Assistive Technology Selection — Recommend high and low tech assistive devices based on client factors - Nbcot Registered Occupational Therapists Otr

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Historical Context & Motivation

The field of assistive technology (AT) has evolved from rudimentary adaptive tools crafted by individuals to a sophisticated, evidence-based discipline embedded in occupational therapy practice. Early assistive devices—wooden prosthetics, wheeled chairs, and magnifying lenses—date back centuries, but the formalization of AT as a professional domain is decidedly modern. The recognition that people with disabilities deserve equitable access to participation in occupations drove legislative, technological, and clinical advances throughout the twentieth century, fundamentally reshaping how occupational therapists approach intervention planning.

1988 • Technology-Related Assistance for Individuals with Disabilities Act (Tech Act)

The first U.S. federal legislation to define assistive technology devices and services, establishing state-level AT programs and mandating consumer-responsive systems. This law set the conceptual framework that OTs still reference today when categorizing AT.

1990 • Americans with Disabilities Act (ADA)

The ADA broadened civil rights protections for individuals with disabilities and reinforced the role of AT in ensuring reasonable accommodations in employment, public services, and telecommunications. OTs became essential consultants in workplace and community AT provision.

1998 • Assistive Technology Act Reauthorization

Reauthorized and expanded the Tech Act, emphasizing AT device lending programs, reutilization, and state financing activities. This legislation deepened the infrastructure that OTs rely on for device trials and client training.

2004 • IDEA Reauthorization & AT in Education

The Individuals with Disabilities Education Improvement Act mandated that individualized education program (IEP) teams consider AT for every child with a disability, elevating the role of OTs in school-based AT assessment and recommendation.

2010s–Present • Smart Devices, AI, and Universal Design

The proliferation of smartphones, voice-activated assistants, brain-computer interfaces, and 3D-printed adaptive equipment has dramatically expanded the AT landscape. OTs now navigate a continuum from simple low-tech solutions to complex high-tech systems, making systematic selection frameworks more critical than ever.

Despite these advances, a persistent challenge remains: research consistently shows that approximately one-third of all assistive devices are abandoned within the first year of acquisition. This abandonment rate underscores a critical gap in clinical practice—the need for a systematic, client-centered approach to AT selection that accounts for the full complexity of human factors, environmental contexts, and occupational demands. How can occupational therapists ensure that the devices they recommend genuinely enhance a client's participation rather than collecting dust in a closet? This question drives the frameworks and principles explored throughout this lesson.

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Core Principles of Assistive Technology Selection

Effective assistive technology selection in occupational therapy is grounded in several interlocking principles that ensure the recommended device aligns with a client's capacities, preferences, occupational goals, and environmental contexts. These principles draw from the Person-Environment-Occupation (PEO) model, the Human Activity Assistive Technology (HAAT) model, and the Matching Person and Technology (MPT) model—each of which offers a structured lens for clinical reasoning. Understanding these foundational ideas is essential before examining specific device categories or conducting device trials.

Client-Centered Selection

The client's values, preferences, motivation, and self-efficacy are the starting point for every AT recommendation. A device that the client does not want to use—regardless of clinical appropriateness—will be abandoned. Engage the client as an active collaborator, not a passive recipient.

Least Restrictive Technology Principle

Begin with the simplest, least expensive, and least intrusive device that meets the occupational goal. Low-tech solutions often provide greater reliability, require less training, and carry lower abandonment risk. Escalate to high-tech only when low-tech options are insufficient.

Contextual Fit

AT must function within the client's actual environments—home, school, workplace, community. Physical layout, social norms, caregiver capacity, and cultural attitudes all influence whether a device will be used consistently and effectively.

Continuum of Technology

AT exists on a spectrum from no-tech (strategy-based) through low-tech (simple, non-electronic) to high-tech (electronic, computerized, or powered). Effective OTs consider the full continuum rather than defaulting to either end.

Dynamic Reassessment

Client needs evolve over time due to changes in health status, life roles, environments, and available technology. AT recommendations are not one-time decisions but ongoing processes requiring periodic reassessment and modification.

