| | Effect of Motorized Scooters on Physical Performance and Mobility: A Randomized Clinical TrialAbstract Hoenig H, Pieper C, Branch LG, Cohen HJ. Effect of motorized scooters on physical performance and mobility: a randomized clinical trial. ObjectiveTo investigate the effects of providing a motorized scooter on physical performance and mobility. DesignRandomized clinical trial comparing scooter users with usual care. SettingOne academic and 1 Veterans Affairs medical center. ParticipantsAmbulatory, community-dwelling outpatients with rheumatoid arthritis or osteoarthritis of the knee. InterventionProvision of a motorized scooter for 3 months. Main Outcome MeasuresSix-minute walk distance (6MWD) and mobility methods in diverse locations at baseline, 1 month, and 3 months, and accidents while using the scooter. ResultsThe majority of scooter subjects (n=16/22 [72.7%]) used the scooter 4 or more days per week. The difference ± standard deviation between the 2 groups in change in 6MWD over the study period was not statistically significant (scooter users, 16.9±73.0m [55.5±239.6ft]; usual care, 17.2±72.5m [56.5±238.0ft], P=.55). Four (18.1%) scooter users reported 9 accidents. Over the study period, the proportion of persons reporting use of a scooter (provided by the study or otherwise available) increased in the scooter-users group (eg, food stores, 16.7% to 52.6%; doctor’s office, 0% to 35.7%) but not the usual-care group (food stores, 9.1% to 9.5%; doctor’s office, 0% to 0%). ConclusionsMotorized scooters provided to ambulatory persons with arthritis were used intermittently. The greatest short-term risk from scooter usage appeared to be minor collisions. Key Words: Activities of daily living, Assistive technology, Bedrest, Cardiovascular deconditioning, Durable medical equipment, Exercise, Mobility limitation, Occupational therapy, Osteoarthritis, Outcome and process assessment, Physical therapy, Randomized controlled trials, Rehabilitation, Residential mobility, Rheumatoid arthritis, Walking, Wheelchairs THIRD-PARTY PAYERS REQUIRE physician prescription of durable medical equipment such as motorized scooters, necessitating physician judgments about their medical appropriateness.1 Although the usage of tools to cope with mobility impairments dates back at least 3000 years,2 data are limited on the effectiveness of mobility equipment as it is applied to daily life. Scooter prescription, especially for ambulatory patients, is particularly controversial because of the expense of the device, recent Medicare fraud,3 and uncertainty about the risk of deconditioning.4 Given the compelling data supporting the health benefits of physical activity,5 a scooter might cause harm if it were used instead of walking. Alternatively, some argue that a motorized scooter might increase activity levels by enabling people to participate in activities that would otherwise not be possible.6, 7 The lack of empirical data leaves uncertainty about the clinical indications for prescription of a motorized scooter.8 The overarching purpose of this study was to study objectively the effects of provision of a mobility aid on physical performance and day-to-day mobility. Motorized scooters were used as the exemplar device because, as discussed earlier, scooters are particularly controversial and their usage is more likely to be optional than other types of mobility aids. The primary research question was whether provision of a motorized scooter for 3 months would result in a clinically significant change in 6-minute walk distance (6MWD) compared with similar subjects who did not have a motorized scooter. Secondary questions included the effect of provision of a motorized scooter on mobility in diverse community locations, accidents related to scooter use, and subjective perceptions of the helpfulness of a scooter in daily life. Methods  Approval was obtained for this study from the institutional review boards of Duke University and the Durham Veterans Affairs (VA) Medical Center (VAMC), and all subjects provided informed consent. Study Design and Intervention This was a randomized trial performed by using a computer-generated random numbers table and concealed allocation (sequential, sealed envelopes filled by a person unconnected with the study), administered by the project coordinator after subject enrollment. Neither the subjects nor the investigators were blinded to the intervention. The goal of the study was to examine the effectiveness of a motorized scooter. Effectiveness studies examine the “usefulness of a particular treatment to the individuals receiving it under typical clinical conditions.”9(p206) The intervention consisted of provision of a motorized scooter (the Legenda) and a lift to transport the scooter (the Backsaverb or the Outriderb) for a 3-month period of time. Study personnel did not provide subjects with directions on when or where to use the scooter. Per standard clinical practices at the time of the study, subjects were instructed in the operation of the scooter and lift by the medical supplier at the time the lift was installed on the