When Walking Fails: Mobility Problems of Adults with Chronic Conditions

From the New England Journal of Medicine, February 19, 2004

In this wonderful book, Lisa Iezzoni opens a window to the overlooked world of people with mobility problems. She draws from

extensive interviews of 119 mobility-challenged people (whose insights she quotes liberally), undertaken during her many months

of policy research as a Robert Wood Johnson Health Policy Fellow. Her material is also a product of her experiences with her

own mobility problems, which developed during medical school, where she experienced distressing prejudice and intolerance.

Few physicians have received training in this area or know how to discuss mobility problems with patients and where to refer

them. Many people live with impaired mobility, and there are many effective interventions and approaches for improving their

lives, yet only a small fraction of these people receive the assessment and care that they need. It is important for all health

care professionals to be aware of and deal with issues related to problems of mobility in adults. The book begins with a systematic

survey of the epidemiology of mobility problems (which affect about 10 percent of the adult population), the conditions that cause

them, and the effects of these problems on health care and costs to society. Iezzoni liberally intersperses facts with often

heart-wrenching quotations from patients and anecdotes of her personal experiences. She describes the normal gait cycle and how

it is affected by a number of disabling conditions. She explores the ways that people conceptualize their disabilities and the

ways that families and society react to the disabilities. Furthermore, Iezzoni relates the history of social programs, geared

toward improving the lives of disabled people, that emerged from neglect in the early 20th century. These include the Social

Security Act of 1935, Medicare and Medicaid in the mid-1960s, and programs associated with the Americans with Disabilities Act

of 1990 (spurred on by the disability-rights movement), along with more recent reactions and retrenchments. Iezzoni gives a tour

through the sometimes Kafkaesque labyrinth of entitlement programs and government regulations, which reflect the good intentions

of their designers but are often difficult to maneuver and make sense of. People with disabilities cope in a variety of ways,

and their methods of coping can affect functional outcomes. Some people are able to accept major limitations with positive inner

strength, but regardless, most face a variety of setbacks and disappointments. Life for them has changed, and they face the reality

of major loss of independence in an often cruel and intolerant society. Simply performing activities of daily life involves large

expenditures of energy and requires creative adaptations. This book does much more than make health care professionals aware of

the mobility problems of adults. It contains useful and practical information that can help all of us to provide care more effectively.

Iezzoni suggests ways that patients can help physicians be more responsive to the patients’ needs. She describes the programs that are

available to people with disabilities and also analyzes the treacherous disincentives for their use that discourage people from getting

the help they need. Many public disability welfare programs pay people not to work but give almost nothing for adaptive equipment that

would enable them to work. And the benefits often stop completely if the person can somehow become employed. Iezzoni explores the

difficulties of driving and the factors involved in deciding whether to drive with adaptive equipment or to stop altogether.

She suggests ways to benefit from physical therapy, occupational therapy, and prosthetics, and she discusses the major types of

assistive devices, including canes, crutches, walkers, wheelchairs, and motorized scooters. In addition, she describes the insidious

tendency for physicians and patients alike to delay using assistive and adaptive equipment, particularly wheelchairs, because of

the fear of hastening the progression of the disability. But these devices can vastly improve the quality of life in many ways

not imagined by people who have been barely getting by without them. Iezzoni’s chapter on wheeled mobility is an eye-opening essay

on the amazing benefits enjoyed by people who use wheelchairs and scooters, as well as the major impediments that people face when

deciding to start using them. She discusses who will pay for mobility assessments and aids, which is often a major stumbling block

but one that can usually be surmounted with knowledge of the available programs and with persistence. In the last chapter, Iezzoni

describes her fantasy of a one-stop Mobility Mart that would solve most of the problems identified in her book. It would provide

an interdisciplinary team of professionals to assess needs and prescribe the full spectrum of mobility aids and assistive devices,

networks of peer counselors or support groups, information about community resources, and insurance advisers. An appendix of resources

enhances this useful, interesting, and well-written book, which contains more than enough information to qualify as a textbook but

is fast and enjoyable to read. It will appeal to professionals and laypeople alike. Laurence Z. Rubenstein, M.D.

Copyright ? 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark

of the MMS. –This text refers to the Hardcover edition.

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