A 44-Year-Old Woman With Difficulty Walking

DR DELBANCO: Mrs D is a 44-year-old woman with amyotrophic lateral sclerosis (ALS) who is having increasing difficulty ambulating. Married, with children and a grandchild, she lives outside Boston. Mrs D has commercial, managed care health insurance and is currently applying for Social Security Disability Insurance. She received primary care in a community-based practice, but for the past year, her principal physician has been Dr V, a neurologist at Beth Israel Deaconess Medical Center.

In fall 1998, Mrs D noted stiffening of her leg muscles on awakening, followed shortly thereafter by a feeling of "deadness" and resistance to motion. During active exercise as part of a weight control program, she began to trip while running and fell several times. She next developed morning leg spasms, without sensory symptoms, followed by twitching, initially involving the legs, but spreading subsequently to the trunk and facial muscles. Results of imaging studies of the brain and spine were normal, as was a lumbar puncture. Results of blood tests, including titers for Lyme disease, thyroid function tests, vitamin B₁₂ levels, rapid plasma reagin, human T-lymphotropic virus 1 antibodies, protein electrophoresis, and anti-G_m1 profiles were normal. In summer 1999, electromyographic and nerve conduction studies revealed "findings suggestive of a generalized disorder of motor neurons or their axons." Her physician felt that ALS was the likely diagnosis, prescribed riluzole, 50 mg twice daily, for Mrs D and referred her to Dr V, whose examination revealed intact cranial nerves, normal sensory findings, spastic paraparesis, with increased tone in the extremities accompanied by hyperreflexia, clonus of the ankles, and upgoing toes. Gait was spastic, with circumduction of the right leg. Dr V concurred with the diagnosis of ALS and prescribed topiramate, 50 mg twice daily, as part of a clinical trial. In addition, Dr V prescribed tizanidine, 2 mg 3 times daily, which helped somewhat in varying dosages but tended to sedate Mrs D excessively.

There is no family history of neurological disease. Mrs D's past medical history includes smoking (30 pack-year history), 1 glass of wine daily, mild obesity, seasonal allergies, and allergy to penicillin. Other than her neurological disease, her general physical examination was unremarkable.

A physical therapist evaluated Mrs D and noted impaired balance and gait, with particular difficulty initiating movement. Mrs D began a stretching program and started leaning on her husband's arm for support while walking. She became weaker and was trained to use a cane, which initially helped to ensure that her heel strike was maintained. Three months ago she began using forearm crutches. An occupational therapist evaluated activities in the home and provided a rolling walker with a seat and basket, a shower seat, and reaching tongs for picking up items. Mrs D became depressed; a consulting psychiatrist prescribed fluoxetine hydrochloride, 20 mg daily, which Mrs D discontinued after noting increased spasticity in her legs. Her family moved to a wheelchair-accessible home, and she retired from her job.

Currently, she is considering using a wheelchair or motorized scooter.

At first, walking was difficult, just stiffness, and my neurologist put me on muscle relaxants, which helped, but it's been getting steadily worse. I have good days and bad days. I found that I was holding onto my husband when we were out, and from there, we decided that a cane would be appropriate. Then I started having more difficulty with the cane. That's when we decided to try Canadian crutches.

I thought the Canadian crutches were great because I didn't have to hold on to my husband anymore. When I left work, I started going to occupational therapy. From there, we decided, along with my physical therapist, that a walker would be appropriate. I had a problem with the insurance company, it took a little bit of work to get them to pay for a Rolator (rolling walker). I didn't want a walker that you had to lift. I wanted to be productive at home.

Visits with the occupational therapist are tremendously helpful. She has shown me many little tricks around the house, and I have neat little gadgets that are helpful. The care that I'm getting makes me less scared. The doctors and therapists that I've been seeing have made me feel more hopeful.

I just started looking into the wheelchair issue. I don't need one all the time, and I certainly want to walk on my feet for as long as I can. I want to keep the strength up in my legs, and I want to use them. I feel like my only option is to use a wheelchair, because I'm so afraid of falling. Several times a day, every day, I have an episode where I hit my toe or catch my foot on the floor or the ground, and I almost fall. So falling is a big fear that I'm concerned about.

When I first saw Mrs D, she definitely needed a cane, but didn't take it to work. Her husband worked where she did. She would have him come by to help escort her to lunch, and she would lean on him. She was trying to maintain a semblance of normalcy at work.