car. All subjects and their physicians were instructed to continue any regular exercise program and medications during the study period but to avoid starting or changing medications or exercises, including walking specifically for exercise. Patient Sample and Setting Several considerations determined the study population. More physically impaired, activity-restricted persons might use the scooter more, yet those same people might have less potential to experience deconditioning because of already being deconditioned. Validated measures of physical performance for physically impaired persons are limited in so far as they may require mobility skills out of the range of persons with disability and/or have inaccurate results because of altered physiologic responses and/or lack validation.10 Therefore, the study sample was limited to adults who were able to walk independently for at least 15m (50ft) based on direct observation over a 15-m course. To control for disease-specific effects, enrollment was limited to persons who met American Rheumatological Association (ARA) clinical criteria for osteoarthritis (OA) of the knee or rheumatoid arthritis (RA)11 based on physical examination and review of the medical record. Other inclusion and exclusion criteria included approval by the patient’s primary care physician or rheumatologist, no cardiac disease that would preclude exercise testing (eg, recent acute myocardial infarction), stable rheumatologic disease (<10mg/d of prednisone, no change in medications in the preceding 3 months, no surgery planned for the next 3–6 months), concurrence to avoid changes in medications for the next 3 to 6 months, a valid North Carolina driver’s license, a Mini-Mental State Examination (MMSE)12 score of greater than 26/30, and ownership of an automobile that would accommodate a scooter lift and heavy-duty shock absorbers. Study subjects were recruited from January 1999 through December 2002 by using methods that might be typical of commercial vendors (advertisements and directly mailing), including advertisements in the newspaper and in 2 medical centers (1 VA, 1 academic) and direct mailing (4536 letters) to patients from an academic rheumatology practice, patients from the Rheumatology and Orthopedic Clinics at the VAMC, and patients at the VA Ambulatory Care Clinic or discharged from the VA hospital with a primary diagnosis of OA or RA (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM], codes 714.X–715.X) or orthopedic knee surgery (ICD-9-CM procedure codes 81.22, 81.47, 80.26, 80.16, 81.54). Subjects called a central number and were screened over the telephone via self-report to affirm a diagnosis of RA or OA with knee pain, ability to walk, and type of automobile. Persons who screened positive telephonically were seen in person to obtain the MMSE and informed consent; then, a physician or physical therapist checked ARA criteria for OA or RA and the ability to walk; and, finally, the patient’s physician was contacted for approval. If the person met all eligibility criteria, he/she was randomized to receive a scooter or the usual care. The study had a limited number of motorized scooters, constraining the number of active subjects at any given time, although subjects might be screened and randomized at any time. If the subject was in the scooter arm of the study, baseline data were collected within 1 week before modifying the car and training in use of the scooter. The median length of time from randomization to baseline data collection was 36 days (scooter, 41; usual care, 29), and the mean was 47 days (scooter, 43; usual care, 50.3). Measures All measures, except self-reported measures on scooter accidents and satisfaction, were collected in person, on site at the VAMC at baseline (1-wk before provision of the scooter), 1 month, and 3 months. Dependent Variables Six-minute walk distance The 6MWD was selected as the primary outcome measure for several reasons. The 6MWD correlates highly with other measures of functional performance,13, 14 test-retest reliability is excellent,14 it has been shown to be sensitive to the effects of walking exercise in subjects with knee OA,15, 16, 17 and it appears to be more sensitive to the effects of walking exercise than other physical performance measures.18 Measuring assistive technology outcomes can be challenging,19, 20 nonetheless, several additional outcomes were examined, including mobility, accidents, and satisfaction. Mobility Based on a previously developed questionnaire,21 we collected self-reported data at 1 and 3 months on the mobility method (walked without assistance, walked with assistance, used scooter, other) used during the preceding week in a variety of locations (work place, school, friend or relative’s house, food store, drug store, other store, restaurant or bar, religious building, park, movie, sporting event, library, other places of recreation, civic building, bank or ATM [asynchronous transfer mode] machines, doctor’s office, dentist or other medical office, other). Results are reported as the proportion of subjects going to a specific