R2. Seating & Mobility Index (SMI) as an Assessment & Classification Protocol for Complex Rehabilitation Technology (CRT)

Project Leader(s): Rachel Hibbs, DPT, NCS, ATP & Gianna Rodriguez, MD

Co-Leaders:  Julie Mannlein, PT, ATP, Theresa F. Berner, MOT, OTR/L, ATP, & Juli Harrison OTD, OTR/L, ATP

Other Project Personnel: Lauren Terhorst, PhD, Carmen P. DiGiovine, PhD, ATP/SMS, RET, Richard M. Schein, PhD, MPH, & Hanju Zhu, MPH

Overview

One of the largest problems the field of CRT faces is funding and reimbursement for the technology. Documentation is not uniform from clinic to clinic, and it can be difficult to numerically measure the client’s need for different devices. The Centers for Medicare & Medicaid (CMS) coverage policies for CRT devices are also based more on diagnostic criteria and use within the home rather than the functional or participation needs of the person. The overall objective of this project is to systematically develop a unified and validated method for clinicians to assess and quantify a person’s need for different types and levels of CRT based on function, participation, and environmental factors rather than diagnosis. The tool will be called the Seating & Mobility Index (SMI) whereby items will be developed and operationally defined based on the International Classification of Function, Disability, and Health (ICF) constructs of body structures and function, activities and capacity, participation and performance (individual and societal), contextual factors (personal and environmental), and the importance of how these components affect and influence factors internal and external to an individual’s health status.

The clinical development and testing will be done so collaboratively through the University of Pittsburgh, The Ohio State University, and the University of Michigan all high-ranking academic institutions with Assistive Technology Centers. The project will be guided by an Advisory Group and other DRRP Team Members. This includes people with disabilities who will provide input on the development of the SMI. They will provide input into the components of the tool related to meaningfulness and burden during a CRT assessment. Clinician groups outside the project will also be engaged to assist with content validation.

The anticipated outcome of this project will be a first of its kind Seating & Mobility Index that has undergone initial content validation and inter-rater reliability as an indicator for levels of CRT interventions. It will streamline and standardize many components of the CRT assessment process to reduce burdens and more effectively document and communicate need and justification for interventions for insurance review purposes. It will also be used to build a new CRT policy model.

Update

As of May 1, 2025

Sub-Project #1: Review of Literature – COMPLETED

A review of current systematic reviews of assessment tools for measures of physical function or status, environment, participation, and activity that are related to a person’s need to use CRT was undertaken. Five hundred twelve systematic reviews were screened for inclusion, of which 223 were included for full text review to identify tools that could potentially be included as part of the SMI. From this search, 317 assessment tools were identified to be further evaluated. The team is currently reviewing these tools for clinical utility and validity to prepare a manageable list for use in survey of professionals in the field. In preparation of survey of professionals in the field, a template of the survey questions has been drafted for use when the initial list of 317 articles has been reviewed and whereby the team has eliminated tools for inclusion 41. A clinically relevant table of these tools is being developed with information gathered from review process for distribution to clinician reference.

Dissemination Activities

A clinically relevant table listing outcome tools associated with wheeled mobility and seating assessments filtered by ICF Categories, hyperlinks to more information of the tool and what it measures can be downloaded below.

Sub-Project #2: Clinician Viewpoints on Implementation of Outcomes Survey – DISSEMINATION

  • An online survey was prepared for clinical professionals in the field and approved by the IRB based on results from sub-project #1
  • Collected 34 responses from clinical subject matter experts (SMEs) in the field
  • Twenty-five of the 43 listed objective measures were familiar to the SMEs
  • Responses varied for each of the three statements of frequency, usefulness to justify CRT, and burdensome
  • Most frequently used tools: MMT, TUG, Braden Scale, FMA, MAS, WPT, and MFRT

Manuscript titled, ‘A Cross-Sectional Descriptive Analysis of Clinician Opinions on Objective Measurement Tools and Utility for a Wheeled Mobility Device’ was revised based on internal team feedback. The plan is to submit to journal before the end date of grant.

Conclusion: This cross-sectional study showed how experienced seating and mobility clinicians assessed forty-three commonly used outcome measurement tools in wheelchair evaluation. Discrepancies were found in frequency, usefulness, and burden among those tools, with MMT and MAS being used most frequently, FMA and WPT being identified as the most useful, and MMT, TUG, Braden, and MAS having least burden. Time was recognized as the reason in administration burden for most tools compared to space, equipment, and training. This study also underscored the inconsistency in wheelchair evaluation across clinicians.

