In health care, customer service is not a luxury — it is foundational. Our personal experiences with service shape whether we trust a business enough to return. We expect to feel seen, heard and valued. In Complex Rehab Technology, that expectation should be non‑negotiable. The decisions we make directly affect safety, health, comfort, independence and quality of life. When we fall short, the consequences extend far beyond dissatisfaction; they can cause lasting harm.
Communication, clinical judgment and professional accountability are, in my opinion, among the strongest predictors of optimal outcomes in CRT. When any of these fail, even well-intentioned care can become dangerous. The following case, while uncomfortable, illustrates why our industry must hold itself to a higher standard.
Nearly six years ago, I was the physical therapist that evaluated a client whom I will call Sarah. Sarah was in her 60s and had spastic quadriplegic cerebral palsy. She lived in an apartment with a longtime friend who has spastic diplegic cerebral palsy with intermittent nursing care. Sarah had used a power wheelchair in the past but was bedbound and presented with severe contractures in all extremities, scoliosis and significant medical fragility. Her roommate, who also has cerebral palsy, would crawl on the ground to attend to her needs. Sarah had limited nursing care.
At the time of the initial evaluation, it was clear that Sarah required custom seating due to multiple non‑correctable postural asymmetries. We collaborated on the design of a power wheelchair using the same base and drive configuration she had successfully used in the past. The Assistive Technology Professional (“John”) involved had strong technical knowledge but limited clinical experience in custom seating and was dependent on my skills to complete the seating process.
When Sarah’s seating system was delivered, I performed a gentle correction of her pelvic alignment after transferring her into her new seating. A popping sound was noted. Sarah initially reported that she felt fine but soon requested to return to bed. I was informed later that Sarah had sustained a femur fracture related to severe osteopenia. Sarah and her roommate did not attribute the injury to malpractice and expressed understanding of the risks involved. They indicated they would reach out when ready to resume services, but they never did.
Five years later, John asked me to complete an evaluation for Sarah’s new power wheelchair. John and I returned to Sarah’s home, joined by her roommate, her nurse and a manufacturer representative invited by John. The representative was from John’s preferred manufacturer, not the manufacturer Sarah had been using. During the visit, much of the ATP’s communication was directed toward Sarah’s roommate (his longtime friend) rather than Sarah herself while the therapist and manufacturer representative evaluated Sarah. Clinically, Sarah presented herself in a healthier state due to increased nursing care, but her contractures had worsened, including fixed internal rotation and knee flexion of the left leg, with persistent extension positioning of the right leg since the femur fracture.
Given her history and body changes, all parties agreed that another custom mold would not be appropriate. Instead, we (the manufacturer rep and I) designed a seating system using foam and adjustable air components, with the agreement that the setup would be trialed prior to funding submission.
The trial was successful. However, Sarah’s nurse expressed concern about Sarah’s ability to safely operate a power wheelchair, though the team remained optimistic and Sarah was motivated. Funding was approved, but the delivery process revealed another critical breakdown. Because the order had not been flagged as requiring a team delivery, the wheelchair was scheduled just prior to month end with a technician who had never met Sarah. The delivery was refused on site because Sarah “did not fit” in the chair. Fortunately, she was not injured during the attempted transfer.
I became aware of this incident after the technician approached me. When I raised concerns about the communication failures, safety risks and liability involved, John did not appear to understand why the situation was so serious and why I was so upset, which I found infuriating. John’s lack of accountability in this situation and the lack of accountability from John’s superiors to John was even further disappointing and infuriating.
Several weeks later, the manufacturer representative and I returned to Sarah’s home. The wheelchair had already been accepted with the assurance that adjustments would be made. John was not present as he was “busy with evaluations.”  We determined that Sarah had gained additional weight due to tube feeding changes and did not fit the originally delivered back support, and her lower extremity positioning did not reflect the plan established during evaluation. We collaborated with John to replace the back support with a wider size. The rep and I returned later to complete installation, which included multiple adjustments. Sarah demonstrated ability to initiate driving but would need further assessment for joystick placement and programming. We requested the nurse to coordinate further training for nursing staff and trials for Sarah. At the nurse’s request, Sarah was returned to bed. The nurse never scheduled the requested follow-up visits to address driving and staff training. John did not follow up with Sarah to advocate for further visits.
