| | Mobility Assistive Device Utilization in a Prospective Study of Patients With First-Ever StrokeAbstract Jutai J, Coulson S, Teasell R, Bayley M, Garland J, Mayo N, Wood-Dauphinee S. Mobility assistive device utilization in a prospective study of patients with first-ever stroke. ObjectiveTo estimate the extent to which clinical and functional features of stroke were related to the use of mobility assistive technology devices. DesignLongitudinal study of quality of life after stroke. SettingHospitals, rehabilitation centers, and universities in Ontario and Quebec. ParticipantsSubjects (N=316) with confirmed initial stroke were included in this analysis. Fifty-eight percent of the overall sample were men (n=184). The mean age of this sample at the time of the stroke ± standard deviation was 65.3±15.3 years (range, 19–96y). One hundred thirty-five patients received a mobility assistive device poststroke, and 181 did not. InterventionAssistive devices for mobility (canes, walkers, wheelchairs). Main Outcome MeasuresAssistive device use and mobility capacity. ResultsMobility device nonusers were less physically disabled than device users on a variety of measures. Poor physical functioning but good cognition were reliably associated with mobility device use. Use of multiple mobility assistive devices was more often associated with poorer physical functioning than was single device use. For single device users, wheelchair use was predicted by cognition, functional independence, and stroke recovery. Cane users, compared with walker users, had better mobility and were less physically impaired by stroke. ConclusionsPatients were well matched to device type based on their mobility capacity. The findings of this study suggest that assistive device prescription-outcome relationships in stroke can be effectively and meaningfully modeled. MOBILITY REFERS TO THE ability to move from 1 place to another1 and requires both motor function and capacity to move from 1 position to another or 1 place to another. Motor impairment and mobility limitations can impede the ability to perform activities of daily living that require use of the lower limbs.2 A common sequela of stroke, mobility limitation is often the first function to be addressed in the early stages of physical rehabilitation.3 Assistive technology devices (ATDs), including aids to mobility such as canes, walkers, and wheelchairs, can be useful to accommodate the limitations in daily activities that result from a disabling condition like stroke. They have the potential to reduce residual disability, delay decline in function, decrease burden of care, and lower health care costs.4, 5, 6, 7, 8 There is also evidence that ATDs may significantly reduce the requirement for hours of personal care.9, 10 The importance of ATDs can be expected to increase over time as public policy shifts to earlier community reintegration and places greater emphasis on self-care and care delivered in the home and community. Seniors with stroke who live at home own a large number of ATDs, averaging almost 16 per person.11 For those who reside at home after completion of a hospital rehabilitation program, canes, and walkers are frequently used,12, 13 largely because tolerance for walking (ie, cardiovascular endurance) tends to be significantly reduced.14, 15, 16, 17 Canes and walkers appear to effectively compensate for decreased postural stability and also to enhance participation in life’s roles,18 especially if hemiplegia is present.19 The published data, although informative about the needs and circumstances of device use, have not yielded valid estimates for how frequently ATDs are prescribed for mobility limitations poststroke.12 Estimates have come from studies that were not specific to stroke, that did not provide sufficient information on devices used, and that did not systematically and prospectively track device use. As a consequence, we do not have reliable data on the kinds of ATDs typically adopted by people with stroke to reduce mobility limitations, or on how device utilization is related to important clinical features of stroke. It is important to examine whether variations in device strength (ie, the amount of support provided by a device) when used for a particular activity limitation, as in mobility, are predictably associated with the capacity and performance of necessary activities. In this way, we may improve the conceptualization of intervention-outcome relationships in stroke rehabilitation and thereby advance research in this field.12, 20 It is logical to assume that the major forms of mobility ATDs, namely, canes, walkers, and wheelchairs, should differ significantly in the degree to which they reduce mobility