Abstract
This AOTA Position Statement describes how assistive technology (AT) fits within the occupational therapy scope of practice and how occupational therapy practitioners uniquely contribute to teams that provide AT evaluations, recommendations, and training.
This AOTA Position Statement describes how assistive technology (AT) fits within the occupational therapy scope of practice and how occupational therapy practitioners uniquely contribute to teams that provide AT evaluations, recommendations, and training.
Assistive technology (AT) was first defined in the Technology-Related Assistance for Individuals With Disabilities Act of 1988 (Pub. L. 100-407), which has recently been updated as the 21st Century Assistive Technology Act (AT Act; 2022, H.R. 9028). At the original creation of this legislation, AT was considered a novel intervention strategy, primarily in the then-emerging areas of computer accommodation and wheelchair seating and mobility (Flexer, 2020). Interventions were frequently custom designed and fabricated on the basis of recommendations offered by AT specialty teams that included a mixture of rehabilitation engineers, physical and occupational therapy practitioners, speech-language pathologists, orthotists and prosthetists, and technicians.
The AT field has evolved dramatically since that time. AT products are more sophisticated, and product features more nuanced; costs have fallen with economies of scale; disability-accommodation options are now embedded in the operating systems of computers and phones; wheelchair seating and mobility options that were once customized by hand are now available as off-the-shelf options; continuing education opportunities on AT content have proliferated at national conferences; consumer awareness of AT has profoundly expanded; certifications attesting to advanced clinical expertise have been developed and accredited; research journals dedicated to AT content were begun and are thriving; and AT-related content in preprofessional allied health programs has grown commensurately.
AT touches virtually every practice setting, age group, disability profile, and occupation that falls within our scope of practice. Occupational therapy practitioners are now frequently asked, if not expected, to make recommendations and provide training for AT devices and software in settings, including early intervention, schools, acute care, adult rehabilitation, community-based vocational programs, and skilled nursing facilities. For occupational therapy practitioners, AT is no longer a fringe specialization area involving a small fraction of our profession. As occupational therapy practitioners we have a shared responsibility to contribute to the assessment, recommendation, implementation, and training of AT that is appropriate for our clients (Appendix A provides case examples).
This Position Statement provides an overview of the following questions: How does AT fit within occupational therapy’s scope of practice? How do occupational therapy practitioners uniquely contribute to teams that are providing AT evaluations, recommendations, and training? What are the minimum roles that occupational therapy practitioners are expected to have on AT teams, and what contributions are they expected to make? What additional value can occupational therapy practitioners provide to such teams as their individual expertise grows? How can occupational therapy practitioners remain current with the universe of technology devices that may potentially support clients who have physical, sensory, cognitive, or learning disabilities?
This Position Statement is a tool that can serve multiple related purposes: (1) legislative advocacy on behalf of our profession, (2) interdisciplinary education and advocacy within our respective practice settings, (3) a refresher for experienced practitioners, and (4) a primer for entry-level occupational therapy and occupational therapy assistant students studying AT.
Definitions
The AT Act provides updated federal definitions of AT devices and services. An AT device is “any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities” (H.R. 9028, 29 U.S.C. 2202[2]). The AT Act further describes an assistive technology service as “any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device” (H.R. 9028, 29 U.S.C. 2202[2]). The World Health Organization (WHO; 2018), International Organization for Standardization (2016), and the World Federation of Occupational Therapists (2019) have all adopted definitions using variations of the same terms.
In all cases, the elements are similar: AT is broadly used to describe devices, services, and systems. AT devices include those that are purchased and used off-the-shelf, as well as those that are custom made to meet an individual’s unique needs. In most cases, AT devices are modified, configured, or adjusted to align with an individual’s performance capabilities, task expectations, and usage environments. AT devices are assistive to the extent that they support functional performance of people with disabilities.
For the purposes of this Position Statement, we focus on the AT device categories encountered most frequently in occupational therapy practice. These can be loosely grouped into the following functional categories: personal mobility (including ambulation aids, wheeled mobility devices, external supports to enhance seated posture and skeletal alignment, and cushions that support sitting comfort and posture), community mobility (including modifications that support vehicle boarding and disembarking, as well as those that support vehicle navigation), communication technologies (including speech- generating devices, low-tech communication boards, hearing aids, and device captioning features), computers and mobile technologies (including physical devices and software that support device accessibility and use), robotics (including upper extremity robotic trainers and exoskeletons), technologies for the home (including physical modifications to the home environment, as well as smart home technologies), and activities of daily living (ADLs) and self-care (e.g., bathroom aids, dressing aids).
