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Assistive technology assessments

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OTs can help clients access the right equipment to increase function, independence and quality of life.

Assistive technology (AT). Many occupational therapy practitioners specialize in this area, even more work with AT some of the time, and many more work with clients who are using or could benefit from AT. Assessing for AT is crucial to match the appropriate equipment and its implementation to a client's specific needs. Occupational therapy practitioners are well-trained to perform an assistive technology assessment. OTs can evaluate functional needs and capabilities, not just measure skills. OTs also have expertise in the areas of physical, sensory and cognitive deficits. Finally, OTs routinely look at occupations. The purpose of assistive technology is to augment or replace skills to allow a client to perform occupations.


Contents

What is AT?

Assistive technology helps people with physical, sensory and/or cognitive limitations be as functional and independent as possible. Assistive technology may include:

Seating: Simple modifications to a classroom chair, to linear or contoured seating systems in a wheelchair.

Mobility: Gait trainers, walkers, dependent mobility bases (i.e. adaptive strollers), manual wheelchairs, scooters and power wheelchairs.

Augmentative communication: Communication boards, Picture Exchange Communication System (PECS) and speech generating devices.

Computers: Alternative keyboards, alternative mice, rate enhancement software and voice input.

Electronic aids to daily living (EADLs): Large-button remote controls to full-scale home automation accessed by switch scanning or voice. This includes control of audiovisual equipment, lights, appliances, doors and phones.


Assessment Settings

AT assessments can occur in a number of settings.

Clinics. The medical clinic is likely to utilize a team of evaluators which may include an occupational therapist, physical therapist, speech language pathologist, physician, rehabilitation engineer and/or a social worker.

Most medical clinics use a family-centered care model. The client must leave his or her natural environments, and it may be more difficult for the client's existing team members (i.e. treating therapists, teacher, etc.) to attend. However, this model often offers a qualified and experienced team with plenty of equipment available to use in an evaluation.

Many of these clinics also offer support for a variety of assistive technology devices, enabling team members to integrate all recommendations. For example, if a client is receiving a power wheelchair and an augmentative communication (AAC) device, the team can ensure that the AAC device can be mounted to the power wheelchair.

Unfortunately, many clinics have closed their doors in the last several years, primarily due to declining reimbursement.

DME suppliers. The durable medical equipment supplier often performs AT assessments, though almost exclusively for seating and mobility. The supplier may be responsible for mounting a communication device or computer to a wheelchair or for interfacing AT devices to a power wheelchair. If a client has limited access, he may need to use the same switch site for accessing their communication device (i.e. single switch scanning) and accessing the power wheelchair (i.e. forward directional control). The supplier can interface the communication device through the power wheelchair electronics to share this switch site.

The supplier may or may not involve the caregivers, treating therapists or other team members in an evaluation. The supplier may be more likely to limit product options to those that are more profitable. This is not necessarily unethical; it is called "staying in business." However, someone who is not working for a DME supplier may be able to present the client with more options.

Natural settings. The final most common assessment setting is the client's natural environments: home, school, work and even occasionally out in the community. This assessment may involve a single evaluator or an entire multi-disciplinary team. Often, other team members who work with the client on a regular basis are able to attend. The client may be more at ease and the assessment is usually more realistic as the resources and barriers in that environment are more apparent. The evaluator(s) may have less equipment to perform an assessment on-site than in a clinic setting.


Assessment Process

The AT assessment follows the same process as most occupational therapy evaluations and includes obtaining background information and client goals, evaluating current functioning and specific AT needs, and making recommendations.

Background information. This includes basic demographics, medical status, current therapies, home setting and whether the client is in school or working.

Client and caregiver goals. These may differ from the goals of other team members and may include short and long term goals. Goals may differ for each environment as well.

Current functioning. This can include a number of client factors such as range of motion limitations, muscle tone, reflexes, motor control, vision, hearing, cognitive status, communication, skin integrity, reported pain, past surgeries, pending medical procedures, ADLs and current equipment.