limitations, but this assumption is not well documented. Understanding the relationship between mobility benefit and ATD use is challenged by the fact that it is not feasible to use laboratory-based measures of walking capacity at the population level. Instead, population-based research relies on self-report ratings of walking difficulty or need for assistance. This study reports findings from the Canadian Stroke Network study, entitled Understanding Health-Related Quality of Life Post-Stroke. The primary aim of the present study was to estimate the extent to which clinical and functional features of stroke were related to device utilization. We hypothesized that these features are reliably associated with the use of mobility devices. Methods  Participating patients were recruited as part of a longitudinal investigation of patients with first-ever stroke. We recruited a total of 678 patients from 3 sites in Ontario and Quebec, and followed up at 3-month intervals for 12 months. The participants had confirmed initial stroke (either ischemic or hemorrhagic). Patients with severe comorbidity that was likely to dominate the pattern of care, or result in serious health decline or death within the study period, (eg, metastatic disease, end-stage renal disease) were excluded from the recruitment process. Patients were required to speak either French or English. Patients admitted consecutively to the participating hospitals, who met the recruitment criteria outlined above, were asked to participate. In this study, we report the results from an analysis of the data from the baseline and first assessments of a year-long study of people with first-ever stroke. First assessments took place approximately 1 month after hospitalization for stroke. Measurements Each participant received a comprehensive assessment, with a variety of clinical and functional measures. A registered occupational or physical therapist, not involved in the design of the study or in the treatment of the patients, made the initial baseline evaluation while the person was still hospitalized. Clinical information was obtained from the medical chart. Over the next year, 4 follow-up assessments were made through interviews conducted over the telephone by therapists experienced in interviewing. The scales measured utilized self-report methods of assessment, and therefore interviewing via the telephone was an appropriate data collection method for the follow-up assessments. Clinical Features of Stroke The clinical features associated with stroke onset that were examined in this study included stroke severity using the Canadian Neurological Scale (CNS), its mentation and motor function subscales, as well as its total score21, 22; primary side of brain lesion; presence of neglect, hemianopia, or loss of equilibrium. These were recorded within 72 hours poststroke and extracted from the medical chart after acute-care hospital admission. Loss of equilibrium was typically assessed by a neurology consultant, who noted if a person fell as a result of their stroke or if their balance was abnormal after stroke. Also measured at this time was degree of functional independence in personal care and gross assessment of mobility, using the Barthel Index.23 At 1, 3, 6, and 12 months poststroke, we measured cognitive impairment using the brief Mini-Mental State Examination (MMSE; cut point for cognitive impairment, 77%–80% [17/22]).24 To indicate mobility at these points in time, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning (PF) scale and the Stroke Impact Scale (SIS) mobility subscale were used. The validity of the SF-36 PF scale and the SIS mobility subscale for measuring mobility have been well documented.25, 26 Also measured was the person’s perception of his/her stroke recovery using the recovery visual analog scale (VAS) of the SIS.25 Other than the 3 CNS measures, all measures were scored 0 to 100. For all measures, higher scores are better. Functional Measures of Stroke The SIS was developed as a stroke-specific health-related quality of life outcome measure.25 The SIS is a self-administered questionnaire that measures 8 domains, including mobility and strength. The SIS mobility subscale is a composite measure used to examine physical mobility and comprises 9 items. Each item begins with the stem, “In the past 2 weeks, how difficult was it to …,” and is rated on a 5-point scale (1, could not do at all; 2, very difficult; 3, somewhat difficult; 4, a little difficult; 5, not difficult at all). The 9 items were “… stay sitting without losing your balance?,” “… stay standing without losing your balance?,” “… walk without losing your balance?,” “… move from a bed to a chair?,” “… walk one block?,” “… walk