Editor's note: This text-based course is a transcript of the Using Assistive Technology To Increase Participation In Daily Life Podcast, presented by Theresa Berner, MOT, OTR/L, ATP; Dennis Cleary, MS, OTD, OTR/L.
- After this course, participants will be able to:
- Analyze how patients might benefit from adaptive sports, leisure, and recreation.
- Examine how environmental controls can increase independence and participation for individuals with disabilities.
- Evaluate various levels of preparation occupational therapy personnel can achieve when working in assistive technology.
Dennis: Thank you, everyone, for joining us. I am so happy to be joined by Teresa Berner, an occupational therapist, a longtime friend of mine, and a rehabilitation clinic manager at the Ohio State University Wexner Medical Center. Teresa, thanks so much for being here. Could you tell us a little about yourself and how you became interested in assistive technology and adaptive sports, which you have been doing for a long time?
Theresa: Absolutely. Thanks for having me. I am excited to talk about this topic because it is one that people often ask for information. I started as an inpatient rehab occupational therapist, working with individuals with spinal cord injuries. As I was trying to find ways to help them work through the injury, many things inside and outside the clinic were helpful and valuable. One example is they needed mobility, so I started working on the manual and power wheelchairs. Initially, nobody wants to use a wheelchair because they are convinced they will recover and walk, and they all want to go to physical therapy. I started saying, "Well, where do you want to go, and what do you want to do?" I started looking at the equipment as a tool to help them do things that they needed to live their life. I told them to think of the equipment as allowing them to continue with their life while their body was recovering. For higher-level injuries, they needed to interact and access the environment. I love tinkering, so I became the "MacGyver" of the rehab team. They would bring challenges down to me, and we would try to find a solution. Back then, we did not have the electronic resources we do now.
Dennis: Was this back in the 90s?
Theresa: Yes, it was. Regarding the adjustment, I could not tell them the journey they were on because I was a young clinician. They stared at me like, "What do you know?" I started reaching out to different peer supports, like adaptive sports teams. We would go to a quad basketball practice or a quad rugby game. I started noticing how adapted sports were a way to connect them with other people. This was the beginning of my journey with adapted sports, everyday equipment, and adapted sports equipment.
I started in 1993 and was in inpatient rehab for 11 years. As I began building programs, the outpatient era and healthcare started shifting. People were not staying in inpatient for very long, so the hospital asked me to move to outpatient. At first, I did not want to, but I thought I would try it. Once there, I realized there were people other than those with spinal cord injuries that needed assistive technology. I got involved with RESNA, the Rehabilitation Engineering and Assistive Technology Society of North America, which we will discuss later. I started learning more about this area of practice, which has evolved over the years.
Fast forward 29 years later, I have an Assisted Technology Center at OSU. We serve a variety of different people and have many services. You can be involved in assistive technology at any level as an OT. You could be involved at the patient level, at a program level, or run a big center. There are many opportunities in this treatment realm.
Dennis: Could you talk more about the assistive technology center? Who comes, how do you get referrals, and those sorts of things? It may have started as a wheelchair clinic at one point.
Theresa: The clinic has a wheelchair product line and a driving program. We do clinical assessments in the clinic and then go out on the road. There are vehicles that we use to take people out on the road. We also have augmentative alternative communication devices with a speech-language pathologist providing consultation, and our newest product line is a smart clinic where we have all the home automation. I have 14 staff including occupational therapists, physical therapists, speech-language pathologists, and two rehab engineers. There is also support personnel that helps us with the scheduling and billing.
Dennis: Gotcha. My area of practice is individuals with intellectual and developmental disabilities. I only have a moderate amount of knowledge about wheelchair positioning, seating, and mobility, but I found that using only one vendor was not always the best solution. This was when I started bringing some individuals to see you. A clinic such as yours is a way to understand the various lines and products better.
Theresa: Yes, we become care partners. An advantage of coming to a clinic is that we will have access to much different equipment. We have upwards of 25 different power and 15 manual wheelchairs. We also have hundreds of cushions. Our clinic is a neutral ground where one vendor is not trying to sell a particular product. As an OT, you can be partners with the seating clinics.
Dennis: What I liked is that not only were you there for the evaluation, but you also were there for the fitting. It was nice to have multiple sets of eyes on a client, especially for folks that needed complex molded seating. Another advantage is that the vendors sell more wheelchairs a year through your clinic than they would through a typical therapist, so it helps them to improve the process.
