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Service Dogs and People with Physical Disabilities Partnerships: A Systematic Review

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Occupational therapists have recognized the benefits that service dogs can provide people with disabilities. There are many anecdotal publications extolling the benefits of working with service dogs, but few rigorous studies exist to provide the evidence of the usefulness of this type of assistive technology option. This systematic review evaluates the published research that supports the use of service dogs for people with mobility-related physical disabilities. Articles were identified by computerized search of PubMed, CINAHL, PsycINFO, OT Seeker, the Cochrane Database of Systematic Reviews, SportDiscus, Education Research Complete, Public Administration Abstracts, Web of Knowledge and Academic Search Premier databases with no date range specified. The keywords used in the search included disabled persons, assistance dogs or service dogs and mobility impairments. The reference lists of the research papers were checked as was the personal citation database of the lead author. Twelve studies met the inclusion criteria and whereas the findings are promising, they are inconclusive and limited because of the level of evidence, which included one Level I, six Level III, four Level IV and one Level V. All of the studies reviewed had research design quality concerns including small participant sizes, poor descriptions of the interventions, outcome measures with minimal psychometrics and lack of power calculations. Findings indicated three major themes including social/participation, functional and psychological outcomes; all of which are areas in the occupational therapy scope of practice. Occupational therapists may play a critical role in referral, assessment, assisting clients and consulting with training organizations before, during and after the service dog placement process. In order for health care professionals to have confidence in recommending this type of assistive technology, the evidence to support such decisions must be strengthened. Copyright
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RESEARCH ARTICLE
Service Dogs and People with Physical Disabilities
Partnerships: A Systematic Review
Melissa Winkle
1
*
, Terry K. Crowe
2
& Ingrid Hendrix
3
1
Dogwood Therapy Service Inc, Albuquerque, NM, USA
2
Occupational Therapy Graduate Program, University of New Mexico, Albuquerque, NM, USA
3
Health Sciences Library and Informatics Center, University of New Mexico, Albuquerque, NM, USA
Abstract
Occupational therapists have recognized the benets that service dogs can provide people with disabilities.
There are many anecdotal publications extolling the benets of working with service dogs, but few rigorous
studies exist to provide the evidence of the usefulness of this type of assistive technology option. This system-
atic review evaluates the published research that supports the use of service dogs for people with mobility
related physical disabilities.
Articles were identied by computerized search of PubMed, CINAHL, PsycINFO, OT Seeker, the Cochrane
Database of Systematic Reviews, SportDiscus, Education Research Complete, Public Administration Abstracts,
Web of Knowledge and Academic Search Premier databases with no date range specied. The keywords used
in the search included disabled persons, assistance dogs or service dogs and mobility impairments. The refer-
ence lists of the research papers were checked as was the personal citation database of the lead author. Twelve
studies met the inclusion criteria and whereas the ndings are promising, they are inconclusive and limited
because of the level of evidence, which included one Level I, six Level III, four Level IV and one Level V.
All of the studies reviewed had research design qualityconcernsincludingsmall participant sizes, poor
descriptions of the interventions, outcome measures with minimal psychometrics and lack of power calcula-
tions. Findings indicated three major themes including social/participation, functional and psychological out-
comes; all of which are areas in the occupational therapy scope of practice. Occupational therapists may play
a critical role in referral, assessment, assisting clients and consulting with training organizations before, during
and after the service dog placement process. In order for health care professionals to have condence in
recommending this type of assistive technology, the evidence to support such decisions must be strengthened.
Copyright © 2011 John Wiley & Sons, Ltd.
Received 25 October 2010; Revised 24 February 2011; Accepted 29 March 2011
Keywords
occupational therapy; physical disabilities; service dog
*Correspondence
Melissa Winkle, Dogwood Therapy Service Inc, 7818 Pan American Freeway NE, Albuquerque, NM 87109, USA.
Email: melissa@dogwoodtherapy.com
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.323
Introduction
Dogs have been found to be important social supports
with health benets in the role of companions, pets
and visitors (Friedmann et al., 1980; Allen et al.,
2001; Allen et al., 2002). The Delta Society, an interna-
tional human services organization that facilitates
humananimal interactions, refers to casual visitations
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
as animalassisted activities (AAA) (Delta Society, 2009).
Dogs also participate in intervention sessions, which
are referred to as animalassisted therapy (AAT)(Delta
Society, 2009). In addition, dogs are trained and per-
manently placed with individuals as assistance dogs
(guide dogs, hearing dogs and service dogs) (Figure 1).
Guide dogs assist individuals who have visual disabil-
ities or are blind (SachsEricsson et al., 2002; Assistance
Dogs International, 2009a). Hearing dogs assist individ-
uals who are hard of hearing or are deaf (Guest et al.,
2006; Assistance Dogs International, 2009b). Service
dogs are trained to assist people who have mobility
and balance challenges, to alert or respond to medical
issues such as diabetes and seizures and to support peo-
ple with psychiatric disabilities and autism (Assistance
Dogs International, 2009c). This systematic literature
review is focused on service dogs that work with
people who have physical disabilities. Service dogs
may help to conserve energy and prevent further in-
jury by activating devices and door openers, assisting
with obtaining supplies and helping people undress.
They can retrieve dropped items, drag a laundry
basket, and provide counter balance for transitional
movements. In addition, they may detect and re-
spond to medical crisis including carrying medica-
tions, alerting to monitors, retrieving a phone,
using a switch to call emergency services, and going
for help (Assistance Dogs International, 2009c).
