Non-prescription DME and Assistive Devices

Overview and Description

Durable medical equipment (DME) can be defined by Medicare as equipment that can withstand repeated use, is used for medical reasons, is used at home, and is typically only useful to those with a disability or injury.¹ One of the largest areas for DME is improving mobility and includes equipment such as walkers and canes. It is important to note that not all durable medical equipment needs to be prescribed by a physician, and DME may not be covered by insurance.  The importance of DME equipment does not rest on whether it is prescribed or not, and often over-the-counter DME is essential for treating a patient.  This article will highlight DME that can be acquired by patients without a prescription. 

Assistive devices and technology aid in performing specific tasks that are more difficult to perform due to a disability, which may not be medical, more efficiently. Assistive devices can be simple such as magnifying glasses or involve complex technology such as computerized communication systems. DME and assistive devices both aim to improve the functional lives of patients and, therefore, will be discussed together. Also, there is an overlap in what can be viewed as DME or assistive devices, such as hearing aids. Including a discussion of available DME and assistive devices between physiatrists and their patients is essential. As the practice of physical medicine and rehabilitation is evolving, there must be the utilization of current technologies and devices to propel this field forward. Further awareness of such equipment and devices can also be beneficial in achieving health goals set by other medical team members, including physical therapists (PT), occupational therapists (OT), and speech and language pathologists.

Relevance to Clinical Practice

First and foremost, any added equipment or device to the patient’s routine must be beneficial to the individual themselves. This can be to either address their physical needs or improve their quality of life (QoL) in other ways. Second, we must be mindful of the setting in which these tools can be utilized and the feasibility of them. Devices in the home setting may not have the same efficacy when used in public. Some of the various devices mentioned in this article and their aspects will be summarized in Table 1. Third, according to Centers for Medicare and Medicaid Services, retail spending for durable medical equipment increased 21.8 percent in 2021 to $67.1 billion, noting that out-of-pocket spending is one of the primary drivers for this increase.² Since this article is discussing non-prescription DME and assistive devices, physiatrists must also be conscientious of the cost burden that is placed on the patient by recommending these tools. What one patient may see to be affordable may not be the case for another patient.

Table 1. DME and Assistive Devices

Mobility DME such as canes and walkers, and even scooters and wheelchairs, can be purchased without a prescription. These types of mobility equipment can be inexpensive (for example, one can buy a cane for $10-20 and a simple 2-wheeled walker for as little as $40. A 4-wheeled walker with hand brakes, a basket, and a seat with a cushion that can withstand up to 500 lbs. can be about $200) and can be beneficial in a space-limited setting, such as within a home. Reverse walkers can be an aid in maintaining an extension posture in those who tend to have a flexed posture standing.³ It is important to note that the patient can use different mobility devices in different settings to assure comfort and stability depending on the situation. According to the Centers for Disease Control and Prevention, each year, around $50 billion is spent on medical costs related to non-fatal fall injuries alone.⁴ With the goal of decreasing fall risk, there has been an increase in mobility device utilization by community-dwelling adults over the past few decades.⁵ However, as the number of Americans aged 65 and older continues to increase, the number of falls is expected to increase as well.⁴ While mobility DMEs provide promising solutions, the fall risk that may come from the use of mobility devices must be recognized as well. While there was no increased risk of falls noted between any specific mobility device, one study did find that cane-only users are more likely to limit activity due to worry about falling.⁵ The emotional stressor of falls should be discussed with patients. Every member of the team, including the physiatrist, PT, and OT, should discuss this with the patient to ensure they are using the mobility device they feel the most confident in. These mobility aids should encourage patients in their ability to perform activities of daily living (ADL), not hinder them.  Another aim of DME is to maintain the safety of patients while they perform ADL independently. For example, the inability to complete bathing or toileting needs safely and independently is associated with decreased QoL.⁶ According to a 2021 article, in the United States, 42% of older adults with impairments that make toileting and bathing difficult lack the equipment necessary to assist them.⁷ This lack of equipment is not limited to older adults but also to those with neurological or physical impairments that may limit toileting ability. DME, such as a bedside commode or a toilet frame for safety, can increase the confidence of patients to live independently. Grab bars and shower seats can also increase safety while in the bathroom. However, it is important to consider the impact of this equipment on the support system and caregivers of the patient. If the patient is unable to empty the bedside commode themselves, this may increase the burden on the caregivers. Further, the correct training by members of the occupational therapy team may be beneficial to ensure no injury occurs while utilizing this equipment.

