Maria Teresa Agati,Alessandro Giustini,Adelmo Gian Martino Mazzocchi

1 Assistive technology:approach to reach the best autonomy possible

1.1 What do we mean by Assistive technology

When in this article we speak about"Assistive Technology"or more simply about aids,we refer to devices"external to the body,lasting,aimed at only one person and which have the goal of helping and supporting a person to carry out different functions,to maintain certain positions,to compensate for any deficit and,in general,to prevent the worsening of the disability and to improve autonomy.Excluded from this is therefore anything that needs to be surgically implanted,single use devices such as catheters or stoma bags,and also all devices aimed at collective or public use including rehabilitation equipment.

With the term prosthesis we indicate those devices that substitute a part of the body that is missing,recovering all functionality or a part of it;with the term orthosis we indicate the devices that serve to support or improve the functioning of a body structure which is present but compromised;with the more generic term of aids we indicate all those devices that a person needs to carry out functions(walk,move around......)or to assume certain positions(seated position,erect position......)or to carry out daily activities or to render possible,or at least less arduous,assistance by a family member or helper."(Information Service and Aid Assessment(SIVA),Milan,Nomenclator of aids：Reclassification).

Therefore in this article we will speak about assistive technologies aimed at the private person who lives at home and not about those technologies used to make access easier to public places or rehabilitation centres,hospitals,nursing homes or other residential care structures.

1.2 Not the right to an aid but the right to a rehabilitative project

In Italy,since 1978 aids have been supplied free of charge to disabled people.At the time,though,it was a form of assistance motivated more by the desire for compensation(prostheses and wheelchairs were initially supplied to disabled servicemen and only subsequently also to disabled civilians)and the list of aids to be provided was made up rather perfunctorily,without taking effectively into consideration the real needs of the person they were destined to.In practice,the list was realised more due to the urging of the demands of disabled people,relating to the economic resources that were intended to be destined to the sector,rather than by following an appropriate evaluation of the real needs of disabled people or with the proper knowledge of what existed on the market,but consequent to availability of the economic resources necessaryto satisfy needs.

In the nineties,particularly after the publication of Law 104 from 1992"Law-framework for the assistance,social integration and rights of handicapped people."the criteria with which the Italian state faced the issue of the supply of aids changed radically.

Law 104 confirms the specific rights of people with disability and,consequently,of social duty：society must provide concrete answers in terms of treatments,structures,interventions designed to guarantee conformity with the decreed rights.

Like rehabilitative treatment and interventions on a social and health level,the supply of prostheses,orthoses and aids also becomes an instrument to implement what the law prescribes："......the removal of disabling causes,promotion of a disabled person's autonomy and realisation of the best social integration possible.".

We pass therefore from the right to an aid to the right to autonomy and to social integration and consequently the choice of assistive technologies which the state must make available is no longer linked to a sort of haggling between invalid associations and the Government,but it must be about the evaluation of what should be made available so that,for each person,the project most capable of best developing his potential can be carried out.It is no longer about"giving gifts",but about considering an aid as one of the instruments to reach the assigned goal：best autonomy possible.

It is evident that this must bring about,on one hand,the availability of suitable economic resources but,on the other hand,a precise evaluation of how much is right to assign to this sector,in a complex balance between costs and effects.

It is not only an aid that must be provided but also a"path"along which,through various types of intervention including the supply of aids,the person is accompanied towards"the recovery of a functional competence that,for pathological reasons,has been lost or the evocation of a competence that was not acquired during development."(Rehabilitation guidelines)assuring......"primary and secondary prevention in all phases of growth and development of the child to avoid or opportunely verify the onset of impairment or to reduce and overcome the damage of an additional disability"and"the supply and repair of equipment,prostheses and technical aids necessary for the treatment of disabilities and to avoid handicaps."(Law 104).

In consequence to this different approach,it is not possible to realise a schematic model the use of which would make it possible to attribute to specific categories of people/disabilities one or more defined categories of aid—but a system of intervention must be devised which includes：

· the assessment of existing potential,

· the prefiguration of short,medium and long term goals,

· the definition of a plan of treatment and of the aid,or aids necessary to reach the defined goals,

· the assessment the intervention results,

· It is a complex process in which various factors interact,not least the costs/benefits ratio,especially linked to the aid provided being actually used by the assisted person or that it is able to positively modify their situation.