All types of assistance dogs are becoming increas-
ingly recognized for supporting people with disabilities
to carry out daily meaningful occupations (Roth, 1994;
Rabschutz, 2006; Rintala et al., 2008). From an occupa-
tional therapy perspective, the recommendation for
service dogs as assistive technology options is an
emerging practice area, and the evidence of the effec-
tiveness is in its infancy (Winkle & Zimmerman,
2009). Some major barriers in the analysis of the exist-
ing literature discussing the roles that dogs can play are
the lack of uniform terminology and inconsistent train-
ing standards across disciplines and organizations
(Winkle & Caneld, 2008). This is now changing with
the establishment of Assistance Dogs International, a
volunteer membership organization for assistance dog
training organizations (Assistance Dogs International,
2008). Twentyseven countries in the America, Asia,
Europe, New Zealand, and Australia are listed as mem-
bers of Assistance Dogs International. Their mission is
to facilitate communication and learning among mem-
ber organizations, educate the public and to set mini-
mum standards for assistance dog trainers, the dogs
being trained, and the assistance dog recipients.
The lengthy national waitlists with professional service
dog training organizations provide evidence that signi-
cant numbers of individuals with disabilities are inter-
ested in such interventions (SachsEricsson et al.,
2002). The purpose of this study is to review the literature
focused on the use of service dogs for people with mobility
related physical disabilities. The following research
question guided the selection of research studies for
the review: What is the evidence for the effectiveness
(social/participation, function and psychological) of
service dogs for children and adults with physical
disabilities?
Methods for conducting the
evidencebased review
The focus of this review was on original, peerreviewed,
quantitative research addressing the topic of the effects
of service dogs in partnership with people with mobil-
ity impairments. Extensive literature searches were
conducted, and ndings were evaluated with inclusion
and exclusion criteria to accurately reect the goal of
this review.
Literature Search
Database searches, which were completed over a 2year
period (2008 to 2010) included: PubMed, CINAHL,
PsycINFO, OT Seeker, the Cochrane Database of
Animal Assisted Activities
(AAA)
Casual Visiting
Animal Assisted Therapy
(AAT)
Dog assists in meeting
established measurable
goals
Assistance Dog Categories
* Guide Dogs
* Hearing Dogs
* Service Dogs
- Physical Disabilities
- Medical/Seizure Response
- Autism Spectrum Disorders
- Psychiatric Disabilities
Figure 1 Types of animalassisted (dog) interventions
Service Dogs and People Partnerships Winkle et al.
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Systematic Reviews, SportDiscus, Education Research
Complete, Public Administration Abstracts, Web of
Knowledge and Academic Search Premier. Searches were
limited to English language, with no date limits and con-
trolled vocabulary were used to perform a comprehen-
sive search. Careful consideration was given to the
combination of terms such as canine or dog, which
led to numerous false hits. The same text words were
used across all databases, but subject headings were
modied depending on the database searched to opti-
mize results. Keywords used included dogs and disabled
persons, assistance dog* or service dog*, and (dog* and
(handicap* or disab*)). The search excluded papers us-
ing terms relating to disabilities not covered by this re-
view, such as visual or hearing impaired, mental
disorders or autism.
Inclusion and exclusion criteria
The initial searches yielded 432 papers, with an addi-
tional 119 identied in the lead authors personal cita-
tion database. After removal of duplicate records, two
of the authors reviewed the titles and abstracts to fur-
ther exclude descriptive or anecdotal papers, review
papers, qualitative studies or dissertations. The full text
of the remaining 23 papers was closely examined for
focus on the effect of service dogs with people with am-
bulatory disabilities (neurological, congenital or ac-
quired) and for examining any aspect of the service
dog partnerships with psychosocial and/or functional
outcomes. Twelve papers met inclusion and exclusion
criteria for this review (Figure 2).
Results
An earlier review of the evidence supporting service
dog partnerships with people with disabilities, included
six of the 12 papers we evaluated Modlin (2000). Levels
of evidence classications consist of a hierarchy of
research designs that range from the greatest to the
least according to the studys ability to reduce bias.
Qualityrating schemes give a means of assessing the
scientic rigour of a research study. Each paper was
scored for level of evidence using the American Acad-
emy of Cerebral Palsy and Developmental Medicine
(AACPDM) 5 level evaluation system (Darrah et al.,
2008) and for the quality of the study using the
AACPDM 7point scale (Table 1).
Records identified through
database searching
(n = 432)
ScreeningIncluded Eligibility Identification
Additional records identified
through other sources
(n = 119)
Records after duplicates removed
(n = 371)
Records screened
(n = 220)
Records excluded
(n = 197)
Full-text articles assessed
for eligibility
(n = 23)
Full-text articles excluded,
with reasons
(n = 11)
Studies included in
synthesis
(n = 12)
Figure 2 Flowchart of article excluded and included for review
Winkle et al. Service Dogs and People Partnerships
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
The current evidence to support service dog/people
with disabilities partnerships included one Level II
study, six Level III studies, four Level IV studies and
one Level V studies (Table 2). All 12 studies rated 4
or below in the quality of study indicating weak re-
search designs resulting in potential bias. Four of the
12 studies were not afrmatively rated on any of the
seven quality questions. Based on our criteria for eval-
uation, we found no study that included the dual crite-
ria for high quality. Thus the conclusions drawn from
the results must be considered with caution.
Table 3 summarizes the 12 papers examining the ef-
cacy of service dogs regarding study objectives, re-
search design, participants, intervention description,
outcome measures and results.
Discussion
Social/participation effects of service dogs
Service dogs seem to positively inuence socialization
and community participation in a variety of environ-
ments. Two studies observed partnerships in natural
environments (Eddy et al., 1988; Mader et al., 1989)
and reported that community members smiled and
conversed with children and adults with service dogs
more than children and adults without service dogs,
and community members did not avoid the person
with a disability as much when a service dog was pres-
ent. Hart et al. (1987) found that participants who used
wheelchairs with service dogs reported more social
greetings and approaches in comparison with partici-
pants without service dogs, and compared with the pe-
riod before participants obtained dogs. In a study
conducted in the UK, Lane et al. (1998) found that
92% of children and adult participants with physical
disabilities (n= 57) reported that people frequently
stopped to talk with them when they were out with
their dog, and 75% reported that they had made new
friends since owning their dog. One hundred percent
of a large sample (n= 202) of adults with physical dis-
abilities reported that they were approached more often
in public when they had their dogs with them (Fairman
& Huebner, 2000). These studies concluded that service
dogs facilitated social interaction for children and
adults with physical disabilities. Lane and colleagues
(1998) concluded that a service dog serves to shift
the focus of attention away from the recipients disabil-
ity toward their competence in handling a highly
trained dog(p. 58). However, a few studies reported
concerns for dogs acting as social facilitatorssuch
as requiring extra time, more attention on the dog then
the person and petting the dog, which may interfere
Table 1. AACPDM levels of evidence (Darrah et al., 2008)