Theresa: What you are describing is the RESNA wheelchair delivery process. RESNA is an organization that supports assisted technology for many professionals. You can be a member if you are a therapist, engineer, or vendor. RESNA writes position papers about best practices for complex rehab wheelchairs and other equipment. They recommend having the whole team together at the evaluation and trial to ensure that what you have recommended is implemented and used.
Dennis: I also liked that clients could try to propel on different surfaces like carpet or tile, as you had a variety to make it a more realistic environment. Do you find that helpful when recommending equipment?
Theresa: Yeah. It is great to hear how our customers feel after going to the clinic. I call it a "lived experience." If you Google wheelchair skills program, there are standardized assessments that you use for wheelchair skills training. The client can train in a scooter, a manual chair, or a power chair. You can even do training with a caregiver. The assessment teaches how to navigate various surfaces and access different doorways and barriers. There are also basic and advanced navigation options. We hope to bring somebody through a series of surface tests, ramps, and thresholds, so that they can decide what feature of a chair may help them the best, depending on what they face in their environment.
Dennis: I think most occupational therapy personnel listening have a decent understanding of wheelchairs and what that would be. Can you talk about the partnership between an OT and an SLP for augmentative communication equipment and how they can combine this with a wheelchair recommendation?
Theresa: I have explored this through my practice. I had times when I thought I could do it all and did not need an SLP. However, this is not true, as the speech pathologist understands all communication components. When looking at a device for assisting or augmenting communication, they assess low-tech and high-tech options. Device selection is inherent to where that person is in either their disease process or disability.
We want to ensure that that device is integrated with the wheelchair. How that device gets attached to the wheelchair is where the OTs and PTs need to come into the process. We also assess to see if the device interferes with vision and transfers. We look at how they will access the equipment and if it can be interfaced with the wheelchair. And we can support what that SLP set up by practicing the skills of this device with the client.
One thing we recently discussed with the SLP is what the clients were going to use for communication once out of the wheelchair. This is one example of how all the clinicians complement each other. Regarding attachment and access, physical and occupational therapists can both address wheelchair seating because we are looking at the physical constraints and the equipment interfacing.
Dennis: I have to tell you a funny story. When I was a young clinician, smartphones came on the market. Yeah. One of my patients said, "I think it was designed for a quad." Before smartphones, someone with a spinal cord injury had to keep track of medications, phone numbers, aides' schedules, and doctors' appointments. As therapists, we had many modalities to help them store and keep track of this information. Smartphones created one compartmentalized piece of equipment. Many years later, we can interface the smartphone with a power wheelchair and the environment using apps. There is an integration of access across the board. We can look at those repeated tasks they need help with and match that to available technology.
The able-bodied world has embraced environmental adaptations and uses them daily, making it even easier for somebody with a disability. This technology does not require expensive rewiring or modifications and is now more mainstream. The bad part is that insurance does not pay for it because it is mainstream, so we have to look at creative funding solutions.
Regarding funding solutions, I will warn everybody that sometimes you have non-profits that think it is fancy and will provide Alexa or a Google home to everyone. However, the device will get abandoned if the person does not know how to use it. Do not undervalue the occupational therapist's role in matching a client's needs to the technology. We have a valuable role that is worthy of clinical intervention time.
At the Assisted Technology Center, how do you have that set up for clients?
Theresa: We try to have representation of many different devices as we do not want to show a bias. I also want to talk about the other areas of smart technology. If you are unsure which way to go, the United Spinal Association has a technology access group with resources. You can also Google different devices because consumers will write about their experiences. For example, it is hard in a hospital setting to use Alexa because it is noisy and can also become a security issue.
Dennis: Plus, the wifi issue is always fun.
Theresa: Right. Having the conversation is still valuable. You do not have to have everything at your fingertips, but you can make them aware of options. Once you point things out, clients can often run with it. Other times, you may need to hold their hand. Sometimes OTs are reluctant to start because they feel they are not the expert, but you only have to have that conversation.
Adapted gaming has become a great resource. We have had people who assumed they could no longer use a device due to hand impairments. There are adapted switch controllers on the market and many e-gaming initiatives. People can be socially connected with a community through e-gaming and not have to leave their houses.
Dennis: This was especially true during COVID. Many people were connecting with their networks and establishing new networks. People with disabilities were able to benefit from that.
Theresa: Absolutely. We are seeing a whole initiative in the Assisted Technology Center. We can introduce it and show them some examples, like X-Box.
Dennis: A recent podcast on OccupationalTherapy.com with a University of Michigan OT talking about gaming as an intervention. I think it is helpful for us to have general knowledge about available options to share with the individuals we support. Within the Assisted Technology Center context and regarding RESNA, what kind of certifications can occupational therapy personnel or others get that would be useful for those interested in assisted technology?
