date from 10/1/10
7   Set 1 AND Set 2 AND Set 4 7 1 Limits: English, Publication date from 10/1/10
8   Set 1 AND Set 5 631 11
9   Set 6 OR Set 7 OR Set 8 864 20
10   Set 9 Limits: English, with Abstracts, All Adult (19+ years) 156 7 Limits: with abstracts, All adult (19+ years)
11 Alternate Set 9 Limits: English, with Abstracts 453 17 Limits: with Abstracts
12   Set 11 NOT "Child"[Mesh] 410 14
13   Set 12 NOT Set 10 275 8
14 Final search Set 10 + Set 13 431 15
* PubMed search tags: [MeSH] = MeSH heading; [tiab] = title and abstract.

TABLE A-2. Number of Studies Found, by Study Design and Population*
Study Design* Caregiving Staff in Facilities Home Care Workers Older Adults with Disabilities at Home Family Caregivers of Older Adults and Family Caregiver/ Older Adult Dyads**   Total  
Specific Devices Multi-Component Programs
I. Systematic review of multiple randomized controlled trials 0 0 0 0 0 0
II. Randomized controlled trial 3

(Danyard et al., 2001; Yassi et al., 2001; Baptiste et al., 2006)

0 1

(Kraus et al., 2002)


(Becker-Omvig & Smith, 2010; Sheffield, 2011; Mirza & Hammel, 2009; Rose et al., 2010; Gitlin et al., 2006; Szanton et al., 2010; Szanton et al., 2011; Mann et al., 1999; Petersson, 2008; Wilson et al., 2009)


(Gitlin et al., 2003; Gitlin et al., 2005; Schulz et al., 2009)

III(a). Quasi-experimental: comparison group 3

(Owen, Keene, & Olsen, 2002; Engst et al., 2004; Engst et al., 2005)


(Morgan & Chow, 2007; Engkvist, 2006)


(Craib et al., 2007; Engkvist et al., 2006)

0 0 6
III(b). Quasi-experimental: single group pre/post 4

(Li, Wolf, & Evanoff, 2004; Alamgir et al., 2008; Chhokar et al., 2005; Park et al., 2009)


(Hunter, Brandon, & Davenport, 2010; Charney et al., 2006; Nelson et al., 2006; Brophy, Achimore, & Moore-Dawson, 2001; Collins et al., 2004; Lynch & Freund, 2000)


(Nevala et al., 2003; Leff et al., 2000)


(Gottlieb & Caro, 2001; Stark et al., 2009; Horowitz et al., 2006)


(Gitlin, Jacobs, & Earland, 2010; Nichols et al., 2011; Marquardt et al., 2011)

IV. Non-experimental studies (cross-sectional, single group post-test only, retrospective) 2

(Trinkoff et al., 2003; Khatutsky et al., 2010)


(Owen & Garg, 1994)

0 1

(Liu & Lapane, 2009)


(NAC, 2011)

V. Qualitative (focus groups, individual interviews, observation, literature reviews) 0 0 0 2

(Demiris et al., 2008; Mann et al., 2002)


(Carswell et al., 2009, Sabata, Liebig, & Pynoos, 2005; Messecar, 2002; Kinney et al., 2004)

Total 12 9 4 16 11 52
* Levels I-V are adapted from Moore et al."s (1995) five-tiered model for viewing research design strength.
** One study (Schultz et al., 2009) included care recipients with spinal cord injury age 35 and older and their family caregivers.

TABLE A-3. Studies on Specific Technologies for Caregiving Workforce in Nursing Homes/Hospitals
Author/ Publish Date Study Participants and Sample Size Intervention/ Study Explanation Key Findings
Alamgiret al., 2008 3 long-term care facilities in Vancouver, Canada. Longitudinal study conducted with analysis of injury trends from 6 years pre-intervention to 4 years post-intervention.

Study evaluated the effectiveness of overhead lifts in preventing MSIs. 110 lifts were installed in the 3 facilities.

Injury Prevention
The relative risk for MSI and working days lost per bed decreased after installation of the ceiling lifts, compared with the pre-intervention period.

The estimated payback period (recovering costs of the ceiling lifts with savings from decreased injury claims) was around 6.2-6.3 years when just using direct costs, but 2.06-3.2 years factoring in indirect costs.

Baptisteet al., 2006 77 caregiving staff in the acute care unit of a large Southeastern Veterans Administration hospital. Every 2 weeks, each of the 8 acute care units received 1 of 8 randomly selected devices. 7 of the 8 devices were commercially available lateral-transfer devices or friction-reducing devices: (1/2) 2 types of air-assisted devices (the AIRPAL and the HoverMatt), (3) a silicone-filled tubular sheet (the Slipp); (4/5) 2 types of twin flat sheet sets with extended pull straps (the Flat Sheet Set and Maxi Slide); (6) a hollow fabric sleeve with straps to assist the transfer (Resident Transfer Assist); (7) a hollow fabric sleeve that requires a push action to perform the transfer (the Maxi Trans). The eighth device was the traditional draw sheet, which served as a baseline measure.

Data was collected through caregiver surveys, which measured comfort, ease of use, perceived injury risk, time efficiency, and patient safety through caregiver ratings. 179 transfers were completed using the 8 devices.

Technology Rankings
Air-assisted devices were preferred, with the AIRPAL and HoverMatt ranking first and second, respectively. The Resident Transfer Assist ranked third, the Maxi Slide forth and the Slipp fifth. The Flat Sheet Set had an overall rank of sixth, with caregivers reporting that the device was slippery and unmanageable and that they had difficulty keeping the 2 sheets together beneath the patient during the transfer. The draw sheet, which is the traditional lateral-transfer device used in many settings, was the worst method and not recommended. As this is a commonly used device, Baptiste et al., argued against its continued use.
Chhokaret al., 2005 A Canadian-based extended care facility. Longitudinal study to examine the effects of an overhead ceiling lift in 1 extended care facility. Injury trends 3 years pre and 3 years post-intervention were analyzed, spanning from 1995-2001. Lifts were installed in 1998.