Part A: type of research design
Level non
empirical Group research
I. Systematic review of randomized control trials, large randomized controlled trial (RCT) (n> 100)
II. Smaller RCTs (n< 100), systematic reviews of cohort studies, outcome research(very large ecologic studies)
III. Cohort studies (must have concurrent control group), systematic reviews of case control study
IV. Case series cohort study without concurrent control group (e.g. with historic control group)
Case control study
V. Expert opinion
Case study or report
Bench research
Common sense/anecdotes
Part B: quality of study
1. Were inclusion and exclusion criteria of the study population well described and followed?
2. Was the intervention well described and was there adherence to the intervention assignment? For twogroup designs, was the control
exposure also well described?
3. Were the measures used clearly described, valid and reliable for measuring the outcomes of interest?
4. Was the outcome assessor unaware of the intervention status of the participants (i.e. was there blind assessment)?
5. Did the authors conduct and report appropriate statistical evaluation including power calculations?
6. Was dropout/loss to followup reported and less than 20%? For twogroup designs, was dropout balanced?
7. Considering the potential within the study design, were appropriate methods for controlling confounding variables and limiting
potential biases used?
AACPDM, American Academy for Cerebral Palsy & Developmental Medicine.
Service Dogs and People Partnerships Winkle et al.
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
with the dogs concentration and training (Eddy et al.,
1988).
Although one study reported a decrease in loneliness
for people with mobility impairments (Valentine et al.,
1993), another study (Collins et al., 2006) found no dif-
ference in loneliness for people with disabilities with
and without dogs. Adults with physical disabilities with
service dogs (n= 202) reported that their dogs provided
emotional support and feelings of security (Fairman &
Huebner, 2000). Lane et al. (1998) found that a major-
ity of the child and adult participants with physical dis-
abilities in their study reported a close, affectionate and
comforting relationship with their dog. In conclusion,
service dogs seem to have many positive social effects
for people with disabilities, which might increase their
participation in the community.
Functional effects of service dogs
Children and adults with physical disabilities report
that service dogs most commonly assist them with re-
trieving items out of reach, opening doors, getting
around the community, getting around the house,
shopping, and the dog barking to alert others in emer-
gencies (Lane et al., 1998; Fairman & Huebner, 2000;
Rintala et al., 2008). Two studies assessed whether hav-
ing a service dog decreased the need to have others help
in daily tasks. Allen and Blascovich (1996) found that a
service dog partnership decreased the paid assistance
needed by an average of 60 hours over 2 weeks and ex-
trapolated a $60,000 savings over an 8 years. Fairman
and Huebner (2000) found that service dogs reduced
paid human assistance by an average of 2 hours per
week resulting in a savings of $600 per year. Service
dogs may contribute to increasing a sense of indepen-
dence and a decrease in reliance on others for people
with disabilities. This nding can also have important
benets to family members. Reduction in the time
needed for caregiving can have an overall positive im-
pact on all family members. In qualitative interviews
with 22 people with service dogs, four themes emerged:
1) decreased burden for caregivers, 2) greater caregiver
peace of mind, 3) freeing up caregiver time for doing
other things and 4) caregivers enjoying the dog as a
member of the family (Rintala et al., 2002). It should
be emphasized that these were perceptions of the people
with disabilities, not the caregivers.
Psychological effects of service dogs
Studies from the United States, Japan and the UK
found that people with physical disabilities partnered
with service dogs reported several psychological bene-
ts including signicant increases in selfesteem, inter-
nal locus of control, well being and positive affect
(Allen & Blascovich, 1996; Rintala et al., 2002; Collins
et al., 2006; Shintani et al., 2010). Collins et al. (2006)
found that people with progressive conditions (e.g.
multiple sclerosis and Parkinsons disease) who have
service dogs demonstrated signicantly higher positive
affect scores and that service dogs moderated the effects
of depression. However, psychosocial characteristics
did not differ signicantly between those partnered
with service dogs and those without.
Table 2. Study quality assessment based on the AACPDM
a
: assessing quality of conduct of a study (ODonnell et al., 2004)
Study Level 1 2 3 4 5 6 7 Total
b
Allen & Blascovich (1996) II √√ √√4
Collins et al. (2006) III √√ √3
Eddy et al. 1988 III 0
Fairman & Huebner (2000) IV 1
Hart et al. (1987) III 0
Lane et al. (1998) IV 0
Mader et al. (1989) III √√ 2
Ng et al. (2000) IV 0
Rintala et al. (2008) III 1
Rintala et al. (2002) IV √√2
Shintani, et al. (2010) III √√ 2
Valentine et al. (1993) V1
a
AACPDM, American Academy for Cerebral Palsy & Developmental Medicine.
b
Strong (yesscore 6 or 7), moderate (score 4 or 5) or weak (score 3).
