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Overview and Description

As physicians focusing on function, considering how our patients interface with their environment is a crucial part of evaluation and management. For the purpose of this review, environmental assessment is broken into four broad categories that represent the general areas with which people regularly interact: workplace, home, public spaces and transportation. Each category contains unique components and potential environmental risk factors that may contribute to injury, prevent recovery, or limit accessibility to those with impaired mobility.  It is important to evaluate for potential environmental risk factors that may predispose to injury, create barriers to injury recovery, or present safety and accessibility concerns for those with functional impairments. Once identified, recommendations for steps toward risk modification can be made in order to maximize the safety and recovery of our patients.

Accessibility Laws and Universal Design

An accommodating environment is essential for persons with disabilities (PwDs) to fully participate in the community, and live meaningful lives. The impact of the environment on function, overall satisfaction, and provide equal opportunities for PwDs is well known1. Therefore, a thorough environmental assessment starts with an understanding of accessibility and universal design.

In the United States, accessibility is considered a civil right and is a federal law. The Office for Civil Rights (OCR) for both the Department of Justice and the Department of Education defines accessibility as “when a person with a disability is afforded the opportunity to acquire the same information, engage in the same interactions, and enjoy the same services as a person without a disability in an equally integrated and equally effective manner, with substantially equivalent ease of use” 2. Several laws ensure accessibility within the built environment, starting with the Architectural Barriers Act of 1968 (ABA), which requires that federal and federally funded buildings and facilities that are built, designed, or altered after August 12, 1968 be accessible to PwDs. The law covers the US post offices, Veterans Affairs medical facilities, national parks, Social Security Administration offices, federal office buildings, US courthouses, federal prisons as well as non-government facilities that receive federal funding (e.g. public housing units and mass transit systems) 3.

Following the ABA, The Rehabilitation Act of 1973 was passed as the first disability rights law prohibiting discrimination against PwDs in programs and activities receiving Federal funding and laid the foundation for the Americans with Disabilities Act of 1990. It also established the US Access Board when Congress realized that compliance to the ABA was inconsistent, and there were no Federal accessibility design standards. Since then, the US Access Board has been responsible for the development of accessibility guidelines, and maintaining the design criteria for the built environment, transit vehicles, telecommunications equipment, medical diagnostic equipment, and information technology4. This was followed in 1986 by the Air Carrier Access Act which governs accessibility regulations for the airline industry. It covers not only assistance for PwDs in the airport including transportation of durable medical equipment (DME), but also accessibility standards for aircrafts and airports3.

These landmark laws set the stage for the passing of the Americans with Disabilities Act of 1990 (ADA), which ensured equal opportunities for PwDs in employment, state and local government activities and public accommodations. It came at the heels of an international campaign launched by the United Nations to set up standard rules ensuring PwDs had the rights and freedoms their non-disabled counterparts also enjoyed. The ADA includes public accessibility requirements outlined in the 2010 ADA Standards for accessible design5. These requirements mandate specific building codes that improve accessibility and prevent discrimination of those with mobility, stamina, sight, hearing, communication, and learning disabilities6. Both the ADA and Universal Design (UD) focus on improving accessibility for those with disability. There are seven principles of Universal Design, which is a term coined by the late Ronald L. Mace, a fellow of the American Institute of Architects, who suffered from polio leading to wheelchair use the rest of his life. The Principles are:

  • Principle 1: Equitable Use
  • Principle 2: Flexibility in Use
  • Principle 3: Simple and Intuitive Use
  • Principle 4: Perceptible Information
  • Principle 5: Tolerance for Error
  • Principle 6: Low Physical Effort
  • Principle 7: Size and Space for Approach and Use7

The principles encompass the idea that products and environments that meet UD standards are usable by all people to the greatest extent possible, without the need for adaptation or specialized design [8]. For example, a building with a stairway to enter would also have a ramp to comply with ADA regulations. UD would pair the ramp with an automatic door that opens as one approaches it, so that a person walking independently, carrying heavy bags, using a wheelchair or pushing a stroller could easily access the entrance. UD aims to design homes that can accommodate the individual at any functional level, allowing the owner to age in the home without the need for future home renovations. Involving older adults and considering their needs as a primary or “lead user” in creating an environment meeting UD standards has been recommended8.

It is important to note, however, that countries outside of the United States may not have laws protecting PwDs and therefore may not ascribe to universal design standards to ensure environmental accessibility. The UN Department of Economic and Social Affairs can provide information on whether or not a country has signed the United Nations Convention on the Rights of Persons with Disabilities9. The goals of the Convention provide support and context for universal design as the preferred design framework, as it aims not only to remove barriers but also augment experience for PwDs.

