Following a catastrophic injury, such as a spinal cord injury, the accessibility of one’s home becomes a crucial factor in his or her return to function. Inpatient rehabilitation therapists are often called upon to offer information about home modifications, and caregivers are forced to make decisions about what modifications are necessary, reasonable, and optimal for function. The following is a brief overview of some of the factors to consider when providing information to someone in need of accessible housing for a wheelchair user.

It is advisable to preface any home-modification recommendations with the disclaimer that therapists cannot speak to the structural feasibility of any recommendations, and that a contractor should be consulted prior to any major modifications. Structural changes should be done in compliance with applicable codes and ordinances, and recommendations are not all-inclusive.

What is Necessary and Functional?

Understandably, caregivers often find the prospect of modifying a home very stressful. It is important, however, for caregivers to understand that all of the modifications do not need to be completed at the time of the patient’s discharge. What is necessary is very different from what is functional. Because of the nature of rehabilitation, therapists often need to wait to make recommendations about specifics until close to the end of the patient’s stay. Waiting to modify a bathroom, for example, can be the difference between using a tub bench in the existing tub and needing to install a roll-in shower. Being clear that only a few modifications must be completed at the time of discharge can help decrease one source of stress for the caregiver.

Two accessible entrances/exits are always strongly recommended to await the patient when he or she returns home. This will ensure safety in the event of a fire or other emergency. A ramp with a manageable slope is often all that is needed to make an entryway accessible. Modifications may need to be made to doorknobs to accommodate hands with paresis, and storm doors may need to be removed to increase the ease of entrance/exit. Installing smoke detectors (if not already present) is important, as a wheelchair user will often require as much time as possible to exit the home safely in the case of a fire. Informing the fire department that an individual in the home uses a chair is important, too. In this way, if emergency personnel are required, they will arrive expecting to help someone who uses a chair.

Upon discharge from an inpatient rehabilitation facility, the wheelchair user needs access to a room large enough for a bed and a transfer to and from the bed. Often upon discharge from the hospital, that room is a bedroom, the living room, or sometimes even the kitchen. As long as the individual can get into the house and into an appropriate bed, the personal care required for a spinal-cord-injury patient can take place adequately while additional modifications are being made.

When considering what home modifications will optimize an individual’s function, it is important to think about the person’s life roles prior to injury and how those will change because of the injury. Did he or she cook before the injury? Will he or she take on this role upon returning home? Asking questions similar to these can help the wheelchair user and the caregiver make sound decisions about how best to use resources. The following suggestions are general, and they are not intended to be appropriate for all patients.

General Requirements

In any room, it is recommended that an open space be available that is large enough to accommodate the turning radius of a manual or power wheelchair. Doorways should be wide enough to accommodate the chair, and they should be able to open to at least 90°. Special hinges can be installed to eliminate the space that an open door occupies, increasing doorway width. The wheelchair’s width and the space required for the wheelchair to turn should be considered when constructing hallways. Any exposed pipes under sinks should be insulated to avoid burns to insensate skin, and transitions between floors should be as smooth as possible. Hard, smooth floor surfaces like wood or linoleum are generally sturdier and easier to maneuver over than carpet.

Parking

A covered parking area and a covered walkway to an accessible entrance are important for a wheelchair user. Without these, if it rains, the individual might be drenched by the time he or she gets to and transfers into the vehicle, disassembles, and loads his or her chair. Covering is also preferred for power wheelchair users. An adequate space should be available next to the vehicle to allow room for transfers or lifts.

The Kitchen

A truly accessible kitchen will be open, with plenty of room around the refrigerator and oven. Some wheelchair users prefer an oven that is raised. The range’s dials or controls should be at the front of the appliance to avoid having to reach over hot eyes to adjust temperatures. A mirror should be tilted over the range to allow a clear view into pots and pans from a seated position. Roll-under cooktops may be advisable for avid cooks, especially those with paresis of the upper extremities. Likewise, flat-top ranges can be easier and safer for those with paresis of the uppers, as items can slide easily onto and off of the eyes.