fast?,” “… climb one flight of stairs?,” “… climb several flights of stairs?,” and “… get in and out of a car?” The SIS strength subscale asks the respondent to rate the strength of each of the following in the past week: arm, hand, leg, and foot and ankle most affected by their stroke. It is rated on a 5-point scale with 1 being no strength at all and 5 being a lot of strength. The SIS strength subscale was used for descriptive purposes and was not used in the analyses. We used the PF scale of the SF-3627 as a measure of mobility capacity because most of its items are associated with mobility (8 of 10 items). Each item begins with the stem, “Does your health now limit you a lot, limit you a little, or not limit you at all in …” and is rated on a 3-point scale (1, yes, limited a lot; 2, yes, limited a little; 3, no, not limited at all). The 10 items were “… vigorous activities such as running, lifting heavy objects, or participating in vigorous sports,” “… moderate activities, such as vacuum cleaning, bowling or playing golf” “… lifting and carrying groceries,” “… climbing several flights of stairs,” “… climbing one flight of stairs,” “… bending, kneeling, or stooping,” “… walking more than one mile,” “… walking several hundred yards,” “… walking one-hundred yards,” and “… bathing or dressing yourself.” Previous research has found that the SF-36 PF scale is highly correlated with the FIM instrument locomotion items28, 29 and with mobility capacity as assessed directly using items of the Activity Measure for Post-Acute Care30, 31 in patients with stroke who are able to use mobility devices.20 This indicates that the 3 measures assess the same basic construct of mobility. FIM scores were not available for the participants in this study. In a preliminary study of stroke patients in the United States, scores on the SF-36 PF appeared to more clearly distinguish patients on the basis of the type of device used most often for mobility (cane, walker, or wheelchair) than did FIM locomotion scores, with cane users scoring the highest, wheelchair users scoring the lowest, and walker users scoring in between.20 Thus, we have hypothesized that canes, walkers, and wheelchairs can be ordered meaningfully along a dimension of intervention strength and are predictably associated with mobility capacity as measured using the SF-36 PF scale. Measurement of Device Use The mobility devices procured after stroke were canes (ie, single-tip support canes), walkers (mainly standard pickup walkers) and wheelchairs. The primary ATD refers to the device that patients with stroke said was the one they were most dependent on for daily functioning. At each assessment, the interviewer asked whether a mobility ATD had been acquired since the previous interview, and noted which device the participant described as their primary ATD. In the assessment interview, if the patient was using an assistive device, his/her device use status was determined to be either single (had only 1 mobility device at time of assessment) or multiple (had a primary mobility device at assessment plus at least 1 other mobility aid). It is important to note that the wheelchair users in this research were not necessarily wheelchair bound,32 and were capable of some mobility outside of wheelchair use, either independently or with the assistance of a person or another assistive device. The study was approved by the ethics committees of the participating rehabilitation hospitals, rehabilitation centers, and universities. Statistical Analyses We used chi-square tests to examine the association of various clinical features with use or nonuse, single or multiple device use, and primary device type (cane, walker, or wheelchair). Spearman ρ correlations were used to examine the strength of relationships between functional measures and age. Logistic regression analyses, using clinical and functional variables, were undertaken to try to predict various types of device use. The level of statistical significance was set at P less than .05. Results Of 678 patients recruited to the study, 316 had complete scores for all clinical and functional measures at baseline and 1-month interviews that were used for analysis. Participants who were not included in the data analysis were those who received an ATD whose type was not described or was a type other than the 3 mobility devices used in this analysis, those whose stroke was not their first, and for whom the side of lesion was described as either both or missing. Of these participants, 181 did not use or obtain an ATD for the duration of the study period (nonusers) and 135 participants procured a mobility ATD within 1 year after their stroke. Usable data were therefore