65 ceiling lifts, servicing 125 beds and 3 bathtubs, were installed in the facility. Education on use of the lifts was provided to all patient-handling staff.

Injury Prevention
While the number of claims and claim costs had been increasing prior to the intervention, these trends reversed during the intervention period, indicating a decrease in injuries.

An estimated $412,754 was saved during the 3 years post-intervention. Substantial decreases in the number of claims, costs, and time-loss were not observed until 2 years post-intervention.

Engstet al., 2004 A 75-bed unit in a long-term care facility (in Canada) was the intervention group. Another unit in the same hospital served as the comparison group.

50 of the 75 residents in the intervention group participated and 50 of 75 residents in the control unit participated. For the intervention group, selection was based on their continence program and potential benefits to participation.

A new individualized scheduled toileting program for residents with incontinence was implemented. This included 10 mechanical lifts (5 sit-stand lifts and 5 seated lifts) that were purchased for the intervention group's unit to use. Staff were trained on use of these mechanical lifts. Both the intervention and comparison groups received education on recognizing agitation in residents.

32 workers in the intervention unit completed pre and post-intervention questionnaires, with 17 workers in the comparison unit doing the same.

Injury Prevention
The use of a mechanical lift to transfer residents to and from a toilet reduced physical risk of MSD/MSI for nursing home workers, in comparison to cleaning residents in beds. The intervention led to decreases in the amount of force necessary to complete the task and the duration and severity of awkward postures (neck, shoulder, lower back) that are typical when cleaning residents.

Patient Response
In addition, resident agitation significantly decreased in the comparison group, while increasing in the comparison group.

Engstet al., 2005 34 staff members from a 75-bed extended care unit in Canada that received ceiling lifts served as the intervention group.

16 staff members of a 75-bed extended care unit in the same hospital, which did not receive lifts, served as the comparison group.

Ceiling lifts were installed in the intervention unit, which took 6 months to complete. During this time, staff in the intervention unit were trained on lift use.

A pre-intervention questionnaire was administered to both groups. The post-intervention questionnaire was administered a year later, after the intervention period had ended.

Total costs for the intervention were $284,297, which included purchasing and installing the intervention and hiring a program coordinator. Savings over 1 year for "all resident handling" were $9,835 in MSI claims and for "lifting and transferring tasks" were $14,493 in MSI claims. The payback period was estimated at 9.6 years for resident handling tasks and 6.5 years for lift and transfer tasks, due to savings from reduced compensation costs.

Injury Prevention
Perceived risk of injury and discomfort to neck, shoulders, upper and lower back, and arms/hands for care staff significantly decreased. All staff in the intervention group felt that the ceiling lifts made lifting residents easier and 96% felt that the lifts made their job easier to perform.

Khatutsky et al., 2010 Data from the 2004 National Nursing Assistant Survey; the 2004 National Nursing Home Survey; Online Survey, Certification, and Reporting; and the Area Resource File. Retrospective analysis on the effect lifting device availability had on the probability of being injured. Injury Findings
Multi-variate analysis did not find availability of lifting devices reduced probability of being injured. The analysis did find that mandatory overtime, poor training, being a new worker, and not having enough time to provide ADL help increased the probability of injury. The study concluded that injuries are a major issue and possible interventions include more comprehensive training, reducing mandatory overtime, and providing support for certified nurse assistants new to the field.
Li, Wolf, & Evanoff, 2004 61 staff members were surveyed pre-intervention; 36 completed a follow-up survey. The staff came from 3 nursing units in a small community hospital in a suburb of St. Louis, Missouri. Mechanical patient lifts were provided and hands-on training sessions in lift usage was conducted by hospital personnel and all staff involved in patient-handling were expected to attend.

1 portable full body sling lift and 2 portable stand-up sling lifts ("E-Z Lift" and "E-Z Stand" by EZ Way Inc, Minneapolis, Minnesota). Friction-reducing sheets (Maxi-slides) were used to position patients in bed in preparation for lift usage.

Injury Prevention
Musculoskeletal symptoms and MSIs decreased. Correlating with that, lost workday injury rates also decreased.

Annual workers' compensation costs for nursing personnel on the intervention units declined from an average of $484 per full-time equivalent (FTE) pre-intervention to $151 per FTE post-intervention.

Owen, Keene, & Olson, 2002 The medical-surgical units of two rural hospitals in the Mid-western US. The study included 37 volunteers at the experimental site and 20 volunteers at the control site. All were female nursing personnel staff working in the medical-surgical units. 5 assistive devices were implemented at the experimental site, including: (1) a mechanical, battery-operated lift for transferring non-weight-bearing patients to and from bed to chair and commode, (2) a battery-operated stand-up lift for transferring weight-bearing patients with the same tasks, (3) a walking belt with handles for transferring weight-bearing patients who need less assistance with the above tasks, (4) a friction-reducing sheet for use in transferring people from bed to stretcher and vice versa and for lifting up in bed, and (5) a toileting device for toileting in bed. Injury Prevention
For all tasks, nursing staff in the experimental site rated perceived exertion significantly lower than the control site study participants for both shoulder and lower back. The number of back injuries, lost work, and restricted days also decreased in the experimental group. At the control hospital, back and shoulder injuries, lost workdays and restricted days remained stable.

Patient Response
Patients were also surveyed about their feelings of comfort and security. At the experimental site, patients reported higher comfort levels and security levels in the transfer or lift when assistive devices were used.

