Linking Virginia’s Resources Together
Woodrow Wilson Rehabiliatation Center (Fall 06)
Seating, Positioning, and Mobility
SEATING, POSITIONING & MOBILITY
Objectives:
- Recognize seating and mobility problems that impact a person’s daily function.
- Determine when a referral should be generated and who the appropriate recipient would be.
- Communication of expectations related to an assistive technology request.
- Identify key characteristics and qualifications of quality resources.
Presenters: Laurie Dubose, OTR/L
Senior Occupational Therapist
Woodrow Wilson Rehabilitation Center
Greta Nelson, PT, MS
Senior Physical Therapist
Woodrow Wilson Rehabilitation Center
INTRODUCTION
Assistive Technology associated with seating, positioning and mobility can be as varied and complex as physical disabilities themselves. An interdisciplinary approach to the complex problems regarding seating, positioning and mobility yields the best solution. Attainment of appropriate assistive technology related to seating, positioning and mobility could mean increased independence and productivity for many DRS clients. Counselors are an integral team member and their ability to recognize problems, ask the right questions and coordinate resources is critical.
IDENTIFYING PROBLEMS THAT IMPACT FUNCTION
Clients with disabilities most commonly identified with seating, positioning and mobility problems include those with: spinal cord injury, traumatic brain injury, cerebral vascular accidents, cerebral palsy, multiple traumas, spina bifida, amputations, cardiac diseases, metabolic disorders, diabetes and low back pain.
Consider the following potential problems and how they impact on the client’s abilities to perform in environments related to the Individualized Plan for Employment (IPE).
Improper fit of existing technology
Broken or inappropriate technology
Compromised skin integrity and risk of skin breakdown
Poor biomechanical or ergonomic posture
Presence of pain or discomfort
Impaired balance
Diminished endurance or problems with fatigue
Inability to push, pull, reach, lift, and transport products from one area to another
Inaccessibility to home, school, work, community settings
Lack of transportation to medical appointments, school, community, work
DETERMINING IF A REFERRAL SHOULD BE GENERATED
Common situations that warrant assistive technology team evaluation and intervention:
The client has had numerous prior services without resolution of the problems and the previous technology may have been abandoned.
Referral back to the original source who provided the intervention or technology has not been able to resolve the issue.
An exact duplicate of the technology (simple replacement of technology that is meeting client’s needs) would not suffice.
The client’s vocational and avocational potential is uncertain. A referral is indicated to explore options available prior to defining assistive technology needs related to the IPE.
The seating and mobility problem is impairing daily function, employability, or goal attainment.
Presence of one problem has multiple implications that require a holistic and integrated team assessment.
The problem is a matter of actual medical or vocational need rather than client preference or convenience.
The medical prognosis or general physical condition is worsening. This may or may not be directly related to technology use.
The referring party should ensure that there is a funding source (medical, vocational or other) authorized for the evaluation and technology.
SELECTING APPROPRIATE PROVIDERS/RESOURCES
Interdisciplinary team composition and capabilities are important. Seating, positioning and mobility needs cover a broad spectrum, from the most basic to
the extremely complex. As seating, positioning and mobility needs vary from client to client, so too does the composition of the interdisciplinary team. In short, the makeup of the team is determined by the client’s needs. For clients with more complex needs, or a broader scope of needs, an interdisciplinary team consisting of multiple disciplines with specific areas of expertise will be required. As shown below, up to sixteen disciplines are available to participate in the delivery of seating, positioning and mobility services and technology.
Members of the seating and mobility interdisciplinary team may be composed of any a/o all of the following:
The Client: The client is the most important member of the team. Whenever possible, he or she should participate actively in all steps of the service delivery process. The client is responsible for identifying his or her general needs, especially as they relate to the IPE, and communicating these needs with relevant information to the team. The client should also provide input and feedback to the team from beginning to end.
The Client’s Family, Personal Caregivers or Primary Care Attendant: If the client utilizes a personal care attendant, then that person should be included on the team with the client’s consent. This person in all likelihood will assist the client in the daily use, care and maintenance of the assistive devices provided. Therefore, they have a key role in the selection of the assistive technology. They need to be comfortable with the technology and have the capability to use, care for and help maintain the device(s).
The Rehabilitation Counselor: The counselor is responsible for identifying with the client and others any potential needs, problems or issues that the client may experience. He or she is also responsible for making the appropriate referrals once seating, positioning and mobility needs are identified. Additionally, the counselor needs to be familiar with the resources that are available and the capabilities of the potential service providers. Should additional disciplines (PT, OT, Rehabilitation Engineering, etc.) be brought onto the team, the counselor should determine why each discipline is needed and what the discipline is expected to provide. Once the interdisciplinary team makes recommendations, the counselor is responsible for reviewing the recommendations and coordinating the purchase of the recommended services or devices once approved. Finally the counselor assists in following up on the delivery of the services and devices to ensure that the client’s needs have been met.
