Multiple sclerosis (MS), a neurodegenerative disorder of the central nervous system, currently affects approximately 400,000 U.S. residents, with 200 newly diagnosed individuals each week [1-2]. MS causes a wide variety of neurological deficits, with ambulatory impairment as the most obvious cause of disability [3-4]. Within 10 to 15 years of disease onset, 80 percent of persons with MS experience gait problems due to muscle weakness or spasticity, fatigue, and balance impairments [5-7]. To facilitate mobility, persons with MS frequently employ mobility assistive technology (MAT), such as canes, crutches, walkers, wheelchairs, and scooters.
Matching the most appropriate MAT to the needs of a person with MS is vital to his or her daily mobility. Mobility impairments frequently restrict participation in work, family, social, vocational, and leisure activities . Furthermore, persons with MS often experience difficulties adapting to the changing and progressive nature of mobility loss, frequently marked by exacerbations and remissions . These difficulties can compound relatively high levels of emotional distress, which can exacerbate efforts to accommodate mobility with MAT . A 2008 survey of persons with MS found that 37 percent were too embarrassed to use MAT, while 36 percent reported that they do not use their MAT as much as they should .
In addition to standard MAT, new and emerging technologies are undergoing development that could accommodate mobility needs for persons with MS. More studies are exploring the consequences and patterns of MAT use among persons with MS. However, no recent review has examined the growing scientific evidence-based literature about MAT use in MS. We aimed to systematically review the published literature concerning MAT use among persons with MS.
We searched the literature using the electronic reference lists Ovid MEDLINE[R] (1950-2008), CINAHL[R] (Cumulative Index to Nursing and Allied Health Literature) (1982-2008), PubMed (1966-2006), and Scopus (1985-2008). The searches used the following keywords: falls, mobility, multiple sclerosis, cane, walker, wheelchair, assistive technology, and psychological problems. We considered only publications concerning persons with MS with impaired mobility and published in a peer-reviewed journal. After reviewing potential articles, we located 50 that met the initial criteria of providing good evidence of the types of MAT devices and their benefits for persons with MS (details of these studies are presented in the Appendix, available online only).
The articles reviewed in our literature review were evaluated and included according to their levels of evidence (LOEs) and significance, as proposed by Sackett et al. . Their approach is based on evidence-based medicine, which they defined as "a practice of integrating individual clinical expertise with the best available external clinical evidence from systematic research" . To make the process of evaluating published research more efficient, Sackett et al. outlined LOEs and stratified them in order from strongest to weakest:
* I: Evidence is obtained from meta-analysis of multiple, well-designed, controlled studies.
* II: Evidence is obtained from at least one well-designed experimental study.
* III: Evidence is obtained from well-designed, quasi-experimental studies such as nonrandomized, controlled single-group, pre-post, cohort, time, or matched-case control series.
* IV: Evidence is obtained from well-designed, nonexperimental studies such as comparative and correlational descriptive and case studies.
* V: Evidence is obtained from case reports and clinical examples.
PATTERNS OF MOBILITY IMPAIRMENTS
Multiple Sclerosis and Risk of Falling
Persons with MS are particularly predisposed to various impairments, including fatigue and falls due to brain and spinal cord involvement [13-14]. …