Unfortunately, with this disease, often just about the time that patients become comfortable with 1 adaptive aid, then their need changes. Mrs D does well with the crutches. Most likely, her gait disturbance will progress. In time, she will need a motorized means of getting around or a hand-pushed wheelchair. But I suspect that she will require a wheelchair for mobility, and it's hard to predict when that will be.

I've never had a patient with ALS who was able to get insurance coverage for a scooter or motorized wheelchair. There are several ways that patients with ALS get short shrift from their insurance. When these patients stop working, which ultimately most will, and apply for disability insurance, it takes several months to obtain it. Then it takes 2 years from the time they are awarded disability before Medicare will start to pay for anything.

What is the prevalence and burden of disabilities in the United States? What are the rates of disability caused by ambulation problems? What are the psychosocial and emotional consequences of mobility problems? What are appropriate roles for primary care physicians, physiatrists, physical therapists, and occupational therapists in evaluating patients' mobility? What different mobility aids are available, and when is their use appropriate? What are the major personal barriers to using mobility aids, and how can physicians work best with patients to address these barriers? What are the economic barriers to obtaining mobility-related clinical services (such as physical therapy) and mobility aids? What other resources are available for people with mobility problems? What do you recommend for Mrs D?

Dr Iezzoni: Mrs D is a lovely woman who understands the implications of her diagnosis. She is trying to be upbeat, to ease the fears of family and friends by a brave public face. But her ALS is progressing. She described 1 recent evening while visiting friends when she became temporarily unable to walk and needed to be carried. "When should I start using a wheelchair," she asked me, "and will I ever leave it?"

I had an opportunity to speak alone with Mrs D's husband, and I asked him what would help him most. Surprisingly, he did not inquire about cures for ALS but focused on living day-to-day. "Tell me how to make the quality of her life the best it can be every single day," he said.

Few medical interventions slow progressive ALS. Today's most promising therapy, riluzole, is controversial.^{1 - 2} As Dr V noted, Mrs D's entire care team should focus on maximizing quality of life and preventing secondary complications.³ Her most pressing current concern involves walking.

While specific interventions obviously vary by the cause of mobility problems, my comments consider issues that span many conditions that impair mobility. During the past 30 years, the definition of disability has evolved to difficulty conducting daily activities due to specific health conditions interacting with the social and physical environments.^{4 - 6} Therefore, reducing disability requires dual actions: restoring mobility or compensating for its loss and improving accessibility within the environment.

About 49 million Americans have a disabling condition, of whom about one third cannot perform usual age-appropriate activities such as working, going to school, and caring for themselves. Disabilities generate about $160 billion (1994 dollars) annually in direct medical expenditures and incur $155 billion from lost productivity and other indirect costs.⁴ Impaired mobility is the leading cause of functional limitations among adults.⁵

The disability supplement of the 1994-1995 National Health Interview Survey (NHIS-D)⁷ included questions about mobility aids and difficulties walking, climbing stairs, and standing. Among 142,572 persons aged 18 years and older, 10.1% (population estimate, 18.98 million people) reported at least some difficulty, with 3.1% (estimated, 5.82 million) indicating major mobility problems.⁸ Of those reporting major problems, 87.6% said that their difficulties would last more than 12 months.

On average, those reporting mobility problems were in their early to mid-60s; 41.5% with moderate and 28.0% with major mobility difficulties were younger than 50 years when their limitations began. In the survey, 3.6% of women vs 2.7% of men reported major mobility problems, as did 4.5% of blacks, 3.4% of Hispanics, and 3.1% of whites. Of the top 10 chronic conditions causing mobility problems, arthritis and back problems account for almost 40% of difficulties.⁸ One review suggests that multiple diagnoses cause gait disorders among as much as 75% of elderly people.⁹

The NHIS-D provides cross-sectional views of only those persons residing outside nursing homes and other residential facilities. Of approximately 2.1 million Medicare beneficiaries living in long-term care facilities, 85.2% have mobility limitations, including 50.7% of persons younger than 65 years.¹⁰

Longitudinal analyses of older persons suggest that serious functional limitations have declined substantially in recent years.^{11 - 12} Nevertheless, while today only 12.8% of US residents are older than 65 years, this fraction will rise to more than 20% by 2030. Given that chronic conditions likely will remain widespread, the absolute numbers of people with mobility problems will increase significantly during the next several decades.

Many people with mobility problems do not use mobility aids.¹³ Only 26.1% of NHIS-D respondents who reported being chronically unable to walk several blocks use wheelchairs or scooters (author's unpublished data, 2000). Mrs D said that what really scares her about ALS is being unable to swallow and breathe; limited mobility is troubling but manageable. Nevertheless, she admitted that using a wheelchair would embarrass her.