Side-by-side refrigerator/freezers are generally more accessible to wheelchair users than those with the freezer on the top or bottom. Roll-under sinks and countertops are optimal, though accessible storage (usually bottom cabinets) should be considered. Lazy Susans and pullout shelving can maximize accessible storage. Lever-type faucet handles are easiest to use if hand function is impaired. Outlets mounted on the edges of countertops are easily accessible (a surge protector taped to the counter is a low-cost alternative), and a rolling cart should be provided for the transport of hot, cold, or sharp items (to avoid risking skin integrity by placing these items on a paretic lap).

The Bathroom

Handrails are recommended around the commode, in a standard tub, and in a roll-in shower. There should be space next to the commode for a wheelchair, and room enough for a chair to be positioned parallel to the tub. These specifications are not necessary for safe transfers to a raised toilet seat or tub bench, but the additional room is preferable.

A handheld showerhead is usually recommended for wheelchair users. It is important for the individual to be very aware of the water temperature throughout the shower to avoid burns to insensate skin. The handheld showerhead should be able to hang without allowing the water to run on areas of the individual where sensation is decreased. A scald guard should be installed, or the hot water heater should be set to 120° or less, to avoid accidental scalding.

As in the kitchen, roll-under sinks are optimal, and faucets should have lever-type handles if hand function is impaired. Mirrors can be tilted slightly downward, allowing the individual to see himself from a seated position.

The Bedroom

Lowering the clothes rods in closets can make hanging clothes easier to access from a seated position. It is advisable to keep a telephone within the wheelchair user’s reach while in bed in case of emergency. In addition, simple home-automation devices can be purchased to allow the wheelchair user to access lights, fans, call systems, and other appliances by remote control.

Multilevel Homes

Making homes with more than one level accessible for a wheelchair user is always a challenging endeavor. There are two basic kinds of lifts—one is elevator-like, and the other involves a seat that rides a rail up the stairs. Both options are expensive, and they can be dangerous in the event of an emergency. While the individual with strong upper-extremity function can learn to “bump” up and down the stairs, the process is time- and energy-consuming. Single-level homes are generally the safest and most cost-efficient option for wheelchair users.

Limited Resources

Creativity and flexibility come into play when resources for home modifications are limited. One example involves a small rented home. (No permanent modifications were possible.) The front entrance was accessible with a ramp, but the only other door to the home was in a very small kitchen. To make this a second accessible entrance, the family simply moved the refrigerator to the dining room. It wasn’t a conventional setup, but it made the home safe and functional.

Widening a doorway is not always an option in rented homes or when resources are limited. Removing the door and hinges (and sometimes the molding!) can increase doorway width by a few inches, and curtains can be hung to preserve privacy. The components can be replaced relatively easily.

Cabinetry exists to make roll-under sinks aesthetically pleasing. However, when resources are limited, it is acceptable to make pipes safe by insulating them with a towel and duct tape. A curtain can be hung under the countertop to improve aesthetics.

The ideas expressed in this article are not all-inclusive, and they will not work for everyone. The rehabilitation therapist must clarify his or her role in the home-modification process as a resource rather than as an expert in accessible architecture. A large part of the skilled service lies in helping the patient and caregiver decide how to best prioritize modifications and use resources. To my knowledge, there is no universal standard for accessibility measurements in the home. Several standards for community modifications exist, and the concept of universal design is becoming more popular.

The following is a list of a few of the Web sites I have found helpful. These can serve as excellent resources when discussing, for example, ramp specifications or grab-bar heights.

• www.ADA.gov. Americans with Disabilities Act Accessibility Guidelines for public places are available at this Web site.

• www.design.ncsu.edu. The Center for Universal Design is a part of North Carolina State University, Raleigh, NC, and is dedicated to making all architecture as accessible as possible to all people.

• www.hud.gov/fhefhag.html. US Department of Housing and Urban Development Fair Housing Accessibility Guidelines are available at this Web site.

Amanda Gillot, MS, OTR/L, an occupational therapist at the Shepherd Center in Atlanta, specializes in inpatient rehabilitation of individuals with a dual diagnosis of spinal cord injury and brain injury. She can be reached at amanda_gillot@shepherd.org.