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The necessity of best practice in Complex Rehabilitation Technology

We get into occupational therapy, physiotherapy and rehabilitation equipment provision because we love helping people live their best lives, preferably with a perfectly adjusted wheelchair, not a crash cart and a prescription pad. However, in Complex Rehab Technology, if we don’t follow best practice, our “non-life or death” job can suddenly feel a bit more ….. life or death. In my discovery of the world of seating and mobility, it quickly became clear that when wheelchair provision isn’t done correctly, the results can be catastrophic. For this reason, the topic of best practice should be at the forefront of everyone’s minds across the industry. It’s simply not good enough to say, “The OT/physiotherapist/Assistive Technology Professional writes the prescription; therefore, the blame is on them if something goes wrong.” It’s our collective job to advocate if we don’t agree with something.

In many ways, the necessity of best practice to me has always been somewhat bizarre. It can sometimes feel as though so much time is dedicated to following best practice that it limits our ability to simply help people in the moment. Yet these standards exist for a reason. Through experience and education within our wonderful field, I quickly realized that my ignorance of such a belief would hold me back. I cannot even begin to count the number of times during my OT placements I ran around “like a headless chicken” doing my best but working significantly harder than I had to and relying more on instincts than anything else. During this time, I realized that sometimes, despite our best efforts, while we want to help, we may not know how to help. In a nutshell, best practice aims to give us a framework and structure to help us help people.

From an OT perspective, although there is no exact definition of best practice, we generally consider best practice to have three essential pillars within its definition: It is evidence-based, client-centered and consistent with professional standards and ethics. I think our industry can absolutely learn from these three pillars, but to make this article more profession specific, I am going to suggest we further expand this definition to include an emphasis on timely repairs and service for our end users to ensure our clinical effort translates into effective, safe and accountable outcomes for our clients. This article serves as a deep dive into each of these pillars though clinical examples and, hopefully, a bit of humor. 

 Defining best practice in OT and CRT

Best practice in OT is not universally defined between different professional registration bodies; however, it generally encompasses the aforementioned three core pillars. In addition to best practice, we also need to integrate the best available research evidence, the practitioner’s skilled and clinical expertise, and the best available equipment within the funding context. Professional organizations like the American Occupational Therapy Association mandate that care must be occupation-centered [i](focusing on participation in daily life roles) and fundamentally client-centered (guided by the individual’s goals and context). In the CRT space, this definition extends to a system-level expectation: The provision of high-quality, individually configured equipment must be supported by timely service and repair infrastructure. This holistic framework ensures that the prescribed technology effectively meets the user’s current and anticipated medical, physical and environmental needs, thereby functioning as a true enabler of independence and participation.

The importance of best practice guidelines

The establishment of formal best practice guidelines is critical for several interconnected reasons that center on quality, accountability and public protection. First, they ensure quality and effectiveness by requiring practitioners to move beyond traditional methods and base their interventions on scientific evidence, leading to optimal functional outcomes. Second, these standards protect the public and client interests by mandating that services are safe, ethical and tailored to the client’s self-defined needs and goals, reinforcing the ethical principle of client autonomy. For CRT users specifically, adherence to these guidelines, particularly those related to skilled clinical reasoning within the interdisciplinary team, mitigates the risk of secondary complications, like pressure injuries, and catastrophic device failures. Ultimately, best practice guidelines reinforce professional accountability and consistency, strengthening the OT, physiotherapist or ATP’s role in advocating for and securing access to medically necessary CRT services.

The power of evidence: Diagnoses, assessment and accountability

The first pillar of best practice is Evidence Based Practice (EBP), requiring us to fully understand why we must keep up with the latest evidence and commit to continuous professional development. In the world of seating and mobility prescription, the clinical landscape is shaped not only by our initial training but also by the real-life scenarios we face: the complex, unexpected and deeply human. One such case recently reminded me how essential it is for all clinicians, especially those prescribing mobility aids, to maintain this commitment: always grasping a patient’s diagnosis and prognosis and staying current with best practices, even in their simplest form.

