by Rosemarie Rossetti, PhD, CLIPP, and Monique Chabot, OTD, OTR/L, CLIPP, CAPS
Rosemarie Rossetti’s Story
When I came home from the rehabilitation center in a wheelchair for the first time after my T12-L1 incomplete spinal cord injury in June 1998, my husband, Mark, pulled me in my wheelchair up three steps at the front door. He then pushed me over the carpeted great room, too weak to roll myself. In the kitchen, I rolled on the linoleum and tried to get an unreachable glass out of the wall cabinet. Mark handed me the glass. I took it to the sink but couldn’t reach the faucet. Mark poured me a glass of water.
The realization I was so dependent on Mark hit me hard. So much was out of reach in the kitchen, including the freezer, microwave, and shelves. There was no knee space under the sink or cooktop. The 36-inch-high counters were too high for comfort. The oven door was hinged on the bottom, making it very difficult for me to position myself to use the oven. Frustration was intense as I tried to imagine how to live independently. With my home not accessible, I was keenly aware of the obstacles that intensified my disability.
Entering and Exiting the Home and Internal Mobility
Entering and exiting the home is a primary concern; inability causes the person to become homebound and unable to leave the home in an emergency. Many homes have at least one step at entrances. Each entry should be evaluated for the possibility of adding a ramp, either wood with appropriate weatherizing materials or aluminum. While the code for ramps requires 12 inches in length for every 1 inch of rise, there is a growing movement to change the code to 18 inches in length for every 1 inch of rise to make an easier-to-traverse ramp. When a ramp is not possible, installing a vertical platform lift brings people up to the level of a landing at the door.
Once inside, various access challenges can arise. Beyond wider doorways and 5-foot turning radiuses, thresholds can be problematic. Thresholds should be no more than ½ inch high beveled. If unable to decrease the threshold height, two small ramps (aluminum or rubber) on either side of the threshold can solve the problem. Automatic door-opening systems can be installed to remove the need to physically open the door. A version is available for nearly any door, controllable via remote control, push pads, and motion sensors. Swing-away door hinges add 2 inches of space when replacing regular door hinges—just enough to fit a wheelchair.
Rossetti’s Home – Universal Design Living Laboratory
My husband and I decided to design and build our new home in Columbus, Ohio, to meet my accessibility needs. We hired an architect and assembled a team of interior designers and more than 200 corporate contributors. Serving as the general contractors, my husband and I spent 32 months building our home. This home, named the Universal Design Living Laboratory, is the top-rated Universal Design home in North America, earning three national Universal Design certifications. A virtual tour of the home can be seen online.
Universal Design is a framework for the design of living and working spaces and products, intending to accommodate the widest range of people of all sizes, ages, abilities, and situations without special or separate design.
Living in the Universal Design Living Laboratory using a manual wheelchair gives me a unique perspective. I have learned the importance of space planning and that small differences in the width of a door, the height of a threshold, the slope of a ramp, and the height of a countertop or wall cabinet can impact a person’s independence.
Bathrooms often provide a unique set of challenges given space restraints, the location of plumbing, and the variety of tasks occurring in the room. Two problematic tasks in the bathroom are toileting and transfers into the bathing area. Transfer boards and tub benches/chairs are frequent recommendations. These help only when there is enough space for them to safely fit in the area. Some shower chairs are too wide to fit into tubs.
Clinicians frequently recommend handheld showers, but they are not always placed within reach when seated. Being able to adjust the height of the shower nozzle on a vertical bar or through use of a shower arm holder makes for a functional shower head. Another important area to address is the ability to reach and manipulate the shower controls for water force and temperature. This may require reinstallation of the faucet unit or use of a voice-activated smart shower control. Also, consider the direction of the water flow through the positioning of the shower nozzle. Water should not be directed where it would spray outside the shower. An on/off pause button on the shower head saves water and controls the water flow quickly.
Patients often receive three-in-one commode chairs to make toileting more convenient for those unable to reach the bathroom. Clinicians sometimes remove the bucket to use the frame as a raised toilet seat. However, Medicare will not pay for items in the bathroom. In order for Medicare to cover a three-in-one commode chair, a clinician will have to prove the client cannot reach the bathroom in an appropriate amount of time. Some people will require a drop arm handrail on the commode chair to safely transfer.
Placement for grab bars is unique to each person. Considerations need to be made for the direction of approach for transfers, height and location of the bars to maximize muscle strength during use, and orientation to support their intended use such as stabilization during clothing management. At the same time, grab bars that are too short, too high, or in the wrong location are initially more useful than no grab bars at all. Some bathtubs are designed with integrated grab bars, removing the need to drill into pre-existing walls and tiles.
A continuing myth is placing grab bars into studs. This can be dangerous as the type and integrity of stud wood are unknown, potentially leading to a stud cracking during installation. It is easy to catch the side of the stud versus the middle with a stud finder. Many contractors prefer to use toggle bolts which can be rated for up to 600 pounds. This allows clinicians to place the bars wherever is best for their patient. Some surfaces are not suitable for toggle bolts, such as plastic shower stall inserts, so always consult with a contractor.