available for 135 mobility ATD users (43% of total ATDs users recruited) and 181 nonusers (51% of total nonusers recruited) (fig 1). The average time from stroke to first assessment ± standard deviation (SD) for device users was 31.2±9.7 days (range, 12–66d) and 33.8±22.7 (range, 11–76d) for nonusers. The number of patients in each device category are presented in table 1, along with the demographic variables of sex and age. For each type of device, the table shows the number of patients for whom the device was either their sole device (single) or primary device among more than 1 mobility device (multiple). Fifty-eight percent (n=184) of the overall sample were men. The mean age of this sample (N=316) at the time of the stroke was 65.3±15.3 years (range, 19–96y). Nonusers were younger than users, with the mean age being 63.0±15.4 years (range, 19–93y), compared with users whose mean age was 68.5±14.7 years (range, 26–96y). Nearly twice as many canes as other mobility devices were used. Device Use and Device Type Chi-square analysis revealed that there was a significant relationship between single or multiple device use and type of primary device used (P<.001). Cane users were more likely to be single rather than multiple device users. Users of walkers and wheelchairs were as likely to be single device users as to be multiple device users. Clinical Features Table 2 summarizes the demographic characteristics of the sample as well as the clinical and functional measures in relation to various patterns of device use. Overall proportions are presented, as well as comparisons for each of the following: any use versus nonuse; single versus multiple device use; cane or walker use versus the use of a wheelchair; and cane versus walker use. Clinical features examined include the presence of neglect, hemianopia, loss of equilibrium, and the primary side of lesion. Chi-square tests examining the relationship between single or multiple device use, device type, and device nonuse with these clinical features revealed no significant associations. Age was segmented into 2 groups to differentiate between the young-old and the old-old.33, 34 Chi-square analyses revealed a significant relationship between device use and nonuse with age dichotomized using 75 years as the cutpoint (P<.05); a higher proportion of persons over the age of 75 years used a device. Age was also significantly related to cane and walker use (P<.01), with a higher proportion of walker users being over the age of 75. Sex was found to be significantly associated with device use and nonuse (P<.05). There were equal numbers of men and women in the user group, but more men than women in the nonuser group. | | |  | Features | Overall (N=316) | Any Use (n=135) vs None (n=181)⁎ | Single (n=93) vs Multiple (n=42) | Cane or Walker (n=104) vs Wheelchair (n=31) | Cane (n=61) vs Walker (n=43) | |
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| Age (under 75y) | 71.5 | 64.4 vs76.8‡ | 60.2vs73.8† | 62.5vs71 | 73.8vs46.5‡ | | | Sex (male) | 58.2 | 51.1vs63.5‡ | 51.6vs50 | 51.9vs48.4 | 55.7vs46.5 | | | Clinical measures taken at baseline (in-hospital) | | | Side of lesion (left) | 42.4 | 37vs46.4 | 39.8vs31 | 38.5vs32.3 | 36.1vs41.9 | | | Neglect (present) | 11.7 | 12.6vs11 | 14vs9.5 | 10.6vs19.4 | 16.4vs2.3 | | | Hemianopia (present) | 13.3 | 11.9vs14.4 | 12.9vs9.5 | 10.6vs16.1 | 13.1vs7 | | | Loss of equilibrium (present) | 21.5 | 23.7vs19.9 | 25.8vs19 | 26.9vs12.9 | 27.9vs25.6 | | | Functional measures taken at baseline (in-hospital) | | | CNS mentation | 5(4.5,5) | 5(4.5,5)vs5(4.3,5) | 4.5(4.5,5)vs5(4.5,5) | 4.8(4.5,5)vs5(4.5,5) | 4.5(4.3,5)vs5(4.5,5) | | | CNS motor functions | 4.5(3,6) | 4(2,5.5)vs5(4,6.5) | 4(2.5,6)vs3.8(0.9,5.5) | 4.5(3,6)vs1.5(0.5,2.5) | 4(2.3,6)vs5(4,6) | | | CNS total | 9.5(7.5,10.5) | 8.5(6.5,10)vs9.5(8,11) | 9(7,10)vs8.3(5.5,9.6) | 9.3(7.6,10.5)vs6.5(5,7.5) | 8.5(6.5,10.5)vs9.5(9,11) | | | Barthel Index | 90(65,100) | 65(45,85)vs100(85,100) | 75(52.5,90)vs52.5(38.8,65) | 75(60,90)vs45(35,50) | 80(65,92.5)vs65(50,85) | | | Functional measures taken at 1-month poststroke | | | MMSE | 95.5(86.4,100) | 95.5(86.4,100)vs95.5(86.4,100) | 95.5(86.4,100)vs90.9(85.2,100) | 95.5(86.4,100)vs90.9(77.3,100) | 95.5(86.4,100)vs90.9(81.8,100) | | | SIS strength subscale | 75(50,93.8) | 50(37.5,75)vs81.3(62.5,100) | 62.5(37.5,81.3)vs37.5(25,59.4) | 68.8(50,81.3)vs25(12.5,37.5) | 68.8(50,87.5)vs59.4(48.4,76.6) | | | SIS mobility subscale | 75(50.7,94.4) | 52.8(25,75)vs91.7(75,100) | 61.1(34.7,81.9)vs34.7(18.1,53.5) | 61.1(40.3,77.8)vs19.4(11.1,30.6) | 75(55.6,84.7)vs50(25,61.1) | | | Stroke recovery VAS | 70(40,88.6) | 50(30,75)vs75(50,90) | 60(32.5,75)vs47.5(23.8,60) | 60(40,75)vs30(10,50) | 65(41,77.5)vs50(40,70) | | | SF-36 PF | 45(10,80) | 15(5,40)vs70(45,90) | 30(5,50)vs5(0,20) | 30(10,45)vs0(0,5) | 35(17.5,5.5)vs15(5,30) | | | | |