Winkle et al. Service Dogs and People Partnerships
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Table 3. Study characteristics
Study objectives/
research design
Participants total/groups Intervention
description
Outcome measures Results
Allen & Blascovich
(1996)
To assess the impact
of service dogs on
the lives of people
with disabilities in
respect to
psychological
wellbeing and social
participation and to
evaluate the economic
impact of service dogs
Randomized
controlled trail
N= 48, randomly
assigned to two groups,
sample of convenience
24 participants with
service dogs
24 participants
on waitlist
1. Experimental
group received
dogs 1 month
after study began
2. Control group
(wait list group)
received dogs
13 months after
study began
3. Dogs trained
from 6 to 12
months before
placement
4. Individualized
special training
5. Difcult to
determine if
all dogs were
trained by the
same organization
Data collected
every 6 months over
2 years/five times
Mailed surveys:
(Spheres of Control
Scale Internal
Locus of Control,
Rosenberg
SelfEsteem Scale,
Affect Balance Scale,
Community
Integration
Questionnaire,
school attendance,
employment,
paid/unpaid
assistance hours)
Significantly
different
improvement
6 months
after receiving
service dogs with
improvement
continued
up to 2 years
Psychologically,
all participants
showed
improvement in
selfesteem,
internal locus of
control, well
being and social
interaction within
6 months of
receiving service dog
Signicant
difference in
school attendance
and employment
After 12 months,
the presence of a
service dog was
associated with a
decrease of
approximately 60
biweekly paid
assistance hours
Collins et al., (2006)
To examine whether
dog/adult partnerships
impacted psychosocial
wellbeing and
community participation
Crosssectional,
nonrandomized
control study
N= 152, sample of
convenience, people
with disabilities
(58% used
powered mobility)
76 participants
with service dogs
76 participants
without service dogs
8 group categories
created based on
gender, age and
progressive/
nonprogressive
type of disability
1. No specified
training
reported for
service dog or
person/dog pairs
2. Participants
recruited
throughout the
United
States from
multiple
groups training
service dogs
3. Length of
person/dog
partnership ranged
from 0 to 13.1 years
Mailed surveys
(Centre for
Epidemiologic
Studies Depression
Scale, Positive and
Negative Affect
Scale, Rosenberg
SelfEsteem Scale,
UCLA Loneliness
Scale Version 3,
Craig Handicap
Assessment
Reporting
Technique)
Positive/negative
effect,
selfesteem,
depressive
symptoms and
loneliness scores
did not signicantly
differ between groups
Among
participants
with depression,
service dog
partnership was
associated with
more positive
affect scores
Participant/dog
partners with
progressive
conditions scored
signicantly
higher on positive
Service Dogs and People Partnerships Winkle et al.
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Table 3. (Continued)
Study objectives/
research design
Participants total/groups Intervention
description
Outcome measures Results
affect than
participants with
progressive
conditions without
service dogs
Eddy et al. (1988)
To examine whether
dog/adult partnerships
receive more frequent
social acknowledgments
from ablebodied
people than people in
wheelchairs without
service dogs
Prospective study with
nonrandomized
control group
N= 20, sample of
convenience
10 (4 women, 6 men)
with service dogs
10 (6 men, 4 women)
without service dogs
1. Dog and owner/
dog training
not described
2. Dogs all trained
through Canine
Companions for
Independence
(Santa Rosa, CA)
3. Length of time
participant
owned dog
not reported
Naturalistic
observations
reporting responses
of others
(smile, conversation,
touch, gaze aversion,
path avoidance)
Smiles and
conversation
significantly
increased
for participants with
service dogs
Gaze and path
avoidance
decreased with
service dogs but
signicance
level not reported
Fairman & Huebner (2000)
To examine the
functional assistance
(emotional, social,
economic) provided by
service dogs, to describe
the training provided
and problems with
service dog ownership
and to examine the
level of satisfaction
with dog ownership
Posttest survey with
no control group
N= 202, adults with
physical disabilities,
sample of convenience
No comparison group
51.4% survey return rate
1. Dogs and person/
dog pair trained by
one organization
2. Training not
dened
3. Length of
ownership of
dog not clear
Mailed surveys:
28item survey
(author designed)
focusing on functional
assistance provided
by service dogs
(activities
of daily living,
work and productive
activities, play/
leisure activities)
Activities that
service dogs most
often assisted with:
retrieving out of
reach/dropped
items (99%); getting
around community
(84%); getting
around the house
(78%); and
shopping (76%)
100% of
participants
reported that they
were approached
more in public, and
their dogs provided
emotional support
and feelings of
security
Service dogs
reduced the hours of
paid human
assistance by an
average of 2 hours/
week and reduced
(p= .006) saving
average of
$600/year(p= .003)
Hart et al. (1987)
To examine the
socializing effects of a
service dogs in public
Prospective study with
N= 28, sample of
convenience
19 participants using
wheelchairs with
service dogs
1. All owned
service dogs
2. All dog/person
pairs trained by
Canine Companions
for Independence
Cannot determine
if data collected by
written survey
or interview
Survey asked
(number
Higher number of
social greetings
reported from adults
and children on
typical shopping trips
with dog compared
Winkle et al. Service Dogs and People Partnerships
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Table 3. (Continued)
Study objectives/
research design
Participants total/groups Intervention
description
Outcome measures Results
nonrandomized
control group
9 participants
without service dogs
(Santa Rosa, CA)
3. No specied
training described
for service dog
or person/dog pair
of adults/children
approaching them
in a friendly way
during a typical
shopping trip,
number of times/
week go out alone
during daytime,
number of times/
week go out
alone at night)
with trips without dog
Participants with
dogs reported more
social approaches
than comparison
group without dogs
After obtaining
dogs, 11 of 19
participants
increased their night
outings alone
Lane et al. (1998)
To examine potential
effects of service dogs:
dog as a social facilitator;
dog as an affectionate
relationship; dog as an
emotional/selfesteem
support; and dog as an
inuence on
selfperceived
physical health
Onegroup, posttest
survey design
N= 57, sample of
convenience, children
and adults with physical
disabilities
No comparison group
81% return rate
1. All dog/person
pairs trained by same
group (Dogs for the
Disabled in England)
2. Dog/person partner
training not described
Study designed
questionnaire
(telephone interview
or personal interview)
with 41 items
(Demographics, Social
Integration,
Affectionate/
Supportive
Relationship,
Selfperceived Health,
General Satisfaction
with Dog, Most
Important Tasks
Dog Performs)
Activities that
service dogs
performed most
often: retrieving/
carrying (84%);
opening doors
(40%);
companionship
(35%); command
barking (35%)
Majority of
participants
reported a close
affectionate
relationship with
the dog, increased
social integration,
dog providing
comfort, selfesteem
and support,
enhanced
selfperceived health
Levels of
satisfaction with
dogs work and the
quality of the
person/dog
relationship
signicantly greater
if ownership was
participants idea
Mader, Hart & Bergin
(1989)
To examine
whether dog/children
with disabilities
partnerships
receive more
frequent social
acknowledgements
than children
without service dogs
N= 10, sample of
convenience
5 children with
service dog (1017 yrs)
5 children without
service dog (1216 yrs)
All used wheelchairs
1. All dogs trained by
same group (Canine
Companions for
Independence in
Santa Rosa, CA)
2. Child/dog pair
training not described
Naturalistic
observations
reporting responses
(percentages) of other
people on school
playground and in
shopping mall:
friendly glances,
conversations, smiles
In school settings,
children with dogs
received significantly
more glances and
direct conversation
than children
without dogs
Service Dogs and People Partnerships Winkle et al.
