Author(s): Mark Williams, MD, Sony Issac, MD, Meghan Cochrane, DO
Originally published: September 10, 2015 Last updated: June 27, 2024
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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. Environmental interaction for all individuals, irrespective of functional status, is a necessary component of leading a fulfilling life.

Concepts of environmental accessibility and universal design will be discussed and applied to 4 general environs commonly inhabited by individuals: public spaces, transportation, workplace, and home.

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.

The role (importance) of the physiatrist in evaluating various aspects of environments inhabited by patients will be emphasized, as this leads to not only innovative strategies that overcome certain environmental barriers, but also to the identification of issues warranting advocacy.

Accessibility laws

Disability is defined as, “a physical or mental impairment that substantially limits 1 or more life activities.”37 History has shown society has discriminated against individuals with physical or mental disabilities by precluding their right to full participation in all aspects of society. Such discrimination continues to prevail in critical areas such as employment, housing, public accommodations, education, transportation, access to public spaces etc.38

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.”39

A series of laws in the US strive to ensure accessibility within the built environment. The first federal law to address accessibility is the Architectural Barriers Act (ABA), passed by congress in 1968, which requires that federal and federally funded buildings and facilities that are built, designed, or altered after August 12, 1968, be accessible to persons with disabilities (PwD). 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).40

The Rehabilitation Act of 1973 was passed as the first disability rights law prohibiting discrimination against PwDs in programs and activities receiving Federal funding.41 The US Access Board was established in the same year after Congress realized that ABA compliance was poor and there were no Federal accessibility design standards. The US Access Board was charged with ensuring Federal agency ABA compliance and proposing solutions to environmental barrier problems addressed by the ABA.42

The Rehabilitation Act Amendment of 1978 authorized the Access Board to establish design guidelines under the ABA to establish a minimum level of accessibility.43

In 1982, the Access Board published accessibility guidelines for buildings and facilities subject to the ABA, entitled, “Minimum Guidelines and Requirements for Accessible Design.” This was the first comprehensive set of access requirements established by the federal government. The guidelines served as the basis for the Uniform Federal Accessibility Standards (UFAS), implemented by federal agencies to enforce the ABA.44

The Air Carrier Access Act (ACAA) of 1986 governed access regulations for the airline industry.45 It covers not only assistance for PwDs in the airport including transportation of durable medical equipment (DME), but also accessibility standards for aircrafts and airports.45

On July 26th, 1990 the Americans with Disabilities Act (ADA) was signed into law. The ADA is a major Civil Rights law that prohibits discrimination and guarantees that people with disabilities have the same opportunities as everyone else to participate in the mainstream of American life. The Act aligns with the Nation’s proper goals to assure equality of opportunity, full participation, independent living, and economic self-sufficiency for individuals with disabilities. 46,47

The ADA has several main objectives. In order to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities, the ADA organizes regulations addressing access issues into 5 sections, to titles, each relating to different areas of public life:48

  • Title 1: workplace
  • Title 2: state and local government services
  • Title 3: places of public accommodation and commercial facilities
  • Title 4: telecommunications for people who have hearing or speech impairments through telecommunications relay services
  • Title 5: miscellaneous instructions to Federal agencies that enforce the ADA

Regulations issued under the different titles by various Federal agencies set requirements and establish enforcement procedures.48

The ADA’s other main objective, “to provide clear, strong, consistent, enforceable standards addressing discrimination against individuals with disabilities” refers to the ADA Accessibility Standards, which are design standards issued under the Americans with Disabilities Act (ADA) by the Department of Justice and the Department of Transportation to ensure access to the built environment for people with disabilities.49 The Standards are based on minimum accessibility guidelines adopted by the Access Board in 2004, known as the ADA Accessibility Guidelines (2004 ADAAG). The Standards are enforced nation-wide and apply to, “places of public accommodation, commercial facilities, and state and local government facilities in new construction, alterations, and additions.50

Universal Design

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 Use51

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.52

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.. The aforementioned accessibility legislation and concept of universal design can be applied to the following settings so that each may accommodate all persons, including individuals with disabilities: public spaces and transportation, workplace, home.