Other inexpensive DMEs, such as transfer boards, can be useful for patients who utilize wheelchairs. For example, a slide board may cost about $30, and a tub transfer bench may be between $60 -$120 online. All of these can easily be purchased through Amazon, Lowes, Home Depot, etc., but the cost of having multiple DME can add up quickly. Transferring to and from wheelchairs is linked to increased fall risk and injuries of the upper limb. Transfer boards are inexpensive and can decrease the risk of injury in the patient from falls and play a role in decreasing the weight born by upper limbs. Transfer boards can also be beneficial for caregivers in limiting the physical strain they may endure from lifting the patient between transfers to and from the wheelchair.

DME can also address issues such as pain. Transcutaneous electrical nerve stimulation (TENS) utilizes low-voltage electrical current to treat pain without any significant adverse effects. A systematic review of patients with pain concluded that there was a clinically significant reduction of pain during or immediately after TENS application compared to placebo. These benefits were found irrespective of diagnosis and whether the pain is acute or chronic.⁸ This allows for another tool patients can use to treat pain that does not involve pharmaceuticals or increased toxicity risk. A newer device has a TENS unit with inferential current therapy (IFC) and electro-muscular stimulation. Yet another device called Alpha stim can address anxiety, insomnia, and pain. It is being widely used in Veteran’s Administration hospitals. Cold laser of newer frequency generators is now FDA-approved and can be bought online to help decrease pain.⁹ Whole body vibration has been shown to help with osteoporosis¹⁰ and can cost anywhere from $120 to $3000.

Therapeutic footwear can also be used to tackle pain in patients. Foot orthotics are devices that can be inserted into shoes and provide cushioning and off-loading of foot structures. They are used along with medical treatment for conditions ranging from alleviating pain in rheumatoid arthritis to decreasing the risk of diabetic foot ulcers. Over-the-counter orthotics can also be accessed without a prescription and usually at a lower cost than custom-made orthotics. While the gold standard is custom-made orthotics, a review comparing the two concluded that there was no difference in the effectiveness of treatment of foot pain between the custom-made and over-the-counter groups.¹¹ This can lessen the financial burden on patients from getting custom-made orthotics.

Assistive devices also function to improve ADL and the QoL of patients. They function to increase or maintain the capabilities in different populations. Assistive devices may not be viewed as medically necessary by insurance and do not need the capacity for withstanding wear-and-tear such as by durable medical equipment. However, assistive devices can enhance life in many ways. Simple assistive devices can include equipment such as a universal cuff which allows patients with decreased grip strength to hold on to items such as a toothbrush. This can aid in grooming more independently. Fastener adaptations include button aids or zipper pulls that aid in dressing, especially in those with limited prehension. Reachers, which come in varying handle grips and lengths, can be useful for individuals with limited upper and lower extremity mobility. Meanwhile, infrared sensors can easily turn the water on and off at the sink performing hygiene activities.³ Universal cuffs or built-up foam grips can also be useful while eating when the grasp is limited. For people with tremors, there are devices that help balance out the tremor and achieve a steadier grip with the utensils used. Other adapted utensils include a rocker knife, which is pushed into the food and rocked back and forth until the food is cut, which can be used with only one hand.³ These adaptations from conventional utensils can also bring back social functions, such as eating alongside their partner rather than needing a caregiver to feed them, and therefore improve QoL. Further, adaptive devices that allow the magnification of text or text-to-audio can enhance retention of recreational activities such as reading.