Dissemination Activities

  • Manuscript in Preparation: ‘A Cross Sectional Descriptive Analysis of Clinician Opinions on Objective Measurement Tools and Utility for a Wheeled Mobility Device’

Sub-Project #3: Development of Clinical Documentation – In-Progress

Dissemination Activities

Sub-Project #4: Development of Seating Mobility Index (SMI) – In-Progress

  • Identified a scoring strategy based on stratification of each item’s traditional scoring. Gathering information about cutoff scores and useful standardized metrics for each item in toolbox.
  • Solicited feedback on beta version of SMI in March to current DRRP Clinical and Consumer stakeholders for any remaining edits
  • Prepared 20+ case studies for reliability testing 
  • Created Qualtrics Survey with randomization and logic modeling 
  • IRB Approved 
  • Data Collection ended and each case study had four independent clinicians evaluate the SMI
  • Due to the ordinal nature of the items in the SMI scale, we established interrater reliability using Fleiss’ Multirater Kappa. A kappa score of 0.61 – 0.99. was set as the statistically acceptable standard because it would indicate substantial to near perfect agreement
  • Each grouping from the research team, clinician participants, and then research team & clinician participants together had a kappa statistic greater than 0.62 indicating a high level of agreement. This indicates a strong agreement between the scores given by each rater for the SMI
  • The SMI provides a new instrument for clinicians and researchers to assess the quality of seating and mobility.
  • A manuscript titled ” Reliability Testing of the Seating and Mobility Index’ is being finalized and will be submitted to a journal for review before the end date of grant

Dissemination Activities

Development and Reliability of the Seating Mobility Index (SMI). Abstract submitted to the 2025 Academy of Spinal Cord Injury Professionals (ASCIP) in Philadelphia, PA

Harrison, J., Hibbs, R., Klein, J. & Mannlein, J. (2025, March 21). Developing the Seating and Mobility Index: Project Updates. Short Course Presented at the 39th International Seating Symposium. Assistive Technology, 37:sup2, S18, https://doi.org/10.1080/10400435.2025.2463822

Hibbs, R.M., Harrison, J., & Schein, R.M. (2024, June). Validation of an Objective Assessment Tool for Seating and Mobility Evaluations. Instructional Course presented at European Seating Symposium, Dublin, Ireland.

Hibbs, R.M., & Schein, R.M. (2024, September). Validation and Integration to Clinical Practice of an Objective Seating and Mobility Assessment Tool. Platform presentation at the Academy of Spinal Cord Injury Professionals (ASCIP). Chicago, Illinois.

Hibbs, R., Harrison, J., Rodriguez, G., & Mannlein, J., (2023, April 13). Development of the Seating Mobility Index. International Seating Symposium (ISS).

Other Project Dissemination Activities

**Schmeler, M.R., Schein, R.M. DiGiovine, C., Pramana, G., Busquets, M.P., Zhu, H., & Dicianno, B. (2025). Elements of a Value-Based Approach to Complex Rehabilitation Technology Service, Policy, and Payment. Instructional Course Presented at the 39th International Seating Symposium. Assistive Technology, 37:sup2, S25, https://doi.org/10.1080/10400435.2025.2463822

**Hibbs, R., Schein, R.M., Schmeler, M.R. & DiGiovine, C.P. (2023,November). Towards an Evidence-Based Coverage Policy for Complex Wheelchair and Seating & Mobility Devices. Paper Presented at the Oceania Seating Symposium. Melbourne, Australia

**Schmeler, M.R. & Hibbs, R. (2023, September). Development of an Equitable Coverage Policy for Complex Wheelchair Seating and Mobility Devices. Paper Presented at the Academy of Spinal Cord Injury Professionals (ASCIP).

**Schein, R., Schmeler, M.R., DiGiovine, C.P., & Hibbs, R. (2023, July). Steps Taken into the Assessment and Investigation of an Equitable Wheelchair Coverage Policy. Paper Presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). https://www.resna.org/Events/RESNA-2023-Annual-Conference/Program-by-Track/SM-Seating-and-Mobility-including-CRT/323-steps-taken-into-the-assessment-and-investigation-of-an-equitable-wheelchair-coverage-policy

**Schmeler, M.R., DiGiovine, C.P., Hibbs, R. & Schein, R.M. (2023, July). Steps Taken into the Assessment and Investigation of an Equitable Wheelchair Coverage Policy. Instructional Course Accepted to present at RESNA.

**Schmeler, M.R., DiGiovine, C.P., & Schein, R.M. (2023, June). Assessment and Investigation of an Equitable Wheelchair Coverage Policy. Instructional Course Presented at VGM Heartland Conference. 

**Schmeler, M.R., DiGiovine, C.P., Hibbs, R., & Schein, R.M. (2022, July). Towards a Contemporary & Equitable Wheelchair Coverage Policy. Instructional Course presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). Hibbs, R., Rodriguez, G., Mannlein, J., & Wright, M. (2022, February). Development of the Seating Mobility Index. International Seating Symposium (ISS). Virtual Conference.

In collaboration with the R2 project and with invited panelists an ISS Webinar Series: Network ISS. University of Pittsburgh, Network ISS: A Prelude to Pittsburgh (Producer). (2021). Complex Rehabilitation Technology Service Delivery and Clinical Assessment Research: What Happens Behind the Curtain. http://rstce.pitt.edu/RST CE_Webinar/2021/RSTCE_ISS WS2021.04.html

Semancik, B., Schmeler, M.R., Schein, R.M., & Hibbs, R. (2021). Face Validity of Standardized Assessments for Wheeled Mobility & Seating Evaluations. Published online ahead of print, 2021 Sep 30. Assistive Technology. https://doi.org/10.1080/1 0400435.2021.1974980

**  above dissemination activities were paper presentations at conference/symposia in collaboration with other project updates

The contents of this website were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPGE0014-01-00). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this website do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.