116271

WALKING AIDS FOR ENABLING ACTIVITY AND PARTICIPATION: A

SYSTEMATIC REVIEW

Kim Bertrand1, MSc

Marie-Hélène Raymond1 PhD Candidate

William B. Miller2, 3, 4,PhD

Kathleen A. Martin Ginis5, PhD

Louise Demers1,6, PhD

1- Université de Montréal, Faculty of medicine, School of Rehabilitation,

Montreal, QC, Canada;

2- GF Strong Rehabilitation Research Lab, Vancouver, BC, Canada;

3- Rehabilitation Research Program, Vancouver Coastal Health Research Institute,

Vancouver BC, Canada;

4- Department of Occupational Sciences and Occupational Therapy, Faculty of

Medicine, University of British Columbia, Vancouver BC, Canada;

5- School of Health and Exercise Sciences; University of British Columbia

Okanagan, Kelowna BC, Canada;

6- Research Center, Institut Universitaire de gériatrie de Montréal, CIUSS du

Centre-Sud-de-l’Île-de-Montréal, Canada

Short title: Walking aids, activity and participation

ABSTRACT

Objective: Examine how walking aids (canes, crutches, walkers and rollators) enable

activity and participation among adults with physical disabilities.

Data sources: Medline, Embase, all EBM reviews, PsychInfo, CINAHL and Web of

Science databases were used to identify studies published since 2008. Quantitative and

qualitative designs were included.

Data extraction: Data regarding participants, assistive device use, outcome measures and

domains of participation were extracted. Two reviewers independently rated the level of

evidence and methodological quality of the studies. Outcomes were categorized per types

of walking aids and domains of activity and participation.

Data synthesis: Thirteen studies were included. Two involved canes, four pertained to

rollators and seven dealt with multiple types of walking aids. Mobility was the most

frequently examined domain of activity and participation. Both negative and positive

results were found. Negative outcomes were linked to the physical characteristics of the

device, the use environment and personal reluctance. When incorporated in daily life,

walking aids were found to enable several domains of activity and participation.

Conclusion: Whether walking aids facilitate activity and participation may depend on the

user’s ability to overcome obstacles and integrate them in daily life. More high-quality

research is needed to draw conclusions about their effectiveness.

Key words: walking aids, assistive technology, mobility, activity and participation

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Closest MESH terms: self-help devices, mobility limitations, human activities, activities

of daily living, social participation

Journal of Rehabilitation Medicine

Corresponding author:

Louise Demers, Ph.D.Université de MontréalFaculty of medicine, School of Rehabilitation,C.P. 6128, succursale Centre-ville Montreal (Quebec) H3C 3J7 CanadaTelephone : 1-514-343-5780Fax: 1-514-343-2105louise.demers@umontreal.ca

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INTRODUCTION

Adults with physical disabilities face activity and participation challenges (1-5)

that can influence their level of life satisfaction (6). To overcome impairments in physical

functions, many people use mobility aids such as a cane, crutches, a walker, a rollator or

a wheelchair (7). More and more people use mobility-related devices, with walking aids

(WAs) being the most commonly used (8-11).

Functionally, WAs increase the base of support and the amount of somatosensory

information, which help to reduce the load on the lower limbs and increase stability (7).

WAs can facilitate activities and participation of people with physical disabilities. In a

2009 systematic review (12) involving 8 studies, Salminen and colleagues concluded that

using various types of mobility aids help increase participation in activities for people

with mobility limitations. Furthermore, the results of Hammel et al.’s qualitative study

conducted among 45 people with disabilities, 10 caregivers and 10 service providers

suggest that mobility aids contribute toward a significant commitment in life and an

increase in feelings of control, freedom, worthiness and dignity (13). Authors of studies

specific to WAs have come to the same conclusion. Some walker users report going

about their activities more easily and feeling confident, independent and safe and having

more self-esteem (7, 14, 15); however, the quality of evidence of these studies limits the

confidence that can be placed in these results.

In turn, using WAs can also involve some disadvantages. Using a cane or a walker

can have destabilizing effects, interfere with the movement when recovering one’s

balance and generate major metabolic and physiological issues when moving (7).

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Excessive use of a cane or crutch use is hypothesized to induce upper extremity nerve

entrapment injuries in poststroke patients (16). Using WAs also requires attention and

neuro-motor resources, which can compromise stability when the person is performing a

task (7). Furthermore, many people who use walkers daily claim to feel vulnerable and

dependent (14). They report having to pay more attention when they move, having

changed their self-image, feeling watched and having the impression of taking more

space with the size of the walker (14). These aspects could explain the results of Allen et

al.’s study (17) which suggests that only one third of people receiving various types of

mobility aids use them.

Thus far, some studies suggest that WAs may benefit adults with physical

disabilities whereas other studies suggest that they may interfere with personal

preferences and are not worth the additional effort required to use them. Salminen’s

review examined mobility aids in general(12) in relation to activities and participation.