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KEY TAKEAWAY

Think of AT selection like choosing a vehicle for a specific journey. You wouldn't buy a commercial truck to drive two blocks to the grocery store, nor would you take a bicycle across a mountain pass in winter. The best assistive device is the one that matches the terrain (environment), the cargo (occupational demand), the driver's skill (client factors), and the budget (resources). Over-engineering wastes resources and frustrates the user; under-engineering leaves critical needs unmet. The OT's role is to be the navigator who maps the route and recommends the right vehicle.

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The AT Selection Decision Framework

The following diagram illustrates a comprehensive decision framework for assistive technology selection that integrates client factors, environmental considerations, occupational demands, and the technology continuum. This visual model synthesizes elements from the HAAT and MPT models into a clinically actionable flowchart that an occupational therapist can apply during the evaluation and intervention planning process.

The AT Selection Decision Framework begins with a comprehensive assessment of client factors, environmental context, and occupational demands. These inputs feed into the technology continuum, guided by the Least Restrictive Technology Principle, culminating in a trial-train-reassess cycle.

Notice that the framework is deliberately cyclical rather than linear. The feedback loop at the bottom reflects a core tenet of occupational therapy practice: intervention outcomes must be monitored, and AT recommendations should be modified when the client's status, goals, or context changes. An OT who prescribes a device and never follows up is practicing incomplete care. The three assessment domains—client factors, environment, and occupation—mirror the PEO model and ensure that no critical variable is overlooked during clinical reasoning.

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Clinical Reasoning Mechanisms for AT Selection

While assistive technology selection does not typically involve mathematical formulas, it does rely on structured clinical reasoning models that function analogously to decision algorithms. The Human Activity Assistive Technology (HAAT) model, developed by Cook and Hussey, provides the most widely referenced framework. It conceptualizes AT use as a system with four interacting components: the human (the client), the activity (the occupation), the assistive technology device, and the context (the environment). A mismatch in any one component compromises the entire system.

The HAAT Model Components

HAAT Component	Assessment Focus	Clinical Questions
Human	Physical, cognitive, sensory, and psychosocial capacities; motivation; prior AT experience	Can the client physically operate this device? Does the client have the cognitive capacity to learn its use? Is the client motivated to incorporate it into daily routines?
Activity	Task demands, performance standards, frequency, and complexity of the target occupation	What specific steps does this activity require? Where in the task sequence does performance break down? What level of independence is desired?
Assistive Technology	Device interface, processor, output; durability, portability, cost, and maintenance	Does this device address the identified performance gap? Is it reliable enough for daily use? Can it be repaired locally? Is it affordable and fundable?
Context	Physical setting, social supports, cultural norms, institutional policies, and funding streams	Will this device function in the client's home/workplace? Do caregivers support its use? Are there cultural barriers to acceptance? Is funding available?

HAAT model components and corresponding clinical assessment questions

The Matching Person and Technology (MPT) Model

Scherer's Matching Person and Technology (MPT) model provides a complementary lens by emphasizing the psychosocial dimensions of AT adoption. The MPT model posits that successful AT use depends on the interaction among three domains: the milieu (environmental factors), the person (temperament, personality, preferences), and the technology (functions and features). Scherer's accompanying assessment instruments—the Assistive Technology Device Predisposition Assessment (ATD PA)—quantify the likelihood of successful device adoption and are particularly useful for identifying clients at risk for abandonment. The MPT model reminds clinicians that a technologically superior device can fail if it clashes with the client's self-image, lifestyle, or support network.

The HAAT model visualizes AT use as a system where human capacities, activity demands, and assistive technology features must converge in optimal fit, all within the surrounding context. A mismatch in any domain undermines the system.

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The Assistive Technology Continuum — Low-Tech to High-Tech

Assistive technology exists along a continuum that ranges from no-tech strategies (compensatory techniques requiring no device at all) through low-tech devices (simple, non-electronic aids) and mid-tech devices (basic electronic or battery-operated aids) to high-tech devices (complex computerized, powered, or software-based systems). Understanding this continuum is critical for NBCOT exam preparation because the exam frequently tests a candidate's ability to recommend the most appropriate level of technology for a given clinical scenario. The principle of least restrictive technology dictates that the OT should consider simpler solutions first and escalate only when lower-tech options are insufficient to achieve the client's occupational goals.