Environmental Assessment: Special Considerations

An environmental assessment must take into consideration a variety of components depending on the environment itself, and the individual interacting with that particular setting. For public spaces, transportation, and the workplace having a working knowledge of the aforementioned laws and regulations can aid the clinician in providing recommendations for those with accessibility needs. Familiarity with current accessibility standards and future accessibility goals helps the clinician advocate for patients whose needs are not being met and presents an opportunity to contribute to future accessibility projects. In addition to evaluating the natural and built environment, the workplace and home assessment also requires an assessment of the individual and their risk factors for injury in those settings. 

Public Spaces and Transportation

Both the ABA and the ADA in the United States provide the standards for access to the built environment, while the US Access Board provide guidelines and best practices for accessibility standards. In particular, Titles II and III of the ADA cover regulations for public transportation and public accommodations respectively. Air travel regulations for accessibility, on the other hand, are covered by the Air Carrier Access Act (ACAA).

With respect to public transportation, the laws contain provisions addressing buses, rapid rail, light rail, commuter rail, and intercity rail. For public spaces, which is defined as any area open to the public, accessibility standards apply to restaurants, retail stores, hotels, movie theaters, private schools, convention centers, doctors’ offices, homeless shelters, transportation depots, zoos, funeral homes, day care centers, and recreation facilities including sports stadiums and fitness clubs.

While a complete review of the design requirements put forth by the ADA and ABA is beyond the scope of this review, clinicians should have some awareness of these requirements to help with assessment of public spaces and transportation. In transport facilities, environmental assessment for accessibility and availability should include the following:

  1. Public access route
  2. Ramps/ Platforms
  3. Entrances
  4. Stairs
  5. Escalators and lifts
  6. Curbs/ barriers/ guardrails
  7. Pedestrian crossings
  8. Footbridge and/or underpasses
  9. Bus stops, railway platforms, railway stations10

For public spaces, ADA requirements are extensive and specific with recommendations for both existing and newly constructed facilities and encompass accessibility from the parking lot to facility layout. ADA standards for accessible design require buildings to have entrance access that does not require stairs, and these entrances are required to incorporate specific grade requirements. Access routes should be at least 36 inches wide to accommodate wheelchair travel and door widths/bathrooms need to be accessible with 5-foot clearances to allow wheelchair turning. Title III of the ADA focuses on the following priorities with respect to environmental assessment:

  1. Accessible approach and entrance
  2. Access to goods and services
  3. Access to public toilet rooms
  4. Access to other items such as water fountains and public telephones.

A complete description of current requirements can be reviewed at www.ADAchecklist.org6. While these requirements do not extend to private properties, the recommendations can be applied to the home when evaluating in home accessibility needs. In addition, it is again important to note that countries outside the United States may or may not have laws similar to the ADA, the ABA or the ACAA. For more specific information about each country’s standards of accessibility for PwDs, go to the Department of State’s website to find out more prior to planning for travel: https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages.html.


In the workplace, poor posture and repetitive stressful movements often lead to musculoskeletal disorders and missed time from work. Epidemiological evidence has demonstrated a causal dose-response relationship between musculoskeletal disorders (MSDs) and workplace exposure to sustained non-neutral postures, high repetition, high force movements and vibration11. Biomechanical laboratory studies demonstrate increased tissue stress and decreased performance when forces are exerted on the trunk and upper limbs at positions away from neutral, overhead, and repetitive tasks12,13. Repeated and prolonged tissue strain can lead to gradual breakdown and increased potential for injury. A poor workplace environment can cause an employee to perform repetitive tasks in suboptimal postural alignment and place him at a mechanical disadvantage. Understanding and identifying workplace environmental risk factors contributing to the development of MSDs are essential to providing recommendations aimed at reducing these risks.


Considerations for home environments include fall prevention and function in the home. For example, falls are the primary cause of injuries for older adults and are major contributors to morbidity and mortality in the elderly14.  Age-related decline in vision, strength, endurance and mobility can impact the function of elderly individuals living in homes which are not configured to accommodate these changes. Likewise, individuals with impaired mobility due to neurologic or orthopedic conditions are also at risk for falls. Room setup, home furnishings, and building design can contribute to fall risk, leading to injury and a decline in quality of life. Environmental interventions to reduce fall risk include assessment and modification of the environment and tasks performed, home modifications, and the use of assistive technology to improve independence and safety15.  Environmental barriers to safety and function should be discussed in the clinic and prior to discharge from acute rehabilitation. Once these barriers are identified, recommendations regarding proper home modifications and assistive devices can limit risks and improve function.