As a seasoned prescriber in Ireland of high-technology power wheelchairs, I’ve been fortunate to accumulate a range of experience. Still, even with that background, I found myself in new waters when I began working in Canada. One of my first complex cases here was truly a baptism by fire: a gentleman newly diagnosed with Parkinson’s disease, referred for a powered wheelchair. The case itself was complicated not only by the nature of the disease but also by challenging personal circumstances and system-level barriers, including my own unfamiliarity with the local funding process. The client needed a high-tech solution, and it was clear that this would not be a routine case.

To add another layer of complexity, the OT I was working with was also an almost brand-new prescriber, and this was their first time prescribing a high technology powered wheelchair. After we made our introductions and engaged in a conversation about our respective backgrounds, it became clear that they needed some professional development, especially around seating assessments and the principles behind them. The OT in this example had never completed a MAT (mechanical assessment tool) evaluation — a crucial part of any complex seating evaluation. So, I sent over some general forms, links to relevant YouTube videos (e.g., how to assess hip range of motion), and we spent a few evenings discussing the process and reviewing what to look for during the evaluation. I also shared something I learned early in my own OT career — that it’s okay, and sometimes essential, to lean on your physiotherapy colleagues. I encouraged this OT to connect with their physiotherapy colleagues to get hands-on practice with range of motion testing and supporting limbs.

Unfortunately, this knowledge gap is not unusual in our field. Many prescribers are simply “thrown into the deep end” and expected to learn as they go. This reality makes our roles as educators and mentors even more vital. It also reinforces the need to stay informed and up to date with evidence-based practice because in many cases, our knowledge may be the only resource another clinician has access to.

Side note: While I was in OT school, we weren’t taught anything about MAT evaluations. It was deemed “not necessary,” something I still view as a major oversight, but that’s a topic for another article, I’m sure … .The point is, most OTs simply don’t have the hands-on experience required for this kind of evaluation, and we need to guide them toward the right resources when time and support are limited.

By the time the assessment came around, the OT was well prepared. They had reviewed the forms, practiced the techniques and were eager to learn. They asked me to lead, and I was more than happy to support them through it. It was during this session that we made an important clinical discovery: The client had limited hip flexion. This would significantly impact our prescription, and it was my role to help the OT understand why. 

After explaining that we cannot sit this person at a 90-degree hip angle and getting a somewhat puzzled look back, I decided to probe, and I asked a simple question: “What would happen if we didn’t accommodate for this limited hip flexion?” The OT paused, then said, “Would it cause discomfort?”

“Certainly,” I replied. “But what else?”

After a thoughtful silence, I started explaining the biomechanics. If we tried to seat someone with restricted hip flexion at 90 degrees, they would not be able to maintain that position. They would naturally slide forward to achieve their maximum flexion angle. The OT’s eyes lit up as the pieces came together.

“Wait, so you’re telling me that if I missed that, it would cause sliding?”

“Exactly,” I said. “On top of discomfort and potentially pain and sheer. And what happens when someone slides forward?” and I did a small demonstration on my office chair to add a visual aid.

“Well, the cushion would no longer be supporting the right parts of their pelvis, and the backrest wouldn’t make full contact with their back.”

And so, the pieces of the CRT puzzle began to fall into place.

These are the kinds of lightbulb moments that illustrate just how essential clinical reasoning is and how critical it is to continually seek knowledge, especially around conditions like Parkinson’s, where posture, tone and motor control can change over time.

Keeping up with the evidence and trust

Another pivotal moment in this client’s case came during an anthropometric aspect of the seating assessment. The OT measured the client’s hip width at 20 inches and proposed a 22-inch-wide chair. This was a classic example of outdated methodology, which is unfortunately still taught at some OT schools, adding a little extra room in case they wear a coat and for comfort. However, based on current best practice, we now know that a snugger fit typically results in better posture, pressure distribution and control. I also pointed out that with Parkinson’s disease, clients often experience weight loss, not gain, particularly if their medications or overall health status doesn’t suggest otherwise. Overall, in this case a larger seat would be placing the client at risk of developing a windswept posture.