However, this review dates from 2009, and no systematic review focusing specifically on

walking aid studies is available. This is an important gap given the many people who use

walking aids (9). This systematic review thus seeks to examine whether and how WAs

enable activity and participation of adults with physical disabilities.

METHODOLOGY

Search strategy

In May 2015, a search strategy was performed using electronic databases Medline

(Ovid MEDLINE® in-process and other non-indexed citations and Ovid Medline®, 1946

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to present), Embase (1996 to present), all EBM reviews (Cochrane DSR, ACP Journal

Club, DARE, CCTR, CMR, HTA, and NHSEED), PsychInfo (to May 2015 week 2) and

CINAHL. A librarian was consulted to identify the keywords specific to each database.

The search was conducted in a hybrid fashion; in other words, by subject and keyword in

the title and summary. Given that the review by Salminen et al. (12) on mobility aids

covered the years 1996 to 2008, we targeted publications since 2008 inclusively. The

Web of Science database was searched to find relevant articles citing those previously

chosen. Finally, a manual search was conducted in the reference lists to identify other

eligible articles.

Inclusion and exclusion criteria and study selection

All types of quantitative and qualitative studies were accepted. Systematic reviews

were eliminated; however, their reference lists were reviewed to identify relevant studies

to include. Study participants had to be 18 years and older. WAs could include the cane,

crutches, the walker, the rollator but excluded experimental prototypes not commercially

available. As part of this study, the walker is described as a 3-sided tubular device with

no wheels or with 2 or 4 small wheels, while the rollator refers to a 3-sided tubular

walking aid with four wheels, a seat, back support, brakes, handles and a basket (18). The

WAs were named differently in a few articles (14, 19). Articles dealing with several

technical mobility aids, of which most were WAs, were accepted. The articles had to

include outcomes and results that were conceptually linked to one or more domains of

activity and participation as defined by the International Classification of Functioning,

Disability and Health (ICF) (20).

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Data extraction and quality assessment

Data regarding the study design, objectives, participants, assistive device

intervention or use, outcomes and instruments, and main results were extracted by the

first author and discussed among the research team for accuracy. Data pertaining to

activity and participation domains were also extracted and summarized separately.

Quantitative studies were assigned a level of evidence based on criteria recommended by

the Center for Evidence Based Medicine (21) : 1a, systematic review of randomized

controlled trials (RCT); 1b, RCT with a narrow confidence interval; 1c, all or none of the

case series; 2a, systematic review cohort studies; 2b, cohort study/low quality RCT; 2c,

outcomes research; 3a, systematic review of a case-controlled study; 3b, case-controlled

study; 4, case series, poor cohort case-controlled study; and 5, expert opinion. Qualitative

studies were assigned a level of evidence based on Kearney’s criteria (18) with the levels

as follows: I, findings restricted by a priori framework; II, descriptive categories; III,

shared pathway or meaning; IV, depiction of experiential variation; and V, dense

explanatory description.

Two evaluators evaluated the quality of each study independently. Agreement on

quality level was reached by consensus and a third person was involved in one case of

disagreement. The Critical Appraisal Skills Programme (CASP) checklists were used

(22). Quantitative studies were rated with the CASP cohort study checklist because it was

the most appropriate for our study pool. This checklist has 12 items, including two

questions split into two parts, for a total of 14 questions to answer. Items 7 (What are the

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results?), 8 (How precise are the results?) and 12 (What are the implications for practice?)

were not recorded as they cannot be responded by Yes, No or Can’t Tell. Also, item 6

(and its two questions) on the follow-up was eliminated because it did not apply to our

studies. Items were scored Yes, No or Can’t Tell and a point was given for each question

to which evaluators answered Yes. The maximum score was therefore out of 9. Specific

score ranges were assigned the following quality designations: Excellent (9), Good (6-8),

Fair (3-5) and Poor (1-2). Qualitative studies were rated similarly with the CASP

qualitative checklist (22) that includes 10 questions. The last question about the research

value was slightly reworded so that all questions could be answered by Yes, No or Can’t

Tell. Each question included sub-questions allowing evaluators to refine/specify their

answer. We gave one point for each question to which participants answered Yes when

most sub-questions received an affirmative response. As proposed by Mortenson et al.

(23), score ranges were assigned the following quality designations: Excellent (9-10),

Good (6-8), Fair (3-5) and Poor (1-2).

RESULTS

Study characteristics and methodological quality

The search generated 1317 articles after eliminating duplicates. From the titles

and abstracts, the first author identified 60 articles that met the inclusion/exclusion

criteria. Comprehensive reading of these articles further reduced their number. Doubtful

cases were read and discussed by three members of the research team and resolved

through consensus. At this point of the process, nine articles corresponded to the

inclusion/exclusion criteria (see Figure 1). A search in Web of Science yielded four more

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articles for a total of 13 articles. No other articles were found as part of the manual

search.