location, the proportion using a scooter among those who went to that location, and a count of the total number of different locations visited. Data were collected on number of steps per day for a 1-week period at baseline and at 1 and 3 months by using a pedometer.c Scooter accidents At 1 month and 3 months, subjects reported if they had experienced an “accident” while using the scooter, and, if so, how many accidents they had experienced and they described the accidents. Satisfaction At 3 months, scooter users reported how helpful they found the scooter (5-level Likert scale ranging from very helpful to very unhelpful), if they intended to obtain a scooter of their own (yes vs no), and they answered several open-ended questions including (1) “In what ways was the scooter helpful?” (2) “In what ways was the scooter unhelpful?” and (3) “In what ways did you use the scooter?” Independent Variables Because of the relatively small sample size and the randomized methodology, the only independent variable included in the primary analysis was study group assignment. Several additional variables were measured for purposes of secondary analyses and to describe the population. Disease characteristics Disease activity was measured by pain. Many measures of disease activity in RA are not applicable to OA. Pain, on the other hand, is responsive to therapeutic interventions in RA22, 23 and to the effects of walking exercise in patients with OA,24 and it might directly affect the primary outcome measure, 6MWD. Pain was measured with a 10-cm, horizontal, double-anchored visual analog scale at baseline and at 3 months.25(p341-4) Physical function Physical function (difficulty with self-care tasks and use of assistive technology for mobility in particular) was measured with the Health Assessment Questionnaire26 and by measurement of the number of seconds to walk 15m at a comfortable walking pace.27 Sociodemographic characteristics Sociodemographic variables include self-reported data on date of birth, sex, race, and education. Intervention characteristics Frequency of scooter usage was measured by self-report at 3 months by using a Likert scale (more than once daily, once daily, 4–6 times a week, 2–3 times a week, about once a week, less than once a week). The question structure was derived from questionnaires of similar types of activities25 and the response options based on typical wheelchair use found in prior work.21, 28 Studies29, 30 have shown self-report and objective measures of physical activity to have moderate to strong correlations. Prior studies showed that self-reported wheelchair usage did not suffer from recall bias,21 and it had good construct validity (eg, environmental barriers predicted lower self-reported wheelchair usage28). Statistical Analysis The primary outcome was change in 6MWD over 3 months; thus, analyses were limited to subjects with data at baseline and at 3 months. Because subjects were randomized to a group, the primary analysis was a t test (and the nonparametric equivalent to the t test, the 2-sample Wilcoxon). Follow-up sensitivity analyses explored whether the observed effect differed according to baseline walking speed (gait speed above vs below the median) or pain at the end of the trial (above vs below the median) by using a general linear model with group, the predictor, and the interaction of these 2 variables. Power The study goal was to enroll 50 persons, with an estimated dropout rate of 20% for a final sample of 40 persons completing the study, which would provide the statistical power to detect a standardized difference of approximately .80 in 6MWD, with a 2-tailed α of .05 and β of .20, providing sufficient power to detect the moderate to large effect size that might be expected with a substantive change in walking activity17, 31 because of the scooter and distances equivalent to those required for community mobility.32 The final study sample of 43 subjects provided sufficient power to detect a standardized difference of .86 (ie, a change of ≥59.7m [≥199ft] in 6MWD based on the standard deviation [SD] of this study sample) with a 2-tailed α of .05 and β of .20. Results Fifty-three persons met inclusion and exclusion criteria and were randomized (scooter, 26; usual care, 26), 47 started the study (scooter, 24; usual care, 23), and 43 completed the study (scooter, 22; usual care, 21) (fig 1). Knee OA was the primary diagnosis in most subjects enrolled in the study (scooter, 19; usual care, 21), the balance having RA. The study population was reflective of the veteran population in general (table 1), with a mean age of 63 years, 60% white, 79% male, and 26% with less than a high school education. The majority of participants (67%) reported that they already were using a mobility aid, primarily a cane. Over 60% of participants reported difficulty walking on level ground, and 86% reported difficulty climbing stairs. During the week before starting the study, the mean pain level was 5.5/10. Statistically significant differences at baseline between the scooter and the usual-care groups were present for age and for wheelchair usage (although the 2 groups did not differ in use of other mobility aids). There were few changes in medication during the study (medications changes: scooter, 4; usual care, 5). On average, the scooters were used several times weekly, with 40.9% of the sample reporting daily scooter usage. | | |  | Characteristic | Scooter (n=22) | Usual Care (n=21) | P | |