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Table 3. (Continued)
Study objectives/
research design
Participants total/groups Intervention
description
Outcome measures Results
Nonrandomized
control study
Ng et al. (2000)
To assess whether
service dog/children
with disabilities
partnerships increases
independence
Descriptive before and
after case series without
control group study
N= 5, sample of
convenience
No comparison
group
Children 11
17 years (mean
14.4); (2 girls, 3 boys);
1 boy dropped out
1. Children received
dog and completed
2 week training
programme
2. Visited by dog
trainer after
completed training
3. Skill refresher
course each year
Description of changes
(pre/post and followup
1to4yearsafter
dog placement)
Questionnaire with 32
activities, which a dog
could assist (school,
mobility and physical,
home and selfcare,
community and store,
psychological
and social)
All 4 children
reporting increased
independence on
most items
Two children
reported no change
in the mobility
and physical area
Rintala et al. (2008)
To examine the
functional
assistance of
service dogs
and the
satisfaction
and problems
of owning a service
dog for adults with
disabilities
Prepost, wait list
nonrandomized
control group study
N= 33, sample of
convenience, adults
with mobility
impairments
18 with service dogs
15 on wait list,
2 participants in
both service dog
and wait list
1. Dog and owner/
dog training
not described
2. 3 assistance
dog training
organizations
involved
Data collected at
referral
and either 6 months
after receiving dog
or 6 months on
waitlist
Mailed surveys
(Demographic
Impairments,
Predog Task Checklist,
Postdog Task Checklist,
Dog Performance,
ShortForm Health
Survey, Functional
Independence
Measure
Motor Subscale, Craig
Handicap Assessment
and Reporting
Technique,
Satisfaction with
Life Scale)
On average,
participants
were satisfied with
assistance dogs, and
dogs had a major
positive impact on
their lives
Activities dogs most
often assisted with:
retrieving items
(89%); carrying
items (79%); barking
in emergency (78%);
opening/closing
doors (56%),
pushing automatic
doors (56%)
Reported decreased
dependence on
other persons with
reduced hours of
paid assistance
Rintala et al. (2002)
To qualitatively and
quantitatively assess the
benets of the
placement
of service dogs with
persons with mobility
impairments
Prepost with followup,
no control group
Sample of convenience
N= 22 Time 1
N= 14 Time 2
N= 16 Time 3
N= 12 Time 4
N= 4 Time 5
No comparison group
1. Dog and owner/
dog training
not described
2. All trained at Texas
Hearing and
Service Dogs
Data collected
when participant
placed on waiting list,
just prior to receiving
dog, 6, 12, and
24 months after
receiving dog
Interviews (qualitative)
and mailed
quantitative
questionnaires
(Demographic and
Disability
Information,
Expected and Actual
Effects of Dog,
After placement
participants
indicated that the
service dogs had
assisted them in the
expected domains
Overall satisfaction
with service dogs was
very high at all
postplacement
measurements
The majority of
participants
reported increases in
8 of 11 life areas
including increases
Winkle et al. Service Dogs and People Partnerships
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Table 3. (Continued)
Study objectives/
research design
Participants total/groups Intervention
description
Outcome measures Results
Rosenberg
Selfesteem Scale)
in the number of
friends, selfesteem,
physical tness,
social interaction,
leisure interests,
independence,
happiness and
quality of life
Qualitative data
indicated that service
dogs helped organize
participantsdays
Small but signicant
improvement in
selfesteem reported
after receiving a
service dog
Shintani et al.
(2010)
To assess the effects
of service dogs on
healthrelated quality
of life
Survey with
control group
N= 38, sample of
convenience
10 participants with
service dogs
28 participants without
service dog but
would have qualied
for service dog
Training took place
in Japan but
no description
of dog/person
training provided
Short Form Health
Survey Version 2.0
(SF36v2) Subscales
(Physical Functioning,
Role Physical, Bodily
Pain, General Health
Perceptions, Vitality,
Social Functioning,
Role Emotional,
Mental Health)
Significant higher
scores on Physical
Functioning and
role Emotional
subscales
Signicant
difference
in Mental
Component
Summary Score
Valentine et al. (1993)
To survey the
psychosocial impact of
dog/people with
mobility impairments
partnerships
Descriptive case report
N= 10, sample of
convenience
10 persons with
mobility impairments
No comparison group
1. All owned service
dogs
2. Quality of dog
and person/dog
pair training not
described
Authordeveloped
27item telephone
interviews
(3045 minutes
duration), Service
Dog Importance
and Satisfaction
Scale (practical
importance, emotional
importance, social
importance, overall
satisfaction)
People with service
dogs perceived their
lives to be better after
dog ownership
100% stated they
had more freedom
90% reported
decreased loneliness,
increased feelings of
safety and increased
independence
80% reported
feeling more
assertive,
content, increased
friendly encounters
with others and
increased selfesteem
One person noted
negative changes
because of requiring
more work and less
access to public
transportation
Service Dogs and People Partnerships Winkle et al.
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
Issues of service dog ownership
Five studies discussed difculties associated with own-
ing a service dog (Valentine et al., 1993; Lane et al.,
1998; Fairman & Huebner, 2000; Rintala et al., 2002;
Rintala et al., 2008). Participants reported that whereas
there were few issues, overall physical maintenance
(grooming and vet bills) was the biggest problem.