Relevance to Clinical Practice

General Considerations

Evaluation of environmental risk factors in clinical practice can be difficult. Ideally, direct observation of the patient interacting with their environment would prove most beneficial; however, this is typically not feasible in clinical practice. Recent advances in telehealth have allowed clinicians to provide environmental assessments remotely, though challenges are still present. Therefore, a detailed history from the patient is essential to accurately identify risk factors and functional barriers, then follow-up with a telehealth evaluation if available.

Public Spaces and Transportation

While PwDs have the same desire to travel both domestically and internationally as their non-disabled counterparts, simply leaving home to go out to the community can be a challenge due to the environmental barriers that exist16. While this review focuses on the environmental barriers, as clinicians it is important to be aware of the intrinsic, economic, and interactive barriers that PwDs face as it provides avenues for education and advocacy. That said, for both physicians and patients alike, the first step in navigating the built environment is to be well-versed in the aforementioned laws and regulations. Traveling outside the United States brings additional challenges including older hotels, historic sites, inaccessible developing countries, and of course, language barriers. While the ADA exists in the US, travelers should become familiar with accessibility laws in their country of destination. It is also important to remember that minimum design requirements may be different in other countries, which could mean that hotels, restaurants, attractions and transportation may have limited accessibility.

Because public spaces and transportation can vary depending on location, clinicians should focus on preparing patients on how to maneuver whatever environmental barrier they may find. Reducing risk factors includes educating patients on creating a mobility and ADLs needs checklist17. If traveling with a wheelchair or assistive device, patients should know components of their devices, what components are at risk for breaking, and what can be replaced or quickly fixed. Clinicians should also encourage patients to discuss and advocate for their specific accessibility needs when booking their transportation and hotels. While there is a universal definition for accessibility, public accommodations may not always meet it. For example, in hotels, narrow doorways, elevators/ lifts may be more commonplace in some regions, and roll in showers may not be available; while in other hotels, rooms may include a trapeze or ceiling lift, yet all these examples could be in a hotel that is deemed “accessible” 18.  Knowing the minimum requirements for accessibility can help guide patients to ask questions that should be posed to the hotels, attractions, restaurants or even transportation of choice.            

Workplace Modification

Proper ergonomic work programs are multidimensional and include systems that provide workplace assessments and employee education, monitor worker injury, provide employee education, and control potential hazards. The goal is to reduce work-related musculoskeletal injuries.

Current recommendations are based on promoting neutral postural alignment to improve comfort, encouraging proper use of tools, utilizing techniques to minimize fatigue, and decreasing prolonged or repetitive musculoskeletal stress. Neutral posture denotes joint positions that exert the least amount of stress on the surrounding tissues. To accomplish this, attention should be paid to the work process, set-up of equipment and/or furniture, location of items needed to be accessed throughout the workday, and obstacles on the ground. Cyclic job rotations have also been recommended, and an algorithm has been proposed to facilitate its implementation19. In addition, administrative support, proper education, and employee buy-in are crucial for proposed changes to be effective.

One of the most common modifications involve computer workstations.  This includes monitors, keyboards, wrist/palm supports, chairs, and footrests. Additional work modifications should take into consideration industry specific environments such as operating/procedure rooms, meat packing plants, or garment factories.  The following resources from OSHA provide some examples of common workplace environmental risks and recommended solutions:

Home Safety Evaluation

Home safety evaluations are best performed by trained health care providers who assess the suitability of an individual’s home in relation to their current functional status.  Evaluations should also take into account an individual’s medical conditions and, if applicable, address needs relating to anticipated functional, visual, and cognitive decline in the upcoming years.  The goal is to reduce fall risks through collaborative efforts between the individuals at risk, their caregivers, and their clinicians.

Fall prevention interventions consist of individual fall risk assessment for intrinsic and extrinsic factors, education on fall prevention and adaptive equipment use, therapy/exercises to improve strength and balance, home safety evaluation including assistive equipment evaluation.  When performing home evaluations, attention should be paid to hazards that may increase fall risks.  These include floor level objects such as carpets and trailing cables, clutter, placement of furniture, and entry height of bathtubs or walk-in showers.  Stairs should be in good condition and free from objects, handrails should be installed on both sides, stair steepness should be appropriate and up to code, and non-skid strips should be considered for added traction.  Living spaces and entryways should also be well lit, light switches should be available at both the top and bottom of stairwells, bedside light should be within reachable distance from bed, and night lights should be considered in hallways.