Theresa: The most common advanced certification is the Assisted Technology Professional (ATP). This is a broader certification for somebody working in assisted technology. You have to work so many hours in the field, and there are different other criteria based on your professional degree. It gives you a platform to interface with the consumers. Medicare requires a supplier that provides power wheelchairs to have this certification. It is a level of recognition, and you must take a certain number of continuing education hours to maintain it. And if you are involved in mainly wheelchair seating and positioning, there is a second certification that you get in addition to the ATP called a Seating Mobility Specialist (SMS). You can have both ATP and SMS certifications. These are highly recognized areas that I encourage listeners to check out.
Dennis: Despite having "engineer" in the name, RESNA has many other professionals. Correct?
Theresa: The Rehab Engineering Society in North America (RESNA) is the home for anyone who wants to work in assisted technology. The group has areas of interest like school-based practice, seating, mobility, or communication. Most therapists end up clumping into one group as we collaborate so much. Engineers have their subgroups. It is a great learning environment and promotes networking.
Dennis: Even though I do not live in Columbus, Ohio, anymore, I still reach out for a consult now and then. A few weeks ago, you connected me to a speech-language pathologist and a rehab engineer for some ideas for a woman that was difficult to understand but would be using a hospital-wide telephone system as part of her job. How do rehab engineers complement therapy interventions?
Theresa: A rehab engineer can have a mechanical, biomedical, or electrical engineering degree. They can have any engineering undergrad degree and get advanced training in the rehabilitation field. They learn how to apply technology to a person's needs. They are often very good with the technological piece, and therapists who work in AT usually have a natural inclination to want to tinker. What I have learned is there is an area where therapists tend to level off due to a knowledge gap about technology. I have seen this in the past five to six years because of the complexity of technology. We advocated for a rehab engineer to come to the clinic with us as a "value-added" service, so we do not bill the client. The rehab engineer supports the clinicians and allows us to prioritize our time and ensure that the equipment is serving at its highest level.
Our rehab engineer is Liz. How I look at it is that she has enough clinical knowledge to understand the person, but she has more mechanical expertise and the time to program, upload, integrate, and set up the devices. OT or PT's time is utilized for the interface of the patient with the equipment, and therapists love that. They do not want to spend their time programming or setting up equipment. They want to interact with that person. The engineer can then stick around and see how the equipment and their work are utilized. It has been a great partnership, and I hope to see more rehab engineers in clinics. They are in the VA and academia, but you do not see them as much in clinical settings.
Dennis: I think it can go both ways. I have had a couple of experiences where a rehab engineer has vended a communication device that was not appropriate for somebody. They understood the device but maybe did not understand the human side. The collaboration between the therapist and the rehab engineer is a great model.
In terms of looking at different environmental controls, can you give us an example of a product that helped somebody increase their independence?
Theresa: The one that resonated with me had to do with privacy. I had an individual with a complex disability who always needed a caregiver or family to either turn on, set up, or shut off to interface with a device. This necessitated another person in the room that could hear their conversation. As soon as technology allowed the person access to their smartphone or computer, they had independence and privacy. Many of the automated and voice-activated controls have been game-changers for folks.
Dennis: True. For people with intellectual and developmental disabilities, we can give them some independence and remotely watch for safety. This has been especially helpful with a shortage of direct care staff. You said it is difficult to get insurance to cover some commercially available setups. Are you able to bill for evaluation and treatment for assistive technology?
Theresa: I will talk about the billing, and then can I talk about the reimbursement? As a clinician, anything that you do with a person, your therapeutic interaction, you can bill. For example, if I do a pressure mapping on a wheelchair, I am not billing for that. I am using pressure mapping to give me a picture of the pressure distribution of that person. I view gaming as recreational play or therapeutic intervention. These services are always billable. I tell therapists, "If you can pull someone off the street and show them exactly how they can modify and implement this activity, then it is not skilled." You need to think about how you are adjusting, adapting, or matching a feature to their ability level. That is the therapeutic piece. Again, you do not have to have the device in front of you. You can get on the internet and say, "Let's explore what may be available and talk about how you can find these resources on your own." That is a therapeutic interaction and all billable.
Everything insurance pays for has to have a code, and there are no codes for all this fun stuff. And, as you know, insurance believes that none of this fun stuff is medically necessary. If there is no code for it, how do you get it? You look at alternate resources, like those used for the DD population, as an example. They have funding through their county and some other funding sources. Individuals that are on Medicaid have waivers that may pay for equipment. They may also have a non-discretionary budget that they feel will help them with their independence.