Other issues included being challenged or denied access
into a public facility or affordable housing, inappropri-
ate petting of the service dog while it was working, or
inappropriate behavior of the dog in public.
Satisfaction with the owner/dog partnership and the
dogs performance was rated highest in situations where
it was the person with the disabilitys idea to obtain a ser-
vice dog (Lane et al., 1998). These issues all have impli-
cations for clients considering obtaining a service dog
and occupational therapists should be aware of these
difculties when making recommendations.
Limitations of research
Although studies found a positive relationship between
having a service dog and social/participation, functional
and psychological benets, all of the studies had many
concerns related to their quality of research design. All
12 studies were rated weak (see Table 1). Small partici-
pant sizes, poor descriptions of the interventions, out-
come measures with minimal psychometrics and lack
of power calculations led to all of the studies to be rated
as weak. It is difcult to conduct a blind investigation
of the benets of service dogs, so it is impossible to rule
out the contribution of participant expectations.
Participants
Seven of the 12 studies had a comparison group; the
other ve consisted of one group descriptive studies.
Only two of the comparison had sample sizes greater
than 20 in each group increasing the probability of a
Type II error (i.e. reporting a nonsignicant difference
when a true difference is present). Because of the spe-
cialized sample composition requiring all participants
to have disabilities, all groups were samples of conve-
nience. This type of sampling can cause bias because
of selfselection (Portney & Watkins, 2009) as partici-
pant attributes may inuence outcomes, which can re-
duce generalization. Three of the no comparison
studies had groups of less than 25 participants with
one study having 202 respondents and another with
57 respondents. In general, inclusion and exclusion cri-
teria were vague. In those studies with comparison
groups, often there were unequal demographic differ-
ences including gender, type and severity of disabilities,
marital status or ethnicity. Group differences may have
existed because the comparison group may not have
qualied to receive a service dog because they may
not have met inclusion criteria. In addition, recruit-
ment strategies of intervention and comparison groups
sometimes differed. In total, 625 people participated
across studies, with 329 involved in studies with com-
parison groups. Three studies (Mader et al., 1989; Lane
et al., 1998; Ng et al., 2000) included children 18 years
and under.
Intervention
A major concern across studies was an inadequate de-
scription of the intervention, that being the training
of the service dog and the service dog/person partner-
ship. Although several of the studies incorporated ser-
vice dogs trained by one organization (eight studies),
four other studies used dogs from multiple organiza-
tions. Three of the studies used dogs trained by the
Canine Companions for Independence in Santa Rosa,
California (Hart et al., 1987; Eddy et al., 1988; Mader
et al., 1989). Without knowing the length and quality
of the specialized training of the service dog, criteria
for dog or person placement readiness or the content,
length and quality of the training for dog or person, it
is impossible to replicate these studies.
Outcome measures
Although standardized measures were occasionally
used, investigator authored measures designed espe-
cially for the study, or rating scales with no report of re-
liability or validity, were most often used. Four of the
12 studies used at least one standardized instrument
(Allen & Blascovich, 1996; Collins et al., 2006; Rintala
et al., 2008; Shintani et al., 2010). Selfreported instru-
ments were either completed by mail, telephone inter-
view or facetoface interviews or completion of a
written survey. Two studies (Eddy et al., 1988; Mader
et al., 1989) involved observation of the participants
in a naturalistic environment. Both of these studies
did not report observational interrater reliability de-
creasing condence in their subjective results. Most
studies measured the activities and participation classi-
cations (community integration, school attendance,
Winkle et al. Service Dogs and People Partnerships
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
social integration, and performance of activities of daily
living, productive and leisure activities) according to the
World Health OrganizationsInternational Classica-
tion of Impairments, Disabilities, and Handicaps
(2009). In addition, none of the seven studies with com-
parison groups reported a power calculation making it
impossible to estimate the probability of a Type II error.
Recommendations for future
research
Although the ndings of this systematic literature re-
view are promising, they are inconclusive and limited.
This suggests the need for more rigorous studies to
demonstrate the effectiveness of service dog/person
partnerships. Areas for further investigation include
the benets of service dogs in comparison with pet
dogs, selection and training criteria for service dogs
and recipients and cost effectiveness. Additional quali-
tative studies examining meaningfulness of service
dog use, caregiver perspectives, perceived indepen-
dence, health maintenance and prevention of further
disability should be considered. Finally, the abandon-
ment (not used or not accepted) rate of assistive tech-
nology and durable medical equipment could be
compared with that of service dog use. Research in
these content areas could facilitate the evidence to view
service dogs as assistive technologyand also as a
means to decrease human assistance to carry out activ-
ities of daily living. This is also critical considering the
need to demonstrate successful outcomes to facilitate
third party funding of service dogs as an assistive tech-
nology option. In addition, standardized longitudinal
studies are needed to evaluate service dog/people part-
nerships in relation to changes with aging, medical
conditions, or dog behaviour and handler skills.
Dening the characteristics of individuals who would
benet from a service dog might assist with inclusion
criteria that are more predictive of positive outcomes.
Given the extreme shortage of trained dogs and the po-
tential cost of the dog/person partnership training and
care, predicting positive outcomes based on person
and dog characteristics are vital. Finally, if we are to rec-
ommend service dogs (or any kind of assistance dog) as
an assistive technology option, we must study the dog
person evaluation and matching process, training and
placement procedures and content, and outcomes for
both the person and the dog, across assistance dog
training organizations. Anecdotally, the literature
strongly supports the benets of service dogs, but the
research evidence needs to show how service dogs can
make a difference in the lives of people with disabilities.
Implications to occupational
therapy practice
Two of the studies reviewed involved occupational
therapists (Fairman & Huebner, 2000; Ng et al.,
2000). The remaining studies were conducted within
other disciplines. However, given the holistic, client
centred approach of occupational therapy, the collat-
eral work of psychologists, nurses, social workers, reha-
bilitation specialists, medical doctors, veterinarians and
service dog trainers only strengthens our analysis.