| ⁎ This includes only those patients who had complete scores on all measures and had side of lesion listed as either left or right. The user group includes only mobility (cane, walker, or wheelchair) device users (user, n=135; nonuser, n=181). †To interpret the cell results, for example, 60.2% of single device users were aged less than 75 years and 39.8% were aged 75 or greater, compared with 73.8% of multiple device users aged less than 75 and 26.2% aged 75 or higher. ‡Chi-square tests determined relationships to be significant (P<.05). |
Correlations Nonparametric correlations (Spearman ρ) examining age, CNS mentation, CNS motor functions, CNS total score, Barthel Index, MMSE, SIS mobility, SIS stroke recovery, VAS, and SF-36 PF were performed for the total sample of users and nonusers (N=316). Age was found to correlate negatively (P<.01) with each of the Barthel Index (ρ=–.18), MMSE (ρ=–.26), SIS mobility subscale (ρ=–.29), SIS stroke recovery VAS (ρ=–.16), and SF-36 PF (ρ=–.27). A strong relationship was found between many of the functional measures used in this analysis, as seen in table 3. For example, SF-36 PF (a measure of mobility capacity) correlated positively (P<.01) with the stroke severity measures of CNS motor functions (ρ=.35) and total score (ρ=.35), stroke recovery (SIS stroke recovery VAS, ρ=.58), functional independence as measured by the Barthel Index (ρ=.66), MMSE cognitive functioning (ρ=.21), as well as the second measure of mobility capacity, the SIS mobility subscale (ρ=.87). Functional Measures Table 4 presents the descriptive statistics for functional measures of stroke as a function of device type (cane, walker, wheelchair) and device use (single vs multiple) and nonuse. Mean scores on the Barthel Index, MMSE, SIS mobility subscale, and SIS stroke recovery VAS showed similar patterns regarding device types for multiple device users, with wheelchair users having the lowest scores, followed by walker users, with cane users having the highest scores. This pattern was repeated for single device users, with scores for wheelchair users much lower than scores for cane and walker users, as would be expected from patients who relied on this form of mobility. For example, on the Barthel Index, which measures functional independence in personal care and mobility, single device cane users (mean, 77.2±20.1; range, 0–100) scored higher than walker users (mean, 68.8±22.3; range, 5–100) and both scored higher than wheelchair users (mean, 40.0±12.6; range, 15–65). The difference between device types were more pronounced for the single device users. | | | | Device Type | Device Use | CNS Mentation | CNS Motor Functions | CNS Total | Barthel | MMSE | SIS Mobility | SIS SRV | SF-36 PF | |
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| Nonuser | None | 4.4±0.9 | 4.6±2.0 | 9.1±2.3 | 89.4±17.0 | 89.6±15.6 | 83.1±21.9 | 69.6±26.5 | 63.2±30.0 | | | User | Total | 4.5±0.8 | 3.7±2.2 | 8.2±2.5 | 65.4±23.7 | 89.7±12.3 | 50.7±28.2 | 52.2±26.3 | 24.9±25.8 | | | Cane | Single | 4.4±0.8 | 3.7±2.2 | 8.1±2.7 | 77.2±20.1 | 91.8±12.3 | 68.9±23.2 | 61.7±22.8 | 38.4±27.1 | | | | Multiple | 4.8±0.3 | 5.0±1.3 | 9.8±1.5 | 71.7±16.1 | 89.4±5.2 | 63.0±14.0 | 46.7±23.1 | 33.3±7.6 | | | Walker | Single | 4.5±0.9 | 5.1±1.1 | 9.5±1.4 | 68.8±22.3 | 87.7±14.0 | 46.4±24.4 | 53.0±28.2 | 24.0±24.1 | | | | Multiple | 4.5±0.9 | 4.8±1.8 | 9.3±2.5 | 61.6±25.4 | 89.0±10.1 | 42.7±19.9 | 51.5±22.3 | 18.9±17.8 | | | Wheelchair | Single | 4.7±0.5 | 2.2±1.9 | 6.9±1.8 | 40.0±12.6 | 81.8±14.9 | 22.7±23.9 | 24.1±20.1 | 5.0±13.4 | | | | Multiple | 4.6±0.7 | 1.5±1.3 | 6.1±1.6 | 44.3±11.8 | 91.4±10.0 | 24.2±15.6 | 40.8±27.3 | 2.3±3.4 | | | Scale range | 1.5–5 | 0–6.5 | 1.5–11.5 | 0–100 | 0–100 | 0–100 | 0–100 | 0–100 | | | | |
Mean SF-36 PF scores for the primary mobility device types were: cane, 38.4±27.1 (range, 0–90); walker, 24.0±24.1 (range, 0–95); and wheelchair, 5.0±13.4 (range, 0–45). No wheelchair user obtained a score higher than 45. Only 5 walker users scored greater than 45. As the primary mobility ATD, wheelchairs were used exclusively by patients who had poor capacity in mobility. This is in contrast to canes, which, although they were the primary devices mainly for patients with significant mobility limitations, were used by patients who represented a very wide range of mobility. As a global measure of stroke severity in terms of weakness, the CNS motor function results suggested that wheelchair users were weaker than cane users, who were slightly, but significantly, weaker than walker users. CNS motor function mean scores for