Park et al., 2009 All nursing homes in Ohio (887 total nursing homes). In 2000-2001, the Ohio Bureau of Workers' Compensation (BWC) sponsored interventions to reduce injuries in nursing homes, including training, consultation, and grants of up to $40,000 to purchase equipment, including lifts, electric beds, and other devices. This study evaluated the impact of the intervention on back injury claim rates using BWC data on claims, interventions, and employer payroll for all Ohio nursing homes during 1995-2004. Injury Prevention
The greatest impacts were seen with equipment. A $500 equipment purchase per nursing home worker was associated with a 21% reduction in back injury rate.

This injury rate reduction translated to an estimated $768 reduction in claim costs per worker, a present value of $495 with a 5% discount rate applied.

Trinkoff, Brady, & Nielsen, 2003 1,163 actively licensed RNs in two states, 57% of whom worked in hospitals. These RNs also worked in nursing homes and home health agencies. Survey asked about the availability of AT (lifting devices, lifting teams, transfer sheets, adjustable beds) and the availability/use of training programs. Data analysis measured the effectiveness of these in lowering odds of neck and back MSDs. Injury Prevention
Both lifting teams and lifting devices were associated with lower odds of back MSI/MSD. In contrast, availability of transfer boards/sliding sheets and adjustable beds were associated with higher odds of back MSD for those using those devices.
Danyardet al., 2001 Winnipeg's Health Sciences Center (HSC)
Used the same selection criteria as study (below). Unit Assistants from each ward were selected for participation -- Sample size was 36 UAs, 12 from each arm of the study.
Utilized a quasi-dynamic biomechanical computer model of the lumbar spine (WATBAK) to calculate the magnitude of the compressive and shear forces acting at the L4-L5 level during patient-handling Injury Prevention
This study examined both peak spinal pressure and cumulative spinal loading. Researchers found that education/ technique training and the use of new AT resulted in reduced spinal loading for several tasks. However, the use of AT contributes to an increased cumulative spinal loading. Use of AT takes much longer than manual transfer, in many instances, resulting in prolonged forward flexed trunk postures. Over the course of months or years, this can also cause problems.
Yassiet al., 2001 Winnipeg's HSC
3 wards with the highest risk for MSD were chosen from the Winnipeg HSC, an acute and tertiary care hospital in Canada: medical, surgical, and rehabilitative. Each ward was randomly assigned to 1 arm of the study (resulting in 1 medical, 1 surgical, and 1 rehabilitative unit on each arm -- a total of 9 wards). Only permanent staff to each ward were included, float pool staff were not.
1 ward used usual practice, while the other 2 wards had various patient-handling devices, including a mechanical total body lift, a transfer belt or sit-stand lift or mechanical total body lift, slide devices, and transfer belts. The devices were used to move patients from floor to bed or chair, from bed to chair or chair to bed, from bed to stretcher or vice versa, moving patient in bed, or walking with patient, respectively. Injury Prevention
The wards with accessible mechanical equipment showed decreased fatigue of workers, improved comfort with patient-handling tasks, and increased perception of safety among staff.
Number of Studies: 12.

TABLE A-4. Studies on AT/Ergonomic Interventions for Caregiving Workforce in Nursing Homes/Hospitals
Author/ Publish Date Study Participants and Sample Size Intervention/Study Explanation Key Findings
Brophyet al., 2001 A 525-bed nursing home in upstate New York. A 5-step ergonomics program consisting of: (1) creation of a resident transfer evaluation team, (2) establishment of an accident review committee, (3) mandatory ergonomics training for new nursing aides, (4) regular maintenance checks for lifting equipment, and (5) direct access to the management and budget process.

During the 7-year study period, the facility purchased 8 smooth movers, 10 hydraulic stretchers, 7 Hoyer lifts, 1 Arjo lift, 9 Sarita lifts, and 1 Maxilift.

Injury Prevention
Comparing the pre-intervention period (1992-93) and the intervention period (1994-98), significant reductions were seen in low-back injuries (from 15.7 to 11.0 per 100 full-time nursing aids), lost workdays (from 1,476 per year to 625 per year), and lost workdays per full-time nursing assistant (from 7.8 to 3.0).

The yearly cost associated with low-back injuries declined from $201,100 before the intervention to $91,800 during the intervention.

Charneyet al., 2006 Washington Hospital Services, a self-insured workers' compensation program, implemented the zero lift program in 31 of its 38 hospitals. Zero lift program -- The program replaced manual lifting, transferring, and re-positioning of patients with mechanical lifting or use of other patient assist devices.

Equipment "vendor fairs" were held that allowed patient-care staff to have "hands-on" experience with the equipment. A zero lift committee was established which was responsible for implementing the program, including making purchasing decisions. Equipment purchased included vertical lifts, lateral-transfer stretchers, sit-to-stand lifts, ceiling lifts, and non-friction transfer sheets for re-positioning.

Injury Prevention
Patient-handling injury claims decreased by 43% in participating hospitals from 2000 to 2004 (from 3.51 to 2.23), and the time lost frequency rate decreased by approximately 50% (from 1.91 to 1.03 per 100 FTEs).

Patient Response
Patients experienced fewer injuries during lifts (fewer skin tears, falls, less pain).

Collins et al., 2004 6 nursing homes across 2 states with a total of 1,728 nursing staff. 6-year study of a "best practices" MSI prevention program from 1995 through 2000. The program included mechanical lifting equipment and re-positioning aids, worker training on the use of the lifts, a medical management program, and a written zero lift policy.

The equipment included friction-reducing sheets for re-positioning residents in bed and two types of mechanical lifts, based on the resident's level of physical dependency.

Injury Prevention
Resident handling injury claims rates decreased significantly in the post-intervention period.

Patient Response
Assaults and violent acts by residents towards caregivers declined after the safe resident handling and movement program was implemented.

Expenses to purchase lifting equipment and provide worker training, the initial investment was recovered in slightly less than 3 years.