The studies included are described in Table 1 and data specific to activities and

participation are presented in Table 2. Most studies incorporated various categories of

WAs (24-30), four articles targeted rollators (14, 19, 31, 32) and two studies looked at

different types of canes (33, 34). Study samples were small. Only four articles included

samples with more than 100 participants (24, 28, 29, 32). Two articles targeted a

population having suffered a stroke (33, 34) and two others targeted people who had

suffered a spinal cord injury (24, 28). The other studies did not target people with a

specific diagnosis. In most articles reviewed, participants were 65 years and older. Only

two articles had participants whose mean age was lower than 65 (28, 34), and the lowest

mean age documented was 46.2 years old (28). The articles were produced in various

parts of the world. In total, three articles came from North America (19, 24, 27), seven

studies from Europe (14, 25, 26, 30-33), two from Asia (28, 29) and one from Africa

(34).

From the 13 studies, seven used quantitative methods, (24, 28, 29, 31-34), five

used qualitative methods (14, 25-27, 30) and one article used mixed methods (19). As

noted in Table 2, most quantitative studies provided a relatively low level of evidence (2c

and lower). Qualitative studies were better quality and provided a level of evidence of III

(14, 25, 26, 30) and IV (13). The study with mixed methods (19) obtained a level of IV

for the quantitative section and II for the qualitative section. The results of the

methodological quality assessment are shown in Table 2. The quality of the quantitative

studies varied considerably, ranging from Fair to Excellent on the CASP checklist. The

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quality of the qualitative studies was relatively better than the quantitative ones, with

Good and Excellent ratings.

Summary of activity and participation domains influenced by WAs

As shown in Table 2, ICF activity and participation domains discussed in the

studies include mobility (14, 19, 24, 26, 28, 29, 31, 33), self-care (24-26), domestic life

(25-27, 31, 32), community, social and civic life (25, 26, 31), interpersonal interactions

and relationships (14, 27, 32) and major life areas (32). Two studies examined activity

and participation domains as a whole (19, 34). Specific results pertaining to mobility will

be presented first, followed by all other domains.

Walking aids to enable mobility

Results in this section are organized according to the types of assistive devices

studied. Four studies mainly targeting rollators (14, 19, 26, 31) reported associations with

mobility. Rollators allow people to walk longer and more frequently (14, 19, 31) and to

go outside (26, 31). Having a seat on the device gives people the chance to rest whenever

they need to (14, 26).

Canes were found to enable mobility. Allet et al. (33) looked at three different

types of canes among participants having suffered a first stroke and not able to walk more

than 5 metres with no aid. With a cane, participants travelled a mean distance of 100

metres consecutively in 6 minutes (33). From the three types of canes studied, the single

cane was the most appreciated and the one linked to the greatest walking distance.

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Three studies (24, 28, 29) assessed mobility in relation to various walking aid

categories. The first two involved samples of participants with a spinal cord injury.

Participants who used canes or crutches reported being better able to move within the

community and to climb stairs than those who used walkers (24). Walking distance and

speed were greater with a cane than a walker, but remained lower than the minimum

values required to be considered functional within the community (28). Another study

(29) looked at the same three types of WAs, but with elderly people with no specific

diagnosis. The results suggest that their use is positively associated with functional

mobility as measured by the Rivermead Mobility Index and Physical Mobility Scale (29);

however, it is important to note that this study was rated as fair methodologically, namely

because of concerns with its external validity.

Walking aids to enable other domains of activity and participation

Six studies reported how providing rollators to individuals with no specific

diagnosis (14, 19, 25, 26, 31, 32) contributes to participants’ activities and participation.

Somewhat negative outcomes were identified in three studies, based on interview data

(19, 25, 26). The results showed that the physical characteristics of the rollator, such as its

weight, can interfere with certain activities such as using public transportation or going to

places that have stairs (19, 25, 26, 30). In turn, four studies reported positive impacts (25,

26, 31, 32). The rollator makes going out for leisure, to shop or to socialize easier and

more frequent (25, 30-32). It helps people to participate more frequently in cultural

events (31). Furthermore, users claim to be able to talk to another person while walking,

which helps them to maintain social relationships (26). The rollator makes it easier to

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complete household tasks such as carrying grocery bags, cooking and getting the mail

(19, 25, 26, 30).

The study involving canes (34) concluded that following a stroke, people who use

WAs participate to a lesser extent than those not using WAs, as measured with the Craig

Handicap Assessment Reporting Technique.

Finally, six studies involving several categories of WAs provided relevant

information on barriers and facilitators to activities and participation. Several negative

points emerged. Physical environment challenges were emphasized in five studies, such

as inability to access public transportation (25) or family members’ homes (35) due to

architectural barriers, or difficulty manoeuvring in crowded public places (26) or even at

home (30) . One study mentioned that walking aid users must plan their travels before

leaving to make sure there are no obstacles (25). The poor aesthetics of WAs and the

stigma that can be linked to using them are reported in two studies (14, 27). For these

reasons certain users prefer staying home rather than going out and being seen with this

sort of device (27). On the other hand, other positive aspects were unanimous among the

reviewed studies. The authors agreed that WAs help develop a feeling of safety and

independence on a daily basis among people with physical disabilities (14, 19, 25-27, 32).

