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CRT in the Classroom

School is a great place to learn mobility skills... but policies are complicated

Given how much time kids spend at school — and how greatly mobility impacts learning — you'd think classrooms would be ideal environments for Complex Rehab Technology (CRT).

And they can be. But policies can be complicated.

elementary classroom with 3 chairs

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Benefits in the Classroom

Jessica Presperin Pedersen, OTD, MBA, ATP/SMS, Director of Clinical Education for Sunrise Medical North America, noted multiple benefits to using specialized seating in classrooms.

“Modular seating and activity chairs in the classroom allow children to benefit from optimal posture, which in turn opens access activities within the class during the day,” she explained. “These seats enable function for interaction, learning and fun. The child can be integrated with peers, and they can enjoy all of the same activities as their peers.”

The goals of specialized positioning are many, she added. “A floor sitter will provide support for a child, allowing inclusion in reading circles, where the children gather on the carpet to read stories. The child will be able to interact with other children in various floor-play activities, such as cars, trains, or ball play. A stander will bring the child to another level of play for going to the board, standing with peers and interacting. Positioning-wise, the child is able to have hips and knees in a different position than when sitting in the wheelchair. Weight-bearing activities are often promoted by therapists. Evidence shows that physiological benefits include enhanced breathing, digestion, and elimination.

“A system that incorporates a bolster might be used to reduce tone and stretching while encouraging enhanced trunk extension. This may increase reaching activities.”

Fostering Clinician Communication

Angie Kiger, CTRS, ATP/SMS, Portfolio Marketing Manager for Permobil Americas, and Amy Morgan, PT, ATP, Principal Product Manager, Permobil Power Mobility, said questions on CRT used in schools arise from the very start of the procurement process.

“According to the Individuals with Disabilities Education Act (IDEA), assistive technology services and devices used to maintain or improve a student’s function are covered and should be paid for under a school-based model, and CRT can absolutely fall under that,” Kiger said. “Then there’s also the medical base [of funding], and unfortunately, a lot of people don’t understand that. The school therapist will say, ‘I thought you went to Cincinnati Children’s [Hospital, as an example] to get that,’ and vice versa. But the reality is, the school therapist and the clinic-based therapist, for ideal outcomes, need to be in communication. That doesn’t always happen, for a variety of reasons.”

Morgan added, “Both [school and non-school] therapists, generally speaking, want to have input into equipment decision making. But they don’t often have direct access to one another. It’s all through the family. So you’re really dependent upon this third party to connect the two to have that conversation.

“The school therapist finds out the kid was evaluated for a new wheelchair a week after the evaluation, and the parents say, ‘We went to Children’s [hospital] and got the evaluation for the wheelchair.’ The decision had already been made, and maybe it’s connecting to what the school therapist would have recommended, but maybe it’s not. So that becomes challenging.”

When she worked in a wheelchair clinic, Morgan said she “made many efforts to get school therapist input, specifically during our intake process” and asked parents for school therapists’ letters of recommendation that would include their concerns and goals for the child.

“But that rarely happened,” she said. “Maybe they scheduled their appointment in the summer, and they weren’t in school. I wish there was a good solution for this. If we could find a good solution, it would be mutually beneficial.”

Kiger noted that telehealth options could be helpful in bringing school and clinical therapists together. “It is common in more rural areas for the school therapists to be tasked with leading the wheelchair provision process with the assistance of a CRT provider. In some cases, a child may travel on an annual basis for specialty services, such as muscular dystrophy clinic, where a wheelchair evaluation is part of the visit. This can be a double-edged sword, because while the child may have the opportunity to work with professionals who specialize in seating and mobility with access to various equipment to try, those specialists do not have insight into the child’s day-to-day life like his/her school team [does]. This type of potentially sticky situation can happen even if the child’s school is within five miles of the wheelchair clinic. As with most things in life, communication is key. Both the school-based therapist and clinic therapist are dependent upon the family to bridge the communication gap.