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.

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. 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:

  • Public access route
  • Ramps/ Platforms
  • Entrances
  • Stairs
  • Escalators and lifts
  • Curbs/ barriers/ guardrails
  • Pedestrian crossings
  • Footbridge and/or underpasses
  • Bus stops, railway platforms, railway stations53

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.50 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:

  • Accessible approach and entrance
  • Access to goods and services
  • Access to public toilet rooms
  • Access to other items such as water fountains and public telephones50

A complete description of the technical requirements according to the 2010 ADA Standards can be reviewed at www.ADAchecklist.org.50

Workplace

Title 1 of the ADA is designed to help people with disabilities access the same employment opportunities and benefits available to individuals without disabilities. By law, employers must provide reasonable accommodations to individuals with disabilities. A reasonable modification is any modification or adjustment to a job or the work environment that will enable the individual with a disability to perform essential job functions. For example, it is a requirement, according to the ADA Standards that employee work areas have “common use circulation paths” (206.2.8) according to the technical parameters provided in chapter 4 of the Standards, “Accessible Routes”50

Home

While private entities are not part of the ADA Standards, they may still be used as general guidelines to help create the safest possible place of living. The Centers for Disease Control and Prevention provide, “A Home Fall Prevention Checklist for Older Adults.” The purpose of this checklist is to help identify certain hazards in the home so that they may be amended. For example, the checklist asks if there are any throw rugs on the floors and recommends removing them (ideal strategy) or use a non-slip backing, including double-sided tape, to reduce the risk of sustaining a slip and fall.54

Special considerations in the pediatric population

In pediatric PMR, assessments of the built school environment are fundamental for student engagement and learning.56 Architects incorporate this information in the planning of building, rebuilding, and modernizing schools.57 School assessments for children with disabilities involve a comprehensive evaluation of classroom accessibility including entryways, hallways, and bathrooms, to ensure mobility and ease of movement.58 Furniture ergonomics provide appropriate seating and workspaces that accommodate physical and developmental needs.59 Sensory environments are assessed, considering factors such as lighting, noise levels, and visual stimuli, to create a conducive learning atmosphere for children with sensory processing disorders.57 Fall and injury prevention measures are crucial, including the use of non-slip flooring, proper supervision, and safe playground equipment.60 The availability of adaptive equipment and assistive technologies enhance communication, learning, and physical participation.61

At home, creating a safe sleep environment is vital, ensuring the use of appropriate bedding, positioning aids, and monitoring devices to prevent injuries and support restful sleep 62. There are a number of educational resources for families, for example, those published by the American Academy of Pediatrics.63

By addressing these various aspects, healthcare professionals can identify and recommend modifications that promote participation, safety, and independence. These tailored interventions are pivotal in enhancing educational outcomes, social interactions, and overall well-being for children with diverse needs, ensuring they thrive in their academic and home environments.

Relevance to Clinical Practice

ICF and Environment

Meaningful participation in society is predicated upon an individual’s interaction with their environment. The International Classification of Functioning, Disability, and Health (ICF), published by the World Health Organization (WHO) in 2002, is based on the biopsychosocial model of disability and is the first widely accepted classification schema that, for the first time, identifies the key role of environmental factors in the lives of individuals with disabilities.55 Environmental factors make up the physical, social, and attitudinal environment in which people live and conduct their lives on a daily basis. Environmental factors include the physical world and its features, the human-made physical world, other people in different relations and roles, attitudes and values, social systems and services, policies, rules, laws–this article focuses on the built environment. Environmental factors can positively or negatively impact an individual’s participation level in society.55 Facilitators are environmental factors that enhance an individual’s ability to participate. Barriers are factors that inhibit participation.55

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

Physiatrists in particular play a crucial role in being the bridge between persons with disabilities and their community. 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 exist.16 With respect to maneuvering the built environment, it is described in the literature that PwDs often experience heightened anxiety when preparing for travel, especially if public transportation is involved.55 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.