Fortunately, the OT was receptive to this information. Rather than feeling undermined, they appreciated the evidence and rationale I provided. This not only helped the client receive a more appropriate prescription, but it also strengthened the trust and rapport between the OT and me.

Trust is a powerful thing in clinical practice. In this case, it fostered a strong working relationship where I was seen not just as a sales rep, but as a coach, educator and reliable source of up-to-date knowledge. That trust will pay dividends far beyond this one client. The OT now has a better understanding of MAT evaluations, biomechanics, measurement standards and the implications of disease progression. They will carry that knowledge into every future case, sharing it with peers and helping other clients avoid common pitfalls.

There is a bigger lesson here, too. In our field, every interaction is an opportunity to educate, uplift and improve practice. You never know when a seemingly small moment, like explaining hip-flexion limitations, can create a ripple effect that benefits countless future clients. And none of this is possible without a commitment to ongoing learning.

We owe it to ourselves, our colleagues and, most importantly to our clients, to stay informed. Diagnosis and prognosis should always guide clinical decisions, but they must be paired with an understanding of best practices and the willingness to evolve. No one should be navigating complex clinical scenarios alone, especially not new prescribers or therapists facing their first challenging case.

To those reading this who are more experienced, don’t underestimate your role as an educator. You may be someone’s only point of contact with current standards and effective clinical reasoning. And to those newer to the field, don’t be afraid to ask questions and seek out mentorship. It’s how we all grow.

In the end, this experience reminded me that the best outcomes happen when we combine clinical skills with curiosity, compassion and collaboration. Staying current isn’t just about reading journal articles; it’s about being present, asking the right questions and sharing what we know. And in doing so, we become not just better practitioners but also better advocates for the people who rely on us the most.

Client-centeredness in action: The power of listening and prioritizing needs

It can be easy to get caught up in the clinical checklist — posture, pressure relief, propulsion, materials and so on. These are, of course, critical factors in any successful wheelchair prescription. But if there’s one lesson I keep coming back to in my work, it’s this: We need to start by asking the clients what they want. Their goals, their lifestyle, their preferences. Without that, even the most technically “perfect” equipment may fail to meet the needs that matter.

Understanding the person behind the prescription

While I typically work with high technology powered wheelchairs, I also spend a significant amount of time working with rigid manual wheelchairs, a very different clinical puzzle with its own unique challenges and rewards. One recent case truly underscored the importance of being relentlessly client-centered in everything we do.

The client in question was a new wheelchair user, a lifelong above-knee amputee with a prosthetic. He was relatively young, highly motivated and trying to stay active but beginning to feel the strain. He shared that he was experiencing increasing fatigue and was finding it more and more difficult to keep up with his friends in the community. Although he was managing, it was clear that something wasn’t quite working with his current setup.

From our very first conversation, it was obvious that this client had clear goals. He wasn’t someone who stayed indoors or limited his movement to medical appointments and errands. Instead, he was frequently venturing around the city, navigating curbs, commuting, visiting friends and, perhaps most impressively, doing laps at the local athletic track. He was not interested in hiking or off-roading, but he needed something that could keep up with an active urban lifestyle, minimize energy expenditure and be easy to handle independently.  Living in the bustling city of Toronto, he rented a compact apartment with limited storage, so the chair had to fold and be easily stored.

This is exactly where client-centered care starts: Not with assumptions or overly focusing on diagnoses, but with their lived experience.

Balancing function, fit and flexibility

We moved into the equipment trial phase, and I made sure to keep the client’s goals and preferences front and center. He was very clear on what he needed, a chair that was:

• Lightweight for propulsion and lifting
  
• Compact and foldable due to tight storage in his apartment and car
  
• Strong and rigid enough for high daily use
  
• A part of him — like a prosthetic does to its user
  

We trialed a few different models, both rigid and folding. Each had pros and cons. Some were lightweight but lacked the rigidity he needed for smooth, efficient propulsion. Others were strong and agile but too bulky or difficult to fold and store. It was becoming clear that no standard option was ticking all the boxes.

