Assistive Technology PDF

Assistive Technolog y Objectives 1. Define Assistive Technology and associated team members 2. Discuss the Selection Process for equipment 3. Define a Letter of Medical Necessity 4. Discuss and describe types of seated mobility and adaptive standers 5. Discuss and describ...

Assistive Technolog y Objectives 1. Define Assistive Technology and associated team members 2. Discuss the Selection Process for equipment 3. Define a Letter of Medical Necessity 4. Discuss and describe types of seated mobility and adaptive standers 5. Discuss and describe types of walker 6. List types of adaptive commodes and hygiene systems 7. Discuss and describe switches, controls, and access sites 8. Define and describe augmentative and alternative communication 9. List types of computer technology and electronic aides Assistive Technology Assistive technology is defined (by legislation) as any item, piece of equipment or product system that increases, maintains, or improves an individual’s functional status. AT is used to promote the development and acquisition of skills that a client lacks due to disease or injury. Assistive devices improve the ability to perform socially appropriate activities. Campbell, 5th Ed Chapter 33 Assistive Technology Team Campbell Assistive Technology Professionals RESNA: Rehabilitation Engineering and Assistive Technology Society of North America ATP: Assistive Technology Practitioner ATS: Assistive Technology Supplier NRRTS: National Registry of Rehabilitation Technology Suppliers RTS: Rehabilitation Technology Supplier Specialize in seating and mobility CRTS: Certified Rehabilitation Technology Supplier Certified by NRRTS indicates they are members in good standing and have completed RESNA training  Role of Assistive Technology/Adaptive Equipment To allow for safe and proper positioning for function in home, school and free time To provide reinforcement of positions and movements introduced during treatment and reduce use of atypical movements and postures To encourage perceptual, cognitive and social interaction with the environment To assist in daily management of the child To provide safe transportation W/C and Strollers must have approved tie down systems Precautions with assistive technology / adaptive equipment Poor planning Choice Fitting / growth Match with home environment Misuse Is / will the equipment be used as planned Caretaker’s ability to care for the equipment Positioning vs. restraint Equipment can restrict position transitions and movement exploration Safety: Yes, but must have caution, strapping must not limit the function of the child Equipment must not be used to restrain children with difficulty behaviors, many legal guidelines about use of restraints Parents and caretakers Must share with the parents about the benefit to their child How to use the equipment and its purpose Bring attention to expanded environment with locomotion/ equipment Must teach basic maintenance for the equipment Psychosocial Considerations: Equipment can draw attention to a child’s disabilities and his or her differences. Can be emotionally and socially challenging for the child with a disability AND THE PARENTS AS WELL! Can physically separate a child Selection Process 1. Collect initial data: client information, previous equipment, environmental 2. Generate a Problem Statement: Identify overall needs and specific problems in conjunction with the client and family 3. Establish realistic goals and outcomes: Should reflect desired functional gains and consider funding and other restraints Selection Process 4. Perform physical examination: as related to type of device being considered, consider trial devices 5. Generate a working hypothesis: your clinical impression, this will assist in selection of components and justification of equipment 6. Plan the intervention strategy: A global concept of the assistive technology package, match products to client, use your RTS, consider growth and training Selection Process 7. Implement the intervention strategy: 1. Select components and interfaces 2. Secure funding 3. Assemble or construct the assistive technology package (your RTS will probably do this) 4. Deliver the system 5. Provide Training 8. Follow-up and reassessment  Selection Process 1. Collect initial data: client information, previous equipment, environmental 2. Generate a Problem Statement: Identify overall needs and specific problems in conjunction with the client and family 3. Establish realistic goals and outcomes: Should reflect desired functional gains and consider funding and other restraints 4. Perform physical examination: as related to type of device being considered, consider trial devices 5. Generate a working hypothesis: your clinical impression, this will assist in selection of components and justification of equipment 6. Plan the intervention strategy: A global concept of the assistive technology package, match products to client, use your RTS, consider growth and training 7. Implement the