Dennis: I have filled out a number of those Medicaid waiver forms that they want an OT, PT, or a speech-language pathologist to complete. They want an assessment showing how the device or piece of equipment will be helpful for them.
Theresa: There are also many grants for medical devices, home automation, and adapted sports equipment. You can help your clients search for grants and help them apply during your therapy session. The last option is low-interest loans through technology centers. Every state has a tech act. You need to locate the technology resource center in your state. They can connect the client with resources or work with them on low-interest loans. Many people are using GoFundMe.
Dennis: Every state does it a little differently. Ohio State's technology center is through the Department of Engineering, whereas, in Nebraska, it goes to their vocational rehabilitation (VR) folks. Many VR counselors are ATPs and are doing more hands-on types of stuff. I just got four iPads for the year from AT Ohio that we use for our clients in Cincinnati.
As you said, technology has gotten more complicated and specialized. What is a good way for an occupational therapy practitioner to discover what is out there? We can Google, but are there certain resources that you can share?
Theresa: I am a big fan of the United Spinal Association. I did not know about them early in my career. It started as a resource for people with spinal cord injuries, but now it is a resource for many with disabilities. They publish a little booklet called "New Mobility Magazine." It helps you to look at things through the eyes of the consumer. I can say confidently, "I have heard people tell me this is good." The Paralyzed Veterans of America (PVA) is a beautiful resource. Organizations like the Christopher and Dana Reeves Association and the Craig H. Neilson Foundation have popped up.
Dennis: Easter Seals in Indianapolis has a fantastic site as well. One of the cool things you have done in the last ten years is looking at adaptive sports as part of your Assisted Technology Center. What led you to that, and what have been some fruits of that?
Theresa: It has been a journey. I was a young therapist working with many people my age with spinal cord injuries. I could not tell them how life would be, so we started attending different events. When I worked in outpatient, I thought, "How do they get their equipment?" I knew how they got their standard equipment, but I started investigating how they could get a basketball or a rugby wheelchair. Many would hop in their friends' chairs and play, but they were not set up well for them. I knew they could be more successful if they fit correctly in their wheelchair. I started talking to people and found no systematic way to assess an athlete's needs was available. It was more word of mouth, and the equipment was not always set up correctly. I also found out that individuals with all types of disabilities did not learn about adapted sports until five or years after their injury. They lost the opportunity to have networking and peer support during that time.
As we saw the need, we started the Adapted Sports Institute at OSU. It is a virtual center that brings together anybody in this system. We have partnered with Nationwide Children's Hospital to promote adapted sports and wellness. We aim to link with the community to be a resource and advocate for people; many of us volunteer our time. My kids are grown up, so I have gotten back involved with adapted sports. I run an adapted cycling program on Mondays. Often, people think they cannot ride a bike their age or balance, but they do well with a recumbent bike. They all say it was great to feel the wind through their hair. I have had people with neurologic disabilities that have been able to partake in this program. I think the role of the OT is to ensure people are fit and have access to the equipment.
Dennis: Absolutely. I remember when I started volunteering with the wheelchair basketball team in Columbus about ten years ago. The camaraderie is outstanding, but it is also a great learning experience for those newly injured. For example, if they had to fly for a game, they could learn how to travel in a wheelchair by observing others, and it is always more fun when you are doing it with other people. What other sports are you helping to support at Ohio State?
Theresa: We support wheelchair sports like softball, tennis, and quad rugby teams. The new thing is wheelchair football. There is blind soccer, power soccer, and wheelchair racing in track and field. Disabled Sports USA is where you can learn about different events.
Dennis: At Ohio State, they are encouraging their occupational therapy students, as well as physical therapy and speech-language pathology students and other students, to participate in this program. It is good for the students to see the possibilities for folks. What kind of differences do you notice with people after they start participating in sports? Is it different from the results in a "typical" outpatient program?
Theresa: I see a lot more confidence and acceptance. They are now immersed in a community with other people like themselves. It is not a surprise that access and transportation can be a barrier. A sports program can motivate a person to explore getting their license now that they have a reason to do that. It opens up their world and gives them networking opportunities for work and social pursuits. For lack of a better word, it gives them purpose. It is the same thing with able-bodied people, especially during COVID. Many lost connections with people during the pandemic.
With sports, some people stay at the rec level, while others get motivated to work toward a high level of competition, even the Paralympics. I have seen people take off with adapted sports and others absorb it as part of their community. It does not have to be a competitive team, but it could be part of a family outing.