In one study, participants reported that their WAs are part of their lives and that they use

them everywhere, even in the bathroom (26). This positive-negative duality of

perceptions from users toward WAs is clearly indicated in the studies conducted by

Brannstrom (14) and Resnik (27) who found contrasting themes such as confidence and

independence versus feelings of vulnerability and inferiority. Moreover, two qualitative

studies examining the temporal aspect of walking aid use (25, 26) converged regarding

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the perceived impacts of WAs on activities and participation evolving with time and

becoming more positive among experienced users. However, in one study (30)

participants abandoned their WAs over time as their physical condition evolved and

environmental barriers such as stairs and restricted space became too challenging.

DISCUSSION

To our knowledge, this is the first systematic review exploring how WAs enable

activity and participation among adults with physical disabilities. Our search strategy

resulted in 13 articles that supplied generally low and moderate levels of evidence

regarding the benefits of WAs. Indeed, the quantitative articles reviewed were mainly

observational studies with small samples. These studies included some useful information

but were not sufficient to allow formulation of conclusions about the impact of WAs on

activity and participation. As for the qualitative studies, they contained valuable

information on the lived experiences of people using these types of devices. Together, the

studies contribute to our understanding of how using canes, crutches, walkers or rollators

can contribute to mobility and other domains of participation.

There is evidence of factors reducing the potential benefits of WAs on activity and

participation. It was found that physical characteristics such as the weight of the device in

interaction with the physical environment can make it harder to complete certain tasks

(19, 25, 26, 30). For instance, one study reported that these interactions require greater

planning of activities to anticipate and avoid obstacles as much as possible (25). Several

studies also showed people’s reluctance to use WAs (14, 25-27). This aspect represents

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an obstacle to participation when the person decides not to take part in certain activities to

avoid being seen in public with the device. Social stigma related to disability can feed

people’s refusal to use these aids. These results are in keeping with those of Hedberg-

Kristensson et al. who mention that people’s opinion and attitudes influence the level of

acceptance of mobility aids (36). From a service provider’s perspective, it is essential to

explore and consider the person’s attitude toward the walking aid and support the person

throughout the acceptance process. More broadly, efforts should also be directed towards

the social environment to reduce the stigma associated with using WAs.

Despite these obstacles, positive outcomes were identified in the reviewed studies

and mainly emerge when people accept their WA and integrate it into their daily lives.

More specifically, numerous studies acknowledged the facilitating effects of WAs on

mobility, to ease travels in the community and allow users to travel greater distances (14,

19, 29-31). Specifically, the rollator was identified as being appreciated and offering

users the chance to take breaks during their travels. It was also established that the cane

and crutches are the WAs that allow users to travel the greatest distance (24, 28). These

conclusions are, however, not very surprising given that people using a cane or crutches

are usually not as physically disabled as those using a walker or rollator. It must be noted

that controlling for the confounding influence of physical limitations on participation

remains a challenge in studies examining walking aids.

Walking aids can affect participation in multiple ICF domains such as mobility,

self-care, domestic life, community, social and civic life, interpersonal interactions and

relationships. Studies used a mix of objective measures such as walking speed and

distance, as well as self-report questionnaires and narrative content. The number and

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quality of studies using objective vs. subjective measures was not sufficient to distinguish

which types of measures produce the strongest association with WAs. Mobility was the

most frequently studied domain of participation, which was predictable since it is directly

related to the function for which WAs are intended (37). Mobility may also be considered

as a gateway for other domains of participation and broader health-related aspects of

well-being, such as satisfaction and quality of life. As suggested by Jutai et al. (37) in

their taxonomy of assistive technology device outcomes, we expect the effects of WAs to

be cumulative. Gains in mobility from the use of WAs can, in turn, cause changes in

other domains of activity and participation, such as domestic activities and interpersonal

interactions and relationships, which may eventually contribute to increased quality of

life.

The studies examined as part of this review mainly address the cane, the rollator

or a mix of devices, and do not put as much emphasis on crutches and the walker

individually. As a result, it is hard to draw conclusions applicable to all WAs about

whether and how they enable activity and participation. To advance scientific knowledge

regarding WAs for people with physical disabilities, studies that use a prospective design

and better-defined user groups in terms of categories of WAs, age, and diagnosis are

needed. Furthermore, to help confront the negative impacts of WAs that mainly appear

when people have not yet accepted the device, studies on this acceptance process would

be relevant to better support inexperienced users and develop a more positive general

public image of WAs.

Our review has some limitations. First, one individual identified the relevant

studies. Uncertain papers were discussed among the team, which compensated for not

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having two independent people performing the search. Second, we did not contact the

original authors for possible additional articles. As a result, we may have omitted

otherwise eligible studies. Finally, although a systematic approach was used for data

extraction, the classification of individual study results into ICF activity and participation

domains may have involved some elements of subjectivity.

CONCLUSION

Although more advanced and specific studies are required to confirm their

effectiveness, the current data suggest that WAs enable activity and participation for

people with physical disabilities, as long as users are able to overcome certain obstacles

to integrate WAs into their daily lives.