“The good news is with the increase in telehealth, there is even more potential to bring folks who cannot attend appointments in-person to participate. Would a school system support that? I’m sure there would have to be all sorts of releases, but for the school therapist: Maybe they can’t leave during the day, but maybe they could telehealth in and be there for the evaluation.”

Pedersen agreed there can be strength in numbers when creating optimal outcomes for a child. “The outside-the-classroom clinicians, specifically the seating therapist, appreciate getting input from the classroom therapists and teachers,” she said. “Knowing the activities that the child engages in, as well as the therapeutic goals, helps with the recommendations. In many cases, there is a time conflict that the classroom staff is unable to attend in-person, but with the inclusion of telehealth, it is easier to incorporate others into the evaluation.”

Who’s Paying for This?

Funding, always a complicated issue in CRT, gets even more muddied when the school’s obligations are added in. “It’s tricky to know the different Medicare or different Medicaid [policies] for every state and all the private insurances,” Kiger said. “Every school system’s budget is different, too. So you get another thing that goes into that mix.

“I have had PTs and OTs that have said, ‘I would love for the child to be able to drive a power wheelchair, but I can’t bring that up during an IEP [Individualized Education Program] meeting.’ Because they have been told the way that school system interprets the IEP process is that if it’s said during the meeting, and the parent catches a hold of it, then the school is responsible for buying it. And the school says, ‘We don’t have the money to purchase power wheelchairs in our budget.’

“I have heard school therapists say they’re terrified to make CRT evaluations, basically because their powers-that-be have said the school will have to pay for it then.”

“It certainly comes up because then it becomes the school’s requirement to fulfill that goal,” Morgan agreed. “And if they need to buy technology in order to achieve that goal, then they would be responsible for that.

“It’s still the problem of the school therapist not knowing that this appointment is happening. It’s not always at a major medical center. The school therapist often [isn’t] interacting with the family. The kid is bused to school, they’re bused home. It’s not like an outpatient visit, where I could talk to the parents.

“I think I would challenge the school therapists at the IEP maybe not to put it in their goals and their actual official records, but to at least ask the family: ‘Are you planning on doing any type of assistive equipment, assistive device evaluation or assessment with your outpatient therapy team or anything like that over the course of this school year?’ Then maybe at least they can try to find that information out.”

“We do know suppliers are in schools all the time, especially in more rural areas,” Kiger said. “They go into schools and send their techs out to grow the equipment, and that’s where the parent can meet them [and] these therapists. They’ll spec out the equipment right there. Unfortunately, a lot of it does continue to fall on that provider to be a bit of a social worker, which is hard.”

CRT That Makes the Grade

Morgan expects pediatric CRT to withstand the rigors of both classroom activities and childhood adventures: “All pediatric equipment, whether it’s to be used at school or at home or wherever, needs to be durable. Because kids are going to be using it. Those siblings can do some damage, or you have nurses and therapists that come in, and cleaning people, and whoever else.”

Perhaps an even greater challenge is making sure CRT is allowed into the classroom and fully used. Morgan noted that small environments are common: “They’re packing kids nowadays into these classrooms. It does come into play with the [wheelchair’s] maneuverability, footprint, and things like that.

“If a kid uses a standing power wheelchair — I’ll use that as an example, because it tends to be one of the larger-footprint bases because it has to support that standing. Let’s say the school has to accommodate that person’s equipment. That’s where the IEP really comes in and says, ‘Sorry it’s a small classroom, but we have to rearrange, because this is what I need to use, and this is how I interact in this environment.’ The onus is on the school to adapt to whatever the equipment is that the child brings in.”