Assistive devices can be more complex such as augmentative and alternative communication devices. These may include all forms of communication other than oral speech that are used to express thoughts, needs, wants, and ideas. These may be as simple as paper and pencil to communication books or boards to devices that produce voice output (speech generating devices or SGD) and/or written output. Electronic communication aids allow the user to use picture symbols, letters, and/or words and phrases to create messages. Some tools that can be programmed to produce spoken languages are especially beneficial in progressive neurodegenerative diseases that affect speech and language. Cognitive factors limit which assistive technology devices can be used, such as how memory deficits can cause an inability to complete multi-step operations or device commands.³ Therefore, caution should be taken to avoid using complex technological devices when other options may be available. Appropriate early intervention with augmentative and alternative communication devices is also necessary. This is along with a routine and progressive reassessment of treatment modalities to ensure patients can maintain functional communication that allows them to continue ADL.¹² These treatments should be especially discussed with speech pathologists on the team. This will allow for a clear outlook on the expectations and benefits of these tools. 

Other assistive devices can involve home improvements or alterations that may lessen the burden on a patient in their daily life. For example, wireless door locks can allow patients with physical strains to ensure their safety without the physical stress that might be caused by walking to and from their doors. Smart locks that use face recognition to unlock are also being explored, rather than needing to have the dexterity to be able to type into a keypad or use a smart card.¹³ Pet ownership is associated with better cognitive status compared with those who do not own pets, but caring for a pet can be taxing.¹⁴ Therefore, additions to a “smart home” can include a smart pet feeder that dispenses food and water automatically, which can increase a person’s ability to have a pet as they age. Similarly, smart pill dispensers in the home can ensure correct dispensation of medications and prevent accidental overdosing from taking medications twice. Another example includes alarm systems that present bright flashing lights rather than just a ringing sound for patients with difficulty hearing. Meanwhile, Astro is a home robot from Amazon (costs $1600 on their website) that allows for remote care and contact for individuals wanting to live independently. It can follow a person around the home, give reminders and alerts, provide reassurance to caregivers that a loved one is active, and has 24/7 access to a professional emergency helpline.¹⁵ It is important to note that the automation of a home for a young person after a motor vehicle crash compared to an older person who may not have lived most of their lives with smart technologies. However, a paper from 2020 showed that the most required Internet of Things category among the elderly, disabled, and their caregivers is security services. These services include home security and closed-circuit television (CCTV), smart band and mobile SOS bell, and voice-recognition front door lock.¹⁶ These changes will allow patients to feel safer and more comfortable in their own homes.

Cutting Edge/Unique Concepts/Emerging Issues

With technology improving every day, there are great advances in assistive devices as well. Brain-computer interfaces are being studied to help those with communication impairments interact with the world around them, exoskeletons have the potential to become used independently by patients, and the integration of artificial intelligence brings hope to fill missing gaps in the link between technology and medicine. However, improvements in technology do not equate to improvements in patient access.  Patient access and cost burden can be improved by utilizing commercial health monitoring devices already on the market. Apple Watch and Google Pixel Watch include a fall detection feature that sounds an alarm and the ability to do an emergency call. Also, there is a need to increase the number of DMEs and assistive devices that can be covered by Medicare and insurance, as this will lessen the financial burden on patients and, in turn, the strain on the healthcare system.

Gaps in Knowledge/Evidence Base

There is not enough awareness or research conducted on which populations could benefit from DME and assistive devices currently on the market. Increasing communication between physicians and patients about tools that may improve their symptoms can be an important step in improving the QoL of patients. Further, inconsistencies in the terminology used play a factor in the gap in knowledge present. Standardizing terminology used in the setting of assistive devices will streamline the gathering, analysis, and interpretation of data currently available. Inconsistencies in terminology can have detrimental effects on the effective progression of research in rehabilitation and assistive technology.¹⁷