|---|
| Mean age ± SD (y) | 67.2±9.4 | 58.2±11.7 | .01 | | | Sex, male (%) | 86.4 | 71.4 | .24 | | | Race, white (%) | 72.3 | 52.4 | .18 | | | Education, less than high school (%) | 18.2 | 33.3 | .26 | | | Mean hours out of bed baseline ± SD | 13.9±3.1 | 14.5±3.6 | .51 | | | Mobility aid use, any vs none (%) | 59.1 | 76.2 | .24 | | | Specific mobility aids used (%) | | | | | |  Cane | 54.5 | 66.7 | .42 | | | Walker | 9.1 | 9.5 | .96 | | | Crutches | 13.6 | 14.3 | .95 | | | Wheelchair | 18.2 | 0 | .04 | | | Mean pain, baseline ± SD | 5.2±2.2 | 5.8±2.5 | .53 | | | Difficulty walking on level ground (%) | 63.6 | 66.7 | .85 | | | Difficulty climbing stairs (%) | 90.9 | 80.9 | .11 | | | | |
There was no statistically significant difference between the 2 groups (P=.55) in change in 6MWD over time (table 2). Supplemental exploratory analyses (table 3) did not reveal a decline in 6MWD among particular subgroups of scooter users, nor were there statistically significant differences in 6MWD compared with usual care among the particular subgroups examined. Scooter subjects with worse gait at baseline had a strong trend (P=.10) for increased 6MWD over the study period compared with usual care; however, this was because the faster walkers in the usual-care group actually declined in 6MWD. Pain above versus below the median at 3 months did not relate to change in 6MWD (P=.75). 6MWD increased more in daily scooter users compared with those with less frequent scooter usage, but this did not reach statistical significance (P=.39). | | | | Change in 6MWD | Scooter | Usual Care | P | |
|---|
| Baseline to 1 month (m) | 16.6±71.1(54.4±235.2ft) | 18.2±53.5(59.6±175.5ft) | .66 | | | Baseline to 3 months (m) | 16.9±73.0(55.5±239.6ft) | 17.2±69.5(56.5±228.0ft) | .55 | | | | |
| | | | Subgroup | Scooter | Usual Care | P | |
|---|
| Baseline gait speed | | | .10 | | | Slow (<median), m | 5.3±61.1(17.4±200.4ft) | 42.6±60.3(139.8±197.9ft) | | | | Fast (>median), m | 28.5±84.7(93.5±277.8ft) | 8.1±71.6(26.7±234.8ft) | | | | Baseline pain | | | .75 | | | Less pain (<median), m | 20.1±88.0(65.9±288.7ft) | 12.6±86.6(41.4±284.1ft) | | | | More pain (<median), m | 21.0±63.1(68.8±207.0ft) | 23.1±45.0(75.5±147.6ft) | | | | Frequency of scooter usage | | | .39 | | | Daily usage, m | 33.4±64.4(109.4±211.2ft) | NA | | | | Less than daily usage, m | 5.52±85.2(18.1±279.6ft) | NA | | | | | |
Table 4 shows data on mobility for the 4 most commonly accessed locations: shopping, visiting friends, going to the doctor, and going to church. Although there was little change in the proportion of subjects going to specific locations, there was a clear increase in the scooter group in use of a scooter particularly in food stores and going to the doctor. In response to an open-ended question on the ways the scooter was used, 68% cited shopping with 59% reporting using the scooter to go to malls or large, retail, discount stores (ie, Big Box stores); the next most frequent location was visiting others by 27%. Sixteen (72.7%) scooter users cited 24 other diverse ways the scooter was used. However, the total number of places visited ± SD changed little (at baseline: scooter, 9.2±2.4; usual care, 8.7±3.2; at 3mo: scooter, 9.0±2.2; usual care, 9.3±3.35). Pedometer readings were available on scooter and usual-care subjects at baseline and at 1 month (scooter, 18; usual care, 18) and 3 months (scooter, 19; usual care, 19). There was considerable variation across the study subjects, but on average there was little change from baseline for either group (baseline mean steps/d: scooter, 3798.2±3080.5; usual care, 4837.5±3696.1; mean change in steps/d at 1mo: scooter, 129.6±3532.6; usual care, −996.4±3381.4; mean change in steps/d at 3mo: scooter, −887.2±3155.0; usual care, −574.3±3426.6). Satisfaction among the scooter users was generally positive. Over 73% (16/22) of the scooter users found it very helpful, 23% (5/22) found it somewhat helpful, and 4% (1/22) found it somewhat unhelpful. Ten (45.5%) scooter users intended to obtain a scooter of their own. In response to an open-ended question about the helpfulness of the scooter, 19 (86.4%) scooter users cited locations or activities (eg, “get out and see more things and go to more activities,” “go to many places that I couldn’t otherwise”) and 8 (36.4%) cited symptomatic benefits (eg, “didn’t get tired as easily,” “go places without my legs hurting”). However, the scooters were not a panacea. Scooter users reported the following ways that the scooter was not helpful, along with specific problems they encountered while using the scooter: use of the scooter carrier or lift (n=4); weather-related (n=4); narrow doorways or aisles or obstructions (n=4); and lack of sidewalks, curb cuts, or