Engkvist, 2006 3 hospitals took part. The first included 8 wards in a hospital where a NLS had been introduced earlier (called the NLS hospital). The other 2 hospitals had 11 corresponding wards (control hospitals). The study population consisted of all nursing personal employed in the NLS hospital and control hospitals. A total of 487 persons were included, all belonging to 1 health care network in Melborne. In the NLS hospital, nurses tested equipment and participated in the equipment purchasing decisions. Equipment was purchased based on each ward's assessed needs: Purchases included: 3 hoists, 2 standing walker hoists, 210 slide sheets, 3 rolling frames, 25 walk-belts, 44 foot-stools, 41 bed-ladder straps. Injury Prevention
Compared with nurses at the control hospitals, those at the NLS hospital reported fewer injuries, had less pain/symptoms, had less absence from work due to musculoskeletal pain/symptoms, and rated physical tiredness lower.
Hunter, Branson, & Davenport, 2010 Northwest Texas Healthcare System (NWTHS).

This program was for all clinical staff across all units.

A safe patient-handling program, also known as minimal or no lift practice was implemented in the NWTHS.

A vendor, Diligent, was selected for providing lift equipment and assisting in implementing the program. They provided training and education to in-house clinical staff. They also assessed departmental needs for certain devices like ceiling lifts, portable equipment, and support supplies.

Injury Prevention
During the 2.5 years of the program, the number of worker injuries reduced from the baseline of 20 per year to 5 injuries in 2007, 5 in 2008, and 1 injury from December 2008 through July 2009.

Patient Response
Patients and staff provided positive feedback about the lifting equipment used for safe-patient-handling.

Prior to the program, the facility experienced an average of 20 injuries per year, with an average direct cost per injury of $27,402 and average total direct costs per year of $548,040 associated with worker injuries. The total cost of the 3-year program, including equipment, training, and consultation, was $582,081. As a result, the facility nearly recouped the cost of the three-year program within 1 year.

Lynch & Fruend, 2000 Program took place at a 440 bed acute care hospital.

Impact evaluation was done for the 374 nurses and other patient-handling staff who completed training.

A 1-year Back Injury Prevention Program was implemented at a 440-bed acute care hospital. This program included the following components: (1) An ergonomic evaluation of patient-handling; (2) Purchase of patient transfer devices, like walking belts, transfer boards, and patient hoists were selected; (3) A train-the-trainer program was implemented before training for staff, and (4) training of 374 nurses and patient-handling staff was conducted. Injury Prevention
The number of back injures was 30% below the prior 3 years average. Immediately following training, reported injuries in the final quarter were 1/7th of the 3 prior quarters.
Morgan & Chow, 2007 Shady Grove Adventist Hospital -- MD community hospital with 269 beds. A comprehensive ergonomic plan was created in 2001 and implemented in 2003. The plan included patient lifting equipment, as well as establishing policies for no manual lifting and patient-handling, training employees, and other elements. OSHA guidelines were used to determine lifting strategies and equipment, which included the use of gait/transfer belts, full body slings, toileting slings, and bathing mesh slings. It was noted that SGHA would be purchasing ceiling lifts.

All new staff were required to complete electronic ergonomic and patient lifting training. A mandatory annual training was implemented for all clinical and non-clinical staff. Case management was also implemented after staff were injured, to insure proper healing time and future prevention of injuries.

Injury Prevention
Over 2 years, workers' compensation claims related to MSIs decreased from $0.31/$100 of payroll to $0.17/$100 of payroll, lower than the 4 comparison hospitals.

Over a period of 2 years, workers' compensation costs decreased by $238,330.

Nelson et al., 2006 19 nursing home units and 4 SCI units in 7 Southeast United States facilities. A multi-faceted program which included providing patient-handling equipment based on needs identified in an ergonomic assessment, in addition to patient safety leaders and a no lift policy.

Several devices were purchased to assist in the handling of patients, including ceiling mounted patient lifts, floor-based full body sling lifts, mechanical lateral-transfer aids, powered stand assist lifts, friction-reducing devices, and gait belts with handles.

Injury Prevention
There was a decrease in the rate of MSIs.

Technology Rankings
Participants ranked the patient-handling equipment as the most effective component of the intervention, with 96% of respondents rating it as "extremely effective." The no lift policy was ranked second (68% said extremely effective), and the peer safety leader was ranked third (66% said extremely effective).

Significant increases in 2 job satisfaction subscales (professional status and task requirements) were reported.

A cost/benefit analysis projected that annual costs for the program would be $123,037, and it would result in injury costs savings of $327,636 annually, for projected annualized cost savings per year of $204,599. Over a 10-year period this translates to over $2 million dollars of savings, excluding inflation. The analysis did not include the indirect costs of injury and low morale among workers.

Owen & Garg, 1994 A single nursing home. 6 female nursing students participated in the laboratory study and nursing assistants participated in the intervention part of the study. 38 nursing assistants volunteered to identify stressful tasks -- weighing a patient was considered to be one of the most stressful tasks.

A laboratory study was developed to test differences between ways of weighing patients: (1) currently used manual lifting of patient from wheelchair to scale; (2) transfer via hoist, and (3) a wheelchair ramp scale. 6 female senior nursing students were evaluated performing these tasks.

The hoist and wheelchair ramp were then made available to nursing assistants on 2 floors of the facility. A nurse observer discussed the use of this new equipment with nursing assistants to determine their perceived physical stress.

Injury Prevention
The laboratory study found that compressive force to L5S1 and shear force were reduced using the hoist and wheelchair ramp. When the equipment was made available to the nursing assistants, nurse assistants reported that perceived physical stress to shoulder, back, and body was reduced using the hoist and wheelchair ramp.

Patient Response
Resident feelings of comfort and security increased.

Number of Studies: 9.