References

1. Gov. Durable medical equipment (DME) coverage Medicare.gov 2023 [Available from: https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html]
2. National Health Expenditures 2021 Highlights – Centers for Medicare …, 2021, www.cms.gov/files/document/highlights.pdf.
3. Braddom, Randall L. Physical Medicine & Rehabilitation. Saunders, 1996.
4. “Cost of Older Adult Falls.” Centers for Disease Control and Prevention, 9 July 2020, www.cdc.gov/falls/data/fall-cost.html.
5. Gell NM, Wallace RB, LaCroix AZ, Mroz TM, Patel KV. Mobility device use in older adults and incidence of falls and worry about falling: findings from the 2011-2012 national health and aging trends study. J Am Geriatr Soc. 2015 May;63(5):853-9. doi: 10.1111/jgs.13393. Epub 2015 May 6. PMID: 25953070; PMCID: PMC4439269.
6. Edemekong PF, Bomgaars DL, Sukumaran S, et al. Activities of Daily Living. [Updated 2022 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. [Available from: https://www.ncbi.nlm.nih.gov/books/NBK470404/]
7. Lam K, Shi Y, Boscardin J, Covinsky KE. Unmet Need for Equipment to Help with Bathing and Toileting Among Older US Adults. JAMA Intern Med. 2021 May 1;181(5):662-670. doi: 10.1001/jamainternmed.2021.0204. PMID: 33749707; PMCID: PMC7985819.
8. Johnson MI, Paley CA, Jones G, Mulvey MR, Wittkopf PG. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open. 2022 Feb 10;12(2): e051073. doi: 10.1136/bmjopen-2021-051073. PMID: 35144946; PMCID: PMC8845179.
9. Dima R, Tieppo Francio V, Towery C, Davani S. Review of Literature on Low-level Laser Therapy Benefits for Nonpharmacological Pain Control in Chronic Pain and Osteoarthritis. Altern Ther Health Med. 2018;24(5):8-10.
10. C.F Dionellow, D. Sa-Caputo, H.V.F.S. Pereira, et all. Effects of whole-body vibration exercises on bone mineral density of women with postmenopausal osteoporosis without medication: Novel findings and literature review. J Musculoskelet Neuronal Interact 2016 Se; 16(3): 193-203
11. Tran K, Spry C. Custom-Made Foot Orthoses versus Prefabricated foot Orthoses: A Review of Clinical Effectiveness and Cost-Effectiveness [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Sep 23. [Available from: https://www.ncbi.nlm.nih.gov/books/NBK549527/]
12. Fried-Oken M, Mooney A, Peters B. Supporting communication for patients with neurodegenerative disease. NeuroRehabilitation. 2015;37(1):69-87. doi: 10.3233/NRE-151241. PMID: 26409694; PMCID: PMC6380499.
13. Saputra, Rezki, and Nico Surantha. “Smart and Real-Time Door Lock System for an Elderly User Based on Face Recognition.” Bulletin of Electrical Engineering and Informatics, vol. 10, no. 3, 2021, pp. 1345–1355, https://doi.org/10.11591/eei.v10i3.2955
14. Friedmann E, Gee NR, Simonsick EM, et al. Pet Ownership Patterns and Successful Aging Outcomes in Community Dwelling Older Adults. Front Vet Sci. 2020;7:293. Published 2020 Jun 25. doi:10.3389/fvets.2020.00293
15. Charlie Tritschler, Vice President of Products at Amazon. “Meet Astro, a Home Robot Unlike Any Other.” US About Amazon, 28 Sept. 2021, www.aboutamazon.com/news/devices/meet-astro-a-home-robot-unlike-any-other.
16. Lee H, Park YR, Kim HR, et al. Discrepancies in Demand of Internet of Things Services Among Older People and People With Disabilities, Their Caregivers, and Health Care Providers: Face-to-Face Survey Study. J Med Internet Res. 2020;22(4):e16614. Published 2020 Apr 15. doi:10.2196/16614
17. Elsaesser, L.-J., Layton, N., Scherer, M., & Bauer, S. (2022). Standard terminology is critical to advancing rehabilitation and assistive technology: a call to action. Disability and Rehabilitation: Assistive Technology, 17(8), 986-988. https://doi.org/10.1080/17483107.2022.2112985

Author Disclosures

Sunil K Jain, MD
Nothing to Disclose

Areej Ennasr, BS
Nothing to Disclose