Evidence & Outcomes
Will Evidence-Based Practices & Outcomes Measures Drive Complex Rehab Success?
- By Laurie Watanabe
- Mar 01, 2017
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You have so many complex rehab technology success stories.
A grad student who now zips to class in an ultralight chair with
power assist. A mom who takes her power chair to the office and
weight shifts every hour. A dad who uses seat elevation to cook
dinner. A first-grader who mastered her new head array.
Such successes are life changing. They are also hard to quantify
in a spreadsheet. Pharmaceutical companies report that a
drug lowered cholesterol in x number of trial participants, but
it’s tough to prove that a custom-fit wheelchair cushion kept a
consumer free of pressure injuries. Thus, funding and referral
sources ask, “Does complex rehab technology (CRT) work?”
Efforts to justify CRT take many forms, from RESNA position
papers to academic research (see the Functional Mobility
Assessment [FMA] sidebar). In light of this push to measure
CRT outcomes, we asked clinicians and ATPs: How critical are
measurable, evidence-based outcomes to your decision making
when choosing seating and mobility strategies and equipment?
Here’s what they said.
“A Unique System”
Delia “Dee Dee” Freney,
OTR/L, ATP, occupational therapist
Continuing Care Service Center DME
First of all, we work for Kaiser. It’s a unique system. As DME
therapists, we do High Mobility (CRT) clinics with an RTS [rehab
technology supplier], submit the clinical report and approve (as funders) the recommended CRT. There are times where there are
co-pay funders such as MediCal/Medicaid, but for the most part,
we are somewhat a “closed” system.
Even though we are first-level reviewers, there are often nextlevel
reviewers who look at what is being approved and [deny]
CRT. For example, most funding will not cover seat elevators and
power assist. As clinicians, we document functional reasons these
items would benefit the patient based on medical reasons such
as transfers for seat elevators and shoulder pain and arthritis for
We’ve used RESNA position papers for tilt and recline to
support our recommendations for adding these features to power
wheelchairs and recently viewed the application of seat elevating
devices for wheelchair users. As clinicians for an HMO, measurable,
evidence-based outcomes support our recommendations
for the clinical decisions we’ve made rather than influence our
More measurable, evidence-based outcome studies are
important and critical to enable therapists, providers and funders
to justify CRT for end users to enhance their lives with the best
technology available and to be as independent as possible.
Perhaps evidence-based outcome studies would be helpful for
new therapists coming into our world in making decisions for CRT.
Problem-Solving + Creativity
Michelle L. Lange, OTR/L, ABDA, ATP/SMS
Access to Independence, Inc.
I believe it is important to use outcome measures to track whether
our recommendations have actually met a client’s goals. If we
have no measure of the effectiveness of our interventions, we are
less likely to modify — and hopefully improve — those strategies.
Yet on the other hand, I routinely encounter professionals
who request evidence-based articles or assessments to help them
determine the best interventions. I work with complex clients who are each unique individuals. It is unlikely that a journal article
is going to specifically inform me as to where to place a switch
for access to a communication device for a child with cerebral
palsy. I still must rely on basic assessment, problem-solving, and
a degree of creativity.
The Best, Not the Cheapest
Stacey Mullis OTR/L, ATP,
director of clinical education
When I look at our current climate, I think it is becoming necessary
to have evidence-based outcomes in mind when choosing
equipment. The IMPACT ACT of 2014 has brought increased transparency by requiring post-acute care providers to report
standardized patient assessment data on quality of care and
resource use. CMS [Centers for Medicare & Medicaid Services]
then is publicly reporting on these quality measures, two of
which can be related to seating and wheeled mobility: Percent
of residents or patients with pressure ulcers that are new or
worsened; all-cause unplanned readmission measure for 30 days
from long-term care hospitals.
This type of legislation highlights the emphasis being placed
on evidence-based practice and quality of care. By providing
evidence-based outcomes that show how proper equipment
reduces the incidence of wounds and re-hospitalizations by
improving function and productivity, we are justifying the need
for selecting the best equipment for the individual, not cheapest.
We then have data to demonstrate how providing the right
equipment ultimately saves money.
Evidence As Advocacy
Home Medical Equipment
Patient outcome measurements and evidence-based practice are
gaining steam in the industry — for good reason. Historically,
the assumption of most funding agencies has been that CRT
clients don’t need things the rest of us take for granted (being able
to reach into a cupboard, or even standing, for example). That
attitude, along with a general ignorance of the CRT industry,
has led to inadequate funding — or no funding — for equipment
that can keep people independent, healthier and living at home.
Evidence-based practice and outcome measurements are the key
to educating funding sources and others of the benefits of CRT.
Each client is unique. So our approach should be unique and
client centered. Measuring outcomes by evidence of benefit starts
at the initial evaluation by performing a Functional Mobility
Assessment. Interview and document the client’s needs, desires
and goals. This approach creates a team spirit between clinician,
ATP/SMS and the end user. More importantly, it empowers the
client to make decisions regarding his/her own care. With this
baseline the client can be tracked after delivery to verify goals
have been met. Poor marks on the FMA clearly show the need for
a different approach. Documenting improved functional status
can do much to establish the benefits of traditionally non-funded
items, such as power seat elevators and standing devices.
