Choosing the Appropriate Assistive Device: A Card Sorting Activity
Session guide developed by
Maria H. van Zuilen, Ph.D.
Osvaldo L. Rodriguez, M.D.
Miguel A. Paniagua, M.D.
Michael J. Mintzer, M.D.
October 2007
Choosing the Appropriate Assistive Device: A Card Sorting Activity
INDEX OF MAJOR SECTIONS
Description of the Session 3
Objectives 3
Intended Audience and Prerequisites 3
Required Resources 4
Procedures and Implementation 4
Assessment 7
Evaluation 7
Relationship to Other Materials 8
Lessons Learned 8
Citation 8
Copyright Information 8
Acknowledgements: This work was supported by the Donald W. Reynolds Foundation Grant “Comprehensive program to strengthen physicians' training in geriatrics.”
Description of the Session
This 30-40 minute instructional activity is designed for small groups of medical trainees (6-8) to apply basic information learned about assistive devices. Although this session is intended for learners who have received some preliminary instruction on assistive devices, it can be modified readily to be the primary instructional modality for learners who have had little previous exposure. This interactive teaching activity uses a card sorting format in which participants are given a set of cards, each containing a different patient scenario, and are asked to match each card with one of seven assistive devices which are displayed on a table. Once the matches are complete, participants discuss the rationale for their matches and with input from the group members, make needed changes. The facilitator encourages further group discussion to clarify any misconceptions or mismatches. Key points about the use of assistive devices and common mistakes in their use are reinforced.
Objectives
· Given a patient scenario, select the appropriate assistive device and explain the reason for the selection
· Describe the common problems in the use of assistive devices
Note: This activity is NOT intended to teach medical trainees how to prescribe an assistive device. As physicians, they will be able to draw on the expertise of other disciplines to complete a formal evaluation. However, we do want them to be able to recognize when a patient may benefit from an assistive device and when they may be using an inappropriate assistive device for their condition.
Intended Audience and Prerequisites
This session is designed for medical students and/or primary care residents, but can be used for trainees of other healthcare professions who participate in the evaluation and assessment of older adults. It is helpful if the learner has received basic instruction on assistive devices as this session is intended to reinforce prior learning and give learners an opportunity to apply their knowledge. We recommend participants be asked to review the following online training module prior to the session.
Rodriguez O, Phancao F, Ruiz JG. "Assistive Devices" Learning Object. MedEdPortal; 2007. Available from http://www.aamc.org/mededportal. ID = 379.
As noted above, with minor modifications, this session can be used as the primary source of instruction on assistive devices.
Required Resources
· A small room with a table large enough for participants to sort and place all the patient scenario cards under the assistive devices cards
· This guide and a card key listing the appropriate assistive device for each patient scenario (Appendix A)
· 8 large category cards with assistive devices (listed below) and 24 patient scenario cards (Appendix B). Cards should be printed large enough so that participants can easily read their contents while standing around the table.
1. Straight cane
2. Offset cane
3. Crutches
4. Standard walker
5. 2-wheeled walker
6. 3-wheeled walker
7. 4-wheeled walker
8. ?????
· Session evaluation forms (Appendix C)
· OPTIONAL - The actual assistive devices for display and practice
Procedures for Implementation
This session is conducted in four parts:
1. Introduction (5 minutes)
2. Card sorting activity and group feedback (15-20 minutes)
3. Basic principles of correctly using an assistive device (5-10 minutes)
4. Closing the session (5 minutes)
Part 1 - Introduction (5 Minutes)
· Review the learning objectives.
· Ask learners what training they have previously received (e.g., Have they reviewed the online module on assistive devices?). Inform learners that this session will give them the opportunity to apply the knowledge from this previous training.
· Review some key concepts about the use of assistive devices (included in the assistive devices module):
o Use of assistive devices increases with age (25% of those elders up to age 80 and >50% of those over age 80)
o The most heavily used device is a cane (1/3 of all devices compared to walkers and wheelchairs which make up 25 and 10 percent respectively)
o Using assistive devices can help elders maximize their function, decrease dependence on caregivers and increase their own perceived quality-of-life
Part 2 - Card Sorting and Group Feedback (15-20 minutes)
Set up
· Array the eight category cards across the table provided (see diagram below). They can be folded so they stand up and participants can see them better. (There are 24 patient scenarios that the students will sort so no category will have more than 6 or 7)
· Leave enough room on all sides of the table for the learners to easily participate. If the actual assistive devices are available, place them where they can readily be seen.
Example Set up (number of cards under each heading is for demonstration purposes only):
Explaining the Instructional Activity: Card Sorting Game
· Explain that this is an activity that will allow them to apply what they have learned about assistive devices. Participants will have 5-10 minutes to sort their cards and place them under the appropriate category card.
· Give each participant a pack of 4 cards (assuming there are six participants). Each card has a case scenario of a patient who requires an assistive device. Ask participants to place each card under the category of assistive device most appropriate for that patient. If they are unsure, ask them to place it under the “?????” card.
· When all the cards are placed, ask participants to explain the rationale for their choices to their peers. Much of the group discussion typically centers on areas where there is uncertainty. Participants are encouraged to change their choice of placements based on the group discussion.
· The facilitator is present to encourage discussion among the participants and, at the end, to correct any misconceptions that may be voiced.
· Only after participants have gone as far as they can does the facilitator give the group feedback. Start with the group's correct responses, then addresses errors or misconceptions you heard voiced during the group discussion.