intervention strategy: 1. Select components and interfaces 2. Secure funding 3. Assemble or construct the assistive technology package (your RTS will probably do this) 4. Deliver the system 5. Provide Training 8. Follow-up and reassessment member to consider the cost!! & The Aesthetics matter…to the child/family he price reasonable? Is the weight/size of the equipment manageable?, easy to u Areas to assess for assistive technology Physical ROM, deformities, bracing, previous and upcoming medical/surgical interventions Muscle tone, control and strength, hand dominance Reflexes and stabilization postures Sensory deficits Perceptual skills Cognitive deficits Functional abilities Assessing the home and school environment Entrance to the home/school Elevator or walkup For power mobility must demonstrate that device can get in and be stored in the home Doorways Ability to adapt the home How many people in the home / does child have own room Ability to have 2 devices one for home one for school Equipment Selection Dimensions Availability of optional adaptations Are there parts that help improve the fit and specificity of the device? Are these options cost-effective, easily adjusted, and durable? Reputation of the manufacturer Promptness of delivery Cost Reasonable? Less expensive option? Aesthetics To the child and family? Weight, size, and manageability? Ease of use? Letter of Medical Necessity Demographics Diagnosis Functional Abilities & Disabilities Postural control, distance able to ambulate Description of current equipment Description of requested equipment and benefit to the patient Trial of use of equipment Why other equipment not appropriate Specifics about type, parts , components of equipment, why child needs them Accessibility to home or where equipment will be used Trial of the equipment Parents instructed in use of equipment Estimated lifespan of the equipment Letter of Medical Necessity Describe who you are, what you want, and beneficiary’s name Establish your credentials, and relationship to beneficiary Explain the beneficiary’s condition, including diagnosis, or nature of injury Describe beneficiary’s current functional level noting their limitations without the requested equipment State the type of equipment and accessories being requested Describe why the device is medically necessary Show how the requested equipment will result in an increase of function and other physical benefits Knowledge Check Assistive Technology is defined as A. Any piece of equipment that maintains or improves individual functional status B. Used to promote the development and acquisition C. Improves the ability to perform socially appropriate activities D. All of the above Summary Assistive technology is defined (by legislation) as any item, piece of equipment or product system that increases, maintains or improves an individual’s functional status AT is used to promote the development and acquisition of skills that a client lacks due to disease or injury As the therapy provider we can provide information to the family about the benefits and purposes for the equipment being requested We also educate the family and team about how to use adaptive equipment When selecting Assistive technology, remember to consider the cost!! & The Aesthetics matter…to the child/family: Is the price reasonable? Is the weight/size of the equipment manageable?, easy to use? Seating Benefits of Sitting Optimal for upper extremity function Enhances overall functioning by providing an adequate and secure base of support Inhibits atypical tone, providing a stable base from which the upper extremities can function Improves perception of the environment Significant social benefits to being upright in sitting and mobile Seating Assessment: Measurements Effects of Sitting Positions Goal of the sitting position should be to align the child without restricting the movements and postural adjustments available to the child. Increase in extensor tone thought to accompany the sling effect of most wheelchair seats and backrests: thus often need seating insert systems. Reassessment of the seating device is necessary when the patient’s postural tone improves and new skills are acquired.  Effects of Sitting Positions—(cont.) The criteria and limits described for seating are applicable to all types of seating systems and for all disabilities. Consider the effects on tone and abnormal reflexes. Padding and pressure relief warrant increased attention for the child with myelodysplasia. Home or Classroom chairs Adapt home chair with adaptafoam or triwall Commercially available: how much support does child need, tilt in space, tray and dolly? Brands: Rifton, Special Designs, Trip Trap Chair, ……. CHILDREN’S ADAPTED SEATING www.kayeproducts.c om https://www.adaptivemall.com/ Strollers Adapt a regular stroller Get a special stroller, (will it be used on a school bus?) Make the determination stroller vs. wheelchair Brands: Convaid, snug seat, McClaren Wheelchairs Manual vs. stroller, vs. power, vs. scooters