Then, we came across something a bit different: Motion Composites’ Helio Veloce. And while this isn’t a plug for the company, I’d be remiss not to mention it because for this specific client, this chair offered something unique: a rigid folding frame made of carbon fiber — a rare combination that directly addressed his top needs.

Why this chair worked: Matching equipment to the individual

On paper, the Helio Veloce brought several benefits. It had the rigidity and responsiveness of a performance chair, the folding mechanism of a more flexible, space-conscious chair, and the ultralight properties of carbon fiber, which carries not only practical benefits but also clinical ones, too.

Carbon fiber, beyond being light, reduces repetitive strain on the shoulders, something that cannot be overlooked in long-term wheelchair users. This meant easier propulsion, less fatigue and greater long-term joint health — all incredibly important for someone planning to remain active for many years.

When we trialed it, the client immediately noticed the difference. He could lift the chair into his car independently and with ease — a major factor for maintaining autonomy. The rigidity made propulsion smooth and almost effortless. He described it as the first time the wheelchair felt like it “fit” him, like an extension of his body rather than a piece of equipment he had to fight with.

Prioritizing the client over profit

There’s an uncomfortable reality in our field: Sometimes the most appropriate equipment for the client isn’t the most profitable option for the supplier and potentially a more difficult prescription for the clinician. This chair, with its specialized build and materials, was not the most margin-friendly choice. But that didn’t matter, because it was what the client needed.

Client-centered care isn’t just about being nice or agreeable. It’s about advocating, sometimes fiercely, for what will work best for the person in front of you. That might mean more paperwork, less commission or longer justification reports. But it also means delivering better outcomes and preserving the dignity, autonomy and independence of the people we serve.

In this case, the “right” solution didn’t come from a catalogue spec or funding matrix. It came from deep listening, collaborative decision-making and a commitment to finding equipment that aligns with the client’s life, not just their diagnosis.

Why asking matters

There’s an easy trap to fall into, especially for clinicians with experience: thinking we know what’s best before hearing the whole story. But every client is different. Diagnosis alone doesn’t tell us how someone lives, what they value or where they find joy. That information only comes when we ask:

• What do you want to be able to do?
  
• What’s not working right now?
  
• What’s important to you — really important?
  

When we create space for clients to answer these questions honestly, the prescription process shifts. We’re no longer simply fitting a person to a chair, we’re designing a solution around a life.

In this client’s case, his life involved movement, autonomy, community and performance. The right chair had to support those things, or it wasn’t the right chair at all.

Client-centeredness pays forward

One of the most powerful outcomes of a client-centered practice is that it fosters trust. That trust isn’t limited to one transaction — it carries forward. The client is more likely to return for follow-ups, more likely to comply with clinical recommendations and more likely to share their positive experience with others who need support.

Moreover, it helps create a culture among clinicians, especially new or less experienced ones, that centers on the person, not the product. This approach influences teams, builds better interdisciplinary relationships and improves care across the board. This case was a perfect reminder that client-centered care is not optional. It is foundational. When we listen carefully, ask the right questions and design around the client’s goals, we create better outcomes, stronger relationships and more meaningful interventions.

Yes, we bring clinical expertise. Yes, we understand the implications of diagnoses and biomechanics. But it is only when we blend that knowledge with the client’s voice that we achieve real success.

So next time you sit down with a new client, resist the urge to lead with the solution. Instead, start with this:

“What matters most to you?”

The answers will take you exactly where you need to go.

Timely service and repair: Seeing through the client’s eyes

In the world of assistive technology, it’s easy to focus on equipment — frames, batteries, cushions or parts. But what we must never forget is this: When a mobility device fails, a person’s access to life is disrupted. Independence, dignity, social connection and daily function can all vanish in an instant.

We’ve all worked with clients who seem to “pester” us; those who call frequently, express frustration or report seemingly minor issues. It’s tempting to dismiss these situations as overreactions. But it’s worth asking: What if this issue, however small it seems to us, means everything to them?