Additional free resources for home safety evaluations include:

Cutting Edge/ Unique Concepts/ Emerging Issues

New Technology

An increasing number of people are using mobile devices (smartphones, tablets) more frequently for both personal and work-related tasks. These devices present new risk factors for developing MSDs, particularly cervical and upper limb pain. Users tend to access these devices at low viewing angles, promoting sustained neck flexion and slumped posture of the spine. Mobile devices should be raised to a higher viewing angle (i.e., placed on a table and propped up with a viewing case) in order to promote a more neutral posture, especially in the setting of prolonged use20. Smartphone and tablet applications are available to promote acceptable viewing angles and neutral postures. Similar programs also exist for desktop and laptop computers.

On the other hand, technology has also shown promise in improving clinical outcomes. Wearable devices with sensors such as accelerometers, gyroscopes and insole force inducers utilized for detecting near falls have shown promise as a low-cost technology and clinical tool for monitoring21. Similarly, smart work clothes with textile sensors woven into the fabric and wearable soft-robotic-stretch sensors are under development for monitoring and fall detection22,23. Computer programs such as a digital screening tool and a 3D computer game for risk assessment and education have also been developed24,25.

The development of smartphone apps has provided practical solutions for PwDs with visual, hearing, cognitive, and mobility needs to manage public spaces and transportation26. Be My Eyes, for example, is an assisted sight application providing a direct video link and commentary on notable sights, while Seeing AI utilizes artificial intelligence to narrate nearby people, objects, and any text. For those hard of hearing, Tap Tap is an app that senses smoke alarms, a doorbell or someone shouting and alerts the user. With respect to maneuvering the built environment, the advent of smartphone technology has transformed the overall travel experience by changing the nature of travel planning, and the relationship between tourists and their destinations27. A recent study examining the disability travel apps on iOS and Android platforms revealed US and international based accessibility guides, maps, and navigation tools28. While Google Store yielded more total apps, Apple Store produced significantly greater specificity for disability travel apps. The following apps can be found on both platforms:

  • Access Earth
  • AccessAble
  • Accessible Dispatch NYC
  • AccessNow
  • BriteLift
  • Kimap
  • Moby Lynk Customer App
  • MOXI Museum Accessibility Guide
  • Pickup by Capital Metro
  • Taxi Terry’s
  • Travable
  • Trips – Medical Transportation
  • Wheelguide accessibility
  • Wheelmap
  • WheelMate

Unfortunately, to find some of these travel apps, both search engines require specific search terms, which can lead to the lack of awareness in the general population. Improving physician education may elevate the use of these apps by PwDs.

Inclusive Solutions

            Involving stakeholders in environmental assessment and safety interventions are a recent trend, creating “buy in” and increasing the likelihood of adopting these safety measures. Participatory ergonomics engaging workers and employers in reducing work injury risks have been described in construction workers, librarians and factory workers. The experiences of older adults and caregivers have also been involved in fall risk assessment and implementing safety solutions29. Similarly, recommendations for UD modifications created with the help of stroke survivors and their families have been useful30

Gaps in Knowledge/ Evidence Base

While moderate evidence exists for ergonomic design and organizational interventions such as work break schedules in the prevention of MSDs, high quality research regarding these are still lacking31,32.  Similarly, research exploring the cost-benefit ratio in regard to the application of ergonomic design is also limited33. Workplace modifications can be costly; if a fiscal benefit is not clearly conveyed, the immediate financial burden may be seen as outweighing the potential benefit.  In addition, the positive benefits of workplace modifications performed in controlled research settings do not always yield the same results in real-world settings.

The last few years have seen an increase in academic papers about UD, but overall more studies are necessary to demonstrate that broad application of UD provides adequate accessibility while maintaining the quality standards of more traditional design modalities. Retrofitting pre-existing spaces to achieve an accessible environment undoubtedly requires considerable economic resources. Cost-benefit analyses are useful to describe and help prioritize allocation of these resources in the private and public sectors34.


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Original Version of the Topic

Jennifer Yang, MD, Derek Davidson DO, PT. Environmental Assessment. Published 9/10/2015

Author Disclosures

Niña Carmela Tamayo, DO, MS, MPH
Nothing to Disclose

Jennifer Yang, MD
Nothing to Disclose

Que Huong Nguyen, DO
Nothing to Disclose