This is something that I recently thought about when teaching a course on power assist. This topic does not just relate to power assist but to all Assistive Technology (AT).
First, let’s define what I mean when I say proactive versus reactive. The dictionary defines proactive as “taking action by causing change and not only reacting to change when it happens”. While reactive is defined as “reacting to events or situations rather than acting first to change or prevent something”. What approach should we be taking when consider assistive technology? This is not always just a simple answer. We may be seeing an individual who this is not their first prescribed AT device and maybe we feel that we would have made a change sooner to the prescribed AT.
We also need to consider the funding and where the funding is coming from for the individual using the AT. Can there be a potential to be too proactive and cost additional money to the funding system/body? How do we weigh the options and know if something will be required or needed in the future?
The simple answer is that we have to use our best clinical judgement. This should not just be based on the individual’s diagnosis or the clinician’s past experience with similar cases, but it should be based on numerous factors that when looked at together can help to determine the necessity of an AT solution. One of my favourite ways to really look at all these factors is to use the ICF model as shown below. This can help to determine if there are any current changes that need to be made to the individual’s AT (reactive) or whether we need an immediate change to the AT to prevent any impacts to an area in the ICF model. Let’s look at an easy example to start.
A cushion in a wheelchair. Now, I’m not talking about a specific cushion but just a cushion in general in a wheelchair for someone that is a full-time wheelchair user and perhaps has limited sensation. We know the importance of a cushion to help protect from a pressure injury (PI), but should we go ahead and get the cushion before anything is wrong or let them sit without a cushion and wait until they develop a pressure injury? I would hope everyone reading this would say “of course, the individual requires a cushion for their wheelchair”.
We understand the challenges of healing a pressure injury, the cost associated with the PI, and the impact it has on someone’s health and well-being. So, we can see the need for being proactive and not waiting for the event (PI), but instead working to prevent it. This can be an easy way to discuss how proactive AT solutions can often save overall lifetime costs and allow the individual to maintain their lifestyle, independence, health, and well-being.
What about those cases or AT solutions that are not as straight forward? Let’s look at another case example. A 42-year old female who has been using a manual wheelchair for more than 10 years, but suffers from shoulder pain with limited range of motion. Due to limited propulsion resulting in decreased independence, you are suggesting that she is prescribed a power wheelchair. It is also the first time you are working with this client.
You prescribe a power wheelchair with the power seat function tilt for this individual. You were not able to prescribe the power wheelchair sooner since this was your first time with the client, but have you been proactive in your approach? Have you considered all the options? What was one key that I had listed? Limited range of motion in the shoulders. If we moved the client to a power wheelchair because of shoulder dysfunction, did we think proactively about the power seat functions that she will need to access her environment? If the client has limited shoulder range of motion and pain, are we considering their goals and functional capacity in relation to the position they are seated in their wheelchair and the power seat functions they have access to? Does the client ever need to reach overhead in her environment?
If they need to reach overhead and we do not prescribe a power seat function that assists them, then what happens to the client? Maybe they continue to try to reach overhead with pain or perhaps they cannot due to the range of motion and their independence is limited. Despite just seeing the client for the first time, is it a proactive approach? Or, reactive? If we are reactive, have we really made change and reacted to address the whole situation if we only include power tilt?
One final example. A client that is a 28-year old male who is about to get his second manual wheelchair. He recently moved and now lives outside of the city but travels into the city daily. He takes public transport, but he still has to push quite a distance to and from work daily and for all his community activities that he enjoys. He would like to have a replacement of his manual wheelchair. You complete a full assessment and note that he has no pain and full range of motion throughout his body. The client also reports that he is able to achieve all of his activity and participation goals, but that it is getting harder now that he has moved. It often takes twice as long to get to where he wants to go and feels quite fatigued, so he has been going out less.
When you hear this case, what comes into your mind? Are you thinking about how the client could get around more efficiently if he had something like a power assist device? The client states that he does not have pain, but is that the only reason for someone to get a power assist device? After the shoulder pain begins, how much harder will it be to address the issue? We might be proactive here in trying to decrease the risk of shoulder pain, but what else are we doing? The client stated that he is already having a change in his activity and participation level, so is this truly proactive or are we just proactively trying to prevent shoulder dysfunction and being reactive to the changes in the client’s activity and participation level?
It can be a challenge to be truly 100 percent proactive, but are we looking at the whole person and environment and considering all the options? We have to determine the impact of being proactive versus reactive and how that balances with prescribing an AT device. I love using the ICF model to consider how the AT device might positively or negatively impact the individual. This can create my platform and reasoning for justification to funding as well. Remember to also utilise your clinical best practice guides and research to support your decisions, especially when making a proactive decision.
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Rachel Fabiniak, PT, DPT
Director of Clinical Education – Permobil APAC
Rachel Fabiniak began her studies at The Georgia Institute of Technology, where she graduated with her Bachelor of Science in Biology in 2009. Rachel then went on to receive her Doctorate in Physical Therapy from Emory University in 2013.
After receiving her doctorate, Rachel went into clinical practice as a physiotherapist in the Spinal Cord Injury Day Program at Shepherd Center in Atlanta, GA. There she developed a passion for seating and mobility which ultimately lead to her career with Permobil.