Tilt in space vs. recline Inserts: commercial, custom Linear or Planar Generic Contoured or Modular System Custom Molded Cost: How much? Types of Wheelchair Frames Rigid frame Cross-braced (X- Does not fold, but the frame) folding wheels are removable frame Increased stability More adjustability and ease of rolling Better ability to Choice for sports and “grow” recreation Power Wheelchairs Heavy, difficult to disassemble Require a van for transport and ramps Sophisticated electronically Requires frequent fine tuning and adjusting Usually accommodate environmental control systems Can allow changes in position (e.g., reclining) Can be operated using a variety of switches or other types of controls Wheelchair Seat Seat width should allow for growth and should be able to accommodate outerwear for cold winter climates. 1 inch on each side to be appropriate solid seat, used with a cushion, to avoid the slinging effect of upholstery Cushions Are available made of dense foam, or gel, as well as air filled Protect skin from breakdown Change the patient’s placement and alignment within the chair Seat Depth & Backrest Permit comfortable knee flexion without popliteal pressure Backrest below the scapulae (sometimes) - Depends on trunk control. If child has greater trunk control seat back can be lower. Headrest for transportation or postural support Difficult to mount a headrest on a sling-type backrest Footplates and Leg Rests Dictated by patient size and the wheelchair caster wheel size Multiple-angle plates allow for the braced and non-braced foot Removable leg rests are desirable. Wheel Size Achieves the most energy-efficient propulsion Pneumatic tires give a smoother ride (adding some shock absorbency) for older, heavier children. Better on rough terrain Caster Size Caster size is the ultimate compromise. In the small-framed chair, adjustability of the rear axle is lost if the caster is too big. Clearance between the two wheels is minimal. Small tires add maneuverability but get stuck in cracks, ditches. Options range from 5- to 8-inch diameter caster wheels. Armrest Height Should be comfortable Should allow the patient to take some weight off the shoulders Should allow easy access to the wheels. Experienced wheelchair users (and those with good trunk control) prefer to be without armrests Caregivers often rely on them for added support when transferring the chair into and out of vehicles. Locks / Brakes Should be placed for easiest management Can be operated either by pushing or pulling, depending on the patient’s preference and abilities Many companies also offer high- or low-mount options for brakes. Seat Belts Should originate at the angle of the seat and backrest on both sides Close over the child low on the pelvis Anti-tippers are a must on a child’s wheelchair, especially the young child and the novice wheelchair user Lapboards or Trays Must be carefully fitted to the chair so as not to increase the overall width of the chair Lapboards that are made of clear Lucite or a similar material are preferable to opaque lapboards. The see-through lapboard helps facilitate positive body image by allowing children to see their own lower extremities and lower trunk. The ability of others to see the whole child through the lapboard tends to have a positive impact on the child’s CHILDREN’S WHEELCHAIRS https://www.rehabmart.com/post/top-5-best-pediatric-wheelchairs www.seatingsolutions.com Standers & Walkers Standers Useful if the physiologic benefits of weight bearing are the major goal Good Support in the literature for the benefit of weight bearing Bone health Hip development Physiological (benefits constipation) Accommodate hands-free standing Benefit is to allow the child to interact with peers in play or school situations. Standers: Prone vs. Supine Prone to increase head/trunk extension Supine to increase head/neck flexion Mobile standers Freedom standers Children require good head control and good to fair trunk control Rx for home and school Many children are in a standing program in school. This will require Rx with weight bearing status described Standing Prone standers Used frequently for children who require the position of hands-free upright standing The trunk, buttocks, and lower extremities are all supported. Can change the angle to change the amount of weight bearing Can vary the amount of weight bearing Can vary the amount of extension Avoid hyperextension of the neck, exaggerated retraction of the scapulae with the upper extremities in the high-guard position, and poor symmetry and midline position of the trunk Specialized Orthotic Devices Parapodiums Swivel orthosis Reciprocating gait orthosis Supine Stander Allows weight bearing through the trunk and lower extremities Child is secured around the trunk, hips, and knees. Supine stander is angled toward a 90-degree upright position. No upper extremity weight bearing Avoid thoracic kyphosis and forward head. CHILDREN’S STANDING FRAMES https://www.adaptivemall.com/ Walkers, Walkers: anterior vs. posterior, straight or swivel wheels, max or min support, gait trainers Kaye posture control walkers (Posterior rollator) very commonly used Measure: back bar should hit mid-buttock Gait Trainers: Rifton Pacer gait trainer common but expensive Basic Measure: Floor to height of elbow when flexed Need to choose components (prompts) Need more extensive justification  Rifton Pacer Gait Trainer www.rifton.co m Crutches, Canes Crutches: usually forearm crutches, consider weight of crutch and ability of child to learn the pattern Walk Easy brand, very light-weight, good fit of forearm section Canes: less frequently used Potties and Bathers Will they need a free standing system like a commode, can the use an over the toilet system? Will they self bathe or will caretaker perform? Hand held showers, water driven lift, Hoyer lift, tub transfer bench Brands: Columbia, Rifton, Dukki, Children’s adapted toilets and Bathers https://www.especialneeds.com/shop/bath-toilet-incontinence/commodes.html Knowledge Check You’re are working with a 5-year old child with Cerebral Palsy GMFCS level IV who has limited head / neck extension muscle endurance. Their IEP recommends a standing program for this child to improve head and neck muscle strength to build engagement with classmates and classroom teaching during instruction while upright. Which of the following would be the most appropriate for this child? A. Freedom stander B. Prone stander C. Supine stander D. Parapodium Knowledge Check Feedback Slide Answer: B. Prone Stander Rationale: Prone standers are used frequently for children who require the position of hands-free upright standing and have some ability to lift their head against gravity. The trunk, buttocks, and lower extremities are all supported. The benefit of using a prone stand allows for a change in the angle to change the amount of weight bearing and vertical angulation against gravity force. With a prone stander the upper extremities can be utilized to prop and thus increase a child’s ability to push their head up against gravity for periods of time. Since the IEP goal indicated that the child is to build head control during an upright activity in the classroom, the supine stander be too passive, while the other options would not allow for progression of the skill (Freedom stander and parapodium require the child to be fully upright – greater challenge when holding head against gravity – as head won’t have any support in either direction). Summary Adaptive equipment is used to provide proper alignment, increased weight bearing and upright activities for children with mobility limitations. Standers provide increased mobility and weight bearing through the extremities. Elongation of the body in upright has been shown to improve digestive and respiratory function. There are many different types of pediatric walkers that offer increased participation, physical activity and mobility of the legs and trunks. Partially body weight supportive devices that provide gradual weight bearing for larger children can help build endurance and progression to full weight bearing with time and improved postural control. Adaptive toileting systems are important to build confidence and provide a child the ability to engage in completing this daily life activity. If a child is able indicate the ability to void, it is the caregivers, therapists and medical team’s responsiblity to provide the child with methods of accessibility for greater independence and participation.  Examination & Evaluation for Other Assistive Technology Switches, Controls, and Access Sites Augmentative and Alternative Communication Computer Technology Electronic Aids to Daily Living  In addition to Seating, Standing/Walking equipment… Assistive Technology includes specialized switches, communication devices, computers and Electronic Aids to Daily Living (EADL) Often the term Assistive technology is reserved for these devices The physical therapist, as a member of the AT team, is responsible for the physical examination needed for technology use Proper positioning is ESSENTIAL The PT also evaluates the postural control, muscle tone, ROM, righting and equilibrium responses and more to ascertain the information concerning the child’s functional capabilities, specifically: Variety and quality of active movement  Successful technology use requirements Functional movements must be 1. Voluntary 2. Reliable 3. Repeatable 4. Sustainable Collaboration among health professionals Sensory Skills 1. Visual auditory discriminative input 2. Responses to tactile 3. Kinesthetic 4. Proprioceptive input Knowledge of child’s cognitive function level and learning style Important for selection of appropriate access, feedback, application, and training with the various devices  Switches, Controls, and Access Sites Some children may require special switches or controls to operate communication aids, computers, power wheelchairs or EADLs Switch technology teaches cause and effect (as early as 6 months