TABLE A-5. Studies at AT/HM/Ergonomic Interventions for Paid Caregivers in the Home
Publish Date
Study Participants
and Sample Size
Intervention/Study Explanation Key Findings
Craibet al., 2007 6 home support agencies in British Columbia, Canada. 5 of the agencies adopted 1 or more of the interventions, while 1 agency participated as a control group. Interventions used in this study were: (1) an education and training module, (2) a risk assessment tool and resource guide to guide supervisors through assessment of the risks to workers in clients' homes and information on precautions, and (3) a lift equipment registry. 2 manufacturers agreed to provide a combined total of 25 lifts (20 ceiling and 5 freestanding lifts) for the registry. For the 1-year study period, the lifts were loaned to clients who would have to arrange to purchase the lifts by the end of the study period. If funds could not be found to purchase the lift, then the manufacturer would consider donating the lift to the client. Injury Prevention
Overexertion and falls were the majority of workplace injuries, both before and after the interventions. Workers at agencies receiving interventions reported significantly more workplace injuries than those from the comparison site, which may indicate increased ability to recognize injuries and/or awareness of injury reporting at intervention sites. Workers at agencies receiving interventions had fewer time-loss injuries compared with members of the comparison site.

Workers more at risk of injury were those with a history of work injuries, full-time workers, and workers with less than college education.

Kraus et al., 2002 12,772 home attendants in 9 agencies in New York City. This study was organized/supervised by the Citywide Central Insurance Program and its Home Attendant Program of New York City.

9 home care agencies in New York were chosen for a clustered randomized controlled trial. These agencies were randomized into 3 groups: (1) the back-belt group, (2) lifting advice-only group, and (3) control group. Workers in the back-belt group were trained to use the back-belts and were required to utilize them.

Injury Prevention
Home care attendants using back-belts experienced a somewhat lower rate of low-back injury than did those in the advice-only and control groups, which was only marginally significant.

Subgroups at greater risk for new lower back injury were those with a greater body mass index, back problems at entry into the study, and a history of back injury. These groups may benefit more from the use of back-belts.

Leff, Habebach, & Marn,2000 Franklin County Home Health Agency (St. Albans, Vermont)

32 Licensed Nursing Assistants (LNAs) were evaluated for risk of injury during transfer. This was a part of evaluating the current situation for LNAs at the home health agency before implementing the program.

A Performance Improvement team developed an Injury Prevention program, for which they developed solutions and action plans to address Injury Prevention at the agency.

These solutions were grouped into short-term, mid-term, and long-term solutions. The primary short-term solution was safety and health training. Risk management forms were also developed to determine hazardous situations.

Another solution included the provision of a gait belt to each LNA for transfer of patients. It was also determined that LNAs would not have more than 7 patients per day. Mid-term solutions included identifying heavy lift patients and planning LNA shifts accordingly. The long-term solution was to conduct a post-offer, pre-hire PT screening for LNAs. The solutions mentioned above began to be implemented in 1996 and efforts were made to standardize the program.

Injury Prevention
The program gradually reduced LNA back and shoulder injuries. Employee injuries were reduced from 4-10 per quarter to 0-3 per quarter.

Lessons Learned
It took at least a year for the program to show evidence of reducing injury rates, so interventions require patience and persistence. Researchers also suggest that multiple interventions may be necessary for a problem that has multiple causes.

Nevalaet al., 2003 5 personal helpers of people with physical disabilities living at home in Finland. Clothing design changes for people needing assistance transferring to a wheelchair.1

The five helpers, all women, were measured at their worksites for their physical workload and strain before and after clothing redesign. The measurements for physical workload and strain were carried out before the clothing redesign and 1 year after the design. Workers' movements were videotaped and analyzed, and muscular activity and heart rate were measured using portable devices.

Injury Prevention
The redesign of clients' outerwear decreased the physical workload and strain of the personal helpers in some measures including the number of correcting hand motions and grasping motions, fewer forward bent postures, and lower mean muscular activity of the trapezius and of the erector spinae muscle.
Number of Studies: 4.
  1. A jacket for a man using a wheelchair included width increased in the back and decreased in the front, pockets easy to reach and use, velcro closure and buttons as fasteners, velcro closure on the sleeve, and no details in the back. Design changes for pants included velcro and press fastener, thigh pockets, and waist higher in the back and lower in the front to fit the sitting position.

TABLE A-6. Studies on AT/HM/Ergonomic Interventions to Promote Independence for Older Adults with Disability
Author/ Publish Date Study Participants and Sample Size Intervention/Study Explanation Key Findings
Becker-Omvig & Smith, 2010 Older adults living in the community in Howard/ Montgomery County, Maryland. The Joint Howard County – Montgomery County OT Intervention for Older Adults: a pilot program providing older adults in Howard County, Maryland with in-home assessments and OT interventions including HM, AT, consultation, information and referral. OT focuses on the interaction of the person, the environment, and the occupation. Implementation Issues
The program was able to overcome initial resistance from staff and clients through "logical arguments, emotional arguments, building trust, and concrete reality." Lessons learned were the importance of champions, showing efficacy, and training. Challenges included funding for therapists, equipment, and modifications and using existing staff resources (training SWs and others, dissemination).

Cost Savings
Results of a randomized trial indicated that the intervention reduced hours of paid weekly assistance by 48% and cost less than $1,000 per person served.

Promote Independence
This intervention improved functional independence and safety, decreased fear of falling, and showed an increase in quality of life.

Sheffield, 2011 The data for 71 participants in Howard and Montgomery Counties; complete data was available for 60 participants. Howard County/Montgomery County (Maryland) Aging in Place/Better Living at Home program. Same findings as those listed above
Demiriset al., 2008 9 older adult residents in apartments. A participatory evaluation of a "smart home" project implemented in the apartments of nine residents of an independent retirement facility. This included an IMS which had a set of wireless infrared proximity sensors to detect motion and pressure switch pads. The IMS also included a stove sensor, a cabinet sensor, and a bed sensor. The researchers conducted 75 interviews with the 9 residents and conducted observations. Acceptance of Technology
Results indicate that there are three phases of adoption and acceptance of the sensors: (1) familiarization; (2) adjustment and curiosity, and (3) full integration. The residents reacted positively to the sensor technologies and did not feel that these interrupted their daily activities. Additionally, the residents did not express privacy concerns.
Gitlinet al., 2006 319 community living adults, age 70+, who reported difficulty with 1 or more ADLs. Study participants were recruited from an AAA, media announcements, and posters at senior housing and community settings.

