Am Fam Physician. 2021;103(12):737-744
Related FPM article: Durable Medical Equipment: A Streamlined Approach
Related letter: Upright Walkers as Mobility Assistive Devices for Older Adults
Patient information: See related handout on using canes and walkers, written by the authors of this article.
Author disclosure: No relevant financial affiliations.
Many individuals need a mobility assistive device as they age. These devices include canes, crutches, walkers, and wheelchairs. Clinicians should understand how to select the appropriate device and size for individual patients (or work with a physical therapist) and prescribe the device using the patient's health insurance plan. Canes can improve standing tolerance and gait by off-loading a weak or painful limb; however, they are the least stable of all assistive devices, and patients must have sufficient balance, upper body strength, and dexterity to use them safely. Older adults rarely use crutches because of the amount of upper body strength that is needed. Walkers provide a large base of support for patients who have poor balance or who have bilateral lower limb weakness and thus cannot always bear full weight on their legs. A two-wheel rolling walker is more functional and easier to maneuver than a standard walker with no wheels. A four-wheel rolling walker (rollator) can be used by higher-functioning individuals who do not need to fully off-load a lower limb and who need rest breaks for cardiopulmonary endurance reasons, but this is the least stable type of walker. Wheelchairs should be considered for patients who lack the lower body strength, balance, or endurance for ambulation. Proper sizing and patient education are essential to avoid skin breakdown. To use manual wheelchairs, patients must have sufficient upper body strength and coordination. Power chairs may be considered for patients who cannot operate a manual wheelchair or if they need the features of a power wheelchair.
As individuals age, many develop chronic, complex illnesses, including deconditioning, and may need to use a mobility assistive device. Assistive devices such as canes, crutches, walkers, and wheelchairs can help to alleviate the effects of mobility limitations, providing improved independence.1 According to data from the National Health and Aging Trends Study, 29.4% of adults 65 years and older reported using assistive devices within the previous month when outside the home, and 26.2% reported using them inside the home.2 Clinicians should understand how to select the appropriate assistive device (Figure 13–5) and size for individual patients and prescribe the device using the patient's health insurance plan.3
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| The use of assistive devices can improve balance, reduce pain, increase mobility and confidence, and decrease the risk of falls.9,10 | B | Expert opinion and systematic review of observational studies |
| Because many patients obtain assistive devices without recommendations or instructions from a medical professional, clinicians should evaluate these devices for proper fit and use.13,14 | C | Observational studies and patient surveys on how they use the devices |
| When only one upper limb is needed to aid in balance or weight-bearing, a cane is preferred. If both upper limbs are needed, crutches or a walker is more appropriate.4 | C | Clinical review article |
| Wheelchairs can provide patients with improved mobility and quality of life, but proper sizing and patient education are required to avoid injury to bony prominences and skin breakdown due to seat pressure.5 | C | Expert opinion |
The risk and fear of falling and sustaining an injury increase with age.6 In older adults, falls are associated with morbidity and mortality, worse overall functioning, and early admission to long-term care facilities.6 Clinicians should perform a risk assessment for falls in older patients at least annually.7 Resources on how to prevent falls are available from the Centers for Disease Control and Prevention.8
If needed, the use of assistive devices can improve balance, reduce pain, increase mobility and confidence, and decrease the risk of falls.9,10 The correct assistive device can help the patient remain functional for as long as possible and improve their quality of life by increasing independence and the ability to perform activities of daily living.11 These improvements, in turn, may increase the patient's psychological well-being and social engagement. Although assistive devices are thought to prevent falls, they may in fact cause falls if patients do not use them correctly.12 Before prescribing any assistive device, the patient's diagnoses should be considered along with cognitive function, individual goals of care, functional deficits, home environment, and ability to afford the device.11