uneven ground (n=2). Accidents while using the scooter were reported by 4 (18.1%) subjects. These 4 subjects reported a total of 9 accidents with the scooter (running into things [n=7], tipped over in parking lot [n=1], loading the scooter onto the lift [n=1]), for an accident rate of .13 accidents per person-month of scooter usage. Discussion The Industrial and the more recent Technological Revolution greatly expanded the role of technology at all levels of society, a consequence of which has been increased availability of assistive technology for people with physical limitations. Motorized scooters are a highly visible example, dramatically rising in usage over recent years. Powered mobility devices are available routinely in supermarkets, they can be rented at the beach, and they have become a common sight in most assisted living centers. From 1999 to 2002, the Medicare population increased by 1% per year, yet claims for motorized scooters increased nearly 200%3 and expenditures amounted to over $1.2 billion in 2003.3, 33 Increasingly, physicians are called on to make decisions regarding prescription of powered mobility, and detailed prescriptions may be required by third-party payers. It can be challenging to determine medical necessity for assistive technology. The American Medical Association has recommended the following criteria be used when determining medical necessity: “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site, and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider.”34(p5) However, empirical data physicians might use in making these determinations for motorized scooters are extraordinarily limited. In a cross-sectional survey of older adults, Brandt et al35 found that powered mobility was commonly used for shopping and recreation, but the frequency of use was not reported. Another cross-sectional study36 showed considerable variation in power wheelchairs usage, even among reportedly full-time users. Iezzoni37 provided a qualitative view of the ability of powered mobility to restore independence and self-esteem. This study provides prospective, comparative data showing that provision of a motorized scooter to ambulatory persons with arthritis for use ad lib resulted in modest and selective usage. The scooters were predominantly used to access medically necessary locations. Over 50% of the scooter recipients in this study used the scooter to access food stores, and 30% to 50% used it to access doctor’s offices. A significant concern in prescribing motorized scooters is the risk of harm. Scooter prescription, especially for ambulatory patients, is particularly controversial because of their high cost and concerns about deconditioning with scooter usage.4 This study was powered to detect a clinically significant short-term change in physical performance, and the scooters did not result in a statistically significant difference in physical performance. Moreover, 6MWD did not decline in physical performance in any of the subpopulations examined among the scooter users. However, minor collisions were relatively common. Nearly 20% of subjects in this study reported some kind of accident with the scooter, despite instruction in scooter use by experienced personnel. Accidents among powered mobility users in other studies include a 12% rate of “mishaps” found in a cross-sectional study among electric mobility users of public transportation,38 a 6% rate of tips/falls found with a test dummy on a standardized track,39 and powered mobility devices accounted for the majority of the wheelchair-related reports submitted to U.S. Food and Drug Administration from 1975 to 1993.40 Thus, accidents rather than deconditioning seem to be the greatest risk related to the use of a motorized scooter. Training when providing a motorized scooter may need to address specifically the potential for accidents and include practice using the scooter in crowded situations, over uneven ground, and loading and unloading the scooter. One aspect of our findings that requires further consideration is why the scooters were not used more when the study subjects self-selected themselves as being interested in using a scooter in the first place. One possibility relates to limitations in the typical clinical practices for providing mobility aids in the United States. A recent study41 showed that instruction by expert personnel can increase the use of wheelchairs compared with usual care. Scooter usage and related benefits might have been greater had the study examined “best practice” rather than typical clinical practice with instruction being provided by the vendor rather than a clinician. On the other hand, the benefits of the scooter may be relatively limited for people who are able to ambulate, albeit with difficulty. Verbrugge and Sevak42 used data from the National Health Interview Survey to empirically examine the relation of the use of equipment versus human help on perceived difficulty, fatigue, pain, and the amount of time required to perform various self-care tasks. They found that people who relied on equipment alone reported with