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.

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?”