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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 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 system-
atic 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 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 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 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 confidence 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 benefits 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
human–animal interactions, refers to casual visitations
Occup. Ther. Int. (2011) © 2011 John Wiley & Sons, Ltd.
as animal‐assisted activities (AAA) (Delta Society, 2009).
Dogs also participate in intervention sessions, which
are referred to as animal‐assisted 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 (Sachs‐Ericsson 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 & Canfield, 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). Twenty‐seven 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 signifi-
cant numbers of individuals with disabilities are inter-
ested in such interventions (Sachs‐Ericsson 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
evidence‐based review
The focus of this review was on original, peer‐reviewed,
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 findings were evaluated with inclusion
and exclusion criteria to accurately reflect the goal of
this review.
Literature Search
Database searches, which were completed over a 2–year
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 animal‐assisted (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
modified 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 identified in the lead author’s 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 classifications consist of a hierarchy of
research designs that range from the greatest to the
least according to the study’s ability to reduce bias.
Quality‐rating schemes give a means of assessing the
scientific 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 7‐point 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 affirmatively 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-
ficacy 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 influence 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 recipient’s disabil-
ity toward their competence in handling a highly
trained dog”(p. 58). However, a few studies reported
concerns for dogs acting as “social facilitators”such
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 two‐group 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 follow‐up reported and less than 20%? For two‐group 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 dog’s 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 finding can also have important
benefits to family members. Reduction in the time
needed for care‐giving 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-
fits including significant increases in self‐esteem, 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 Parkinson’s disease) who have
service dogs demonstrated significantly higher positive
affect scores and that service dogs moderated the effects
of depression. However, psychosocial characteristics
did not differ significantly 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 (O’Donnell 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) V√1
a
AACPDM, American Academy for Cerebral Palsy & Developmental Medicine.
b
Strong (“yes”score 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
well‐being 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 wait‐list
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. Difficult 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
Self‐Esteem 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
self‐esteem,
internal locus of
control, well‐
being and social
interaction within
6 months of
receiving service dog
•Significant
difference in
school attendance
and employment
•After 12 months,
the presence of a
service dog was
associated with a
decrease of
approximately 60
bi‐weekly paid
assistance hours
Collins et al., (2006)
To examine whether
dog/adult partnerships
impacted psychosocial
well‐being and
community participation
Cross‐sectional,
non‐randomized
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/
non‐progressive
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
Self‐Esteem Scale,
UCLA Loneliness
Scale –Version 3,
Craig Handicap
Assessment
Reporting
Technique)
•Positive/negative
effect,
self‐esteem,
depressive
symptoms and
loneliness scores
did not significantly
differ between groups
•Among
participants
with depression,
service dog
partnership was
associated with
more positive
affect scores
•Participant/dog
partners with
progressive
conditions scored
significantly
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 able‐bodied
people than people in
wheelchairs without
service dogs
Prospective study with
non‐randomized
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
significance
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
Post–test 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
defined
3. Length of
ownership of
dog not clear
Mailed surveys:
28‐item 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
non‐randomized
control group
•9 participants
without service dogs
(Santa Rosa, CA)
3. No specified
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/self‐esteem
support; and dog as an
influence on
self‐perceived
physical health
One‐group, post‐test
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,
Self‐perceived 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, self‐esteem
and support,
enhanced
self‐perceived health
•Levels of
satisfaction with
dog’s work and the
quality of the
person/dog
relationship
significantly greater
if ownership was
participant’s 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 (10–17 yrs)
•5 children without
service dog (12–16 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
Non‐randomized
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 follow‐up
1to4yearsafter
dog placement)
Questionnaire with 32
activities, which a dog
could assist (school,
mobility and physical,
home and self‐care,
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
Pre‐post, wait list
non‐randomized
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
wait‐list
Mailed surveys
(Demographic
Impairments,
Pre‐dog Task Checklist,
Post‐dog Task Checklist,
Dog Performance,
Short‐Form 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
benefits of the
placement
of service dogs with
persons with mobility
impairments
Pre‐post with follow‐up,
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
post‐placement
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
Self‐esteem Scale)
in the number of
friends, self‐esteem,
physical fitness,
social interaction,
leisure interests,
independence,
happiness and
quality of life
•Qualitative data
indicated that service
dogs helped organize
participants’days
•Small but significant
improvement in
self‐esteem reported
after receiving a
service dog
Shintani et al.
(2010)
To assess the effects
of service dogs on
health‐related 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 qualified
for service dog
Training took place
in Japan but
no description
of dog/person
training provided
Short Form Health
Survey Version 2.0
(SF‐36v2) 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
•Significant
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
Author‐developed
27‐item telephone
interviews
(30–45 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 self‐esteem
•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 difficulties 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
dog’s performance was rated highest in situations where
it was the person with the disability’s 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
difficulties when making recommendations.
Limitations of research
Although studies found a positive relationship between
having a service dog and social/participation, functional
and psychological benefits, 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 difficult to conduct a blind investigation
of the benefits 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 five 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 non‐significant 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 self‐selection (Portney & Watkins, 2009) as partici-
pant attributes may influence 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
qualified 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). Self‐reported instru-
ments were either completed by mail, telephone inter-
view or face‐to‐face 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 inter‐rater reliability de-
creasing confidence in their subjective results. Most
studies measured the activities and participation classi-
fications (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 Organizations’International Classifica-
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 findings 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 benefits 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 technology”and 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.
Defining the characteristics of individuals who would
benefit 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 benefits 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
individual’s 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 dog‐training 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 evidence‐based 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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