As rehabilitation specialists, we can probably all agree that helping our patients get the maximum benefit out of using a mobility device or ambulatory aid while minimizing the risk of injuries can be a challenge. Although these devices (cane, walkers, wheelchairs, and standers) can transform people's lives and give them back some sense of independence and control, they have the potential for injury. In fact, many people are injured while using them.

In 2008, 233,028 injuries from crutches, canes, walkers, wheelchairs, and mobility carts were reported.¹

Often, the cause is not malfunction, but rather the fact that many people choose the wrong device for their needs or use them incorrectly. Injuries tend to happen when people with walking problems do not seek advice before choosing a mobility device and do not learn how to use it properly.

Many of our patients say they don't know where to turn for advice. They say that their primary care physicians usually don't know much about their walking difficulties and can't offer much mobility device purchasing guidance. To address this problem, safety guides or "checklists" have been created for people to use before choosing a mobility device that we can pass along to our patients. The following insights can help people be safer and healthier while remaining independent.

WARDING OFF MOBILITY DEVICE MALFUNCTIONS

People use mobility aids for a variety of reasons, including arthritis, back problems, heart and lung conditions, stroke, diabetes, multiple sclerosis (MS), and lower limb loss.

Beth Bullard is the director of case management/patient assessment information coordinator at Northern Colorado Rehabilitation Hospital (ncrh.ernest health.com) in Johnstown. She also volunteers her time as an occupational therapist for people living with MS at the Heuga Center for Multiple Sclerosis (www.heuga.org) in Edwards. In Bullard's experience, most injuries are the result of a poor-fitting, inappropriate, or improperly used device. "Durable medical equipment (DME) malfunctions most often occur when a device is not maintained or used as it was intended," she explains. "If a product has a manufacturer defect, it is often discovered by the vendor or therapist when the device is initially trialed by the potential user."

As an occupational therapist, Bullard works directly with individuals who are in need of a mobility device and in partnership with their physician, any other therapists who are currently treating them, and their desired vendor. "I complete a comprehensive evaluation identifying their goals, current functional abilities, and environmental needs. I make device recommendations, measure and fit the device, and educate and train the individual and/or any caregiver on how to operate and care for the device," she says.

BEFORE SHOPPING

"Regardless of what device someone is shopping for, I highly recommend consumers do their homework. Not only are devices comparatively different, health care professionals are also," Bullard states. "[They should] shop first for the health care provider that is the right fit for [their] needs. Make sure they have the knowledge and experience required to assist [them] with [their] device acquisition. Then with their assistance, [they can] begin to work with vendors and various devices," she says.

As for planning, we all have high and low functioning times in any given day. It is important to recognize challenging times or tasks, and make the appropriate changes in order to be productive. Environmental factors can impact productivity. "Take temperature, for example," Bullard says. "Extreme heat or cold can have an impact on an individual's strength, coordination, and cognition." Medication often has side effects; they can impair balance, vision, and cognition, and cause fatigue, ataxia, or decreased coordination. "A good understanding of the factors that can influence performance will ensure success in choosing the right device."

CANES AND WALKERS

In choosing the right device for patients, Bullard suggests you consider the following:

• How is their balance?
• Do they require unilateral or bilateral support?
• Do they have the sensation and strength in their hands to hold the device?
• Make sure the device is the proper height.
• Ensure it is in good working condition and that the individual can operate it.
• Perform gait training with the device.
• Determine the environments for which this type of device would be the ideal choice and when another would be more suitable.
• Perform routine maintenance checks.
• Replace worn parts when needed (such as cane tips and grips).

WHEELCHAIRS

"Wheelchairs and seating systems need to fit like a suit," Bullard stresses. "A person must be measured properly, and the chair and seating system must fit those measurements." Once delivered:

• Adjust the chair for the individual.
• Perform wheelchair mobility training.
• Make sure the individual knows how to operate all functions on the chair (leg rests, brakes, arm rests, collapsing the chair, and transporting the chair).
• Determine the environments for which this type of device would be the ideal choice and when another would be more suitable.
• Develop a plan for routine maintenance, and replace worn parts as necessary.

STANDERS

Bullard says to identify the purpose of the stander, where it is going to be used, and who will be available to assist the individual in or out of the stander. It's important to measure the individual and order the stander most appropriate for the patient's size, functional abilities, and its purpose. "Once delivered, it must be properly adjusted, a standing program must be developed, and education on all aspects of the stander and program must be completed," she says. "Do regular routine maintenance checks with parts replacement as needed," she adds.

It's a good idea to have annual equipment re-evaluations to ensure that the proper device is being used and that it is in good working order.

RE-EVALUATION, TRAINING, FITTING, AND REPAIR

"There are therapists, usually an OT or PT, who specialize in mobility devices. Many have additional certifications and work in consort with other therapists, physicians, and vendors to provide mobility prescriptions," Bullard says. It is common for facilities to hold mobility clinics. In a clinic, the individual is evaluated for a device and a prescription is generated. "Delivery of the device, re-evaluation, fitting, and training occur at subsequent clinics," she says. Each device comes with an operational manual that lists maintenance requirements. The vendor can work with the purchaser on a schedule for routine maintenance and suggested repairs.

If an individual purchased a device on his own (such as via the Internet, a catalog, or through a pharmacy that does not have a trained DME specialist), he is often left without a contact for fitting, training, or repairs. It would be up to the patient to read and comply with the owner's manual and to seek out the professional who could assist with the device as needed.

OTHER CONSIDERATIONS

Knowledge of insurance plans and the individual's financial situation is also important. Many plans will cover only one device in a several-year period of time. Understanding of these issues can help your patients choose a device that is able to grow and change as their needs change.

"Mobility devices are like shoes. Most of us wouldn't wear flip-flops in the snow or ski boots when surfing," Bullard says. "It's important to use the right mobility device for the right job." Finding that balance between devices can be very liberating and increase a person's ability to participate in work, recreation, or other pursuits.

"The goal is to utilize them effectively in combination," Bullard explains. "Consulting a health care professional who has extensive resources and knowledge of mobility devices will allow an individual to discover the ideal mobility prescription. Life changes, and so do all of us." It is important for your patients to schedule annual visits with a health care professional to evaluate current devices and the potential for new or changes in a mobility prescription.

FINAL THOUGHTS

"Before recommending any device, it is important to first understand individuals and the environment in which they live. Evaluate their roles in life—student, mother, lawyer, or athlete. What does their typical day look like—the gym, work, or shopping? How is their physical living environment set up—home, work, vehicle, school, and community? A comprehensive needs assessment is vital in determining the appropriate device," Bullard concludes.

Of course, individuality is a highly desired feature, and the DME manufacturers have identified and responded to the need for self-expression. Most devices come in a variety of colors; some have interchanging parts for those who like to match their mood or dress. There are even wheels that, when in motion, provide a multicolored flashing light show. You can play it down or spice it up. There is truly something for everyone.

Nina Silberstein is a contributing writer for Physical Therapy Products. For more information, contact .

REFERENCE

1. National Electronic Injury Surveillance System (NEISS) database. www.cpsc.gov/cgibin/NEISSQuery/home.aspx. Accessed June 2, 2009.