The Physician: The physician is frequently required to assess the client’s medical status as they relate to the seating, positioning and mobility issues. Many assistive technology funding sources require a certificate of medical necessity signed by the physician before considering payment for the technology.
The Physical Therapist: The physical therapist’s role may vary depending upon the facility. WWRC’s Seating and Mobility team designates the physical therapist (PT) as the team’s lead therapist for seating, wheeled mobility and ambulatory devices. The PT screens records to assess the client’s primary needs and shares this information with other team members. The PT evaluates the client’s posture, strength, range of motion, skin condition and functional mobility skills and needs as baseline information for determining appropriate intervention options. Clinical trials of these options allow the client and the team to determine the best choice of either scooter, power or manual wheelchair or ambulatory mobility devices.
The Occupational Therapist: The occupational therapist’s role also varies by facility. The occupational therapist on WWRC’s Seating and Mobility team provides significant input for cushion selection, accessibility and transportation options (compatibility with vehicle and wheelchair tie-down systems).
The Durable Medical Equipment (DME) Vendor or Rehabilitation Technology Supplier (RTS): The DME vendor assists the team in identifying commercial devices that may meet the client’s needs. The vendor should have an extensive knowledge of commercially available equipment to include technical specifications, capabilities and limitations.
The vendor should assist the team in acquiring equipment for trial or extended evaluation prior to purchase as well as in acquiring equipment for purchase. The vendor should assist the team in funding procurement, fitting, training and ongoing service of the technology provided.
The Rehabilitation Engineer: The role of the rehabilitation engineer (RE) is to provide engineering and technical expertise to the team relevant to meeting client needs when standard equipment is not appropriate. The RE participates in the team evaluation assisting in problem identification and analysis and proposing technical options for attaining the outcome desired by the team. Often a mock-up of the design is fabricated for further clinical evaluation and revision of the design plan prior to fabrication of a definitive product. The RE is then incorporated into the technology delivery so that device fabrication or modification is customized to the client and the new mobility and seating system. The RE is also responsible for educating the client and any caregivers regarding special use or maintenance requirements of the custom devices and providing follow-up services. The RE contributes significantly to the capacity of the team by locating obscure commercial equipment that may solve a client’s problem, modifying commercial equipment to yield a better fit and function and designing custom equipment when commercial solutions do not exist. Rehabilitation engineers use a structured approach to solving problems based on scientific analysis, design theory and product development principles.
The Vocational Evaluator: The vocational evaluator (VE) is a necessary interdisciplinary team member when a client possesses seating, positioning or mobility problems that hinder a successful vocational evaluation. The VE may also become involved when seating, positioning or mobility issues arise while conducting a job analysis. The role of the VE in these instances is to define for the team the job performance expectations, to strategize alternative methods for performing job tasks or functions and to assist the team in ensuring that these expectations are met.
The Employer: The employer should be part of the team when a client possesses seating, positioning or mobility problems that are evident within the work environment or present a barrier to potential employability. The employer’s primary function is to define the essential job duties and employer expectations so that the team may work to enable the client to meet these expectations.
The Client Advocate: When client advocates participate on the team, their role is to ensure that the client’s needs are adequately represented and considered. The advocate often acts as a liaison between agencies involved in the client’s case.
The School Teacher: The teacher knows the student’s abilities, educational goals and classroom integration requirements. He or she can define problems or issues that arise in the school setting. The teacher can assist in the ongoing monitoring and supervision of the team’s recommendations once the student returns to school.
The Speech-Language Pathologist: For clients with speech or language disabilities, the speech-language pathologist (SLP) may participate on the team. The SLP defines augmentative or alternative communication needs and assists the team in integrating any communication devices with the seating, positioning and mobility recommendations.
The Rehabilitation Nurse: The rehabilitation nurse may be a member of the team for clients who have medical or nursing issues that affect their seating, positioning and mobility needs. Examples include clients with decubitus ulcers and bowel or bladder incontinence issues. The nurse assists in determining strategies to manage these medical/nursing issues that are compatible with the seating, positioning and mobility interventions being evaluated. The nurse may also provide valuable client education regarding resources for improved management of these concerns.
The Prosthetist/Orthotist: Prosthetists are involved in the assessment and fabrication of artificial (prosthetic) limbs. Orthotists are involved in the assessment and fabrication of braces (orthotic devices) to support or replace lost function. These specialists provide ongoing assist with fitting and adjustment to these devices in conjunction with therapists providing client training in their use.