Occupational therapists have the opportunity to offer
individuals evaluation and intervention in every area of
functioning and during all stages of life. Moreover, we
are in the unique position to directly intervene at the
level of the person, the activity, and the environment
and to offer recommendations for assistive technology
options in a variety of environments. As members of
the interdisciplinary team and as client advocates, we
may directly support our clients by becoming educated
about the skills that all assistance dogs (including ser-
vice dogs) offer, become familiar with local assistance
dog training organization options and offer to work di-
rectly with the dogtraining organizations to determine
whether or not clients are good candidates for assistance
dog use. Occupational therapists may also assist clients
and training organizations to overcome barriers before,
during and after the placement process.
Acknowledgements
We want to thank Daphne Barnett, Kim Lane, MOT,
Tanya Nez, OTA and Janet Poole, Ph.D., OTR/L,
FAOTA for assisting with the evidencebased analysis
of the papers. In addition, we were inspired by Fenn,
Melvin, and Benny, the service dogs that were always
at our feet when we met as a team.
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... Consequently, many individuals require a range of support needs across various life domains (Weiss & Burnham, 2015) and may receive funding from one of the 20 major Australian social and injury insurance schemes (Wright et al., 2019). In addition to human supports, aids, and equipment, assistance animals are becoming increasingly utilised to enhance independence and occupational performance (Crowe et al., 2014;Herlache-Pretzer et al., 2017;Winkle et al., 2012). However, currently in Australia, there are inconsistencies in funding rules across insurance schemes and crossjurisdictional differences in assistance animal regulation and legislation (Australian Government Department of Social Services, 2021; Wright et al., 2019). ...
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... Research has documented the increased benefits of assistance animals used to support functioning, when compared to other forms of assistive technology [7][8][9]. Assistance animals can help to enhance users' functional performance and independence by performing specific tasks, like retrieving items or guiding community mobility [3,[10][11][12][13], reducing barriers to functioning, including fatigue and pain [7,10,11,[14][15][16], preventing or resolving problems that may impede functioning like anxiety and self-harming behaviour [17][18][19][20][21], or improving psychological well-being, such as increased sense of worth and control, and better quality of life [19,[22][23][24]. Some studies additionally demonstrate how assistance animals may help improve users' social participation; for instance, increasing time spent participating in social activities or experiencing convivial encounters with others [11,17,25]. ...
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Purpose: This study aimed to investigate: (1) the characteristics of people using, or had previously used, assistance animals within community living in Australia; (2) positive and/or negative experiences of these users; and (3) educational resources that may aid public awareness. Materials and methods: An online survey was distributed through Australian assistance animal organisations and social media channels. Past/current assistance animal users (n = 112) responded to questions on demographic and types of animal supports used, experience of assistance animal use, community attitudes experienced, and perspectives about the need for public education. Data were analysed with descriptive and inferential statistics. Content analysis provided additional insights of the positive and/or negative experiences assistance animal users had faced. Results: Nearly all participants used an assistance dog (n = 111), and 37 (33%) used the animal for more than one type of support. Seventy percent reported experiencing both positive and negative community attitudes/reactions. Length of time of having an assistance animal was associated with significantly higher prevalence of positive attitudes/reactions, whilst users who received medical support from the animal tended to experience more negative community attitudes/reactions than other users. The majority (90%) agreed that more public education is needed regarding assistance animal public access rights. Conclusions: This study is the first in Australia to undertake a large-scale survey of assistance animal users with a range of disability types. It highlights the benefits and challenges of assistance animals, which could be useful to consider when determining the most appropriate support for an individual.
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Cerebral palsy (CP) is a well-researched area of medical science, health science and special education. The growing number of publications every year makes difficult to monitor the progress of this research domain, therefore there is a broad interest for conducting systematic reviews and meta-analyses of interventions in international peer-reviewed scientific journals.Our goal is to analyze the scientific activity of authors who published systematic reviews and meta-analyses of CP intervention studies. To identify the active researchers, institutions, and countries, we used scientometric and bibliometric indicators that assess their productivity, collaborations, and the citations (utilization/usefulness of their studies), also paying attention to the institutional background and the network structure of national and international collaboration.We used Scopus to search for articles and included systematic reviews and meta-analyses of intervention studies, a total of 180 works, in our sample.Our results showed active and large communities of prolific authors and groups of authors with diverse institutional background. Most institutions are universities, hospitals, but we found various other organizations among them. Most of the universities are leading educational institutions according to international rankings; some of them are among the top-ranking ones. In geographical terms, the North American, Australian, and European regions are the most active and most interconnected ones. We assume organizations other than scientific collaboration networks also play a major role in the productivity and dissemination of scientific knowledge in this research area. As an example, we could mention the network, including the US, Australian and European registers. Authors living and working in the Far East, the Middle East or in South America also started to publish relevant articles in the 2010s. The research network structuring scientific knowledge in this area is flourishing.
Article
Introduction: Assistance dogs are trained to support persons living with disability and mitigate limitations that hinder their participation in everyday activities. Despite participation being a frequent challenge for people with disabilities, evidence linking assistance dog provision to improved participation outcomes is underdeveloped. This scoping review aimed to improve understanding by mapping the participation outcomes claimed in research on assistance dogs using the International Classification of Functioning (ICF), Disability and Health framework. Methods: Using the Arksey and O'Malley's six-step framework, this scoping review searched six databases. Data were collected, mapped and summarised in accordance with the domains outlined in the ICF. Results: In total, 38 studies across 41 papers met the inclusion criteria. Included studies investigated assistance dogs who were partnered with people living with physical disabilities, mental illness, autism and chronic conditions that require alerting (e.g., epilepsy and diabetes). Mapping of participation outcomes suggested that assistance dogs can have a positive impact on participation in many areas of daily life. Conclusion: Findings can assist practitioners, funders and policymakers to recognise the value of assistance dogs as a support for people with disability. However, further research is needed to address limitations regarding study designs, for example, the outcome measures used.