Regardless of categorization, the goal of AT interventions is ultimately no different from those of other occupational therapy interventions, namely, to improve quality of life by facilitating improved performance in meaningful life activities (American Occupational Therapy Association [AOTA], 2020c).
Importance of AT in Occupational Therapy Practice
The importance of AT is evident throughout all conditions treated by occupational therapy practitioners. Many of these conditions directly affect a person’s ability to function independently and safely in their environments. Because of this lack of functioning, independence, and safety, these persons would benefit from using AT to facilitate participation. According to the Global Report on Assistive Technology (WHO & United Nations Children’s Fund [UNICEF], 2022), older adults and persons with chronic conditions—specifically, those with musculoskeletal disorders—are among the most common users of AT. There are many other diagnoses that may benefit from AT, including (but not limited to) learning disability, neurodivergence, spinal cord injury, dementia, cerebral palsy, muscular dystrophy, and stroke.
With the rise of mainstream technology, AT has become more available to those who need it most, as well as those who may not need it but benefit from it being available. Most people use some form of AT, whether they realize it or not. In addition, it is expected that most people at some point in their lives will need AT because of disability or aging (WHO & UNICEF, 2022). This may be short-term use of AT, such as during recovery from a fracture, or longer term use as part of the natural aging process.
More than 2.5 billion people worldwide require at least one AT device. This number is expected to grow to more than 3.5 billion by 2050 as the aging population increases (WHO & UNICEF, 2022). Despite the increasing number of people who could benefit from AT and the increase in availability because of modern technology, specific disability-driven ATs are difficult to obtain. Across the globe, 200 million people with low vision don’t have access to AT; 75 million people require the use of a wheelchair, but only 5% to 15% have access; and hearing aid production meets the need for fewer than 10% of people with hearing loss (WHO, 2018).
It is also important to note that many of the ATs that are easier to obtain may not be applicable, affordable, or functional in all environments, regions, and cultures, which only widens the access gap.
There are many clinical benefits of using AT. Overall, AT is medically beneficial because it increases safety and independence, which has a direct impact on the physical and mental health of its users. AT acts as both a means and an end to improve physical and mental health for people with disabilities. For example, when used on a regular basis, AT implemented to help people with dementia yielded many medical benefits, including decreased stress, fewer physical health symptoms, improved quality of life, fewer medication errors, and better monitoring of vital signs (Kruse et al., 2020). Likewise, AT makes managing health more accessible through the use of mobility devices and mobile solutions (WHO & UNICEF, 2022). Through AT use and the resulting independence and safety, the user’s mental health is also likely to improve.
For many, AT is the only reason they can functionally participate in necessary and chosen occupations. To increase function and participation through AT, all areas of the client and the environment must be taken into consideration. This includes physical, cognitive, sensory, emotional, behavioral, and social aspects of the client and the physical parameters of the environment, as well as the client’s attitude with regard to acceptance and the culture of the communities they are members of.
These benefits of AT are not mutually exclusive and are interconnected. For example, although a communication device does increase social participation, it also increases the user’s ability to communicate pain and illness and to interact with medical professionals, and although the use of an adapted video game controller may increase a person’s participation in leisure occupations, it also improves mental health and can prevent them from engaging in negative occupations. The significance of AT can be seen through the wide array of infrastructures created to support its development and use (see Appendix B and Appendix C).
There are several research and funding structures to support occupational therapists in providing AT services. Assistive Technology Journal is the official publication of RESNA, and it includes international research in the multidisciplinary field of AT. Disability and Rehabilitation: Assistive Technology is a journal that publishes research to advance the practice and science of interdisciplinary and integrative AT delivery and product design internationally.
AT-specific conferences also provide support and education in AT. General AT education can be obtained at conferences held by the Assistive Technology Industry Association; California State University, Northridge; RESNA; or Closing the Gap. The International Seating Symposium focuses on seating and mobility, and the Association for Driver Rehabilitation Specialists holds an annual conference focused on driver rehabilitation.