"A correct definition of the goal intended to be achieved with the supply of aids must consider all the three dimensions person/activity/environment,and therefore identify a solution

· that is suitable to the characteristics of the user,

· that works well,

· that effectively allows the carrying out of the planned activities at the desired level of performance and

· that is compatible with the characteristics of the user's environment and with the requirements expressed by other actors involved such as family and any personal helper".

In conclusion,Law 104/92 establishes some fundamental rights of the disabled person,to reach which,in many cases the use of aids is indispensable.The Italian state has decided that those aids indispensable to the realisation of Individual Rehabilitative Projects are provided free of charge by the National Health Service.

In 1999 Ministerial Decree n.332/99 established：

· who can be provided with aids free of charge

· how aids should be distributed

· who decides what aid to supply

· what aids are available(the list of devices to be distributed for free from which to choose from)

The decree establishes that the choice of what aid to supply free of charge can be decided only within the limits of an Individual Rehabilitative Project：

—choice of the suitable aid depends on the assessment of the needs and potential of the person,in relation to which the goals that the person can reach are defined as,usually,such a choice is complex and some types of aid require a competence that the disabled person alone cannot possess;

—the disabled person must be involved in all the phases of the project：from the assessment to the choice of aid,as acceptance of the aid is the key to it being used and therefore to it being effective;

—within the Individual Rehabilitative Project,the necessary training must be organised for the correct use of the aid in normal situations;

—the follow up must check to see if the goals have been reached and if the aid has proven itself to be suitable and is still suitable or whether it needs to be changed.

The Individual Rehabilitative Project is planned by a rehabilitation team made up of different professionals according to the type of disability(therapist,occupational therapist,psychologist,social worker and other specific roles)and to which the disabled person,who will participate in the choice,also belongs.The team is guided by a rehabilitation doctor who has the responsibility of prescribing,for each person,the goals that can be reached,the treatment required,the necessary aids to reach the identified goals and who is also responsible for the achievement of the same defined goals.

2 Two types of intervention:free supply,incentives

Certainly all aids,if of good quality and sure functionality,are useful and serve to facilitate the live of a person with disabilities.But the resources that can be used by various governments to implement policies and improve the quality of life and the participation in it of disabled people are not without limits,therefore each government is forced to make choices.

Italy has chosen to subdivide its state interventions with regards to aids aimed at the private person into two large categories：

· Indispensable aids to achieve the foreseen goals of the rehabilitative plan and,consequently,are considered equal to any other health intervention and provided free of charge upon a doctor's prescription(rehabilitation team)：

· Useful aids,those that,even though not considered strictly indispensable,are however very important in enabling a more active life and better participation in it,so much so that the state has decided to offer incentives and contributions for their purchase to aid their diffusion.

2.1 Useful aids which benefit from incentives and concessions

For the aids that the Italian state cannot afford to provide free of charge but that it considers however important for the improvement of the quality of life and the participation in it,significant incentives and concessions are foreseen,permitting noteworthy savings for disabled people and their families.

· Aids to overcome architectural barriers,for which the state allows particular concessions and contributions and where the disabled person decides in full autonomy the intervention to be carried out or the equipment to be purchased—these will be dealt with later in a separate article.

· Aids to adapt a vehicle for a disabled driver;concessions for disabled people in the purchase of a vehicle and for a disabled person's driving licence.In this field,the regulations become more complex.

For the purchase of a car or another type of vehicle,disabled people or their families can detract 19%of the cost of the vehicle from personal taxes,paying only 4%of value-added tax(VAT)rather than the 20%,they do not pay road traffic tax.

People with certified motor or sensorial disabilities or their families and family members of people with serious physical disabilities as well as families of people affected with Down syndrome,have the right to these particular concessions,according to codified tables.

To obtain a driving licence a particular path must be followed,where the effective capabilities of the person are assessed by health workers(rehabilitation doctor and therapist)using specific equipment able to simulate driving.Adaptations to the car(or any other means the person intends to drive)are chosen;particular training at special sites is given,with adapted vehicles.This topic will also be dealt with later in a special article.

· Aids with reduced value-added tax(VAT).Many objects aimed exclusively at disabled people such as crutches,wheelchairs,deambulators,aids for the removal of architectural barriers and many more,benefit from value-added tax(IVA)at 4%rather than 20%.This concession is applied directly at the sale of the product,regardless from who the purchaser is.

2.2 Essential levels of health assistance and the supply of free aids

If,as we have said,1992,with Law 104 signalled a fundamental change in the political vision of interventions to eliminate all possible handicaps and barriers that can limit the development of remaining potential of disabled people,in 2001 in Italy another fundamental passage came about.