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Background and objective Therapeutic interaction with animals for patients coping with physical and mental health conditions is a growing interest among healthcare providers and researchers. We aimed to comprehensively summarize and evaluate the current state of evidence examining the use of animal-assisted interventions [AAI] for pain relief in healthcare settings. Design Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Methods Two researchers independently assessed publications dated before February 5, 2021 in OVID Medline, CINAHL, and PsychINFO databases, and used the Delphi list to evaluate the quality of the evidence. Results Of the 109 studies screened, a total of 24 studies totaling 1,950 participants were ultimately included. Studies varied in design, including single group trials (8), controlled trials with at least two groups (6), and randomized controlled trials (10). The most common form of pain measurement was the visual or numeric rating scale. For the 18 studies that reported data on changes in pain severity from pre-to-post-test, 13 reported a significant reduction; using the converted common metric we created, these reductions ranged from 0.20 to 3.33 points on a 10-point numeric rating scale. Conclusions AAI may be considered a promising approach in need of further, more rigorous research. Available evidence supporting AAI remains weak due to issues of study quality and design, thereby impeding our ability to draw reliable conclusions on the utility of AAI in relieving pain. Given the rapidly increasing availability of these interventions in hospitals, it is important to better understand its effectiveness.
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This retrospective study of people in wheelchairs who have service dogs reports their experiences with strangers in public before and after obtaining their dogs. The specific hypothesis tested was that the acquisition of a service dog would increase the number of friendly approaches by strangers. Subjects reported a significantly higher number of social greetings from adults and children on typical shopping trips with the dog as compared with those received on trips before they had the dog or with recent trips when the dog was not present. Subjects with service dogs reported more approaches than a control group without dogs. After obtaining dogs, subjects also increased their evening outings.
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Objective: To review outcome research concerning placement of trained assistance dogs (ADs), focusing primarily on service dogs for people with mobility impairments and hearing dogs for individuals who are deaf or hard of hearing. Design: The authors place the relatively small body of literature on ADs in the context of relevant research on the benefits of human-animal contact and pet ownership. Results: While the research specific to ADs generally shows positive benefits, the small number of studies and methodological limitations of these studies preclude any clear conclusions. Recommendations for future research on ADs include the use of longitudinal designs, matched comparison groups, standardized measures that assess diverse areas of functioning, and behavioral self-monitoring for daily activities. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Service dogs are trained to help people with limited mobility. They have been shown to enhance independence and to reduce the need for assistance. However, training is expensive, and most trainers prefer not to work with children. A collaboration between Shriners Hospital, Northern California, and Loving Paws Assistance Dogs of Santa Rosa, California, was initiated to pair children with limited mobility with service dogs. We studied the outcomes of five child-dog pairs. Three were highly successful, one partially succeeded, and one failed. We conclude that the training and pairing of service dogs and disabled children is a difficult but worthwhile enterprise.
Article
Objective. —To assess the value of service dogs for people with ambulatory disabilities.Design. —Randomized, controlled clinical trial.Setting. —Environments of study participants.Participants. —Forty-eight individuals with severe and chronic ambulatory disabilities requiring use of wheelchairs who were recruited from advocacy and support groups for persons with muscular dystrophy, multiple sclerosis, traumatic brain injury, and spinal cord injury. Participants were matched on age, sex, marital status, race, and the nature and severity of the disability in order to create 24 pairs. Within each pair, participants were randomly assigned to either the experimental group or a wait-list control group.Intervention. —Experimental group members received trained service dogs 1 month after the study began, and subjects in the wait-list control group received dogs in month 13 of the study.Main Outcome Measures. —Dependent variables evaluated were self-reported assessments of psychological well-being, internal locus of control, community integration, school attendance, part-time work status, self-esteem, marital status, living arrangements, and number of biweekly paid and unpaid assistance hours. Data collection occurred every 6 months over a 2-year period, resulting in five data collection points for all subjects.Results. —Significant positive changes in all but two dependent measures were associated with the presence of a service dog both between and within groups (P<.001). Psychologically, all participants showed substantial improvements in self-esteem, internal locus of control, and psychological well-being within 6 months after receiving their service dog. Socially, all participants showed similar improvements in community integration. Demographically, all participants showed increases in school attendance and/or part-time employment. Economically, all participants showed dramatic decreases in the number of both paid and unpaid assistance hours.Conclusions. —Trained service dogs can be highly beneficial and potentially cost-effective components of independent living for people with physical disabilities.(JAMA. 1996;275:1001-1006)
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Currently, the supply of service dogs is limited. Of the more than 49 million Americans with a disability, fewer than 16,000 have a service dog. Every year, the Delta Society's National Service Dog Center—a clearinghouse for information about obtaining or training service dogs—receives thousands of calls from people who want, but cannot obtain, such a dog. This article reviews for professionals in rehabilitation the current research into the use of service dogs and/or animal-assisted therapy. Service dogs may help the clients of rehabilitation nurses meet their rehabilitation goals; therefore, it is incumbent upon nurses to be familiar with the research in this area. Another article by Susan Modlin, which discusses the author's personal experience with a service dog training program, will be published in the January/February 2001 issue of Rehabilitation Nursing.
Article
Objective. This study examined the physical, emotional, social, and economic functions of service dogs, the training methods for service dog/owner teams, and problems encountered with service dogs in relationship to occupational therapy literature and domain of concern. Method. A 31-question survey was developed based on the literature and Uniform Terminology (AOTA, 1994) and was completed by 202 service dog owners from 40 states and Canada. Results. Owners reported that service dogs assisted them in 28 functional tasks, helped them to feel safe, increased their social interaction, and reduced physical assistance by others. Problems with service dogs included difficulty with dog maintenance and public awareness of their role as a worker or assistant to the owner. Over 80% of respondents desired additional training in alternative ways to perform daily living tasks. Conclusion. The use of service dogs is consistent with the occupational therapy domain of concern and practice. Occupational therapists might collaborate with service dog trainers and potential owners in referral, assessment, training, and follow-up services.