primary device type were as follows: cane, 3.7±2.2 (range, 0–6.5); walker, 5.1±1.1 (range, 0–6.5); and wheelchair, 2.2±1.9 (range, 0–6). Regression Analyses The clinical and functional variables of side of lesion, mobility capacity (SF-36 PF), stroke severity (CNS mentation, motor function, and total score), stroke recovery and mobility (SIS), functional independence in personal care and mobility (Barthel Index), cognitive impairment (MMSE), and age were entered into logistic regression analyses (forward; likelihood ratio; SPSSa) to predict various types of device use. Regression analyses were conducted for each of the following binomial outcome variables: (1) any device use versus no device use, (2) single device use versus multiple device use, (3) cane or walker use versus wheelchair use, and (4) cane use versus walker use. The results are summarized in table 5. A regression analysis examining device users and nonusers suggested that device use was significantly associated with mobility (SF-36 PF) (odds ratio [OR]=.97; 95% confidence interval [CI], .96–.98), functional independence (Barthel Index) (OR=.96; 95% CI, .95–.98), and cognitive status, as measured by the CNS mentation subscale (OR=1.46; 95% CI, 1.03–2.07) and the MMSE (OR=1.03; 95% CI, 1.01–1.06) (R2=.48; percentage correctly classified, 79.4%). As would be expected, device users were more likely to have less functional independence and lower mobility capacity, therefore requiring mobility devices. Interestingly, users were more likely to have higher levels of cognition. Multiple device use, as opposed to single device use, was significantly associated with age (OR=.97; 95% CI, .94–.99) and level of mobility (SIS mobility subscale) (OR=.97; 95% CI, .95–.98). The total percentage of study participants correctly classified was 71.9% (R2=.24). Multiple device users were more likely to have lower mobility capacity and to be younger than single device users. The sole use of a cane or walker compared with the sole use of a wheelchair was significantly associated with level of functional independence (Barthel Index) (OR=.92; 95% CI, .87–.97), cognitive status (CNS mentation subscale) (OR=4.39; 95% CI, 1.13–16.99), and level of stroke impairment (SIS stroke recovery VAS; OR=.95; 95% CI, .91–.99). These variables correctly classified 93.5% of the study participants (R2=.65). Cognitively, wheelchair users were more likely to be significantly higher functioning, but to be more severely impaired by stroke and have less functional independence than cane and walker users, indicating greater mobility disability. Analysis examining the use of a cane versus a walker as the sole mobility aid indicated that use of a walker was significantly associated with the level of overall weakness as measured by the CNS motor functions subscale (OR=1.76; 95% CI, 1.20–2.59) and level of mobility as measured by the SIS mobility subscale (OR=.95; 95% CI, .93–.98). These variables correctly classified 76.8% of study participants (R2=.38). Walker users had lower levels of stroke severity in terms of general weakness and lower mobility capacity than cane users. Discussion This prospective, longitudinal study of first-ever stroke patients collected comprehensive data about the use of assistive devices for mobility. The findings provide empirical support for a number of reported clinical applications for these devices.12, 35 For this study, canes, walkers, and wheelchairs were commonly procured devices, and canes were used as a primary aid to mobility more often than the other categories of devices. Not surprisingly, wheelchair users had more mobility disability than users of other types of device. Surprisingly, canes were more likely than walkers to be the primary mobility aid for patients who had generalized weakness. Loss of equilibrium was more frequently reported by users of canes and walkers, than by wheelchair users. Cane users had higher levels of mobility than users of walkers and wheelchairs. These findings neither support nor refute the notion that people with stroke who have poor balance are more likely to be prescribed walkers than canes.35 It is possible that the availability of government funding had a significant influence on the relationships we observed. In the 2 provinces where this study took place, the government contributes to the cost of the most basic equipment essential for mobility. The government pays a proportion of a fixed price for each approved device. The kinds of mobility devices covered include selected wheeled walkers, forearm crutches, manual and power wheelchairs, and specialized positioning devices for wheelchairs (ie, seat cushions and back supports). The cost of equipment required for