Why are feelings about mobility so complicated? As disability theorist Michael Oliver observed, walking not only gets people "from place A to place B. . . . It is also culturally symbolic."¹⁴ Bipedal locomotion, not intellect, defined the first human ancestors 3.6 million years ago. Our national ethos assumes citizens acting independently, being self-reliant, and taking control and responsibility. Upright movement permeates American aphorisms, connoting independence, autonomy, perseverance, and strength: "standing on your own 2 feet," "climbing the ladder of success," "standing up for yourself." Temporarily unable to use his injured leg, neurologist Oliver Sacks observed, "erectness is moral, existential, no less than physical."¹⁵

In Western cultures, discomfort with disability dates back centuries. Disability conflicted with citizens' obligations to work and contribute to the broader social good. In the 16th century, rumors arose of people self-mutilating and feigning illness to solicit alms and avoid work. From then onward, "the concept of disability has always been based on a perceived need to detect deception."¹⁶ Attitudes have shifted during the 20th century. President Franklin Delano Roosevelt was virtually never seen publicly in his wheelchair, but beginning in the 1970s, activists in wheelchairs helped engineer a new civil rights movement, culminating in the 1990 Americans with Disabilities Act. Nevertheless, Mrs D is not unique in feeling embarrassed about using a wheelchair.

People's reactions to mobility problems are complex. To understand this better, I interviewed 56 people with walking difficulties caused by diverse conditions. The individuals ranged in age from 32 to 93 years and all had had mobility difficulties for at least several years due to a variety of conditions, including arthritis, back problems, diabetes, multiple sclerosis, asthma, congestive heart failure, and Parkinson disease. Almost all expressed their sense of profound loss of independence and control. They were afraid of and felt guilty about burdening others. They feared being accused of not trying and were indignant at hints of malingering. They also expressed wistful emotions about hopes overturned and vanquished dreams. They never expected it to happen to them. They were stoic and uncomplaining, saying that others are worse off. They hesitated to use mobility aids, afraid of "giving in." They acknowledged vanity and embarrassment. Elderly people, especially, felt resigned and isolated, believing that walking problems were inevitable and that nothing could be done.

Roughly 30% of NHIS-D respondents with major mobility problems reported being frequently depressed or anxious, as is Mrs D, compared with 3.8% of persons without difficulties.⁸ In addition, about 30% said they are not disabled, despite major mobility problems. Clinicians must appreciate patients' complicated feelings, as well as their own attitudes about walking.

Addressing mobility impairments generally requires a team: clinicians caring for patients' underlying medical conditions; experts in functional considerations, such as physiatrists; other physicians (eg, specially trained neurologists, rheumatologists, orthopedists, and geriatricians); and physical and occupational therapists.^{17 - 18} Composition of the optimal team depends on individual patients' specific needs and local clinical expertise. Especially for persons with progressive impairments, care must be ongoing.

Primary care physicians typically receive little formal training in addressing functional concerns, and some believe such activities lie beyond their purview.¹⁹ One general internist told me, "Addressing walking is social worker-type stuff. It's useful, but it's not really internal medicine." While many articles address evaluation of elderly persons, preventing falls, and impairment ratings,^{20 - 23} relatively few studies have appeared in general medical journals on the clinical utility of functional assessments.⁹ Not surprisingly, primary care physicians often fail to recognize fully their patients' functional deficits^{24 - 25} and are uncertain about when to refer patients to rehabilitation specialists.¹⁹ About two thirds of people with disabilities have not received rehabilitation because their physicians did not recommend it.¹⁷ Some physicians' offices remain physically inaccessible and do not have adjustable examining tables.^{26 - 27}

Some persons with physical disabilities have "narrow margins of health,"^{28 - 29} requiring attention for chronic sequelae of their underlying conditions, acute problems (eg, respiratory and urinary tract infections), and mental health concerns (eg, depression). Depending on patients' individual circumstances, primary care physicians must also remember routine screening,³⁰ "wellness," and "health promotion" activities.^{31 - 33} According to the NHIS-D, people with mobility problems are only equally likely as others to receive influenza and pneumonia vaccination and much less likely to receive screening services (eg, mammograms and Papanicolaou tests).³⁴