AOTA also provides occupational therapy practitioners with the support and resources to use AT in their practice. AT is clearly outlined in the Occupational Therapy Practice Framework: Domain and Process (4th ed.; AOTA, 2020c) as an intervention type. In addition, information about AT research can be obtained through the American Journal of Occupational Therapy and the Occupational Therapy Journal of Research, as well as through continuing education offerings on AT in the form of AOTA conferences, webinars, and courses.
Role of Occupational Therapy in AT Service Delivery
AT, Occupation, and the Role of Occupational Therapy
AT devices and services, as addressed earlier, can greatly affect a client’s physical functioning, independence, participation, socialization, and occupations. Occupational therapy practitioners bring a unique perspective and skill set to the evaluation team. Occupational therapy practitioners address client needs in context; for example, if a client is using a speech-generating device for communication, the context must be considered, such as use in a school classroom, a work meeting, or a conversation with family. Many ATs will be used in multiple contexts. Occupational therapy practitioners also bring a comprehensive or holistic approach to evaluation and implementation. For example, if a client requires a speech-generating device, the occupational therapy practitioner will consider all aspects of its use, such as how the device is accessed (e.g., eye gaze), where the device should be mounted in relation to the client (e.g., to optimize vision and access), and whether the client is positioned optimally to facilitate its use.
The AT Service Delivery Process
The AT service delivery process varies with the type of technology being used by the client. The occupational therapy service delivery process must be client centered, team oriented, and ethical, and it must follow accepted standards of practice.
The AT Evaluation
Intake.
The evaluation process begins with obtaining and analyzing intake information from the client and caregivers. Information should include goals and desired outcomes, current equipment, and what past and current equipment and interventions have been used as well as whether they were successful. Information should also include accessibility in the client’s environments, such as home, work, school, community, and vehicle. The goal is not to obtain a certain AT device (e.g., a power wheelchair); instead, the goal is occupation based (e.g., improve mobility) and the AT device is part of the solution.
Team Members.
Depending on the AT-related goals, various team members will be involved. A multidisciplinary approach, when possible, provides a more comprehensive evaluation than an occupational therapy evaluation in isolation. The client and caregivers are the primary team members, and their goals drive the evaluation process. The following are examples of potential team members working with the occupational therapy practitioner: Seating and wheeled mobility and other complex rehabilitation technologies: physical therapist, complex rehabilitation supplier, manufacturer representative Augmentative and alternative communication: speech-language pathologist, manufacturer representative Computers and mobile technologies: vocational rehabilitation counselor, vision specialist, ergonomics specialist Technologies for the home: home modification specialist, smart home specialist, contractor Cognitive and learning technologies: speech- language pathologist, educator
Practice Settings.
AT evaluation and intervention can occur in a number of different practice settings. These include inpatient, outpatient, home and residential, school, work, and community settings. Funding and time constraints may limit evaluation and intervention in more than one setting. Intake information and telehealth visits can help provide important context for these other settings.
Evaluation.
The evaluation process identifies client- specific goals, needs, and parameters and then matches these to appropriate solutions (AOTA, 2020c). Occupational therapy practitioners participating in the AT evaluation rely on clinical observations and activity analysis to determine specific client skills and deficits. These findings can be used to problem-solve needed product parameters before determining optimal AT equipment and intervention solutions. The practitioner must be familiar with product options, how to obtain products for equipment trials when indicated, and where to find other needed resources.
Last, the occupational therapy evaluation and treatment plan should be evidence based to the fullest extent possible. Standardized assessment and training protocols are available; however, these tools may not be applicable to all clients. People using AT represent a heterogeneous population, which can affect research validity.
Intervention.
An AT evaluation results not only in equipment recommendations but in other interventions, as well. For example, manual wheelchair training may be recommended to optimize mobility skills.
Outcomes.
The end goal of the AT service delivery process is to achieve the client’s goals, and this is measured by outcomes. Tracking outcomes informs the occupational therapy service delivery process and indicates any necessary changes to maximize effectiveness. Tracking outcomes includes follow-up to ensure that recommended AT equipment and interventions continue to meet an individual’s needs.