The outcome of this case is, at best, incomplete. Sarah now has a seating system that fits her appropriately, yet it is unlikely she will use it to its full potential. Her dependence on caregivers for transfers limits her ability to advocate for herself, and unresolved caregiver concerns have become a primary barrier to functional use.
This situation was resolved only through the persistence of the therapist and manufacturer representative. The ATP’s limited clinical engagement, inconsistent communication and absence during key decision points contributed to repeated failures in care. Compounding this, business relationships and productivity pressures appeared to outweigh accountability and patient centered decision making.
This case is not about assigning blame to a single individual. It is about recognizing systemic failures that place medically fragile clients at risk. When communication is poor, when roles are unclear and when financial pressures override clinical judgment, patients like Sarah pay the price.
What we do in CRT can mean the difference between dependence and independence, comfort and suffering, and health and injury. While this work exists within a business model, no delivery timeline or sales target should ever supersede safety, dignity and meaningful outcomes. Sarah’s goals should have guided every decision; instead, they were repeatedly sidelined.
I titled this article as “The one that broke me” because, after this incident, I decided to pivot professionally. I am no longer doing seating and mobility evaluations full-time, only on occasion. I found my anger had surpassed a righteous level, and I noted I was chronically frustrated by what I perceived as the constant compromise of best practice for productivity. While I completely understand the nature of business (I ran my own), and the need for revenue to keep running, I can no longer stand by or participate in the perpetual lack of accountability.
I hear technicians asking for more training on seating and positioning principles to offer better service, but productivity demands outweigh their desires to offer more to their customers. I see ATPs who lack the skills to properly discern needs and service their complex customers not held accountable for poor outcomes because of their good productivity. I see high-producing ATPs given increasing administrative support to sustain their crazy schedules, but no accountability given for lack of timely and accurate documentation or availability that causes delays in care. Meanwhile, this causes lesser productive ATPs to be under supported administratively, resulting in their clients also receiving delays in care.
We know better. Hopefully, we want better. So why don’t we do better? This constant compromise of our moral and ethical values is the essence of burnout. We have to stop doing or we have to stop caring. I chose to care, so I then also chose to “do” differently.
We promote “see something, say something” in other areas where we value safety. I’ve seen too much to not say something. I encourage each of us to speak up and to megaphone others who do. Say something when a client’s complexity is out of your skill set. Don’t just abandon the work to someone else. Say something but also commit to learning what you lack. Our professional integrity is built on our commitment to learning and growing our skills each day.
If our field is to mature and earn the trust it requires, we must be willing to reflect honestly on cases like this and ask difficult questions:
- What do I do when a client’s needs exceed my experience or skill set? Am I handling this in the same way I would want other medical professionals to handle my care or that of a loved one?
• How clearly and consistently do I communicate client needs to my team?
• What safeguards exist in my organization to prevent these breakdowns in care?
• Am I willing to accept the same level of accountability that I expect from others?
These are not abstract considerations. They are ethical imperatives. The lives and well-being of people like Sarah depend on how we answer them. The moral integrity of our field depends on it.
Melanie may be reached at melanie.parker.pt@gmail.com
Melanie Parker, DPT, ATP/SMS, has been a physical therapist for 22 years in a variety of clinical settings and has performed seating and mobility evaluations the majority of her career for clients of all ages. She is passionate about a client-focused model and advocating for the best outcomes possible for her clients. She owned and operated Confident Living, a comprehensive seating and mobility clinic in Richmond, Virginia, from 2019 to 2024. She now works in a variety of areas providing therapy and consultative services. Based on the struggles heard and seen from clients and families new to disability and her own struggles to find the resources for her son who has autism, she founded The Whole Family Foundation, a nonprofit to educate, empower and connect families who have a member with a disability in order to strengthen the family unit. Outside of work, she loves spending time with her husband, three teenagers and two dogs, in addition to traveling and being active in her community.