160 were randomly assigned to the experimental group, and 159 were in the control group.

ABLE: This NIH clinical trial is a 6-month home intervention with 5 visits from occupational therapists (4 90-minute visits and one 20-minute telephone contact) to identify functional concerns and compensatory strategies; 1 PT visit (90 minutes). OT and PT sessions involved HM and training in their use; instruction in strategies of problem-solving, energy conservation, safe performance, and fall recovery techniques; and balance and muscle strength training.

After the OT contacts, appropriate HM were identified to be installed before the sixth contact. AAAs ordered HMs like grab bars, rails, and raised toilet seats.

Promoting Independence
At 6 months, ABLE participants had less difficulty than the control group with IADLs and ADLs. Benefits were sustained at 12 months for most outcomes.

Average costs per participant were $439 for equipment and HM and $783 for therapy, for a total of $1,222. Researchers recommended that HMs be reimbursable through Medicare, which is not part of the current policy.

Gottlieb & Caro, 2001 CMs identified 196 home care clients who they believed would be good candidates for assistive equipment.

The participant's age ranged from 61 to 101, with a median age of 81.

Massachusetts Assistive Equipment Demonstration: CMs from participating home care agencies worked to increase access to AT by identifying clients who they thought would be good candidates for assistive equipment, informing clients about equipment options, encouraging use of equipment, assisting with acquisition and installation of equipment, following up with clients regarding additional equipment needs, and incorporating equipment-related activities as part of their routine client reassessment visits. A key component of the demonstration was training conducted by occupational therapists for the participating CMs. Implementation Issues
70% of clients reported using the assistive equipment regularly, 60% found the equipment to be "very helpful", and 90% expressed high overall satisfaction.

Researchers suggest that CMs be provided with more consistent training on assistive equipment, be allocated more time to focus on assistive equipment, and more funds should be allocated for it.

Despite being encouraged to spend $150 on AT for clients, the average amount expended was $76. About half of the equipment distributed was for meal preparation, with others used for bathing, dressing, and mobility.

Horowitz et al., 2006 The sample consisted of older adults who acquired a recent vision impairment and were applying for vision rehabilitation services. They interviewed the sample (n=138) at pre-service and at 5-month follow-up. Participants were asked about their use of optical devices (including magnifier, telescope, special sunglasses, or other) and of adaptive aids related to vision loss (large-print telephone dials, handwriting guides, talking books, other talking items, large-print reading materials, long white cane for mobility or other aids). Reducing Functional Decline
A hierarchical regression analysis was conducted and researchers found that the optical device use was significantly associated with functional disability decline and a decline in depressive symptoms over time. These results were not found with adaptive devices.
Liu & Lapane, 2009 Analysis of the Second Longitudinal Study on Aging (National probability sample of community-dwelling adults 70+ in 1994-1995). The objective of their analysis was to quantify the extent residential modifications reduce the risk of subsequent physical functional decline in older adults Reducing Functional Decline
Results indicate that HM (like railings or bathroom modifications) were associated with reduced risk of decline among community-dwelling adults aged 70+.
Mann et al., 1999 104 home-based frail elderly persons living in western New York. 52 were assigned to the treatment group and 52 to the control group. Participants received a functional assessment, a home environment evaluation, and AT/HM based on their evaluation results Reducing Functional Decline
The intervention group experienced less functional decline than the control group.
Mann et al., 2002 A sample drawn from the Rehabilitation Engineering Research Center on Aging CAS, a 10-year longitudinal study of over 1,000 elders with disabilities which began in 1991. Selected subjects from Western New York. Interviewed 71 elders scheduled for their annual CAS interview in 1998. Reviewed the benefits of home telehealth care, which they define as the provision of health care evaluation, medical advice, and the delivery of services to the home through the use of telecommunication technologies, including information, communications, and monitoring technologies. The researchers used the Rehabilitation Engineering Research Center on Aging CAS. They developed the "Home Care Monitoring Devices" questionnaire to gauge frail older adults' receptivity to devices including a thermometer, metered dosage inhaler, blood pressure monitor, blood glucose monitor, and medication compliance monitor. Acceptance of Technology
The results of the study indicated that the sample strongly accepted the concept of home health monitoring and the different devices. One of the determining factors of perceived intrusiveness of these devices was equipment characteristics. The researchers' analysis of subjective comments found that participants thought these devices would be useful for others, but not necessarily for their own personal use.
Mirza & Hammel, 2009 75 aging individuals with intellectual disabilities living in the community In the ATLAS intervention, aging individuals with intellectual disabilities and their social support network worked with an occupational therapist for 4 sessions to identify and problem-solve issues through environmental strategies, including AT/HM, using a consumer-directed, collaborative approach. Participant Satisfaction
ATLAS was associated with higher levels of performance and satisfaction.
Peterssonet al., 2008 73 subjects recruited from an agency in Sweden providing HM services (intervention group). The intervention group's referrals had been approved and they were scheduled to receive HM. The comparison group consisted of 41 subjects waiting for their applications to be assessed for approval. The purpose of the study was to examine the impact of HM on older adults with disabilities and their self-rated abilities in completing everyday functions. Promote Independence
Research found that older adults with disabilities in Sweden who received HM significantly improved in self-reported independence and safety including toileting and transferring tasks.
Rose, Gitlin, & Dennis, 2010 This was a follow-up study to Gitlin et al., 2006, using data collected from the experimental group. Of the 160 original participants, data on 148 were used for this study. ABLE intervention (see Gitlin et al., 2006 explanation). Implementation Issues
Higher readiness was associated with: younger age, African American race with financial difficulty, use of active-oriented compensatory strategies, use of cognitive oriented strategies, and lower levels of depression. However, the strongest predictor of change (from initial to final session) in older adults' readiness to utilize compensatory strategies of the ABLE intervention was social support. This finding supports the literature discussing the positive health benefits of social support.
Stark et al., 2009 NORC. A client-centered HM program for older adults was implemented. This was a quasi-experimental, single group prospective study, where participants' subjective ratings of daily activity performance were evaluated before and after the intervention (baseline/post/post). Promote Independence
Researchers found that adults in a suburban NORC improved significantly in their subjective ratings of their daily activity performance after receiving a HM. The improvement was maintained for two years.
Szantonet al., 2010 Older adults selected with the help of the Baltimore City Commission on Aging and Retirement, the Baltimore Housing Authority, and Comprehensive Housing Assistance -- they were placed in an intervention and control group. CAPABLE: Building on the ABLE demonstration, the CAPABLE pilot, is comprised of the ABLE program, a client-centered nurse intervention, and home safety/modification handyman services.