This was called"Assistance with regards to Prostheses and Aids"and came into effect in the"Essential Levels of Health Assistance"which comprises all health services:from hospitalisation to outpatient treatments that must be guaranteed to all Italian citizens.

Finally the path was therefore completed for which the supply of aids is no longer a type of"gift"that the State gives to its less fortunate citizens but it becomes for them,in all effects,a full right to receive free of charge the necessary devises to reach the best level of autonomy and participation that the capabilities the disabled person still possesses,allow them.

It is another of those passages of civility of which Italy can be proud and that leads to a significant acceleration on many levels.2.2.1 Aids planned with the rehabilitator

Many types of aid need to become ever more capable to answer to the demands of rehabilitators,therefore they must be studied and projected with the collaboration of those people who work in rehabilitation centres.Only a person who studies man,his possibilities and his limits can understand how an object must be made so that it allows a person to stand up correctly,to have the correct support when walking,to position the wheels(or the backrest)so that the propulsion of the wheelchair is more effective or so that the seating doesn't provoke,over time,dangerous damage to bone structure and morphology of the person.How many cases of scoliosis or decubitus ulcers are caused by an incorrect posture and by inappropriate postural supports!

This is one of the reasons why Italian aids present many more innovational aspects of rehabilitation precision compared to aids in the rest of the world.

2.2.2 Identification of supply paths and cost control

Even though it is the disabled person who is at the centre of any process and any decision,it is the state that pays and,at the same time,wants to protect the health and development of its people,therefore it is important that the person is supplied with the aid he really needs and with which he can improve and,at the same time,require less assistance.The aid is not simply purchased by the disabled person nor is he simply reimbursed but a team of professionals decides together with the person which aid would be the most suitable and which goals could be achieved with that aid and checks that,over time,the foreseen goals are reached.

2.2.3 Identification of the suppliable aids

The list of types of aids is examined from which the doctor can choose,identifying those capable of providing a significant benefit in terms of improvement in the general conditions of the person and the possibility of participating more actively in social life,bearing in mind also the possibility of accession to school and to a working life.

3 The present system of free supply of aids to disabled people

3.1 General indications

Even though in the renewal phase(a new system has already been completed and is now being examined by the Minister of Treasury for evaluation of financial cover),the present system described by the Ministerial Decree n.332 from 1999 is based upon interesting elements which will not be completely changed again,but implemented and improved.

The Italian system for free supply of aids to disabled people is based upon three key points：

· the identification of those who have right to this supply

· the methods and paths which lead to the choice of the suitable device,to the supply and to verification that the device is the correct one and that it is used correctly

· the list of types of prosthesis,orthosis aids that can be supplied with the relative costs or methods of purchase

Some applicable details are usually also necessary,such as for example after how much time is a new supply of the same type allowed or what requisites must the place that supplies aids and prostheses possess.

3.2 Who has the right

Those who have the right to the supply of devices that are indicated in the lists attached to the decree are：

· all disabled serviceman,disabled civilians and service disabled who have a disability certified by the Italian state,

· children who need prevention intervention,care and rehabilitation for a permanent disability;assisted,as later indicated,in connection with their impairment and invalidating disability;

· all those who are awaiting invalidity certification and who have a serious invalidity;

· all those who have undergone amputation,simply upon presentation of a doctor's certificate;

· those admitted to an accredited health structure,public or private,for which the doctor responsible for the operative unit certifies the contextual necessity and urgency of the application of a prosthesis,an orthosis or of an aid before discharge,for the quick activation or the carrying out of a rehabilitative project with regards to a serious and permanent impairment.Contemporaneously to the supply of the prosthesis or orthosis,the procedure for recognition of invalidity must be activated.

People with work invalidity will receive the necessary devices not through the normal assistance programmes for prosthesis and aids,but directly from the National Institute for Insurance against accidents in the workplace(Inail).

To reassume,normally to accede to the service for the free supply of aids and prostheses invalidity must be certified by a specific government commission but,if the disability is serious and evident,certification is sufficient from the doctor responsible for admitting the person and planning the Rehabilitative Project specific to that person so that the aid can be supplied.

In particular for children,during all of the growth phase(indicated up to 18 years of age),the necessary aid can always be supplied,also in order to prevent worsening of the condition.

3.3 Methods of supply

Description of the methods on how the whole path of aid identification should come about of the aids to be supplied to the disabled person up until verification that the aid supplied is suitable to the necessities and to the expectations of the person,is particularly interesting.