Product Acquisition
Consumer-level electronics, such as virtual assistants, can be ordered directly by the client through e-commerce sources, such as Amazon. Specialized computer equipment, such as an alternative keyboard, may be provided through sources such as a local vocational rehabilitation office or a school system. A splint to promote finger isolation for direct access to a tablet display may be provided by practitioners at a rehabilitation clinic. Complex rehabilitation technologies (CRT) include seating and wheeled mobility, gait trainers, standers, bathing and toileting equipment, and more. This equipment is submitted by the complex rehabilitation supplier for funding approval by a third-party payer (e.g., private insurance, Medicaid, Medicare). The occupational therapy practitioner writes a letter of medical necessity (LMN), which is submitted, with other documentation, to the funding source for approval. After it is approved, the supplier orders the recommended equipment and fits it to the client at delivery, ideally with the practitioner present.
Supervision and Role of the Occupational Therapy Assistant
The occupational therapist can provide AT evaluation and intervention across a range of client diagnoses, ages, and contexts within their individual scope of service. The occupational therapy assistant can conduct portions of the comprehensive evaluation if trained and experienced (e.g., range-of-motion [ROM] measurements, ADL independence levels) and provide AT interventions (e.g., switch training) under the supervision of an occupational therapist within their individual scope of practice (AOTA, 2020b).
Ethical Considerations
Occupational therapy practitioners have a responsibility to practice ethically within their scope of practice when providing services related to AT interventions, including environmental accommodations, which are often recommended concurrently. Toward that end, AOTA provides relevant ethical and practical guidelines in its Occupational Therapy Code of Ethics (AOTA, 2020a), Standards of Practice for Occupational Therapy (AOTA, 2021b), and Occupational Therapy Scope of Practice (AOTA, 2021a) documents. With regard to ethics, the profession’s core principles of Beneficence, Nonmaleficence, Autonomy, Justice, Veracity, and Fidelity are central when providing AT assessment, recommendation, implementation, and training services (AOTA, 2020a).
As with other areas of occupational therapy practice, occupational therapy practitioners providing AT-related services must do so within their scope of competence (i.e., having the knowledge, skills, abilities, and, where applicable, advance certifications needed for a particular type of AT device). A key element of ethical practice in AT involves active interprofessional collaboration with other disciplines (e.g., physical therapy, speech- language pathology, nursing, medicine, social work, special education, regular education, case management) that may be salient to a particular client’s context.
Specific to AT practice, RESNA (2022) published its Code of Ethics and Standards of Practice as “a public statement of principles used to promote and maintain high standards of conduct within the multidisciplinary profession of Assistive Technology” (p. 1). The core principles articulated in this document include (a) holding paramount the welfare of clients being served; (b) practicing only in one’s areas of competence; (c) maintaining client confidentiality; (d) disclosing conflicts of interest; (e) complying with applicable laws, regulations, and policies; and (f) acting in a manner that positively reflects on the AT profession.
Regulatory Considerations
The occupational therapist and occupational therapy assistant collaborate to meet the AT needs of individuals, groups, and populations. Under the direction and supervision of the occupational therapist to develop the occupational profile and evaluate occupational performance, the occupational therapy assistant may share skilled assessment data by implementing select assessment tools on which they have been trained (AOTA, 2020b). The occupational therapist and occupational therapy assistant may collaboratively develop, implement, and adjust the AT.
Education and Training
Although there is a wide range of professional expertise to be gained by occupational therapy practitioners with respect to AT, there is a minimum level of education all occupational therapy practitioners receive in accredited occupational therapy and occupational therapy assistant entry-level programs (Accreditation Council for Occupational Therapy Education [ACOTE®], 2018). The 2018 ACOTE® standards specify that all entry-level occupational therapy programs must include education and the demonstration of skills leading to proficiency in students’ ability to “assess the need for and demonstrate the ability to design, fabricate, apply, fit, and train in assistive technologies and devices (e.g., electronic aids to daily living, seating and positioning systems) used to enhance occupational performance and foster participation and well-being” (p. 30) and that occupational therapy assistant programs must “explain the need for and demonstrate strategies with assistive technologies and devices (e.g., electronic aids to daily living, seating and positioning systems) used to enhance occupational performance and foster participation and well-being” (p. 30).