Sources of funding:

This work was supported by a Partnership Grant from the Social Sciences and Humanities

Research Council (SSHRC) of Canada (grant number 895-2013-1021) for the Canadian

Disability Participation Project (www.cdpp.ca). The funding agency has had no influence on the

interpretation of data and final conclusions drawn.

Disclosures: none.

References

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Generic keywordsMedline (791 articles): (social participation OR activities of daily living OR independent living OR involvement)

AND (self-help devices OR cane* OR rollator* OR walker* OR crutch* OR (mobility or locomot* or ambulat*)adj2(aid* or device* or equipment*))

All EBM reviews (62 articles): Same as MedlineEmbase (544 articles): Same as Medline

PsychInfo (167 articles): (participation OR activities of daily living OR independent living OR community involvement) AND (mobilityaids OR cane*OR rollator* OR walker* OR crutch* OR (mobility or locomot* or

ambulat*)adj2(aid* or device* or equipment*))CINAHL (274 articles): (social participation OR activities of daily living OR independent living OR involvement)

AND (Ambulation aids OR cane* OR rollator* OR walker* OR crutch* OR (mobility or locomot* or ambulat*)adj2(aid* or device* or equipment*))

1,838 references from databases

1,317 titles and abstracts screened

521 duplicates eliminated

60 full articles obtained for detailed examination

1,257 references eliminated

NOT “Child” and limit to yr= “2008 to present”

Reasons for elimination:- No results about participation or participation domains(n= 15)- No results about walking aid outcomes (n= 27)- Conference abstract, systematic review or book chapter (n= 7)- Experimental prototype (n= 2)

13 references kept for analysis

4 articles found in bibliography research

9 references

Figure 1: Flowchart of the search strategy and the article selection process.

*=truncation symbol

Table 1: Summary of included studiesAuthor and country

Study design and objective(s)

Participant characteristics

Assistive device intervention or use

Outcomes and instruments used

Main results

Allet et al. 2009 (31)

Switzerland

Cross-over study 1) Examine the effects of 3 different canes on walking capacity and temporo-spatial gait parameters 2) Evaluate patients’ satisfaction with each type of cane at an early stage of gait rehabilitation

N= 25, % male NR, mean age = 67.6 yearsDx: First stroke (mean time poststroke = 42 days)Main selection criteria: early stage of gait rehabilitation, unable to walk more than 5 m alone without walking aid

Subjects tested over 3 consecutive days, each day with another randomly assigned walking aid: Nordic stick, 4-point cane and single cane with ergonomic handgrip

- Temporo-spatial gait parameters: GAITRite- Walking capacity: 6-minute walk test- Subjective benefit: scale from 0 to 10

The greatest walking distance was achieved with the simple cane (mean 115.48 m) followed by the 4-point cane (mean 101.40 m). Gait velocity and step time symmetry were better with the single cane than with the 4-point cane (mean velocity 29.42 cm/s vs. 25.84 cm/s, mean step time difference 0.37s vs. 0.56s). Participants preferred the single cane (subjective rating 7.44 vs. 6.96 for 4-point cane and 4.52 for Nordic stick).

Brandt et al., 2009 (31)

Denmark

Pre-post study designInvestigate mobility-related participation of rollator interventions and whether users view

Total N= 75, from 2 different municipalities. male: 35% in group 1 and 32% in group 2, mean age: group 1= 77 years, group 2= 82 years

Use of a rollator in everyday life Mean duration of use at follow-up: 144 days for group 1, 149 days for group 2

Mobility-related participation: NAME 1.0

After getting a rollator, there was a great variation in change of mobility-related participation but mostly non-significant statistically. Statistically significant improvements post rollator use: taking walks more often (p=

their device as important

Dx: Limitations in leg and back function and/or in balance and/or tirednessMain selection criteria: about to receive a rollator grant from the municipality, age ≥18 years, living at home.

0.014 in group 1 and p=0.04 in group 2), increased participation in cultural and sporting activities (p=0.046 in group 1) and going outdoors for hobbies or sports (0.03 in group 2). In group 1, it also became easier to go to the pharmacy, post office and library (p=0.031), to shop (p=0.009) and to visit family and friends (p=0.026).

Brännstrom et al., 2013 (14)

Sweden

Qualitative study (phenomelogical hermeneutic)Illuminate meanings of the lived experience of living in an ageing body and using a rollator in daily life

N= 7, male 14%, age = 79-95 yearsDx: NRMain selection criteria: People living in their own apartment who were now using a rollator or who had used one in the past.