greater difficulty, fatigue, pain, and time to complete mobility tasks than those who used human help. Thus, the price of self-sufficiency enabled by equipment may be fatigue, slowness, and pain, which potentially trade-off against the psychologic benefits gained from independence. Gignac et al43 examined perceptions of independence related to various coping strategies in over 200 persons with arthritis, including compensatory strategies such as equipment use, substituting help from another person, optimizing one’s physical abilities (eg, through exercise), or selecting which activities to perform and which ones to avoid. Compensation with equipment was the most common approach used for mobility, followed by optimization, then selection, and finally the use of human help. Compensatory strategies for mobility were moderately correlated with feelings of independence, dependence, and helplessness. In contrast, the use of human help and optimization strategies like exercise for mobility were not correlated with feelings of independence or dependence. Rosenfeld and Faircloth44 reported similar findings in a qualitative study with 12 men and women with arthritis who described coping strategies for mobility as impacting their very identity. For the interviewees, movement was profoundly social in nature; it not only allowed for accomplishment of specific tasks, but it was an important way to determine one’s value and commitment to health. Thus, the use of assistive technology may be closely tied to emotional perceptions about disability. In another qualitative study, Clemson et al45 asked women who refused to implement environmental modifications to reduce their risk of falling why they decided not to follow therapist recommendations that might enhance their mobility. The women noted a number of factors as influencing their decisions, but the reasons all centered on perceptions of risk and beliefs about the ability to mediate these risks through behavioral changes. Treadwell and Lenert46 provided an interesting perspective, describing health decisions as being based on relative values rather than absolute values and that these relative values are nonlinear and affected by one’s baseline state. They proposed that the perceived benefits of wheelchair mobility to someone who is bedridden will be greater than will the perceived benefits of being able to walk for someone who is already using a wheelchair. Thus, for someone who is largely bed bound, the increased burdens of fatigue, pain, personal perceptions of dependency and disability, and even accidents, may be well worthwhile given the severe preexisting limitations in independence. However, for someone who has even limited ambulation and is able to attain mobility goals with occasional help from another person, the personal trade-off may be less favorable. Study Limitations The study has a number of limitations. The study had adequate power to detect a clinically important change in physical performance with scooter usage over the short term, but it was not powered to detect minor changes in physical performance or changes that may occur over years of scooter usage. Data pertaining to the reliability and validity of the measures of scooter usage and mobility methods are limited.21, 28 Other studies show that objective and self-reported measures of physical function correlate moderately well with one another among wheelchair users47 and among persons with physical disability.29, 48 Despite randomization, there was a statistically significant difference at baseline in age and in premorbid wheelchair use, although all other variables showed no differences. However, there is no reason to believe that age or premorbid wheelchair use per se would interact with scooter usage in such a way as to affect the outcomes. This study does not speak directly to the potential impact of scooter usage on specific body systems. The 6MWD correlates well with measures of balance, muscle strength, and endurance.13, 14, 49 Study results may not be generalizable to people with more severe disability or with other medical conditions. The use of 3-month recall for accidents using the scooter may be biased because of inaccurate recall. Training in scooter usage did not take place under controlled circumstances because of the study goal of examining “effectiveness” of scooters rather than efficacy. Enhanced training might reduce the high accident rates observed in this study. The study took place over a prolonged period of time, during which scooters became increasingly available in commercial venues, which may have diluted the overall effect of the intervention. Finally, the optimal population in which to examine deconditioning with use of a motorized scooter (ie, ambulatory persons who are not deconditioned) may not be the best population in which to determine the benefits from the device (ie, persons with severe mobility limitations). Conclusions This is the first study to use rigorous methodology to provide prospective data on real-life usage of powered mobility, along with attendant benefits and risks. The study shows