The field of AT provides opportunities to develop expertise in specialized areas. Occupational therapy practitioners may attend continuing education classes, obtain additional graduate-level coursework, and participate in specialized field experiences. Several opportunities are available for preprofessional students as well as professionals in the field to obtain credentials that support their expert knowledge base (RESNA, n.d.-b). Although not required for occupational therapy practice in general, familiarity with AT assessment and intervention processes, advanced experiences, and other qualifications provide credibility for occupational therapy practitioners wishing to specialize in this area of practice.
Practitioners may attend a college or university that offers advanced training in AT, including some that are accredited by the Commission on Accreditation for Rehabilitation Engineering and Assistive Technology Education (CoA-RATE; RESNA, n.d.-a). Completing a certificate or a degree from a CoA-RATE–accredited program ensures specialized education and experience as an AT generalist. Once complete, these individuals will have transcript- designated documentation of their expertise.
RESNA oversees and maintains interdisciplinary credentialing for occupational therapists to be identified as an Assistive Technology Professional (ATP), a Seating and Mobility Specialist (SMS), and, for those who have training as an engineer as well as an occupational therapist, as a Rehabilitation Engineering Technologist (RET). Other specialty certifications within the scope of occupational therapy practice include the Certified Driving Rehabilitation Specialist (CDRS) and the Certified Aging in Place Specialist (CAPS).
Funding and Reimbursement
Occupational therapy practitioners provide AT evaluations and interventions to clients with a variety of diagnoses across several practice settings, including, but not limited to, acute care, early intervention, schools, outpatient clinics, community, and industry. Given the diverse use of AT in occupational therapy practice, funding is contingent on diagnosis, practice setting, and geographic location. Practitioners must become familiar with relevant third-party payer policies in their state and may need to educate payers about the need for AT referrals, interventions, and the expected outcomes.
Conclusion
The use of AT as a means of intervention to support a client’s participation in a desired occupation has always been an integral component of occupational therapy practice. Occupational therapy practitioners collaborate with the client and other professionals and use their understanding of a client’s functioning, the task or occupation, and the environment or context to apply ATs of varying complexity to support the client’s occupational performance. Amid continuous technological evolution, the client-centered focus of occupational therapy practice remains. It is still important to focus on the client, the occupation, and the environment and context when designing interventions that use technology. All occupational therapy practitioners are skilled in analyzing clients’ needs, tasks, the demands of an occupation, and the environment, but they may partner with a multidisciplinary team to relate more complex aspects of technology and person–environment factors during the decision-making process. Practitioners must know when the occupational therapy process requires the additional input of more advanced or specialized personnel. As evidence that supports the use of AT to achieve specific outcomes continues to emerge, practitioners must stay abreast of developments in technology so that these can be incorporated into the occupational therapy process.
Authors
Michelle Lange, OTR/L, ABDA, ATP/SMS
Michelle Silverman, MS, OTR
James Lenker, PhD, OTR/L, FAOTA
Elizabeth Hamlin, OTR/L
Roger O. Smith, PhD, OT, FAOTA, RESNA Fellow
Salvador Bondoc, OTD, OTR/L, CHT, FAOTA
Beth Goodrich, PhD, ATP, FAOTA
Lynn Gitlow, PhD, OTR/L, ATP, FAOTA
Roger O. Smith, PhD, OT, FAOTA, RESNA Fellow
Meredith Gronski, OTD, OTR/L, CLA, FAOTA, Chairperson
Adopted by the Representative Assembly Coordinating Council for the Representative Assembly, January 2024.
Note. This revision replaces the 2016 document “Assistive Technology and Occupational Performance,” previously published and copyrighted in 2016 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 70(Suppl. 2), 7012410030. https://doi.org/10.5014/ajot.2016.706S02
Copyright © 2024 by the American Occupational Therapy Association, Inc.