Assistive Technology Continuum

Simple / Low Cost Complex / High Cost

Category	Definition	Examples	Best Suited For
No-Tech	Compensatory strategies, environmental modifications, or task adaptations that require no device	Hand-over-hand guidance, visual schedules (hand-drawn), verbal cuing hierarchies, joint protection techniques, energy conservation strategies	Clients who are cognitively intact but need behavioral or procedural modifications; transient conditions; resource-limited settings
Low-Tech	Simple, non-electronic devices that are inexpensive, durable, and require minimal training	Built-up handles, reachers, sock aids, button hooks, non-slip mats (Dycem), picture communication boards, pencil grips, weighted utensils, rocker knives	Clients with stable motor deficits, limited financial resources, or low technology tolerance; excellent as first-line interventions
Mid-Tech	Battery-operated or simple electronic devices with limited complexity	Single-message voice output devices (e.g., BIGmack), electric page turners, talking watches, simple switch-adapted toys, battery-operated reachers	Clients who need more than low-tech but cannot manage complex interfaces; good for children and older adults with moderate cognitive limitations
High-Tech	Complex electronic, computerized, or software-based systems requiring significant training and maintenance	Power wheelchairs with tilt/recline, dynamic display AAC devices (e.g., Tobii Dynavox), environmental control units (ECUs), eye-gaze systems, smart home integration, robotic feeding devices, brain-computer interfaces	Clients with severe motor impairments who retain cognitive capacity for learning; clients with progressive conditions requiring scalable solutions; well-funded settings with technical support

Assistive technology categories with definitions, examples, and best-use scenarios

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NBCOT Exam Tip

When answering NBCOT questions about AT selection, always look for answer choices that reflect the least restrictive technology principle. If a low-tech option can achieve the occupational goal, it is almost always the correct answer over a high-tech alternative—unless the question specifies that simpler options have already been tried and failed.

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Worked Example — AT Selection for a Client with Stroke

To illustrate the clinical reasoning process, consider the following case study that integrates client factors, environmental analysis, and the technology continuum into a structured AT recommendation.

Case: Margaret, 68-year-old Female, 3 Months Post-CVA

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Step 1 — Gather Client Factors

Margaret sustained a left middle cerebral artery CVA resulting in right hemiparesis, mild expressive aphasia, and mild cognitive deficits (attention and sequencing). She is right-hand dominant, resulting in significant difficulty with ADLs including feeding, dressing, and written communication. She is motivated but frustrated by her lack of independence. Her prognosis suggests some continued motor recovery over the next 3–6 months.

Key factors: R hemiparesis, mild aphasia, mild cognitive deficits, motivated, potential for recovery
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Step 2 — Assess Environmental Context

Margaret lives alone in a single-story home with a supportive daughter who visits daily. She has Medicare Part B coverage and limited additional financial resources. Her home has standard kitchen appliances and a bathtub (no walk-in shower). Her community is rural with limited access to specialty AT vendors or repair services.

Key factors: Lives alone, caregiver support, limited finances, rural location, Medicare coverage
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Step 3 — Identify Occupational Goals

Margaret's primary goals are: (1) independent feeding, (2) independent upper-body dressing, and (3) ability to communicate basic needs via writing or typing when speech fails. She also values gardening but considers it a lower priority.

Priority occupations: feeding, dressing, written communication
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Step 4 — Apply the Least Restrictive Technology Principle

For feeding, begin with low-tech devices: a built-up handled spoon, rocker knife, and Dycem non-slip mat. These are inexpensive ($5–$25 each), require minimal training, and accommodate her limited grip strength. Since she has potential for motor recovery, avoid committing to a high-tech robotic feeder at this stage. For dressing, recommend low-tech one-handed dressing techniques (no-tech strategy) paired with a button hook, dressing stick, and elastic shoelaces (low-tech). For communication, consider a low-tech picture/word communication board for immediate needs, but also trial a simple mid-tech AAC app on a tablet she already owns, since her cognitive and motor abilities may support touchscreen use with her left hand.