Primary care physicians should assess mobility in routine encounters. The duration and direction of this evaluation depends on patients' underlying medical conditions and differential diagnosis. At a minimum, the review of systems should include questions about mobility-related activities within the home, pain, walking strength, endurance, balance, dizziness, and falls.¹⁷ Vision, mental status, and depression also affect ambulation and require assessment. Complete neurological assessments are essential.³⁵ Physical performance tests help assess balance (eg, asking patients to stand with eyes closed and feet together or to turn 360° or nudging standing patients lightly on the sternum) and gait (eg, timing and observing patients as they walk 10 feet).^{22 - 23 ,36 - 37} Specific instruments are available to evaluate mobility.^{9 ,22 - 23 ,36 - 39}

Primary care physicians should refer patients requiring specialized evaluations of mobility, including patients with unresolved questions about diagnosis and treatment and those needing customized or expensive assistive devices or training for mobility aids.¹⁷ More than 6100 physical medicine and rehabilitation (PMR) specialists (physiatrists) now practice throughout the United States.⁴⁰ Physiatrists evaluate functional needs and pursue nonsurgical interventions to restore or maintain function, frequently working closely with physical and occupational therapists.¹⁸ Subspecialists within physiatry have engineered sophisticated techniques for quantitative gait analysis that identify specific abnormalities.⁴¹ The PMR Web site lists physiatrists practicing in specific communities.⁴⁰

Physical and occupational therapists are trained to address functional concerns. While research about the outcomes of physical and occupational therapy has increased in the last decade, more studies are needed.^{42 - 43} For certain conditions (eg, osteoarthritis, Parkinson disease, and stroke), some studies report that physical therapy improves gait, although improvements may be modest and temporary.⁹ Physical therapy strategies for ALS are controversial.^{44 - 45} Physicians vary widely in degree of involvement of these therapists,¹⁹ but guidelines suggest indications for involving physical and occupational therapists (Table 1).¹⁷ In particular, these professionals assess and train patients in proper and safe use of mobility aids, especially within home environments.

Mobility aids can restore functional independence to people unable to walk.¹³ Aids reduce the risk of dangerous injuries^{46 - 47} and may offer economical alternatives to costly personal assistance and institutionalization.^{48 - 49} New wheelchair technologies enhance quality of life even for people with profound functional limitations.^{50 - 51} However, few studies have investigated the functional impact, choice, and timing of specific mobility aids.⁵² Most studies involve small numbers of volunteers. Research involving disabled persons is generally conducted in laboratories and not under usual living conditions.

Enlisting clinicians experienced in assessing needs and prescribing mobility aids is essential. Ensuring patients' safety while meeting their mobility goals are paramount objectives. Choices about mobility aids depend on many factors beyond lower extremity functioning, including patients' cognitive status and judgment, vision, vestibular function, upper body strength, and global physical endurance, as well as the environment where the equipment will be used.

At the "low-tech" end, canes help off-load weight (eg, from painful joints), augment muscle action, and provide stability.^{53 - 58} For balance, a single finger lightly touching fixed objects, like walls, improves stability better than canes⁵⁴ ; patients often report "furniture surfing" at home, with objects placed strategically for balance. Canes can operate similarly, enhancing balance by conveying tactile information.^{54 - 55} Canes also improve stability by increasing patients' base of support.⁵⁶ Unfortunately, most people get little instruction in the proper use of canes,⁵⁶ although techniques for off-loading weight differ from those for improving balance. As much as 70% of canes are the wrong length, faulty, or damaged.^{9 ,57 ,59} Crutches generally are prescribed when patients must transfer more weight to their arms for weight bearing and propulsion (rather than for balance).⁵³ Canadian (also known as forearm or loftstand) crutches, like Mrs D's, especially assist patients with triceps weakness.⁵³

As Mrs D found, walkers offer additional stability for patients with poor balance and lower extremity weakness. Many types of walkers are now available, from standard rigid models without wheels to collapsible wheeled walkers, with handbrakes, seats, and baskets.⁵⁷ As with canes, walkers should be the proper height, and patients need training to use them. Wheeled walkers are dangerous if they roll forward unexpectedly when patients lean on them, but they are easier to propel on smooth surfaces,⁵⁷ consume less energy,⁶⁰ and require less mental concentration to operate⁶¹ than standard walkers.