For many, especially full-time wheelchair users, a loose bolt or slow repair isn’t just inconvenient, it can be the difference between getting to work or staying home, seeing a friend or staying isolated, managing their health or risking decline. While we might see a technical fault, they are experiencing disruption to their entire world.

I delved into this point in more detail in a previous article for iNRRTS titled, “A clinician’s perspective on what makes a good sales rep.” It may be worth checking out.

So, what can we do?

• Set expectations early. Help clients understand timelines and possible delays but do so with empathy.
  
• Listen actively. Often, people just want to be heard. Validating their frustration goes a long way.
  
• Prioritize based on impact. A “minor” issue for one user may be critical for another.
  
• Follow up. Let clients know they haven’t been forgotten.
  

Above all, we must keep perspective. Timely service and repair aren’t just good practice; it’s a vital part of client-centered care. If we can see through the client’s eyes, we will serve not just their equipment but also their humanity.

Professional standards, ethics and conduct: The supportive expert role

The commitment to best practice requires that every professional, particularly those in a supportive role, strictly adhere to professional standards, ethics and codes of conduct. Our primary duty is to serve as the equipment expert and act as a sounding board, advisor and general counsel for the prescribing OT and the client. This involves sharing evidence-based product knowledge and biomechanical rationales without overstepping the scope of practice of the primary clinician (OT, PT or ATP). It is crucial to respect the clinical decision-making authority of the prescriber while simultaneously upholding your own ethical obligations to the client. This includes adhering to your company’s ethical standards, as well as the codes set forth by professional regulatory bodies like iNRRTS or the relevant clinical registries.

As general advice, if a situation or decision “feels off,” don’t do it, even if your intentions are good. To ensure transparency and accountability in all interactions, it is wise to follow two pieces of timeless advice I received early in my career. 1) “When writing your clinical notes, imagine the client is reading what you are saying over your shoulder.” 2) “If you had to explain objectively what you were doing to a judge or jury, how would they react?” These simple, yet powerful, standards ensure that every action we take is defensible, client-focused and maintains the highest level of professional integrity.

Conclusion

The journey through CRT is ultimately defined by our commitment to best practice. As practitioners and providers, we enter this field driven by a powerful desire to enhance independence, yet this article underscores a crucial, sobering reality: When we deviate from established standards, the results can be genuinely catastrophic. The responsibility for prevention is shared; it extends beyond the prescriber’s signature and requires collective accountability from everyone in the interdisciplinary team.

Our expanded framework for best practice covers four key areas: evidence-based practice, client-centeredness, ethical practice adherence to professional standards, and timely service and repair. These are the blueprint for ensuring high-quality outcomes. The clinical narratives presented illustrate the profound difference these principles make. The moment a subtle limitation in hip flexion is identified or when a chair’s weight is perfectly matched to a client’s active lifestyle, we see the transition from merely supplying equipment to enabling a life.

This requires that experienced professionals act as dedicated mentors and coaches, actively sharing current evidence to close knowledge gaps like something as small as sharing current guidelines for a snug fit rather than extra-space fit (depending on the situation). Simultaneously, we must embrace the art of deep listening, ensuring that the technical ‘perfection’ of a prescription never overshadows the client’s self-defined needs and goals.

Finally, the focus on timely service reminds us that a wheelchair is not just a device; it is a gateway to life. When that gateway is broken, independence is immediately lost. Adhering to professional standards and ethics ensures that every decision made is defensible and client focused. By integrating these core principles, the CRT community moves beyond solving technical problems to truly serving the humanity of those who rely on us, cementing our role as essential advocates for function, dignity and autonomy.

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[i] I realize I should define “occupations” for our non-OT readers: Occupations are the core of occupational therapy. They are defined as everyday activities of daily living that provide meaning and purpose. A somewhat ambiguous definition, but this is why OTs focus on functional activities and activities of daily living.

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Jack may be reached at jackdmurphy02@gmail.com.

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