Recommendations: Low-tech (feeding, dressing) + Mid-tech (AAC app) — escalate only if low-tech fails
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Step 5 — Plan Trial, Training, and Reassessment

Provide Margaret with a 2-week device trial period. Train her and her daughter in proper use of each device, including care and maintenance. Schedule a follow-up at 2 weeks to assess device usage frequency, client satisfaction, and functional outcomes using standardized measures (e.g., Canadian Occupational Performance Measure). If feeding devices are insufficient due to tremor or fatigue, consider upgrading to a weighted utensil set or, if necessary, a mid-tech electric feeder. Reassess the communication plan at 3 months as aphasia may improve.

Plan: 2-week trial → caregiver training → COPM reassessment → escalate as needed

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KEY TAKEAWAY

This case demonstrates the importance of starting simple and scaling up. Margaret's potential for motor recovery means that committing to expensive, complex high-tech devices at 3 months post-stroke could result in costly equipment she no longer needs in 6 months. Low-tech devices serve as a bridge while recovery unfolds, and the reassessment plan ensures the OT can pivot if needed.

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Strengths and Limitations of Low-Tech vs. High-Tech AT

A nuanced understanding of the relative strengths and limitations of different technology levels is essential for making clinically sound AT recommendations. Neither low-tech nor high-tech solutions are inherently superior; each carries advantages and constraints that must be weighed against the specific client scenario. The following comparison addresses the key dimensions an OT must consider.

Dimension	Low-Tech AT	High-Tech AT
Cost	Generally $5–$100; minimal financial burden; often self-purchased without insurance	Often $500–$30,000+; requires insurance authorization, funding justification, or grants
Training Required	Minimal; can often be taught in a single session; intuitive use	Extensive; may require multiple sessions for client and caregivers; ongoing technical support
Durability & Maintenance	Highly durable; no batteries, charging, or software updates needed; easy to replace	Subject to battery failure, software glitches, mechanical wear; may require specialized repair
Functionality Range	Single-function; addresses one specific task component	Multi-function; may address multiple occupational demands simultaneously (e.g., ECU controls lights, TV, thermostat)
Adaptability	Limited; device must be replaced if needs change significantly	Highly adaptable; programmable, customizable interfaces, upgradeable software
Stigma	Generally low; many devices are discreet or resemble everyday objects	Can be higher; visible technology may draw unwanted attention depending on cultural context
Abandonment Risk	Lower; low investment and simplicity promote continued use	Higher; complexity, aesthetic concerns, and changing needs contribute to disuse

Comparative analysis of low-tech vs. high-tech assistive technology across clinical dimensions

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KEY TAKEAWAY

Think of the low-tech versus high-tech decision as analogous to choosing between a hand-drawn map and a GPS navigation system. The hand-drawn map is reliable, requires no power source, and works everywhere—but it cannot recalculate if you make a wrong turn. The GPS offers dynamic routing and real-time updates—but it needs power, connectivity, and a learning curve. The best choice depends on the journey's complexity, the traveler's comfort with technology, and the resources available. In clinical practice, the OT must honestly appraise all these variables rather than defaulting to the most impressive technology.

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Connection to Advanced AT Practice & Emerging Technologies

As occupational therapy practice evolves, the AT landscape is being reshaped by emerging technologies and advanced clinical frameworks. Understanding these developments is important for current practitioners and for NBCOT candidates who may encounter questions about the future of AT service delivery. The following table contrasts foundational AT selection practices with advanced and emerging approaches that represent the cutting edge of the field.