Patients' attitudes—embarrassment and shame—can impede use of canes and walkers. Dr V said that Mrs D resisted using a cane despite frequent falls, but after getting the cane, Mrs D "loved it and thought, I can live with this. This isn't so bad." Some patients find carved or painted canes available in specialty shops more acceptable; colorful rolling walkers with baskets offer practical appeal for shopping and convey a friendly aspect. Involving family members can often help convince patients to use mobility aids. Avoiding "all or nothing" edicts gives patients greater feelings of control. For example, effective "furniture surfers" may not need mobility aids continuously at home but should use them when going out, especially on uneven surfaces and in densely packed crowds, gusty winds, and low light conditions.⁵⁸ Home and lifestyle assessments by occupational therapists can clarify patients' preferences and needs. Supportive physicians can motivate patients to maximize their mobility safely.

Wheelchairs are indicated when patients with progressive conditions can no longer walk safely or when weakness and low endurance prevent them from conducting their daily activities using ambulation aids. Transitioning to a wheelchair symbolizes finality, loss, and defeat to some patients, who may resist wheelchairs, afraid that muscle function, however tenuous, will be lost. Physicians sometimes reinforce this reluctance, quipping "use it or lose it!" This dictum certainly carries mechanistic truth. Even elite athletes lose peak conditioning after several days without exercise. For many people with progressive chronic conditions, however, this belief isolates the legs from the whole person. It assumes that the primary objective is maximizing failing muscle function rather than living full lives free from exhaustion and struggle. Wheelchairs can provide tremendous relief, permitting patients to turn their energies to other pursuits.

Many wheelchair options are available to suit specific needs and goals and include lightweight manual wheelchairs, streamlined powered versions, and customized alternatives (eg, for use on beaches or rough terrain).^{50 - 51} Working with professionals (eg, physical or occupational therapists) knowledgeable about wheelchair technology is critical. Deciding between fixed-frame and collapsible manual chairs or between scooters and 4-wheeled, powered wheelchairs requires understanding their pros and cons.^{50 - 51} Wheelchairs have significant biomechanical ramifications; selection must carefully take into consideration patients' physical needs. Wheelchair occupants are erroneously assumed to be comfortable and safe, but without adequate seat cushions and back supports, wheelchairs are uncomfortable and can cause pressure ulcers and other injuries.⁶² Finding the right wheelchair maximizes quality of life.

Moving to a powered wheelchair escalates concerns about losing conditioning but can also bring independence and empowerment.^{63 - 64} With powered devices, persons with limited endurance or arm function can move themselves without being pushed. For ALS patients, powered wheelchairs prolong independent mobility and enhance quality of life.⁶⁵ Many people still walk short distances whenever possible, as Mrs D plans to do.

Despite their benefits, wheelchairs can cause injuries, especially from tipping and musculoskeletal problems from pushing.⁶⁶ Given persistent architectural and environmental barriers, frustrations arise. Wheelchair users must adapt their homes and cars to be completely mobile. Patients occasionally abandon technologies when needs are not met.⁶⁷ These concerns underscore the imperative for experienced professionals to work with patients and offer realistic, goal-directed advice.

Costs and payment policies present enormous barriers to obtaining mobility-related services. Despite its older and disabled population, Medicare pays for rehabilitation only when patients make continual functional improvements.⁶⁸ For Mrs D, that goal is unrealistic. Private managed care health insurers restrict the numbers of physical and occupational therapy sessions, typically paying only to restore patients to baseline function. Several insurance representatives have told me that funding therapy to maintain function or prevent its decline would generate insatiable demand. Nevertheless, as our population ages, services to slow and prevent functional losses will become essential. Many such services have not yet garnered the "evidence base" that now seems required to justify reimbursement. Assembling this evidence will be challenging because of difficulties in measuring functional changes over time and standardizing the intervention under study.

Mrs D's insurer initially refused to cover her walker. A 1990 national survey found that about 2.5 million Americans reported needing assistive technologies, including mobility aids, but 61.1% could not afford them.⁶⁹ Almost half of persons using assistive devices paid for them entirely out-of-pocket. Improving home accessibility (eg, grab bars, ramps, and widened doorways) is also expensive; 78% of these improvements were paid for out-of-pocket.⁶⁹ The D's sold their house and bought an accessible condominium.

Insurers routinely require physicians to certify "medical necessity" of equipment. Medical necessity letters should include diagnoses, documentation of physical limitations and their impact on daily functioning, specific descriptions of equipment and how it will be used, and a clear rationale justifying its benefits.¹⁷ Initial requests are often denied, despite little evidence that such equipment is overprescribed,⁷⁰ and physicians and patients must submit appeals. The time appeals take is especially problematic for patients with rapidly progressive disease.