Citation. American Occupational Therapy Association. (2024). Assistive technology devices and services in occupational therapy practice. American Journal of Occupational Therapy, 78(Suppl. 1), 7810410130. https://doi.org/10.5014/ajot.2024.78S106
Footnotes
Appendix A. Case Studies
| Occupational Therapy Process | Clinician’s Findings |
|---|---|
| Client description |
|
| Occupational therapy evaluation and goal setting | The OTP at the ALS clinic performed the initial evaluation for the PWC and performed ongoing assessments at quarterly clinics for changes required because of a loss of strength and function over time. The OTP also used trials and skilled clinical reasoning with consideration of PWC control options and mounts for the tablet in collaboration with John, his caregiver, supplier, and SLP. No formal goals were set except to order a new control and mount and to keep John as functional as possible for as long as is feasible. |
| Occupational therapy interventions | The OTP intervened throughout the disease process with low-tech adaptations, and then John started using a complex PWC and an AAC device. He initially used a head mouse for AAC and computer use. As the ALS progressed, his neck muscles got weaker, and he required an eye gaze control for the wheelchair, computer, and AAC devices. |
| Occupational therapy outcomes | John successfully used a tablet-based eye tracker (e.g., the Ability Drive system with a Tobii Dynavox eye tracker) for the PWC full control, AAC and computer use, and control of his iPhone with the PWC. John will potentially be able to use this control until his eye muscles fail or he is in a locked-in state. |
| Research evidence and related resources guiding practice | Masrori & Van Damme (2020), Vance et al. (2021), Ward et al. (2015). |
Note. AAC = augmentative and alternative communication; ADLs = activities of daily living; ALS = amyotrophic lateral sclerosis; OTP = occupational therapy practitioner; PEG = percutaneous endoscopic gastrostomy; SLP = speech-language pathologist; PWC = power wheelchair.
Appendix B. Assistive Technology Service Models
Various assistive technology (AT) service models have been developed that can be useful in AT evaluation and overall service delivery. The Human Activity Assistive Technology (HAAT) model, developed by Al Cook, considers each component (human, activity, AT, and context) individually and together to evaluate, select, and implement AT (Giesbrecht, 2013). The Student, Environments, Tasks, and Tools (SETT) framework, put forth by Joy Zabala (2005), identifies the characteristics of a student/strengths, the environments in which the student learns and grows, and tasks required to be an active learner in those environments. The Person–Environment–Occupation (PEO) model, developed by Mary Law et al. (1996), emphasizes that occupational performance is shaped by the interaction among person, environment, and occupation. The Matching Person and Technology (MPT) model, proposed by Scherer and Craddock (2002), uses person-centered measures for general, assistive, educational, workplace, and health care technology use. The Education Tech Points model, put forth by Bowser and Reed (1995), contains a series of questions (points) to facilitate the AT consideration process.
Appendix C. Worldwide Supports for Assistive Technology
There are many worldwide supports in place for the use of assistive technology (AT):
Global Cooperation on Assistive Technology Initiative (https://www.who.int/initiatives/global-cooperation- on-assistive-technology-(gate)): Aims to improve access to high-quality, affordable assistive technologies globally by focusing on the 5 Ps: people, policy, products, provision, and personnel.
Global Alliance of Assistive Technology Organizations (https://www.gaato.org/): Aims to advance the field of AT and rehabilitation engineering on a global level through research and collaborative projects.
International Society of Wheelchair Professionals (https://www.wheelchairnetwork.org/): Has a mission to be a global resource with respect to wheelchair service standards and provision. They do this through advocacy, education, standards, evidence-based practice, innovation, and a platform for information exchange.
World Federation of Occupational Therapists (https://www.wfot.org): A global community of occupational therapists seeking to improve their practice and the development, use, and practice of occupational therapy.
In the United States there is a well-established set of member associations, research infrastructures, and conferences to support practitioners. RESNA (https://www.resna.org), founded in 1980, is a multidisciplinary member organization that includes practitioners of AT and researchers with expansive backgrounds. Three additional groups provide support to those who manufacture and sell AT products: (1) the Assistive Technology Industry Association (https://www.atia.org), a community of companies in the area of AT for written and spoken communication; (2) the National Mobility Equipment Dealers Association (https://nmeda.org/), which focuses on automotive mobility products; and (3) the National Coalition for Assistive and Rehab Technology, which consists of suppliers and manufacturers seeking to protect access to complex rehabilitation technologies in the area of wheelchair seating and mobility (https://www.ncart.us).