Foundational AT Practice	Advanced / Emerging AT Practice
Categorical device recommendation (e.g., 'reacher for limited ROM')	Precision matching using algorithmic AT recommendation engines and sensor-based functional assessments
Standalone devices for individual tasks (e.g., talking clock, magnifier)	Integrated smart home ecosystems where a single hub (e.g., Amazon Echo, Google Home) controls lighting, locks, appliances, and communication via voice commands
Manual wheelchair with standard cushion	AI-powered power wheelchairs with obstacle avoidance, terrain adaptation, and remote monitoring for pressure relief compliance
Static AAC boards with limited vocabulary	Eye-gaze and brain-computer interface (BCI) AAC systems with predictive language models and machine learning that adapt to user communication patterns
Periodic in-person reassessment of device fit	Telehealth-based AT monitoring with remote device adjustment, usage data analytics, and predictive maintenance alerts

Foundational versus advanced/emerging AT practices

Several emerging areas merit particular attention. 3D printing has democratized the fabrication of custom low-tech devices, allowing OTs to design and produce individualized grips, splints, and adaptive utensils at minimal cost. Wearable technology—from smartwatches that provide medication reminders to exoskeletal gloves that augment grip strength—blurs the line between AT and mainstream consumer electronics. Universal Design for Learning (UDL) principles are also reshaping AT in educational settings, pushing the field toward proactive, population-level technology integration rather than reactive individual device prescription. As an OT, staying current with these trends ensures that your AT recommendations leverage the best available options for your clients.

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Looking Ahead

The NBCOT exam primarily tests foundational AT selection skills, but an increasing number of questions address telehealth service delivery and smart home technology as these become standard components of OT practice. Be prepared to reason about how remote monitoring changes the reassessment process and how commercially available smart devices can serve as low-cost AT for clients with moderate impairments.

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Practice Problems

Question 1: CONCEPTUAL

An OT is selecting assistive technology for a new client. According to the least restrictive technology principle, what should the OT consider first when making an AT recommendation?

Show answer

According to the least restrictive technology principle, the OT should first consider the simplest, least expensive, and least intrusive technology option that can meet the client's identified occupational goals. This means evaluating whether no-tech strategies (compensatory techniques, environmental modifications) or low-tech devices (simple, non-electronic aids) can adequately address the performance gap before recommending mid-tech or high-tech solutions. Starting simple reduces cost, minimizes training burden, lowers abandonment risk, and preserves the client's autonomy. Escalation to more complex technology should occur only when simpler options have been trialed and found insufficient.

Question 2: BASIC APPLICATION

A 75-year-old client with rheumatoid arthritis affecting both hands reports difficulty with self-feeding due to decreased grip strength and pain. She lives alone on a fixed income. Identify two appropriate low-tech AT devices and explain why each is suitable.

Show answer

Two appropriate low-tech devices include: (1) A built-up handled utensil set — the enlarged, lightweight grip diameter reduces the force needed to grasp the utensil, decreasing pain and compensating for reduced grip strength. These typically cost $10–$20. (2) A Dycem non-slip mat — placed under the plate, this prevents the dish from sliding during one-handed or weak-grip eating, reducing frustration and spill risk. Dycem costs approximately $10–$15. Both devices are low-cost (appropriate for a fixed income), require minimal training, and directly address the identified performance components (grip strength and joint protection during feeding).

Question 3: INTERMEDIATE

A 10-year-old child with cerebral palsy (spastic quadriplegia, GMFCS Level IV) needs a communication system. She has good cognitive function and visual tracking but limited upper extremity motor control. She can produce some vocalizations but is largely unintelligible to unfamiliar listeners. Using the HAAT model, analyze the human, activity, and context components and recommend an appropriate AT device.

Show answer

Using the HAAT model: Human: The child has intact cognition and visual tracking, suggesting she can manage a symbol-based or text-based communication system. Her limited motor control rules out devices requiring fine finger movements. Activity: Communication demands span classroom participation, social interaction with peers, and functional requests. She needs a robust vocabulary that grows with her age and academic demands. Context: School setting requires portability and durability; social context demands a system that enables real-time conversation. A high-tech eye-gaze AAC system (e.g., Tobii Dynavox with Snap + Core First) is recommended because it leverages her intact visual tracking, bypasses motor limitations, offers a dynamic, expandable vocabulary, and produces synthesized speech for real-time interaction. A low-tech picture board should also be provided as a backup for equipment failure or outdoor settings where the high-tech device is impractical.