Now using a rollator in daily life or having used one in the past

Narrative interview Two subthemes emerged from the analysis of the interviews: Being vulnerable and dependent and Being confident and independent with the rollator

Brotherton et al., 2012 (24)

United States

Cross-sectional studyIdentify the association between reliance on devices and

N= 429 , male 68.2%, mean age NRDx: Spinal cord injury (mean time post SCI: 9.7 to

Assistive devices used in daily life by respondents: cane (29.9%), walker (19.5%), short leg braces (22.6%),

Distances walked, stairs climbed and devices used to assist walking: self-report questionnaire

Participants who used personal assistance or a walker for ambulation were the least likely to walk 1,000 ft (12.5% of personal assistance users and 15.8% of walker users) and

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people for ambulation and ability to walk functional distances and climb stairs

11.7 years)Main selection criteria: traumatic SCI, age ≥18 years, minimum 1 year post-injury and report being able to walk at least 10 m.

crutches (19.5%), long leg braces (12.5%). Relying on people for ambulation: 11.2%. Not relying on devices or people for ambulation: 33.4%

climb a flight of stairs (31.1% of personal assistance users and 30.3% of walker users). Participants who used a cane or crutches were the most likely to walk 1,000 ft (46.1%) and climb a flight of stairs (77.2%).

Hamzat & Kobiri, 2008 (34)

Ghana

Cross-sectional studyCompare participation and balance between post-stroke individuals who walk with and without a cane

N= 50, male 54%, mean age: aided group = 59.88 years; unaided group = 55.84 yearsDx: hemiparesis secondary to first stroke. Mean time poststroke: aided group: 56.14 wks, unaided group 60.07 wksMain selection criteria: hemiparesis resulting from stroke, ambulates at home with or without assistive device such as a

Assistive devices used in daily life in aided group (n=25): cane, walking stick or quadripod cane

- Balance: Berg Balance Scale - Participation: CHART

The group using a cane had significantly less participation (mean score 12.60 vs. 5.04, p=0.00) and lower mean balance scores (mean score 39.72 vs. 53.68, p=0.00) than the unaided group.

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cane, walking stick or quadripod cane.

Kylberg et al., 2013 (25)Sweden

Multiple case studyExplore very old men’s experiences with mobility device use in everyday life over time

N= 3, male 100%, mean age= 91 yearsDx: NRMain selection criteria: having experiences of mobility device use for walking (excluding wheelchairs)

Cane and rollator in daily life

Comprehensive questionnaire to describe participants’ health and functional profiles, semi-structured interview and observation of an activity in which the mobility device was used.

Mobility device use impacts activities and life over time. Device use increased with age. Mobility devices were important for the men’s social life but the physical environment interfered with their use. Users reported always having to plan their activities in advance and anticipate solutions to problems that may occur.

Löfqvist et al., 2009 (26)

Sweden

Multiple case studyExplore how very old single-living women experience the use of mobility devices over time, in relation to everyday occupations

N= 3, male 0%, mean age= 91 years at the end of the studyDx: NRMain selection criteria: women aged 80-89 years, living alone in ordinary homes in urban environments and who had recent and varied experience with changes in

Rollator, cane or walker in daily life

Comprehensive questionnaire to describe participants’ health and functional profiles, interview using open-ended questions and observation of an experiential walk. Follow-up interview 1-2 weeks later.

Mobility device use increases and develops toward the use of more supportive devices over time. Mobility devices are described as something whose use you have to accept, but also as a constant reminder of your limitations. Strategies and adaptive behaviours are developed over the years when striving to maintain participation. With time, mobility devices were perceived as necessary and mostly positive, and influenced

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mobility device use.

how occupations were performed rather than whether new or extended occupations were performed.

Resnik et al., 2009 (27)

United States

Qualitative study (focus groups)Explore attitudes toward mobility device use among elderly persons by race and ethnicity

N= 61, male 15%, mean age NRDx: NRMain selection criteria: age ≥ 60 years and spoke English or Spanish

Respondents included 32 non-device users and 29 mobility device users: cane (n= 21), walker (n= 10), wheelchair (n= 4), scooter (n= 2), multiple devices (n= 8)

Attitudes toward mobility devices: semi-structured interview guide

For all ethnic groups, positive attitudes supporting mobility aid use related primarily to perceived benefits in maintaining independence and control over activities; however, participants felt that mobility aid use was stigmatizing. Participants had a more positive attitude toward fashionable and sporty devices compared to those that could be linked to greater disability.

Saensook et al., 2014 (28)

Thailand

Cross-sectional studyAssess walking performance of independent ambulatory patients with spinal cord injury (SCI)

N= 140, male 70%, mean age by group (walker= 50.5 years, crutches= 46.2 years, cane= 59.0 years and no WA= 50.8 years)Dx: SCI (mean time post-injury 45.1 to 63.1 months)

Assistive devices used by respondents in daily life and during testing: walker (n=59), crutches (n=12), cane (n=16) No device: n=53

- Walking speed: 10-Meter Walk Test - Walking distance: 6-Minute Walk Test

Walking speed and distance of subjects who did not use a WA were significantly greater than those who walked with a WA (mean walking speed 0.8 m/s in non-WA users vs. 0.3 to 0.6 m/s for WA users, p <0.001. Mean distance walked 242.0 m in non-WA users vs. 76.6 to 168.9 m for WA users, p <0.001). Subjects who walked with a cane had a significantly

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Main selection criteria: ability to walk alone with or without a WA over at least 17 m continuously

better walking speed (0.6 m/s vs. 0.3 m/s, p <0.001) and walking distance (168.9 m vs. 76.6 m, p <0.001) than those who used a walker.