Dennis: Gotcha. I am affiliated with a wheelchair basketball team in South Bend, and during COVID, they had weekly Zoom meetings. I had enough Zoom time at work, so I took some time off. I am now volunteering again for the team. Wheelchair basketball and the quad rugby team in Columbus were primarily folks with spinal cord injuries, but the team here is less competitive. The South Bend Rollers, our local wheelchair basketball team, has a broader variety of folks, not just individuals with spinal cord injuries. There are a couple of folks with spinal cord injuries, but there are other wheelchair users and even a few folks with difficulty ambulating. All are welcome. There is even a double amputee. His wife and kid come and watch him play basketball, so it is a lovely family outing.
You talked about correctly fitting someone in one of these adapted chairs. How does that work? Is that a service you provide, and is it billable through insurance? Do you have different trial chairs?
Theresa: We have been trying to navigate that. The service provision for these adapted sports teams makes sense at the time and place where they take place, so you have to have somebody that is immersed in the community. I will use cycling as an example. We have what is called Discover Cycling. On Mondays, people pre-sign up and meet at a location. I have 50 cycles to disseminate among this group by determining who is a foot propeller, hand propeller, et cetera. If a participant decides they want their equipment, I have them come to the clinic, which is the therapeutic intervention. We fit them for one and discuss the maintenance of it. I may have already figured out it will be a recumbent bike with foot propulsion and a left brake based on the community ride. This is the science that you will not get out in the community.
We have convinced the wheelchair racing team that they should be specially fitted in the clinic. My friends in the VA get to do this all the time because the VA pays for it. Initially, I wondered where all the people were and why they were not coming to me. I figured out it was because they did not know. We found that community exposure implements this process. They get interested and come to the clinic, and then we assess, order, and bill for the time. The bikes come through a grant, so we are teaching them how to get started. We write letters of recommendation to promote the clients receiving this equipment because we have observed them engaging in community mobility.
Dennis: Right. We have been successful locally with fundraising for the wheelchair basketball team. What other stories can you share?
Theresa: We had a girl that incurred a spinal cord injury at age nine. The family was in a car, and somebody t-boned them. During her recovery and rehab, she received an upright bike. She came to a Discover Cycling event and wanted to try a recumbent bike. A group of well-intended nice people wanted to pay for a $6,000 hand cycle that this girl had never tried. Had she not had that chance to experience it and have it properly fit her, it would have gone to waste. This is the connection between helping them know what they are getting and ensuring that it matches their needs.
Dennis: Absolutely. People are well-intentioned, but an abundance of adapted bikes are sitting around. I know that Fred Sammons is a huge advocate for that, but he also partners with local occupational therapy programs to try to distribute those appropriately. Do you have advice for young therapists interested in pursuing assistive technology or adaptive sports? Where should they start?
Theresa: We are always looking for OTs. If you are interested in any form of assisted technology, which I feel comes very naturally to us as therapists, use it. Do not be afraid to do wheelchair seating. Ask questions of your vendors and try out the equipment. It is essential to get involved at any level, even if you do not have to have all the answers. When I started, I did not have a clue and did not have the internet to look things up. You do not need to know all the answers, but you should know what questions to ask.
As far as adapted sports, go out to an event and observe. Do some community outings with your clients. They may feel safer going with you, and you can start slow and simple. Over time, this will evolve because that is what we did. I started this with four patients once a week in a clinic, which has evolved into a full-time assistive technology center with a whole staff of clinicians. You can do it if you are interested.
Dennis: As occupational therapists, we naturally know that participation benefits health. I was happy South Bend was big enough to have a wheelchair basketball team. If you are in a smaller town without something developed, you might need to start something small. However, there are many resources as people use wheelchairs throughout our country. Perhaps something smaller, like adapted tennis, would be doable.
Theresa: There are also the arts. Chair and adapted yoga is becoming popular. I went to an adapted yoga with one of my former patients, and boy, were my abs hurting. It was fun to see both my client and able-bodied people in the audience. Some were in wheelchairs, and some were not. The arts are evolving.
Dennis: Sure. Whenever I play wheelchair basketball, my shoulders have let me know that for several days after that.
Dennis: Teresa Burner, thank you for propelling us through this process. Watching the Assisted Technology Center at Ohio State continue to grow and blossom has been fun. Thanks for your leadership.
Theresa: Thanks for having me. It has been fun.
Dennis: Thanks for joining us, everybody. Take care.
Available in the handout.
Berner, T., & Cleary, D. (2022). Using assistive technology to increase participation in daily life podcast. OccupationalTherapy.com, Article 5554. Available at www.occupationaltherapy.com