The intervention group had their physical, mental, and environmental challenges addressed through 3 services -- OT, nursing, and the assistance of a construction specialist who made necessary home repairs, while the comparison group participated in life-review sessions that have been shown to improve mental activity only. (See study description at

Cost Savings/ Promoting Independence
While findings were not yet available, the pilot is theorized to avert costly health utilization by increasing medication management, problem-solving ability, strength, balance, nutrition, and home safety, while decreasing depression and risk of falls.
Szantonet al., 2011 The study consisted of 40 low-income older adults who have 1 or more ADL difficulties or 2 or more IADLs difficulties in the Baltimore, Maryland area. CAPABLE. Promoting Independence
The researchers found that the study demonstrated moderate to strong effect sizes for mean change differences between the two groups over the course of the study. They also found that 94% of the intervention group stated that CAPABLE made their life easier in comparison to only 53% of the control group.
Wilson et al., 2009 91 older adults with disabilities. The intervention group received an evaluation of their home and potential AT/HM needs which were provided and paid for (in full or in part) by the study. The control group received health care already available through community resources.

Outcomes were tracked through in-home interviews using the OARS and the FIM.

Reducing Functional Decline
Analysis of this data shows that there was slower decline in function over the 2 year intervention period in the treatment group. Additionally, the group was found to be more likely to use AT instead of personal assistance to maintain their independence.
Number of Studies: 16.

TABLE A-7. Studies on AT/HM/Ergonomic Interventions to Support Family Caregiving and Family Caregiver Data
Author/ Publish Date Study Participants and Sample Size Intervention/Study Explanation Key Findings
Studies Involving Family Caregivers
Gitlinet al., 2003 Primary caregivers who reported at least 1 limitation in ADL or 2 dependencies in IADLs of the care recipient were selected/recruited from the Philadelphia Corporation for Aging. 255 people agreed to participate101 were randomly selected as control and 89 as intervention group participants. REACH: Tested ESP, which was part of the NIH's REACH. ESP provided family caregivers of people with ADRD with education about the disease process and how the environment can affect care receivers' behaviors and assistance with problem-solving strategies and ways to modify the home, through 5 home contacts and 1 telephone contact by occupational therapists who provided the education, problem-solving training, and adaptive equipment.

Strategies for HM included using equipment (grab bars or handrails), removing, rearranging, or relabeling objects; using color contrast; and placing objects in purposeful locations.

Reducing Caregiver Stress
The home environmental approach does reduce stress in objective and subjective burdens and enhances select aspects of caregiver well-being. Caregivers reported less upset with memory-related behaviors, less need for assistance, and better affect.
Gitlin, Hauck, & Dennis, 2005 127 of the 190 participants in the previous study. REACH: Following the 6 month active phase of the previous study there was a 6 month maintenance phase. This study measures maintenance of effects from the previous study at 12 months. Reducing Caregiver Stress
Caregiver affect improved and there was a trend for maintenance of skills.
Nichols, Martindale-Adams, Burns, Graney, & Zuber, 2011 Stressed caregivers of people with dementia from 24 VA Veterans Health Administration (VHA) medical centers in 15 states. REACH VA (part of REACH II): The REACH VA initiative provides education, a focus on patient safety, caregiver support, and skill-building for caregivers in dealing with difficult patients. This is an intensive intervention that includes 12 individual home and telephone sessions and 5 telephone support groups over a 6 month period. 24 Home-Based Primary Care programs across the country are participating in the intervention. (See study description at Reducing Caregiver Stress
Outcomes from baseline to 6-month follow-up included significant improvements in burden, depression, impact of depressive symptoms on daily life, caregiving frustrations, and troubling dementia related patient behaviors. Caregivers also reported per day decreases of 2 hours on caregiving duty.

Preliminary examination of Veteran health care use showed declines in inpatient, pharmacy, and outpatient costs. VHA costs to deliver the intervention would be $2.93 per day.

Participant Response
Staff and caregiver satisfaction and perception of benefit were high.

Sabata, Liebig, & Pynoos, 2005 This demonstration project comprised 4 steps, with different samples for each one. (1) Needs assessment: 29 people recruited from the LA Caregiver Resource Center in 4 focus groups to assess the most problematic and physically demanding activities for caregivers, plus 120 randomly selected participants from a list of 300 AAA contacts, for a survey to determine what HM services were available through AAAs. (2) Training: A 10-week course to NFCSP staff, recruited from the NFCSP staff directory. The first 20 registrants from each course offered (there were 2) were offered enrollment, resulting in 40 NFCSP staff participating in training courses. (3) Implementation: Same sample as for Training. (4) Evaluation: Survey sent to training participants. AoA funded Project CARES (Caregiver Adaptations to Reduce Environmental Stress), which sought to train staff of the NFCSP about AT/HM for caregivers.

