Clinically Speaking

Making the Argument for "Open CRT"

• May 01, 2016

Steve Mitchell, OTR/L, ATP, is an occupational therapist who works as a clinical specialist in seating/wheeled mobility & assistive technology for the Spinal Cord Injury & Disorders Service at the Cleveland Veterans Affairs (VA) Medical Center. He has more than 25 years of experience working with people who have neurological conditions. The last 12 of those years have been devoted to providing custom mobility equipment to veterans living with spinal cord injury (SCI), multiple sclerosis, and amyotrophic lateral sclerosis (ALS).

Once his appointments for the day are done, Mitchell starts on his second passion, one deeply and personally connected to his first. He spends days prescribing seating & mobility to produce the best outcomes for his clients, but dedicates many evenings to developing systems he may one day prescribe.

He calls this goal “Open Complex Rehab Technology (CRT).” Mitchell hopes it’s the direction that future assistive technology will take to address the needs of the industry’s most complex clients.

The Role of Product Configuration

“I work at one of the 24 VA regional SCI centers,” Mitchell says. “Most of my veterans have complex needs; their wheelchairs play a critical role in just about everything they do. We will follow each veteran for life.”

He adds that VA seating clinicians are often responsible for functions that are performed by the supplier/ATP in other settings.

“When seating clinicians in the private sector evaluate a client, what they are able to prescribe is frequently constrained by funding,” Mitchell explains. “Much of their time away from the client is used documenting the medical necessity of the equipment to ensure it will be reimbursed. When a veteran requires a complex rehab power chair, we are less constrained in what we can prescribe, but many of us must also assume responsibility for obtaining product specifications and configuring the product without supplier ATP services.”

Working so closely with products has given Mitchell insight into how successful outcomes are created. He notes that they “require more than just a clinical understanding of the user and knowing which products are available. Knowing how to configure the product to effectively meet their needs is equally important. When I’m not working directly with veterans, I devote a significant amount of time identifying the most effective configurations for the needs of the populations I serve.”

Mitchell acknowledges that this has gained him a reputation “of being very product oriented for a therapist,” but he says, “At the end of the day, I am just a therapist trying to get the best outcome for the individual who uses a chair I prescribe. It’s truly an awesome responsibility, when you think about it.”

In 2008, the VA made ALS a service-connected condition, meaning that anyone diagnosed with ALS who served in the military became a potential candidate to receive power mobility from the VA. “Our SCI/D service formed an ALS clinic the next year, and we began seeing veterans with ALS in significant numbers,” Mitchell says.

But there were differences with ALS patients.

“Our service delivery model was completely compressed, because it wasn’t as if [ALS patients] were going to come in and see me to reevaluate their seating,” Mitchell says. “Actually, they’re here to see the doctor for some other reason. Or they’re people I hardly have the chance to evaluate — they’re in the doctor’s office because they have a lot of respiratory issues, or they’re newly diagnosed.”

Due to the severity of ALS, how quickly clients can progress, and how precise their positioning has to be, Mitchell found himself tweaking equipment for individual ALS clients.

“When I came up with workable solutions in the clinic, I didn’t want to do more work than I had to,” Mitchell says. “Instead of having to repeat the same thing, instead of having it done through our [supplier], I was having it done through the customs department of the manufacturer.”

Technology needs vary from client to client, he adds, including whether a patient will eventually need respiratory equipment to be accommodated on the wheelchair. But so many of those needs can’t be predicted when a power chair is first being configured.

That’s where Mitchell’s “Open CRT” strategy comes into play. It can be described succinctly via a single word: Modularity.

Holding Onto Old Rules

Modularity would embrace the probability that the best answer
for any particular ALS patient could be a hybrid power wheelchair system.

One example: “There are elbow stops that I developed that allow us to work with normal armpads, but if we need to do arm troughs, we can pull the inserts off the armpads and put those on there,” Mitchell says. “On one hand, I’m a clinician. On the other, I’m a product person. What I try to do is interface the equipment with the person’s need.”

Creating a successful interface, Mitchell adds, can require adopting new ways of thinking for everyone involved: clinician, ATP and CRT manufacturer.

“What seems to be happening a lot these days is we’re holding onto old rules, and we’re not really looking at what’s best for this population’s needs,” Mitchell says. For instance, while tradition may dictate a head array for late-stage ALS clients, “What I’m finding is if I can get a joystick in the right place, most of our guys are going to be able to use that joystick the rest of the way.”

Preserving function and quality of life is personal to Mitchell, who sustained a spinal cord injury at 17.

“It was the first three weeks after my injury, and I had sensation, but it was abnormal sensation, and I was sitting in just a regular wheelchair in the hospital,” Mitchell said. “I remember being totally miserable and helpless. To think about these guys at the end of their lives — their chairs by and large are sitting to the side because they stopped being driven some time ago. [These clients are] sitting in a hospital bed on their sacrum, uncomfortable and unable to move. Where I think power mobility can play a super important role is if you can give them the ability to control their positioning in their chair, and tilt and reposition, that’s going to be 100 percent more comfortable than the alternative —in a bed, unable to move. I just can’t imagine my last days being that.”

And Mitchell says that’s why Open CRT is needed.

Coming up in Part 2: What Open CRT looks like, and the obstacles in its way.

The opinions expressed in this article represent those of the author and do not represent official policy or positions of the Department of Veterans Affairs.

This article originally appeared in the May 2016 issue of Mobility Management.