Morgan referenced her observations from June’s Cure SMA conference to suggest how schools could get creative by using technology such as power-assist systems: “So many people there were using SmartDrive [Permobil’s power-assist system] and talking about how they have their power chair that is at home, but they use the SmartDrive when they’re going out and about. SmartDrive might not be a poor thing for a school to own, and to use it on multiple manual chairs, to give kids some opportunity to be independent and getting to the playground and to the other places. They’re probably not going to use it within the classroom as much, but moving around and physical education classes and places like that obviously are going to be important.”

Kiger suggested another way schools can get creative indoors: “What if they say, ‘Sorry, that F5 [standing wheelchair] cannot fit in this classroom’? I’d say, ‘Okay, can you get an activity chair that’s adjustable to the child?’ The child’s not going to need to move a ton in the classroom — that’s still nails-on-a-chalkboard to me, because every other child can get up and walk around. But we can transfer them to this activity chair, a lot of which come on wheels. There are ones that roll them up to their desk, and they can engage. But when it comes to going outdoors or going to the cafeteria, or switching classes, absolutely there should be no reason [not to use that power chair].”

Inclusion Is Everything

Ultimately, Kiger and Morgan argued for inclusion above all.

“Let’s say it’s a teenager, a high school student that’s very dependent and is likely not going to be getting in and out of their chair,” Morgan said. “They’re going to use their chair and stay in it the whole school day. That’s one scenario.

“Then you have scenario B, where it’s a little kiddo who is able to do some transferring out. He’s going to be popping in and sitting in the typical chair that the other kids are sitting in. So you have variations. The biggest thing I like seeing is the integration with typical peers that don’t use equipment.”

She noted classrooms that offer different seating — therapy balls, rocking chairs, wobble chairs. “Giving the child with special needs that same ability to choose and use different types of seating in the classroom is a really good thing. They might be able to be in their wheelchair the entire day, but they don’t have to. And if they want to go sit on the floor or in a beanbag chair or in something else, then they can choose to do that.

“I really want to see more of us saying, ‘What are the other kids doing? Let’s make sure that this child [in the wheelchair] also has the same or similar opportunities.’ If your wheelchair has a high seat-to-floor height, give that child an opportunity to get lower, to be able to play at the station that the other kids are playing at, the baby doll station or whatever it is. That’s really important. It is, I think, on us manufacturers to create better options, to be more nimble getting into those areas and getting to the various heights easily within the device. And it’s a challenge for us to build on for other kids as well as they get bigger.”

Morgan remembered a mobility evaluation with a young girl: “We were doing trials with power, and she was moving it fine, but she wasn’t intentionally going places. And we said, ‘Oh, there’s a library book. We need to take this back to the library. Can you show me where the library is?’ And that little girl just went right out the door and drove all the way to the library. It was amazing, and everybody was just jaws on the ground: ‘We would’ve never prescribed power for this kid because it wasn’t really intentional, and I didn’t feel like it was purposeful.’

“Yet when you give them a purpose, then they go. When you’re just saying, ‘Drive and stop and drive and stop,’ that’s not motivating. Finding that type of motivation is a lot easier in school. School is a very natural environment for a child. So it’s a really great place to work on skills and mobility and independent mobility training in the school system, if they’re open to that.”

There is, Morgan acknowledged, a duality of classroom goals. “My outpatient therapy goals can be very strength related in a functional way, increased range of motion, improved strength, etc.,” she said. “I think of parents of boys with Duchenne muscular dystrophy. They said, ‘You therapists need to stretch their heel cords and hamstrings and hip flexors once a week, once a day, whatever.’ The school therapist said, ‘My goals need to be educational. How is stretching their heel cords educational?’

“So this is where something like standing can come into play. You can get creative with how you’re doing the stretches for that child as they’re participating in an educational activity. There’s a lot of creativity needed, even more so with the school-based therapist than in the outpatient setting, because you have to think, ‘How can I achieve that medical outcome that the family wants or the child needs, but also make it educationally based and academically based?”

This article originally appeared in the Jul/Aug 2022 issue of Mobility Management.

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