Samuelsson & Wressle, 2008 (32)

Sweden

Cross-sectional study1) Follow-up on client satisfaction toward products, services and the prescribing process for manual wheelchair and rollator2) Examine differences in satisfaction between manual wheelchair vs. rollator users

N= 262 , male 36%, mean age = 69.8 yearsDx: NRMain selection criteria: manual wheelchair users and rollator users aged 20-84 years who had received their device during a 12-month period

Rollator (n= 175) or wheelchair (n= 87) in daily life. Duration of use: 8-10 months

- Satisfaction: QUEST 2.0- Use of devices, participation in the process, activity and participation, satisfaction and need for follow-up: self-report questionnaire

Overall, rollator users were more satisfied than wheelchair users (p <0.001) for both the device and prescribing process. Rollator users more often reported a positive influence of the device on the “possibility to be mobile” (p ≤ 0.05), “feeling of safety/security” (p ≤0.001), “feeling of independence” and “self-esteem” (p ≤ 0.05). Wheelchair users more often reported a positive influence of the device on the “possibility to work” (p ≤ 0.05) and “possibility to lead an active leisure life” (p ≤ 0.01).

Simsek et al., 2012 (29)

Turkey

Cross-sectional studyExamine assistive device use and mobility level among elderly

N= 163 , male 64.4 %, mean age (women= 73.18 years; men= 73.31 years)Dx: Various

Assistive devices used by respondents in daily life and during testing: cane (n=31),

- Mobility state: Rivermead Mobility Index (RMI)- Specific mobility activities: Physical

Assistive device use was associated with better mobility scores for both men and women (p=0.000 for RMI and p= 0.007 for PMS scores in men, and p= 0.000 for RMI and PMS scores

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people Main selection criteria: age ≥ 65 years , living in or visiting a nursing home, no dx of cognitive deficit or major sensory impairment

crutch (n=4), walker or wheelchair (n=2)No device: n= 125

Mobility Scale (PMS)

in women. Scores NR).

Thomas et al., 2008 (19)

Canada

Mixed method multiple case studyGather pilot data on the variables influencing the functional impact and the use of rollators by community-dwelling older adults

N= 4, male 50%, age 78 to 86 yearsDx: NRMain selection criteria: community-dwelling older adults, aged ≥ 65 years, referred to community-based rehabilitation services to receive an assessment for the prescription of a gait aid

RollatorDuration of use: 1 week to 1 month at first visitFollow-up 1: 4 weeks laterFollow-up 2: within one year after visit 2

- Balance: Berg Balance Scale- Physical mobility: Timed Up and Go- Walking distance: Six-Minute Walk Test- Mobility-related confidence: Activities-Specific Balance Confidence Scale- Participation: Assessment of Life Habits - Experience of having a rollator: semi-structured interview

Quantitative results varied between participants; no trends were observed. Qualitatively, participants reported improved balance and safety with the rollator but not all of them integrated it into their daily lives. Stairs and lack of space were the two most common elements of the built environment that made using the rollator challenging. Participants viewed the rollator as a sign of dependency and a “visual declaration of their physical and functional decline”.

Tomsone et al.,

Multiple case studyExplore very old

N= 3, male 0%, mean age=89 years

Cane, crutches or rollator in daily

Comprehensive questionnaire to

Participants first used a cane outdoors, then indoors, and

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2016 (30)

Latvia

Latvian women’s experiences over time regarding their everyday use of mobility devices

Dx: NRMain selection criteria: having the experience of using a variety of mobility devices over time in different environments

life describe participants’ health and functional profiles, and in-depth interviews with a short walk around the flat to observe participants’ mobility at home.

progressed towards other WAs as their functional capacities declined. Initially, WAs helped them maintain their daily routines inside and outside the home. However, over time environmental barriers such as stairs and lack of space, combined with participants’ declining health, rendered the use of WAs too challenging and participants abandoned them. They turned to other ways of compensating their difficulties, such as asking for help or remaining indoors.

NR= Not reported; Dx= Diagnosis; SCI= Spinal cord injury; WA=Walking aid; NAME= Nordic Assisted Mobility Evaluation;

CHART= Craig Handicap Assessment Reporting Technique; QUEST= Quebec Users Evaluation of Satisfaction with Assistive

Technology; RMI = Rivermead Mobility Index; PMS= Physical Mobility Scale

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Table 2: Quality of included studies, level of evidence, and WA outcomes related to activity and participationAuthor Quality,

Quan (Qual)

Level of evidence,Quan (Qual

Walking aid  Participation domain(s)

Activity and participation

Allet et al., 2009 (33)

9

Excellent

4 Nordic stick, single cane, 4-point cane

Mobility The single cane helped reach a greater distance in the 6-minute walk test compared to the 4-point cane and Nordic stick. Overall, patients deemed that the single cane and 4-point cane were more beneficial than the Nordic stick.