Specific Evaluation of Appropriate AT

Seating. This includes a full evaluation of the current seating system, mat exam and seating simulation, as possible. If the therapist recommends a custom contour seat, she must perform a contoured seating simulation. The therapist may also include pressure mapping in the evaluation.

Mobility. This includes a full evaluation of the client's current mobility and level of function. For example, a client may be able to ambulate, but only for several feet unassisted. If the therapist recommends a manual wheelchair for self-propulsion, she must determine the optimal base and configuration for the client. If the therapist recommends a power wheelchair, she must determine the access method (i.e. joystick or head array) and the optimal base.

A mobility evaluation also includes driving to determine if the client is an appropriate candidate and to determine the optimal access method.

Computer access and use. This includes determining a means of input (keyboard, mouse), output (e-mail, print) and feedback (display, auditory). The client may simply use a switch to operate basic software programs. Other clients may need an alternative keyboard (i.e. enlarged keyboard) for text entry and an alternative mouse (i.e. trackball) for cursor control.

Software is available to increase efficiency, both motorically and cognitively. Software is also available to enlarge or speak what is on the display. The evaluation must determine current reading and writing levels, fine motor skills and visual skills to match appropriate technology.

Augmentative communication. This evaluation is most appropriately done in conjunction with a speech language pathologist. Current receptive and expressive language skills must be determined. If the client requires a speech generating device, determine the access method. This may be direct (finger or pointer to screen location), switch (single or dual, various methods of scanning) or mouse.

The client may require larger representations or certain color contrasts to see the display, auditory feedback during scanning for visual and/or cognitive reasons. The therapist must determine placement for best visual regard and for optimal access.

Electronic aids to daily living. It is best to perform this evaluation in the home environment, as this is typically the most common location for EADL usage. The therapist will evaluate current control of devices within the home environment, as well as the client's vision, cognition and fine motor skills to determine the best EADL for the client.


Recommendations

Equipment. The team reviews the client's needs and abilities which define the parameters the equipment must meet, then discuss and present various options to the client and caregivers. Unfortunately, funding sometimes dictates options. The client may really want a titanium manual wheelchair, but his insurance may not cover it due to the high cost. With the client's and caregiver's input, the team makes final equipment recommendations.

Implementation. Equipment is great when the client uses it, not when it sits in someone's garage. At this stage of the assessment, it is crucial to determine how the client will implement the recommended equipment into his life.


Getting AT to the Client

Equipment procurement. Funding source(s) may require certain documentation to justify the recommended equipment. Private insurance, Medicare and Medicaid usually pay for more medically based equipment, such as seating and mobility equipment and augmentative communication devices. These funding sources often do not cover computer equipment and EADLs, but the school system or vocational rehabilitation may. Part of procuring AT equipment is determining all potential funding options.

Fitting, modification and fabrication, as needed. The therapist or another provider may need to perform additional services when the client receives the equipment. These services can include:

  • Fitting seating and mobility equipment to the client at delivery;
  • Modifying AT equipment (often necessary for commercially available equipment);
  • Custom fabrication;
  • Programming augmentative communication devices for the client's vocabulary needs and setting up devices for specific access requirements;
  • Installing and setting up computer software; and
  • Programming EADLs for the specific devices they will control.

Follow-up. Both client needs and assistive technology change. Regular follow-up is essential to ensure that the recommended AT and implementation is still meeting the client's goals.


Conclusion

Assistive technology is an exciting practice area that can provide clients increased functioning and independence in a variety of occupations. Occupational therapy practitioners are in a unique position to provide AT assessment to clients, resulting in optimal AT equipment procurement and implementation to match specific client needs.


Author: Michelle L. Lange
Email Address: MichelleLange@msn.com
Other Information: Michelle L. Lange, OTR, ABDA, ATP, is owner of Access to Independence in Arvada, CO. She has 20 years experience working with assistive technology. She is currently Secretary of RESNA and a frequent author and presenter.