Outcome measurements and evidence-based practice are one
of the best ways we can protect access to CRT, and advocate for
Steve Mitchell, OTR/L, ATP
Cleveland VA SCI/D Service,
Multidisciplinary ALS Clinic
Evidence-based practice is in healthcare what continuous
product improvement is to a CRT manufacturer. The future of
many of these products will depend on our collective willingness
to adopt both approaches. Successful clinical outcomes
require clinically effective products.
Standardized outcome instruments like the FMA can give
us some idea about how well we are doing. Recently, we began
administering the FMA and are contributing to the database.
As one of the first [Spinal Cord Injury] Centers in the VA to
start providing data, I am certainly interested to see what the
“evidence” tells us over time.
I also know the usefulness of the data of a standardized
outcome measure will always have limits in complex rehab.
Limited sample sizes, complex needs and high heterogeneity
among users guarantee it. The irony is that the harder we try to
control variables and get “the numbers” needed to do a largescale,
well-controlled scientific study, the less likely it will provide
useful information. This applies to both clinicians adopting
evidence-based practice or a manufacturer who uses continuous
product improvement. Neither can get all the information they
need unless they get the input and expertise of the other.
Lastly, we will never see meaningful peer-reviewed evidence
published about the effectiveness of these products unless we
share practice-based evidence. Oftentimes a less formal analysis
of the practice-based evidence we can all collect in our individual
settings can have a much greater effect on our clinical outcomes.
When we identify common problems or potential solutions, we
need to share those things in a responsible, qualified manner —
not just to help someone else, but to allow others to examine,
validate, propose alternatives or build upon what we’ve found.
The Importance to Manufacturers
Nancy Perlich, COTA, ATP,
Measurable, evidence-based decision-making is of utmost
importance whenever manufacturing or choosing any CRT.
The more we know as a manufacturer (testing, consumer and
clinical surveys, research, etc.), the more appropriate and defined
products we can produce for the best outcome for the consumer.
When clinicians use evidence-based outcomes and consumer-centered clinical reasoning, they add support to their choice
of CRT and weight to their documentation that payors should
understand, respect and pay for.
Lori Potts, PT
Any clinician who has worked with children (or adults) with
neuromotor impairments knows the importance of appropriate
CRT. The therapy community has long recognized the importance
of research-based evidence to validate and promote what
we have known through our own experience, and when evidence-based
research is available, it certainly impacts our clinical
However, particularly in pediatrics, there is a dearth of
research. Many clinicians, myself included, rely on what is
considered the lowest level of evidence, basing our decisions on outcomes of case studies and clinical experience. It is important
to note that CMS seems to be placing greater emphasis on
evidence-based practice when formulating coverage policies for
DME. As clinicians and manufacturers, we need to advocate and
collaborate for more and better research.
Elizabeth Cole, MSPT, ATP, director
of clinical applications
One of our goals as an industry is to raise awareness that CRT
products have features, technology and complexity that go
beyond what is provided by DME. We want to show that these
“high-end” products are not just for luxury or convenience, but
that they provide medical and functional benefits not achievable
with standard products. Being able to demonstrate their efficacy
through outcomes measures and scientific evidence is critical to
achieving this recognition, not only from funding sources that
pay for them, but also from clinicians and suppliers who prescribe
and provide them, and legislators who help us change policy.
The technology of CRT products available today is more
sophisticated and complex than ever. Add that to the myriad
choices of different makes and models of products, and the selection
of the best wheelchair and seating for each individual can be
a daunting task. I think it has become increasingly important for
those involved in the selection of seating and mobility solutions
to understand not only what works, but how and why it works.
It’s important to understand the science behind the technology.
As an industry, we should be able to show that outcomes are
improved when CRT is appropriately prescribed and provided.
We should be able to demonstrate the decrease in incidence of
things like pressure injuries, postural deformities, physiological
complications, pain and hospital readmissions. Funding sources
should be able to see overall cost-saving benefits. Clinicians and
suppliers should be able to see the efficacy of their choices. And
the consumers should be able to see the increase in independence,
health and quality of life.
Ginger Walls, PT, MS, NCS, ATP/SMS, regional clinical education
As a clinician, when recommending seating, positioning and
mobility solutions for clients, I rely on a combination of three
things: evidence from the research available; my clinical experience;
and the needs/goals/preferences of the client.
Clinical experience is important because we learn from all our
clients and interactions with the CRT team over the years.
Paying attention to new research, evidence about outcomes,
and new technology is important because it informs our practice
and helps us to consider why we are recommending what we
do, as well as when to implement evidence into our practice and
maybe try something different.