· Challenge participants to consider situations where some of the cards might be put in different categories if certain conditions existed. For example, ask: “What if the 62 y/o man who broke his femur skiing had broken his femur and wrist?” (He would need a wheelchair because there is no other way he could take the weight off his leg.)
Areas for Discussion
· Acknowledge that there may be some areas of overlap (i.e., there may be more than one correct answer). Although we have assigned each patient condition to one assistive device category, participants may correctly argue for another device when they bring in additional elements to the case.
o One area of overlap occurs between the standard walker and a 2-wheeled walker. A standard walker is more safe for weight bearing but impacts walking efficiency – the gait is no longer fluid; it stops and starts. They are very useful when limited or partial weight bearing is required, for example, after hip or knee surgery. A 2-wheeled walker is less safe for weight bearing (because it can move) but allows fluid gait. More and more often they are being used for gait retraining after deconditioning and for situations where weight bearing is required but the legs are able to proceed through a normal gait cycle even if there is a unilateral weakness.
o Another area of overlap is between the different types of canes. A straight cane is used primarily for balance and sensory input. It is not a weight bearing device. An offset cane is also used primarily for balance and sensory input but because of its design, it can offset a minimal degree of weight. A quad cane (not included in this session), being more stable, can be used if there is a unilateral condition that requires mild to moderate weight bearing.
· Walkers are used to provide the most weight support (sometimes associated with severe balance disorders like ataxia where sudden shifts in body weight need to be supported). Walkers provide a wider base of support for patients but they also impact gait fluidity and speed.
· All patients using assistive devices need proper training!
· 3-wheeled walkers should NEVER be used. They are unstable and pose a serious safety risk. (Think about the stability of a child’s tricycle!)
· Reinforce that their job as physicians is:
o To recognize when someone needs an assistive device (related to their knowledge of balance and gait!)
o To recognize when someone is (or might be) using the incorrect device OR is using the correct device incorrectly
o To make appropriate referral to physiatry or physical therapy for assessment and training in the use of an assistive device
· Explain that an assistive device is an extrinsic risk factor for falls. This is largely due to incorrect use. The chart below list some key points about the use of assistive devices and common problems encountered.
Assistive Device / Key points about use / Common problems/mistakesCanes / · Balance and stability is primary use
· Length: crease of wrist when arm hanging (elbows 15-20o)
· Use on contralateral side of MILD weakness or pain / · Used for too much weight bearing
· Not fitted correctly
· Not used correctly
· Rubber tip is worn out and can slip increasing fall risk
Standard Walker / · Good for weight bearing support (elbows 20o)
· Upper body strength is needed
· ↑Stability, ↓Speed / · Carrying the walker to improve gait speed and carrying it over steps
· Putting the walker too far in front of themselves
Two-Wheeled Walker / · For movement disorders (Parkinson’s, ataxia)
· Pushed, not lifted (leaning forward to use the walker helps prevent retropulsion) / · Lifting the device instead of pushing it.
Part 4 - Closing the station (5 minutes)
· Review the learning objectives and make sure participants feel they were met
· Ask if there are any remaining questions
· Remind participants to complete the corresponding session evaluation sheet
Assessment
We have designed a brief online competency assessment (an extended matching multiple choice question) linked directly to the main learning objective covered in this activity. Students are presented with a list of seven assistive devices followed by 10 patient scenarios. They are asked to select the most appropriate device for each patient. In our program, this assessment is administered at the end of the academic year, a few months after the instructional activity. It can easily be incorporated into an existing student assessment.
Evaluation
We have successfully implemented this activity as part of a half day clinical skills session in the spring of 2007 with a class of sophomore medical students. They were asked to complete a brief evaluation of the activity using a five point Likert Scale (1=strongly disagree, 5=strongly agree). The results are summarized below.
Category / N =166A. Please indicate the degree to which you agree with the following statements: / Mean
1. The objectives of the session were clearly defined / 4.7
2. The session was overall well planned and organized / 4.7
3. Each student was provided a hands-on training opportunity / 4.7
B. Please indicate the degree to which you agree that the learning objectives of this station were met:
1. Given a patient scenario, select the appropriate assistive device and justify the selection / 4.7
C. Please rate your preceptor on the following:
1. Demonstrated medical knowledge/skill / 4.8
2. Made session interesting and comfortable / 4.8
3. Explained concepts clearly / 4.8
4. Overall, the preceptor was effective / 4.8
Relationship to Other Materials
As mentioned previously, in our program we ask that students complete the online training module on assistive devices. This module takes approximately 30 minutes to complete.
Rodriguez O, Phancao F, Ruiz JG. "Assistive Devices" Learning Object. MedEdPortal; 2007. Available from http://www.aamc.org/mededportal. ID = 379.
After completion of the session, we recommend that learners take the competency assessment. If the assessment occurs some time after the session, learners can “refresh” their knowledge by revisiting the online module.
Lessons Learned
We have conducted this session with second year medical students. At the time of the session, one of our fourth-year students rotating through the nursing home had a background in physical therapy. He volunteered to facilitate some of the sessions and he received very positive feedback from the students. We have found that with a detailed facilitator’s guide, advanced medical students and members from other disciplines can successfully conduct this and some of our other teaching sessions. It is helpful if facilitators have a background in working with older adults as this allows them to draw on their own experience during the group discussions.
Citation
van Zuilen MH, Rodriguez O, Paniagua, MA, & Mintzer MJ. Choosing the Appropriate Assistive Device: A Card Sorting Activity. Miami, FL: University of Miami, Geriatrics Institute, 2007.
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