occasional use, used only at school or work, an exercise program, sports, or to replace personal and/or public transportation is not covered. In these provinces, only 1 mobility device per person is funded, which may have influenced the selection of devices by persons with limited financial means. The use and nonuse of mobility assistive devices in stroke patients is reliably associated with scores on the SF-36 PF scale, Barthel Index, MMSE, and CNS mentation subscale obtained in-hospital and after hospital discharge. However, in predicting single- versus multiple-device use among device users, the SIS mobility scale appears to be a more sensitive substitute for the SF-36 PF among these measures. In predicting which specific device type (cane, walker, or wheelchair) was used, the SIS mobility scale continued to demonstrate sensitivity, this time in combination with measures of stroke severity (CNS). Though not as pure a measure for the construct of mobility capacity as would be desired, the SF-36 PF provides a relatively cleaner separation of categories of device user and nonuser than was obtainable from measures of stroke severity and functional independence, such as the CNS and the Barthel Index. These measures were all correlated with age. The use of canes and walkers could be predicted on the basis of mobility capacity; however, wheelchair use was not as reliably predicted based on measures of mobility. Other factors, such as stroke severity, loss of balance and postural sway,19 and perhaps also vision, are important and need to be more intensively studied in further research with mobility ATDs. Study Limitations A limitation of this study was that we did not know exactly what types of canes and walkers were used by the participants, nor did we have records of the amount of rehabilitation that participants received prior to procuring their devices. Additionally, the effects observed in this study were not influenced by the presence of neglect or hemianopia, because the study sample included very few patients with these conditions, suggesting that these patients may not typically procure ATDs after hospital discharge. Also, although the functional measures used have been validated for assessing mobility, we acknowledge that they are less than perfect surrogates for direct observations of performance. It is noteworthy that our research participants may not have been using an ATD at the time of first assessment, procuring them rather at a later time in the 1-year study period. Those that were using a device at the first assessment had been doing so for a relatively short time (within a month of procurement) and, in terms of Gitlin’s model,36 they were “early users.” The picture of intervention-outcome relationships presented here can be expected to change as we examine the results from longer term follow-up assessments. Conclusions Clinical features of stroke reliably indicate whether patients are likely to use 1 or more mobility devices from the 3 main categories examined in this study. The use or nonuse of ATDs for mobility, and the types of devices used, are reliably associated with measurements of mobility capacity, functional independence, cognitive status, and stroke severity. Predictably, device nonusers were less physically disabled than device users. Surprisingly, cognitive impairment was reliably associated with device nonuse, independently of physical disability. It is not clear why cognitive status should be so consistently related with the use of what are generally regarded to be simple technologies for assisting mobility. Poor physical functioning but good cognition are clinical features of stroke that are reliably associated with the use of multiple assistive devices for mobility. This finding raises the possibility that some patients might be better able to function with additional devices, but are not getting or using them due to cognitive difficulties. If applied effectively, ATDs can be an important approach to promoting the functional recovery and long-term health of people with stroke. The findings from this study support the feasibility of effectively and meaningfully modeling ATD intervention-outcome relationships in stroke, and thereby advancing research in the field. Supplier Acknowledgment We gratefully acknowledge the technical assistance of Naim Ghany, MASc, with the data analysis. References 1. 1Gove PB. 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Supported by the Canadian Stroke Network (grant no. CSN-2000-011). 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(07)01280-4 doi:10.1016/j.apmr.2007.06.773 © 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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