For example, if we are recommending a power wheelchair and
a power seating system with tilt, recline and elevating legrests
for a client who is at risk of pressure injuries and needs power
seating to perform weight shifts, then we should also understand
the evidence about power seat function utilization, compare it
to our clinical experience, and make client recommendations
accordingly. We know both from our clinical experience and
from evidence that wheelchair users rarely access positions of tilt
and recline necessary to achieve adequate pressure relief. We also
know from evidence that users who receive smartphone basedcoaching
on when to do pressure reliefs, what position to go to,
and how long to stay there, improve their outcomes significantly
in being able to follow an appropriate weight-shifting regimen.
If we understand from our client that they want to be as active,
healthy, and independent as possible, stay in the wheelchair
longer, get more things done, and mitigate risk for skin problems,
then the recommendations are a good fit for the client as well.
Jennith Bernstein, PT, DPT, ATP, regional clinical
Achieving best practices when making equipment recommendations
requires a combination of current research, clinical experience
and client goals. Evidence-based solutions are essential to
innovate practice patterns and equipment applications. When
evidence is translated into a clinical tool that can be used in a
treatment setting, the team can make a more informed decision
to achieve optimal equipment recommendations for each
A Balanced Approach
Missy Ball, MT, PT, ATP
I value research and the insights it can provide the clinician, for
example, with regard to best ergonomic setups for independent
ambulation with least shoulder girdle damage, or tilt and recline
applications to minimize or prevent pressure injury, improve
functionality and comfort.
But I also value clinical expertise and judgment. Seating has
evolved as a result of clinicians, equipment suppliers and manufacturers
working jointly to meet a need and improve on it where
possible. As a physical therapist, one of my roles is to analyze the
movement and function of a client and promote improvement
where possible. My clinical skills (knowledge of movement,
observation and handling techniques) and past experience play a
large part in a wheelchair evaluation. Through the use of these, I
can make an informed decision regarding the specifics of seating
details needed to aid the client, particularly with regard to the
neurologically involved client, such as cerebral palsy or traumatic
brain injury. The more multifaceted the problem of movement,
the more difficult to design and measure specific parameters in
the research. Possibly the reason for less research in seating and
mobility in these areas. Hence, research and clinical expertise are
Angie Kiger, M.Ed, CTRS, ATP/SMS, clinical education specialist
I think people can get too caught up in evidence. I don’t care how
somebody mapped on a cushion in your study. I need to know how [my] actual end user is going to map on it, and also how they
are going to use it.
I look at evidence if I’m trying to get funding, because the
funding world doesn’t necessarily understand clinical best practice.
They don’t understand how the person looks, and they don’t
care how [a product] works. They want numbers. So I will pull
up evidence for that. I know evidence has been very helpful in
getting standers approved. Also, you will run across families who
have tried everything and are tired of theories. They’re being told,
try this, try that. More intellectual users will want to know why
you’re recommending that.
E. Rosen, PT, MPT, MSMS, ATP/SMS, Motion Analysis Center
St. Joseph’s Children’s Hospital
When there are available, measurable, evidence-based outcomes
for the patient I’m seeing, I feel it is very important to use them.
Outcomes measures let me know if I’m truly making a difference
in my interventions. Also, I’m part of the project collecting data
on outcomes so that we can better establish the efficacy of what
we do. This should help with funding as well as buy-in from
referral sources and patients.
Unfortunately, there are no good measurable outcome tools for
some patient populations. These would be dependent clients. In
most cases our intervention is simply to better position them and
prevent pressure injuries. For those clients, I wish we had better
tools that could show positive benefits of our interventions.
That said, with the use of G codes in the adult population and
the likelihood that they are coming to pediatrics once funding
starts to pay based on those codes, we need to find better tools
for all populations that are going to show the benefits of what
we do. If we, as therapists, don’t show that we make a difference,
the ability to work with this population may go away.
John Zona, ATP, CRTS,
rehab & seating specialist
Reliant Medical Group
Medical Equipment, Inc.
I would not say [evidence] is “critical” for determining product
[choices], but it helps. In my clinics we strive to choose the best
equipment to meet the needs of the patient. We ask, “What do
you like and dislike about the old piece of equipment you have,
and what are your goals with the new piece of equipment?”
Pitt’s Functional Mobility Assessment is by far the best I
have seen as far as outcome measures go, but with any outcome
measure, suppliers always want the highest ratings, and many
times you can’t obtain high ratings if you can’t supply (usually
because of insurance coverage) something they really feel they
need (and you do also).
For instance, seat elevators are rarely covered (they should
be) and that can skew the whole assessment, which is still very
important to track, but has nothing to do with the supplier doing
a good job or not.
One of the questions asks about transferring from one surface
to another. Without a seat elevator, that may be very difficult or
even impossible. That will get a “completely disagree” answer.
That one item can skew many questions.
I think the outcome measures try, for the most part, to prove
that rehab suppliers and clinicians are doing good work, making
patients more comfortable, functional and healthier. Good
seating can keep patients out of the hospital, which is very
expensive and can be dangerous.
This article originally appeared in the March 2017 issue of Mobility Management.