Assembling the appropriate disciplines for the seating, positioning and mobility team is only a third of the battle. Of equal importance, is the creation of a team that possesses the knowledge, skill and abilities needed to properly serve your clients. Not every physical or occupational therapist specializes in seating, positioning, splinting, prosthetics and wheeled mobility. Nor does every rehabilitation engineer specialize in seating. Thus, it is extremely important that you become familiar with the resources available and the capabilities of the service providers in your area.
The following qualifications should be carefully evaluated and considered when selecting appropriateproviders/resources:
Experience providing seating, wheelchair, prosthetic, and orthotic evaluations and recommendations.
Amount of hands-on experience with the particular disability.
Amount of experience with the technologies needed by the client.
Provider credentials, certifications, and specialty training in the field.
Classification as an authorized dealer of the recommended technology.
Identifying qualified, experienced, and competent service providers is just one key component of the referral selection process. Of equal importance, is the selection of resources that offer comprehensive, individualized, hands-on evaluations to both determine and justify the most appropriate technologies to match the individual’s needs. Trial evaluations provide the opportunity to combine technologies and evaluate both their compatibility and functional impact prior to purchase. Attainment of the most appropriate assistive technology related to seating, positioning, and mobility contributes to maximizing a client’s independence and productivity.
The following evaluation, procurement, and follow-up services should be sought when evaluating and selecting appropriate providers/resources:
Client and referral expectations are respected and considered.
Alogical, hands-on, individualized physical and functional evaluation is performed.
Education, training, and trial use of assistive technology options is provided to determine the most appropriate assistive technologies. The trials may occur as any/all of the following: formal evaluation, temporary loaner/trial base, a/o a short-term trial/rental basis.
Comparison, rationale, and justification are provided based upon trial evaluation results of various technologies.
Assistance is provided identifying all funding options and procuring technologies recommended.
Education and training in appropriate use, care, and maintenance is provided to the client, family, caregivers, employers, and other.
Follow-up is provided to determine the outcomes associated with technology procurement. If less than desired outcomes occur, the provider must demonstrate efforts to achieve customer satisfaction.
EVALUATION EXPECTATIONS
It is important that the client and the service provider are aware of your expectations as the referral source. Clear, effective communicate to the client and the provider should include:
The goals and expectations for the requested evaluation (i.e., referral needs and questions to be addressed).
Whether it is acceptable to seek repair or modification to existing equipment before recommending new technology.
Whether you are referring the client for equipment that is medically necessary, vocationally needed, or a matter of client preference and the impact of funding for each type of equipment need.
That technology changes quickly and new equipment is continually available while older models may be discontinued; thus, the client may need to be open to trying a variety of new options.
The goals and expertise of an independent vendor from the community may be different from those of a therapist (who has no financial investment in the equipment recommended for purchase). Consideration to equipment procurement including: funding, equipment fit, accessibility, and compatibility with other technology and functional implications may vary.
Funding guidelines often exist that may limit the amount of funds available to cover the cost of technology or may limit coverage to a specified use or location (i.e., Medicare and Medicaid generally only consider technology for household mobility and function, school systems that purchase technology for an individual may only allow technology to be used within the school setting).
- Medically Necessary: services and technology that directly correlate with the client’s medical condition, ability to improve independence (or decrease level of care required), and functional mobility within the home environment.
- Not Medically Necessary: services and technology that relate to school, work, community access, socialization, or client/caregiver convenience
OUTCOMES
Today, assistive technology practitioners are becoming serious and systematic about defining, measuring, and improving the quality of assistive technology devices and services. Purchasers are learning to treat the procurement of health care services much the way they treat other purchases: with decision base on evidence of value for money. Organized systems of health care delivery are seeking to define their claims of high quality with evidence, and they are working to improve their performance. The thought of health care providers, clients, and funding sources are changing from quality as a destination to quality improvement as a journey – and outcomes management is playing a key role in the process. Most importantly, outcomes management is providing direction towards the achievement of a health care system that is empirically self-critical, constantly learning, and continuously improving (Enthoven and Vorhaus, 1997).
Factors to consider that will directly impact the functional outcomesassociated with any recommended technologies:
Prognosis of client’s medical condition (e.g., progressive, stable, improving)
Willingness and motivation to use technology.
Characteristics of applied settings (e.g., home, school, work, community, and transportation).
Education, training, and technology tolerance of client, family, caregivers, employers a/o others.
Local access to resources knowledgeable with care and maintenance.
TECHNOLOGIES AVAILABLE
There is a multitude of seating, positioning, and mobility devices available. Each technology device offers specific and unique characteristics that may or may not meet the needs and be consistent with the skills of the client. As a result, technologies must be systematically evaluated to determine specific features and custom configurations that most appropriate match the client’s individual needs and abilities.