old) Encourages independent play Promotes group participation Gives control to child over part of their environment Access Site Body part that can produce consistent movement (head, elbow, hand, eyes, etc.) Methods for switch activation include pressure (direct touch or breath) or signal transmission (infrared/Bluetooth) Single Switch -> ON/OFF Multiple configuration -> joystick, wafer boards, head arrays and keyboards Integrated Control system is one which several AT devices are controlled with single output but important to have a back up as if malfunction occurs – all access is limited  Augmentative and Alternative Communication In addition to spoken or verbal output, communication includes body language, gestures, facial expressions and written output With verbal output is limited -> AAC should be implemented led by our SLP colleagues Augmentative communication is any procedure or device that facilitates speech or spoken language Alternative communication refers to the communication method used by a person without vocal ability Electronic communication aids offer a much greater range of capabilities and options for users. Simple $100; High end $1000s (use of eye-gaze Computer Technology Keyboard Adaptations and Alternatives Customized or use of software. Can be expanded, or have guards in place for access. Mini keyboards are available Touch screens, tactile keyboards for the visually impaired Mouse Alternatives Moves cursor on a screen, dragging selected items, selection/functions If modified keyboards are not available to conduct these functions for a child with disability there are mouse alternatives Joysticks, trackballs, mousepads, keypad mouse, and head- controlled mouse Rate Enhancement Capable typist write 100 words per minute/Scanner usually 3- 5 words/min Productivity can become an issue in the educational environment Electronic Aids to Daily Living (EADLs) Previously known as ECU: Environmental Control Unit A device or system of devices (direct or remote controls) that allows the operation of electrical appliances or equipment in a variety of ways and places. Applies technology to facilitate the users control over the environment To promote independent access to items required for daily living To improve the quality of life and participation in society Typically includes three parts: Main control (central processing unit) Switch (Transducer) Any device (Peripherals) Examples of Communication devices, adapted switches, computers Bliss Boards, versa talker, light talker PT should work closely with speech pathologist Toys, computers, home access devices Can learn to make switches yourself or purchase Work closely with the OT involved with the child Touch screens, adapted keyboards and mice, voice activated Can work with Board of Ed, VESID and other funding agencies as well as foundations, Starlight foundation, Make A Wish etc. CHILDREN’S ADAPTED TOYS https://www.adaptivedesign.org/ www.adaptivedesign.org The Adaptive Design Association is a nonprofit organization builds custom adaptive equipment for children with disabilities, using readily available materials. They create low-cost or no-cost custom adaptations for people with disabilities in a landscape of expensive and non-custom commercial products. Other Adaptive Equipment Commercially Available Infant positioners Knowledge Check The physical therapist is a valuable part of the Assistive Technology team by providing information about a child’s A. functional capabilities B. Variety and quality of active movement C. Ability to isolate one movement from another D. All of the above Knowledge Check Feedback Slide Answer: D. All of the above Rationale: The physical therapist, as a member of the AT team, is responsible for the physical examination needed for technology use. As movement specialist we assist to ensure proper positioning. The PT also evaluates the postural control, muscle tone, ROM, righting and equilibrium responses and more to ascertain the information concerning the child’s functional capabilities, specifically identifying variety and quality of active movement and the child’s ability to isolate one movement from another. Summary Assistive Technology is a critical component of intervention for children with impairments in body functions and structures and activity limitations in communication, mobility and self-care Five major areas for AT are seating and positioning, wheeled mobility, augmentative and alternative communication, compute accessing, and electronic aids to daily living. The potential impact of AT on a child’s quality of life underlies the importance of evidence-based decision making that is individualized to the child and young adult’s ability to participate at home, school and in their community. References Campbell SK Palisano RJ Orlin MN. Physical Therapy for Children. Fifth ed. St. Louis Missouri: Elsevier; 2017. Chapters 33 Tecklin JS. Pediatric Physical Therapy. Fifth ed. Baltimore MD: Lippincott Williams & Wilkins a Wolters Kluwer business; 2015.