We can see how close attention is paid to the choice of suitable aid and how the whole process is governed by the Rehabilitation Project which is prepared and activated for each single person.

Here are once again all of the most significant aspects：

—Prescription of prosthetic devices is made by a National Health Service specialist doctor,an employee of the NHSor with a private financial agreement,competent for the type of impairment or disability

—Prescription constitutes an integral part of a prevention,cure and rehabilitation programme for injuries or the results of,that,singularly,in concurrence or in coexistence,determine the impairment of the disability.To this end,the first prescription of a prosthetic device must include：

· a detailed diagnosis that ensues from a complete clinical and instrumental assessment of the patient;

· indication of the prosthetic,orthotic or aid device prescribed,complete with identification code written in nomenclator,and indication of any adaptations necessary for its personalisation;

· a therapeutic programme of use of the device including：the therapeutic and rehabilitative significance;the methods,limits and foreseeable duration of use of the device,any possible contraindications,verification methods of the device in relation to the progress of the therapeutic programme.

—the prescription is integrated by full information given to the patient and any eventual helpers,regarding the functional and therapeutical characteristics and of the methods of use of the device itself.

.......

—After the aid has been supplied,the prescribing doctor or his team will check that it corresponds to what has been evaluated and that is has been well adapted to the needs of the person.

.......

—Suppliers are bound to guarantee perfect functioning of the prosthetic devices for the period subsequent to delivery and however not inferior to the guarantee terms indicated within the present regulation.......

Minimum Renewal Times.Another interesting aspect is constituted by the minimal renewal times.The decree states the minimum time that can elapse before an aid of the same type can be supplied again(for example,5 years for an adult's wheelchair).

There are a few exceptions to this rule.

The first is relative to aids during development(those under 18 years of age)：

".......For devices supplied to beneficiaries below 18 years of age,minimum renewal times are not applied;the Local Health Authorities authorise the substitution and modification of the supplied prosthetic devices,based on foreseen clinical controls and according to the therapeutic programme......"

The second is if the prescribing doctor considers it necessary：

".......Minimal renewal times can be abbreviated based on a detailed report by the prescribing doctor for particular therapeutic or rehabilitative necessities or in the case of changes in the psychophysical state of the beneficiary......"

It is evident that the main director of the whole path leading to the supply of the aid is the prescribing doctor,the person who-assisted by the team of experts present in the operative unit in which he works-defines what is suitable to supply to the person to activate the prevention,cure and rehabilitation programme he has planned for that person,and he evaluates that the supplied aid responds fully to what has been prescribed and is therefore able to produce the expected and indicated results of the programme itself.3.4 List of the types of aid that can be supplied

The heart of the system is constituted by the lists containing the types of prostheses and aids from which the doctor can choose what needs to be supplied to the beneficiary.

The types of suppliable devices are identified by a code that derives from ISO classification,to which a fourth level has been added,made up of three figures,which better detail the type of suppliable device.

Example：

ISO classification for wheelchairs for the disabled foresees the following codes：

class 12 ASSISTIVE PRODUCTS FOR PERSONAL MOBILITY

subclass 12 21 Self-propelled wheelchairs,

division 12 21 06 Self-propelled wheelchairs with two hands on the back wheels

The Italian list divides this last group(division)of wheelchairs which ISO classification codifies with the code 12 21 06 into further subgroups(types)：

12 21 06 033 Self-propelling folding wheelchairs with two hands on the back wheels mainly for indoor use.

12 21 06 036 Self-propelling folding wheelchairs with two hands on the back wheels with stabilising frame,mainly for external use

12 21 06 069 Self-propelling folding wheelchairs with two hands on the back wheels extra-light,indicated for non-ambulatory invalid adults and people below the age of 18 who carry out intense external activity.

Structure in composite materials(carbon and/or kevlar)or extra-light highly resistant alloys.......

Our classification system has therefore four levels rather than the three ISO levels：class,subclass and division.

This consents a more detailed description of the characteristics the product must possess,allowing the prescription to be more precise：a doctor cannot simply prescribe a wheelchair but an indoor wheelchair(codice 12 21 06 033)or an outdoor wheelchair with a stabilising frame(12 21 06 036)if the beneficiary is able to move outside or an extra-light active wheelchair for those who can,with such a wheelchair,for example,move around by themselves on long stretches or load it autonomously into a car.

It is equally evident that this also allows more detail in the tariffs and costs to charge to the National Health Service.

The choice of type to prescribe is,as we have seen,the duty of the rehabilitation team and ultimate responsibility lies with the specialist doctor who also assumes responsibility for the expense.