Even if coverage is approved, insurance payments may be incomplete. With Medicare's Supplemental Medical Insurance (Part B), beneficiaries must pay 20% coinsurance. Good-quality manual wheelchairs typically cost from $1000 to $2000; scooters are roughly $2000 to $4500; and technologically sophisticated powered chairs can exceed $30,000. Insurers sometimes deny payment for preferred lower-tech equipment, arguing that the patient's rate of functional decline means more sophisticated, costly equipment will soon be needed.⁶³ Coverage for repairs is often erratic. Based on her experience with other ALS patients, Dr V anticipates that Mrs D's insurance provider will not pay for a powered wheelchair, despite her generalized weakness, falls, and progressive debility.

The federal Technology-Related Assistance for Individuals with Disabilities Act of 1988 (PL 100-407, the "Tech Act"), reauthorized in 1998, aims to increase access to products for improving function and independence. Through the National Institute on Disability and Rehabilitation Research (NIDRR) in the Department of Education, the Tech Act allocates more than $39 million annually to state programs to help people with disabilities identify and understand assistive technologies.⁴ Although Tech Act projects generally do not provide assistive devices directly, some do give practical guidance and legal advice on navigating insurance hurdles. Some disease advocacy organizations either offer equipment or organize trade-ins and redistribution of used devices.

Various services are available to assist people with impaired mobility,¹⁷ although rural areas generally offer fewer resources than urban centers. Local governmental disability agencies provide information about accessible transportation and training programs. Magazines targeting persons with mobility impairments describe not only technological options but also family and lifestyle considerations, wellness activities, and recreational opportunities. Stores and shopping plazas sometimes loan electric scooters to patrons, and wheelchair rentals frequently are available at vacation destinations.

The most expansive information source is now the Internet. Hundreds of sites cater to persons with disabilities, raising the usual cautions about quality of information. The NIDRR and commercial sites offer information about mobility aids, and countless chat rooms address wide-ranging disability concerns. Discussion groups help some people with disabilities learn from each other, but participants' mobility limitations make meetings logistically difficult. Chat rooms remove these physical barriers for interested persons with Internet access.

The week after her interview, Mrs and Mr D were going on vacation. Mrs D wondered whether she should use a wheelchair in the airport. Absolutely, I responded. Wheelchairs are particularly helpful in airports, with their lengthy corridors and slow-moving lines. Mrs D should then investigate powered wheelchairs, such as scooters, which would allow her to leave home independently and safely without fear of falling. She should walk when she feels comfortable but also have the option to ride. Given her progressive disability, Mrs D should continue working with her physical and occupational therapists, including 1 skilled in wheelchair evaluation and training. Despite these recommendations, I am concerned about her insurance provider denying coverage, lengthy appeals, and dashed hopes if she does not get the equipment she needs. Appropriate technology exists to restore Mrs D's mobility. Paying for it remains a question.

A PHYSICIAN: How much do family attitudes affect the motivation and kind of assistance that patients are willing to choose for their own mobility?

DR IEZZONI: Doctors tell me that when patients leave the room, husbands or wives often say, "Can't you get my spouse to use a cane?" Family members are concerned that the patient is going to fall and injure himself or herself. Devising creative ways, along with families, to get patients to begin using assistive devices is important. Sometimes, however, family members oppose the patient using mobility aids and are unrealistic about the patient's abilities and safety. Working with family members so they understand the situation becomes critical. In any case, once patients start using appropriate devices, they generally see their value and are happy to use them, as was Mrs D.

A PHYSICIAN: Can you tell us anything about current education and training about mobility problems in medical schools?

DR IEZZONI: I called the American Association of Medical Colleges to see if they had surveyed medical schools on their curricula around this, but they had not yet done this survey. I do not have any formal information. Some medical schools have students do home health rotations where they might see patients with mobility problems. Some medical schools have students briefly rotate on rehabilitation services. But physicians I interviewed said they didn't remember much about those short rotations. The whole notion of daily functioning as part of patients' health should be built into primary care curricula.

A PHYSICIAN: Some data imply a systematic attempt by insurance companies to deny first appeals for mobility aids. Can physicians do anything to improve the likelihood that patients are granted the aids that they need on first referral? Or is there clearly a policy to deny first appeals to maintain some financial gain?

DR IEZZONI: There seems to be an unspoken policy of first denials. Often patients will not appeal, accepting their insurers' decision without arguing. What usually happens, I've learned from resource specialists at our hospital, is that patients who appeal denials generally eventually obtain coverage. The American Medical Association Guidelines detail what physicians should put in medical necessity letters.¹⁷ When insurers deny the request, however, you must start the appeals process.