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. There are many informational websites that offer tips, tricks and accessibility information for potential travel destinations. The role of the physiatrist in the cases of travel and public transportation include ensuring the patient is well-versed in their assistive devices and the components of said devices. Specific needs for ADLs and iADLs should be discussed with a physician and potentially addressed with a trained physical or occupational therapist (i.e., safe, assisted transfer from wheelchair to airplane seat). Physicians should also advocate for their patients to reach out to potential hotels and airlines to discuss accessibility options.

The following websites are available for persons with disability interested in gaining more information prior to travel:

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. This includes detailed attention to work process; workplace organization and equipment use in order to maximize neutral posture. Cyclic job rotations have also been recommended, and an algorithm has been proposed to facilitate its implementation.19 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.  With the COVID-19 pandemic, consideration must be made for home work environments as well, and care must be taken to ensure that individuals’ workspace at home is ergonomic. 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 and UCSF 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, taking into account an individual’s medical conditions. The goal is to reduce fall risks through collaborative efforts between the individuals at risk, their caregivers, their clinicians and their occupation and physical therapists.

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, and home safety evaluation including assistive equipment evaluation.  When performing home evaluations, attention should be paid to hazards that may increase fall risks, including 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

The use of smartphones, tablets and laptops has become a societal norm for personal and work-related tasks. These devices present risk factors for developing MSDs, particularly cervical and upper limb pain. In fact, a 2019 cross-sectional study of college students showed a positive correlation between hours of phone use and severity of neck pain.35 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 use.20 Smartphone applications that deliver intermittent posture reminders 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 monitoring.21 Similarly, smart work clothes with textile sensors woven into the fabric and wearable soft-robotic-stretch sensors are under development for monitoring and fall detection.22,23 Computer programs such as a digital screening tool and a 3D computer game for risk assessment and education have also been developed.24,25

The development of smartphone apps has provided practical solutions for PwDs with visual, hearing, cognitive, and mobility needs to manage public spaces and transportation.26 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.

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 destinations.27 A recent study examining the disability travel apps on iOS and Android platforms revealed US and international based accessibility guides, maps, and navigation tools.28 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    
  • AccessNow
  • Assistive Touch
  • BriteLift
  • Dragon Dictation
  • Kimap
  • Moby Lynk Customer App
  • MOXI Museum Accessibility Guide
  • Pickup by Capital Metro
  • Taxi Terry’s
  • Travable
  • Trips – Medical Transportation
  • Wheelguide accessibility
  • Wheelmap
  • WheelMate

WheelMate in particular is a crowdsourced application built by PwDs, in which Handicap accessible toilets, parking spaces, and buildings are marked on the application. It is highly useful for persons utilizing wheelchairs, canes or other assistive devices that want to be out in the community.

Additionally, there is a growing number of websites created by PwDs which aggregate much of this data as well, but continuing to improve physician education may elevate the use of these applications by PwDs.

Inclusive solutions

Involving stakeholders in environmental assessment and safety interventions create “buy in” and increase 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 solutions.29 Similarly, recommendations for UD modifications created with the help of stroke survivors and their families have been useful.30 Large corporations can benefit from UD investment in order to save money on lost time to work due to injury as well as improving the overall health of their workforce.

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 lacking.31,32  Similarly, research exploring the cost-benefit ratio in regard to the application of ergonomic design is also limited.33 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 sectors.34

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Original Version of the Topic

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

Previous Revision(s) of the Topic

Niña Carmela Tamayo, DO, MS, MPH, Jennifer Yang, MD, Que Huong Nguyen, DO. Environmental Assessment. 2/23/2021

Author Disclosures

Mark Williams, MD
Nothing to Disclose

Sony Issac, MD
Nothing to Disclose

Meghan Cochrane, DO
Nothing to Disclose