Brandt et al., 2009(31)

5

Fair

2c Rollator Mobility, Domestic life, Community, social and civic life

It was found that the use of a rollator helped people take walks more often, participate in cultural or sporting events more often and go outdoors for hobbies or sports more frequently. Also, in one group it became easier to walk, go to the pharmacy, post office and library, shop and visit friends and family.

Brännstrom et al., 2013 (14)

(8)

Good

(III) Rollator Mobility, Interpersonal interactions and relationships

Although the rollator was hard to accept because of the feelings of shame, most participants mentioned that they loved their rollator. It helped them to continue doing their favourite things. Also, because the rollator had a seat, it allowed

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people to walk longer as they could sit and rest at any time. It also allowed users to be with others as they could have a conversation while walking. Overall, using a rollator allowed people to remain active.

Brotherton et al., 2012 (24)

8

Good

4 Cane, walker, and crutches

Mobility In this study, walking 1,000 ft was identified as a required distance for community ambulation. People using a cane or crutches were most likely to be able to walk this distance and climb a flight of stairs. People using personal assistance or a walker were least likely to climb stairs or walk 1,000 ft.

Hamzat & Kobiri, 2008 (34)

4

Fair

3b Cane All After a stroke, people living in the community and who did not use a WA had better participation than those using a cane. The authors suggest that the use of a cane after a stroke may have a negative impact on participation.

Kylberg et al., 2013 (25)

(9)

Excellent

(III) Cane and rollator

Mobility, Self-care, Domestic life, Community, social and civic life

Participants used both the cane and rollator. The men felt limited and housebound because they had to plan every scenario and anticipate problems that might occur when they went out with their WA; however, WAs were considered important in order not to be excluded from social life. Specifically, the rollator was seen as practical as it enabled men to transport things indoors and bring home groceries or sit and rest when walking outdoors. Although these WAs required new habits and

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planning, findings showed that they supported independence and enabled men to perform activities in everyday life and participate in social life. Overall, WA use enhanced active aging.

Löfqvist et al., 2009 (26)

(10)

Excellent

(III) Rollator, cane and walker

Mobility, Self-care, Domestic life, Community, social and civic life

Mobility device dependency impacted life situations both in a positive and negative way. Some occupations were avoided because users thought it was troublesome; however, some women reported that using a rollator also meant being able to walk outdoors for daily exercise, shop, going to the bank, etc. It also helped manage minor kitchen work.

Resnik et al., 2009 (27)

(9)

Excellent

(IV) Cane and walker

Mobility, Domestic life, Interpersonal interactions and relationships

Many attitudes were expressed toward mobility aids. First, users acknowledged that mobility aids could help them be independent. Nonetheless, some participants still preferred personal assistance because it is less noticeable and younger looking. Secondly, users felt stigmatized and ashamed of needing help. Some reported that they would rather stay home than go out and be seen using a device. Thirdly, some participants reported that using a mobility device could make it difficult or impossible to perform ordinary tasks like carrying objects.

Saensook et al., 2014 (28)

9

Excellent

4 Cane, walker, and crutches

Mobility People with a SCI who walked without a walking aid had better walking speed and distance than those who used a WA. Moreover, cane users had

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greater walking performance than those using a walker. Those who used a WA had a walking speed clearly inferior to the levels required for functional ambulation. Their walking distance was also not sufficient for functional endurance but this was also the case for those who did not use a WA.

Samuelsson & Wressle, 2008 (32)

6

Good

3b Rollator Mobility, Domestic life, Interpersonal interactions and relationships, Major life areas

Most rollator users reported a positive influence on the possibility of leading an active leisure life, socializing, going shopping and being mobile. Less than half of rollator users reported a positive influence on the possibility to work.

Simsek et al., 2012 (29)

5

Fair

4 Cane, crutch, and walker

Mobility For elderly people, using WAs is positively associated with functional mobility.

Thomas et al., 2008 (19)

5 (9)Fair

(quantitative)

Excellent (qualitativ

e)

4 (II) Rollator All Users mentioned that they were able to go for walks outside more frequently with the rollator. One woman said that her ability to participate in activities improved with the rollator because without it, she would not be able to access certain parts of her retirement home; however, using a rollator could negatively affect participation. A man reported that he was limited in his daughter’s home and that the rollator affected his ability to use public transportation.

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Tomsone et al., 2016 (30)

(9)

Excellent

(III) Cane, crutches, rollator

Mobility, Domestic life, Community, social and civic life

WAs initially helped participants maintain their daily routines, do some household work and perform outdoor activities such as going for a walk, shopping and attending public places. However, over time WAs were abandoned as the participants’ physical condition evolved and environmental barriers such as stairs and restricted space became too challenging.

WA=Walking aid

Levels of evidence for quantitative studies: 2c= outcome research; 3b= case-controlled study; 4= case series or poor cohort case-

controlled study.

Levels of evidence for qualitative studies: II= descriptive categories; III= shared pathway or meaning; IV= depiction of experiential

variation.

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