The findings of the needs assessment contributed to the development of the training.

Implementation included proposals or plans of action written by training participants. In the last 2 weeks of the training course, participants were asked to write a proposal or plan of action to identify an activity to be completed within 6 months, identifying resources and partners to complete this activity. Some of these proposals included developing in-service training for caregivers to use HMs and leading a caregiver support group about HMs.

A likert scale was used to rate material usefulness and open-ended questions for participant progress/experience.

Needs Assessment
The needs assessment found the AT/HM most frequently used by caregivers was "grab bars". Caregivers noted that HMs were also useful for the older adult with mobility problems.

The most problematic activities for caregivers of persons with Alzheimer's disease included bathing, toileting, and using steps. The most physically demanding activities were lifting, transferring, and bathing. Caregivers reported that their use of HMs and ATs was limited due to the cost and difficulty in finding someone to make the modifications.

The evaluation component measured the success of training and implementation. Participants felt that they were more knowledgeable about HMs and had more resources available to them to connect clients to services.

Studies Involving Caregiver/Case Recipient Dyad
Carswellet al., 2009 Systematic Literature Review. The authors review the literature available on AT that can assist people with dementia and their caregivers during the night. Reducing Caregiving Stress
Some of the AT helped alleviate caregiver mental or emotional strain through calming the care receiver and alleviating verbal aggression and agitation.
Gitlin, Jacobs, & Earland, 2010 22 occupational therapists implemented ESP to caregivers.

41 caregivers participated to receive ESP services.

ESP (part of REACH) – a two-year translational project was conducted with a home care practice as a reimbursable Medicare Part B Service Reducing Caregiver Stress
Caregivers receiving ESP reported improvements in knowledge, skills, and well-being. 100% of caregivers said they would refer use of ESP to other caregivers.

Since ESP sessions were reimbursed through Medicare when integrated with patient-directed therapy, it has potential for being sustained through this mechanism.

Kinney et al., 2004 19 families who were caring for a relative with dementia. The authors describe the process of installing a monitoring system in the homes of participating families (The SAFE House), which consisted of a camera and sensors routed through a controlled unit to a website that is accessed with a broadband-connected computer. Caregivers are then alerted through text messages from the website if any potentially unsafe activity is detected. Reducing Caregiving Stress
Some of the positive benefits of this system included peace of mind for the caregivers; however, 50% of the caregivers surveyed felt that the system made their lives more difficult because of the technological burden.
Marquardt et al., 2011 Community-dwelling sample of 82 elderly people with dementia. The study examined home environmental features, safety issues, and health-related modifications in the each participant's home. Caregiver reasoning for implementation of HM and barriers to implementation were analyzed. Promoting Independence/ Safety
Caregivers' reasoning for modifying the home included the care receiver's physical limitations, most commonly for bathroom safety. Another primary reason was care receiver memory loss – these modifications included additional lights, signs and labels.
Messecaret al., 2002 24 caregivers of community-dwelling elders with a variety of impairments. Qualitative study of family caregivers' decision to use HM. Environmental Modification Use
The decision to use environmental modifications was determined by a complex evaluation of the benefits and disadvantages for both the caregiver and care receiver. Benefits for care receivers included improved functioning, safety, comfort, energy conservation, and preservation of self-identity. Benefits for caregivers included decreased workload, making monitoring and keeping the elder safe easier, reducing the unpleasantness of tasks, and having their own needs accommodated. Negative outcomes for care receivers included feeling stigmatized by the modification, being disappointed in the amount of improved function, being afraid to use the modification, or being unable to use the modification. Negative outcomes for caregivers included having their workload increased or feeling that the care receiver's functioning was not improved enough to warrant continued use.
National Alliance for Caregiving, 2011 Quantitative online survey of 1,000 technology using family caregivers who were 18+, provided at least 5 hours/ week of unpaid care to an adult relative or friend who needed help due to a physical or mental illness, disability or frailty. The survey examined family caregiver receptivity to 12 technologies that could help them provide care. The researchers also examined barriers to the use of technology, the factors that influence technology use, and sources caregivers trusted for technology information. Technology Use
Caregivers were most receptive to technologies related to delivering, monitoring, tracking, or coordinating the care recipient's medical care. Caregivers under age 50 were more likely to be receptive to technology use. The most commonly reported obstacle was the belief that the technology would be expensive.
Schulz et al., 2009 173 caregiver and care receiver (individuals with SCIs) dyads recruited from Pittsburg and Miami. Participants were randomized into 3 groups: (1) a caregiver/care receiver dyad intervention group, (2) a caregiver-only intervention group, and (3) an information-only control group.

This study does not look at the effect of AT/HM, but does include measurements for physical health symptoms. The study measured quality of life outcomes – depressive symptoms, burden, social support and integration, self-care problems, and physical health symptoms.

The caregiver-only intervention consisted of 5 in-home sessions and 2 telephone sessions (all 60-90 minutes in length) over 6 months. These were designed to provide caregivers with the knowledge to reduce environmental and personal stress, improve upon health and self-care, enhance access to support, and improve emotional well-being.

The dual-target intervention utilized the same model as the caregiver-only intervention for the caregiver of the dyad. For the care recipient, the same elements were provided (like improving emotional well-being). In addition to learning about the benefits to their own emotional/physical well-being, care recipients were taught ways in which they may assist in reducing caregiver burden. In addition to the 5 in-home sessions and 2 phone calls, care recipients also participated in 5 telephone support group sessions.

The control group received a packet of information about SCI, aging, community resources, and caregiving. 3 check-in calls were also conducted.

Dyad Quality of Life
The intervention targeting the caregiver/care receiver dyad improved quality of life of the dyad (measured by depressive symptoms, burden, social support and integration, self-care problems, and physical health symptoms).

No significant effects were obtained through the caregiver-only intervention, raising questions about the efficacy of this approach.

Number of Studies: 11.

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