When I first came home from the rehabilitation center, there were doors on the shower and bathroom that required removal to allow me access in my wheelchair. I was unable to use the bathtub because of my paralysis. When I needed to shower, my husband placed the transfer chair in the shower, and I used a sliding transfer board. When my husband took a shower, he had to remove the chair and store it in the bathtub. A handheld shower nozzle was installed on a vertical bar with a diverter valve to operate the original shower nozzle so Mark could shower while standing. A raised toilet seat on a frame with grab bars was positioned over the existing toilet.
Now my home has a 4-foot by 7-foot curbless master shower with an adjustable-height shower chair on one wall. I can transfer from my wheelchair onto the shower chair by holding on to the grab bar behind the shower chair, then rolling my wheelchair out of the shower. The handheld shower nozzle, water controls, and soap in the shower niche are easy to reach. A second shower head is mounted high on the opposite wall for my husband to use. The floor tiles are slip resistant and sloped slightly toward the channel drain on the back wall for quick water drainage.
To increase my storage access, Mark installed pull-out drawers in the base cabinets. We purchased Lazy Susans for the pantry closet to store canned goods. We acquired a microwave for the countertop since the one above the stove was inaccessible. Items were moved into lower shelves to be more reachable. I used a small desk as a food preparation surface. The breakfast bar was useless to me. A reacher was required to retrieve frozen food from the freezer on top of the refrigerator.
The Universal Design Solution to Kitchen Access
Universal Design features in my kitchen include the overall design of the circulation pattern, cabinet design, countertop height, and appliance selection.
A person in a wheelchair has a limited reach, but few people want all their possessions cluttering a countertop. A guideline recommends that 50% of the storage in a home should be reachable from a seated position, approximately 18 inches to 48 inches high from the floor.
To help create accessible storage in the kitchen, install large deep drawers in the base cabinets to hold various cookware and dishes. Cabinets with pull-out drawers and shelves and pull-down shelves position items at a more accessible height. The shelves of cabinets are often adjustable by moving the metal shelf brackets into a more reachable position. Side-hinged ovens and microwaves at waist height and side-by-side freezers/refrigerators are easier to use.
Attention to the smallest details makes a difference in allowing people with spinal cord injuries and other conditions to live at home safely and independently. Universal Design also makes the modifications usable by everyone in the home. RM
Rosemarie Rossetti, PhD, CLIPP, is an internationally known speaker, trainer, consultant, and author of the Universal Design Toolkit. A virtual tour of her home and more information about her national demonstration home and garden, the Universal Design Living Laboratory, is available at www.udll.com. Information about her speaking and training services can be found at www.RosemarieSpeaks.com.
Monique Chabot, OTD, OTR/L, CLIPP, CAPS, is an assistant professor of occupational therapy at Thomas Jefferson University-East Falls campus. She specializes in home modifications for seniors and serves on the Medical Advisory Board of the Living in Place Institute. For more information, contact RehabEditor@medqor.com.
Stairlifts Rise to the Challenge
When single-floor housing is not an option, stairlifts help wheelchair users get their plans off the ground
By Frank Long, Editorial Director
The idea of single-floor living has great appeal as part of an aging-in-place strategy, but an extensive period of planning and development may not always be an option for people who may find their personal mobility suddenly depends on a wheelchair. For example, a spinal cord injury or brain injury that results in a mobility impairment may change circumstances quickly, and the injured person may have no choice but to remain in a multi-floor home after discharge. Home adaptations and assistive technologies can be used to optimize the level of mobility a wheelchair user has to meet the needs of multi-floor living.
Stairlifts are one assistive technology that can help facilitate a wheelchair user’s ability to move about inside a home. There are several sources that provide these devices to the marketplace, and they are available in a range of price points and lifting capacities. Modern stairlifts are designed so they may be applied indoors to straight staircases or curved staircases, with some manufacturers building models suitable for outdoor use.
Wheelchair users may share living spaces with family members or caregivers who are able-bodied. Because of this, some manufacturers have designed stairlifts that preserve as much open space as possible, such as models that have a low-profile rail design. Foldable arms, footrests, and seats can provide a compact appearance to stairlift components when not in use, while vertical rails with covered gear racks can also contribute to a more aesthetic look.
Other desirable features found on today’s stairlifts include offset swivel seats that can make transfers easier, as well as seat belts and obstruction sensors. Remote control units are a convenient feature that can be found on some models, while others offer battery backup systems that assure stairlifts remain operable in the event of a loss of power to the home.
While it is not unusual for people affected by a spinal cord injury or stroke to feel some anxiety about living at home after discharge, assistive technologies can help promote quality-of-life measures such as self-management and participation. And, while wheelchair users themselves likely will benefit the most from the function that stairlifts provide, there is research that suggests stairlifts can benefit other members of the household with improved mental and physical health status.1
Because life doesn’t always happen on the ground floor, stairlifts remain a vital option when planning a home modification.
Heywood F. The health outcomes of housing adaptations. Disabil Soc. 2004;19(2):129-143.