Many classes of devices are made available：from different limb prostheses(upper,lower,foot,leg,thigh,with different levels of technology)to diverse models of orthopaedic shoes,scoliosis corsets,diverse orthotics with different types of stabilising,manual and electronic wheelchairs,posture systems for adults and children,pushchairs,beds,mattressesand anti-decubitus cushions.

The types are divided into two big groups：

· Prosthetics,orthotics and aids that need a health/rehabilitative project to be individualised based on the person's specific needs,to precisely adapt to each single requirement and to activate training in the use of the device which allows the correct use.

· Technical aids which,even though they must be prescribed by a doctor who guarantees the effective need,do not require a specific individualised intervention.

3.4.1 Products that require an individualised rehabilitative pro-gramme

Belonging to this first group are all prosthetics,orthotics,orthopaedic shoes,which must obviously be custom made for each person.

Also belonging to this group are all those aids which,even though not custom made,are very adjustable and adaptable and can be completed moreover with many accessories or there is a big variety of product so they can be better adapted to the single needs of the person,such as for example,postural systems for adults and children,extra-light or light wheelchairs,stabilisors,some types of deambulators,etc.

The doctor prescribes the type of product and then various health workers come into play,among which the orthopaedic technician and the occupational therapist who deal with identifying the dimensions and suitable accessories and effecting the necessary adaptations and training in the use of the aid.Supply is usually effected by a professional who in Italy we call the Orthopaedic Technician.

There are many different variables that can"change your life"：a seat that is too long or too short,wheelchair wheels too far forward or too far backwards,a backrest that is too high or too low,a suitable cushion.Any of these can make the difference between an active or passive use,between a safe situation or one at risk.

If the wheels of a wheelchair are not in an ergonomically correct position,it takes too much effort to push and the user is unable to overcome the small step on the pavement;if the cushion isn't suitable,extremely dangerous decubiturs ulcers can develop,if the backrest is too high the shoulder movement will be blocked,if it is too low and spine injury is upper and complete,trunk control is made more difficult......

If we place a child with infantile cerebral paralysis on a seat that is too wide because he will grow anyway,we have probably created favourable conditions for the development of a pathological deviation of the spine and,moreover,a condition of instability that does not allow good oculo-manual control......

There are many positive consequents of an appropriately chosen and adapted aid just as there are many negative consequents of an inappropriately dimensioned and unsuitably functional aid.

For these aids the doctor prescribes the type and the different accessories necessary and then the choice of model,of the dimensions and of the most suitable configurations is made by the orthopaedic technician and the occupational therapist in agreement with the user,often by trying different models of aids.

To meet these needs,expository Centres are vitally important and now they are also becoming numerous in China too.

3.4.2 Careproducts that require an easier path

Belonging to this group are those aids which normally do not have to be chosen on the basis of specific morphological characteristics and disability of the person,but they can perform their correct function independently from the characteristics of the single user.

For example,special beds,hoists and lifts,mobile aids to overcome architectural barriers,anti-decubitus mattresses,simpler models of deambulators.

Often in Italy local community health services invite bids for the purchase of these aids and they supply them directly to the beneficiary based upon a simple request from the doctor

In these cases the aid remains the property of the health service which will withdraw it when it is no longer needed.It will be sanitised and after careful maintenance will be used for another person.

Conclusions

The system responds to many requirements：

· competent care of the person in the choice of aid or aids suitable to the possibilities of improvement or to the prevention of further damage;

· control of the of the intervention's effectiveness and of the resources used by the Government;

· more detailed identification and description in the type of aid that can be made available,with the creation of a further level of ISO classification：

The system has a few defects though,that will be overcome in the new reform.

· The list of devices is obsolete;there needs to be a system which renews it annually,removing any device with surpassed technology and including new types with new requirements;

· There is no registration—make or model—of the aids that can be supplied for each type included in the lists;

· Identification methods of costs to the Government need to be refined in relation to the real value of the aid to be purchased：

· The cost monitoring system needs to be improved.

The assessment of these last few years is,however,decidedly positive.Through planned and controlled investments,disabled people in Italy receive aids which are indispensable to their autonomy with methods that assure that the aid supplied is suitable to their needs and will therefore by used effectively.This means that more and more disabled people will develop a distinct sense of safety which allows them an active life and a good percentage can be transformed from subjects needing care into people who earn their living and pay their taxes.

A renewed system(that will in any case be at zero cost as the processes will simply be reorganised)will allow the further improvement of interventions in this sector.