Question 4: APPLIED

A 45-year-old construction foreman sustained a T6 complete spinal cord injury (SCI) 6 months ago. He has full upper extremity function and is independent in his manual wheelchair. He wants to return to a supervisory role at his construction company. His employer is willing to provide reasonable accommodations. Identify at least three AT recommendations across the technology continuum that would support his return to work, and justify each using the HAAT and/or MPT model.

Show answer

Three AT recommendations across the continuum: (1) No-tech/Low-tech: A modified desk and workstation layout at the job site office, including an adjustable-height desk compatible with his wheelchair, a clipboard with a non-slip surface for field notes, and a hard-hat mounting clip for hands-free communication. HAAT justification: Context modification removes physical barriers without requiring specialized technology. (2) Mid-tech: A ruggedized tablet with construction management software and Bluetooth earpiece for hands-free communication on the job site, allowing him to supervise remotely when terrain is inaccessible. MPT justification: The technology matches his intact cognition and upper extremity function, and the tablet is a mainstream device that carries no stigma. (3) High-tech: A vehicle modification with hand controls for independent driving to job sites, funded through vocational rehabilitation. HAAT justification: This addresses the context component (need to travel between sites) and the activity component (supervisory role requires site visits). His strong motivation and intact cognition (MPT person factors) predict excellent adoption.

Question 5: CRITICAL THINKING

Research indicates that approximately one-third of assistive technology devices are abandoned within the first year of acquisition. Drawing on the MPT model, the HAAT model, and the principles of client-centered practice, develop a comprehensive strategy (at least four components) that an OT could implement to reduce AT abandonment rates in their practice setting.

Show answer

A comprehensive AT abandonment reduction strategy should include: (1) Pre-selection psychosocial screening using MPT instruments: Administer the ATD PA before device recommendation to identify clients with low motivation, poor self-efficacy, or mismatched expectations, which are the strongest predictors of abandonment per Scherer's research. (2) Extended device trials in natural environments: Rather than selecting a device based solely on clinic performance, arrange for the client to trial the device in their home, workplace, or community for 1–2 weeks. The HAAT model's context component demands that AT be validated where it will actually be used. (3) Structured caregiver and family training: The MPT model's milieu domain highlights that social support is critical for sustained AT use. Train caregivers not only in device operation but in troubleshooting and encouragement strategies. (4) Systematic follow-up protocol: Schedule reassessment contacts at 2 weeks, 1 month, 3 months, and 6 months post-delivery. Use standardized outcome measures (COPM, QUEST 2.0) to quantify satisfaction and functional impact. Proactively address emerging problems before they lead to abandonment. (5) Client involvement in device selection: Present multiple options and involve the client in choosing based on aesthetics, portability, and personal preference. Client-centered practice is not merely a philosophy; it is an evidence-based abandonment prevention strategy.

SUMMARY

Summary — Assistive Technology Selection

Summary

Effective assistive technology selection requires the occupational therapist to integrate multiple clinical reasoning frameworks into a cohesive, client-centered process. The HAAT model guides the therapist to assess the interplay among the human (client factors), the activity (occupational demands), the assistive technology (device features), and the context (environment), while the MPT model adds critical attention to psychosocial factors that predict adoption or abandonment. The least restrictive technology principle dictates that the simplest effective solution should be considered first, with escalation along the technology continuum (no-tech → low-tech → mid-tech → high-tech) only when simpler options prove insufficient.

Every AT recommendation must be followed by a structured trial, training, and reassessment cycle to verify that the device produces meaningful functional gains in the client's natural environment. Device abandonment remains a significant challenge in the field, and the best defense against it is rigorous client-centered practice: involving the client in selection, training caregivers, and conducting systematic follow-up. As the AT landscape evolves with smart home technology, 3D printing, wearable devices, and telehealth-based monitoring, the OT's role as the expert navigator of the person-technology match becomes ever more essential.