Mobility assistive devices are covered under Medicare Part D as durable medical equipment (i.e., any equipment used for a medical reason that can withstand repeated use). Durable medical equipment is considered medically necessary when prescribed by a physician for use in a patient's home.11 Durable medical equipment may improve safety and decrease the need for caregiver assistance. Medicare Part B payment for approved durable medical equipment is equal to 80% of the total cost. Patients are responsible for paying their deductible (which may change annually and varies based on insurance plan), then 20% of the total cost.3
Ideally, selection of any assistive device should be tailored to the patient's needs and physical attributes. To avoid deconditioning, clinicians should encourage patients who can ambulate to walk as much as possible and avoid the use of power wheelchairs or scooters. Pros and cons of assistive devices and examples of indicated conditions are summarized in Table 1.4,5
| Device | Pros | Cons | Selected indications for use | Approximate cost* |
|---|---|---|---|---|
| Canes | ||||
| Standard | Improves balance, most are adjustable | Should not be used for more than minimal weight-bearing; curved handle may be difficult to grasp and may cause carpal tunnel syndrome; may be uncomfortable to use for patients with hand abnormalities; weight-bearing line is behind the cane shaft, which can make it less supportive | Mild ataxia (sensory, vestibular, or visual), mild lower limb arthritis | $10 to $20 |
| Offset | More supportive than a standard cane, appropriate for intermittent weight-bearing, handgrip is more comfortable than a standard cane and puts less pressure on the hand and wrist, most are adjustable | Often used incorrectly (backward) | Moderate lower limb arthritis | $15 to $40 |
| Quadripod | Larger base of support than other canes, can bear more weight, stands on its own, most are adjustable | Slightly heavier than other canes; awkward to use with all four legs on the ground simultaneously; some types may not fit on stairs | Hemiparesis | $15 to $40 |
| Crutches | ||||
| Axillary | Able to off-load 80% to 100% of weight from a lower limb, inexpensive | Difficult to learn how to use, requires substantial energy expenditure and upper body strength, risk of axillary nerve or artery compression, patient unable to use hands while operating | Lower limb fracture or injury | $16 to $30 |
| Platform | Includes a forearm pad that can be used to bear weight rather than the hand | Difficult to learn how to use | Wrist fracture, rheumatoid arthritis | $75 to $100 |
| Forearm (Lofstrand) | Forearm cuff and handpiece used for weight-bearing; frees hands without having to drop crutch; less cumbersome to use, particularly on stairs | Permits only occasional weight-bearing | Cerebral palsy, paraparesis | $40 to $100 |
| Walkers | ||||
| Standard walker (no wheels) | Most stable walker, folds easily | Needs to be lifted up with each step; slower, less natural gait | Severe myopathy or neuropathy, cerebellar ataxia, lower limb fractures | $20 to $60 |
| Two-wheel rolling walker | Maintains normal gait pattern, does not need to be lifted up with each step | Large turning arc, less stable than standard walker | Lower limb arthritis, pain, or injury; poor balance; severe myopathy or neuropathy; paraparesis; parkinsonism | $35 to $60 |
| Four-wheel rolling walker (rollator) | Easy to propel; highly maneuverable, with small turning arc; typically has a seat for resting and a basket | Should not be used for weight-bearing, less stable than two-wheel walker, does not fold easily | Generalized decreased endurance, spinal stenosis, moderate lower limb arthritis, lung disease, congestive heart failure | $50 to $100 |
| Manual | Improved long-distance mobility, complete off-loading of both lower limbs | Requires substantial energy expenditure and upper body strength, may cause injury to bony prominences and skin breakdown due to seat pressure | End-stage disease, severe lower limb arthritis, frailty, paraplegia | $100 to $200 |
| Power | Improved mobility and activities of daily living for those with severe disability | Powered by battery that needs to be charged, manual wheelchair needed for use during power outages or emergencies | End-stage disease, amyotrophic lateral sclerosis, multiple sclerosis, frailty, quadriplegia | $1,000 to > $2,500 |
Canes
A cane is the least restrictive assistive device but is also the least stable. An individual must have sufficient balance, upper body strength, and dexterity to use a cane. Canes can improve standing tolerance and gait by partially off-loading a weak or painful limb, enhancing the base of support, and improving sensory feedback from the ground. Canes can off-load approximately 10% of the weight from an affected lower limb if used properly.
The cane should be held on the contralateral side of the weak or painful lower limb and advanced simultaneously with the impaired limb. Many canes can be adjusted to fit a patient's height. The top of the cane handle should be at the level of the wrist of an arm hanging by the patient's side. The standing patient should have 20 to 30 degrees of elbow flexion when holding the cane on the ground and positioned as vertically as possible.5
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