that the activities commonly accessed with a scooter by ambulatory people with arthritis appear to be a mixed group that includes activities related both to personal convenience (eg, going to the mall) and to medical necessity (eg, doctor visits). In this ambulatory population, the impact of provision of a scooter on physical performance and on overall levels of activity appeared to be no more than modest. Although the scooter users used their scooters nearly every day, they were not used for such a prolonged period of time as to have a clinically significant effect on physical performance over the study period. Thus, the scooters may function predominantly to facilitate transitions between activities, enabling access to a broader selection within the same spectrum of activities, whereas the activities themselves are performed in a standard fashion. Alternatively, for people with minimal to moderate mobility impairment, the price of independence with a scooter may not trade-off favorably against the greater ease of having some help with tasks that have a strong social component and ready availability of social support (eg, visiting friends). Nationally, rates of disability have declined at the same time as rates of equipment usage have increased for those same activities,50 suggesting that a priority be placed on research focused on assistive technology and physical environment.51 Empirical data are needed on the effects of diverse approaches to help with mobility, from assistive devices, to elder housing built on principals of universal design, to city planning for enhanced walkability. Data are needed across the broad spectrum of potential users of such interventions, ranging from the most disabled to the least disabled. The effect of these interventions should be examined not only in the laboratory but also in the context of the daily lives of people with diverse physical abilities. Future studies might fruitfully examine methods for training patients in the safe use of scooters and lifts, identifying locations in which scooters may or may not be safely used and identifying clinical factors that may modify recommendations for safe scooter use. With such data in hand, we will be able to better inform persons with arthritis and other conditions as they make personal decisions about coping with mobility impairment. Suppliers Acknowledgments We thank Michael Zolkewitz and Katina Hargraves for assistance with data collection and data management and William Logan for editorial review. References 1. 1American Medical Association. Primary care for persons with disabilities: access to assistive technology. Guidelines for the use of assistive technology: evaluation, referral, prescription. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/433/assistivetechnology.pdf. Accessed November 15, 2006. 2. 2The polio stela. Catalog References: ǼGYPTEN II, 1998, Kat 34; Inventory Number ǼIN 134. Ny Carlsberg Glypotek Museum. Available at: http://www.glyptoteket.dk. Accessed November 15, 2006. 3. 3Centers for Medicare and Medicaid Services. New efforts aim at stopping abuse of the power wheelchair benefit in the Medicare program. September 9, 2003. Available at: http://oig.hhs.gov/publications/docs/press/2003/090903release.pdf. Accessed November 15, 2006. 4. 4Iezzoni LI. In: When walking fails. New York: Milbank Memorial Fund; 2003;p. 209–212. 5. 5U.S. Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996;. 6. 6Woods B, Watson N. A short history of powered wheelchairs. Assist Technol. 2003;15:164–180. MEDLINE 7. 7Miles-Tapping C, MacDonald LJ. Lifestyle implications of power mobility. Phys Occup Ther Ger. 1994;12:31–49. 8. 8Iezzoni LI. A 44-year-old woman with difficulty walking. JAMA. 2000;284:2632–2639. MEDLINE |
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a Physical Medicine and Rehabilitation Service, Durham Veterans Administration Medical Center, Durham, NC b GRECC, Durham Veterans Administration Medical Center, Durham, NC c Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC d Division of Biometry, Department of Community and Family Health, Duke University Medical Center, Durham, NC e College of Public Health, University of South Florida, Tampa, FL.  Reprint requests to Helen Hoenig, MD, MPH, Physical Medicine and Rehabilitation Service (117), Durham Veterans Administration Medical Center, 508 Fulton St, Durham, NC 27705
Supported in part by the Paul Beeson Faculty Scholar Program of the American Federation for Aging Research, the Duke University Claude D. Pepper Older Americans Independence Center, National Institute on Aging, National Institutes of Health (grant no. 2P60AG11268) and the Wheeled Mobility Rehabilitation Engineering Research Center, National Institute on Disability and Rehabilitation Research, U.S. Department of Education (grant no. H133E030035-04). Pride Mobility Inc provided the motorized scooters at wholesale cost. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(06)01530-9 doi:10.1016/j.apmr.2006.11.022 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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