Q&A: Choice Paralysis—The Hidden Dangers of Improperly Prescribed Mobility Assistance Devices
For thousands of older Americans, the use of a cane or a walker should offer a better sense of safety and mobility. However, according to research from Brown University, the commoditization of such mobility assistance devices (MADs) does a disservice not only to users’ well-being, but for health outcomes in general.
In an editorial published in May, Ryan Lim ’25, Jonathan Ge '22 MD'26, and Edward Feller, MD, PMD’03, clinical professor of medical science, spoke about their research into the prevalence of “unvetted, undifferentiated, and under-studied MADs” and how minimal guidelines have contributed to injuries among the elderly.
Lim, who served as first author on the article and will attend the Renaissance School of Medicine this August, and Feller discuss their research, the realities of MADs, and what patients and providers need to know.
This interview has been edited for length and clarity.
What qualifies as a mobility assistance device?
Lim: Typically, what we’re referring to with MADs are canes and walkers, but they can encompass a broad category. In this instance, we’re focusing on canes, walkers, and crutches, as those are the most commonly used devices.
Feller: It can be canes and walkers, which are Class I devices as set by the Food and Drug Administration, but these have few avenues for proper vetting. It can also be things like electric wheelchairs, which are Class II, and are much more complicated and require greater scrutiny from the FDA.
How did you first start examining issues surrounding MADs and their commercialization?
Lim: [Feller] took the lead on it initially, but the more we looked into this, the more we saw that the aging population—which is a significant portion of the American population—were using these devices incorrectly. We found that falls in 2023 were the most common accident for individuals over 65 in the US, so that got us thinking about what MADs really do and why falls are still such a big issue. We also started looking up listings at online retailers like Amazon, and we found hundreds of canes and walkers available, but with little oversight or guidance for consumers.
Feller: My wife was actually in need of mobility assistance, and it became apparent that in my basement I have all of these different MADs. It hit me then that these pile up in a way that’s similar to people buying commodities. One of the issues is that canes and walkers are used very sporadically and it’s apparent that there are hundreds of undifferentiated and unresearched devices to choose from on online stores like Amazon and Walmart.
When it comes to the elderly, they research doctors, hospitals, and devices, but when they buy something without competent advice or expertise, it can lead to serious issues.
What can make the use of these devices problematic, or even dangerous, for older patients?
Feller: When you’re online looking for these devices, you’ll see hundreds of listings without any way to determine if you actually need it. As people age or their conditions change, their needs with a device change, so devices that are actually inappropriate are all over these websites. We mention in our paper the concept of “choice overload,” which can complicate the decision-making process as there are too many to choose from.
The difficulty also comes from patients deciding they need a cane or walker, which they may conclude without any expert consultation from an experienced physician. However, because most physicians aren’t experts with MADs, the canes and walkers get bought as a simple commodity and the wrong choices are made. If someone is getting a MAD and they’re not using it for the right purpose, they could slip and fall. It comes down to the size of the device, how it’s held, where it’s used, and so many other aspects that aren’t considered. The FDA doesn’t require these MADs to satisfy anything other than minimal baseline requirements of an acceptable assurance of safety and effectiveness.
It’s important to understand that, rather than being a protective factor, a walker or cane could actually be the cause of the fall if it’s used inappropriately or if it’s not appropriate for the medical indication it’s intended for. I think the simplicity of these devices leads to older patients feeling like anything will work, which is not true. There are costs and health literacy barriers for certain people, so people will also go for what is affordable instead of what is appropriate.
Without proper guidance, they also might not use it for as long as they need to, similar to how medicines don’t work if they’re not prescribed and taken properly. A patient standing up who no longer feels they need to use a cane or walker and begins to walk could still fall and injure themselves.
Lim: One of the biggest issues is that there’s no unified education behind these devices and their use, so many people are using them without being prescribed for their specific situation. A patient might use a cane—and the cane itself may be a good one—but it may be improperly used or sized incorrectly. We found studies that showed people who use canes at improper heights can suffer peripheral nerve damage, and they can have changes in their gaits. The correct MAD depends on the patients’ specific situations, which means the provider has to examine if they’re living in a cluttered house, if they typically navigate confined spaces or stairs, or other aspects of their daily lives.
The other issue that some don’t think about is the stigma surrounding MADs and their use. We have found studies that share anecdotes from patients saying they don’t want to walk with a walker because it makes them feel vulnerable or even weak, resulting in patients not seeking guidance on where and when to properly use it. Sometimes, this mindset can end up taking over how they walk, so rather than using a MAD to help them move, they end up completely relying on it because they believe they are vulnerable. It can lead to them perhaps not focusing on balancing and moving properly, or, if they have cognitive deficits like dementia, they can forget how to use it properly. And all it takes is one moment that can lead to a fall.
What has contributed to the proliferation of these devices?
Lim: With the technological boom of the last 20 years there are no real restrictions, and many of these devices can enter the marketplace without any checks and balances and spread by word of mouth. A patient who has difficulty walking may use a cane and share with others how it worked for them, which leads others to purchase the same or similar device without proper vetting. The internet has created this blind spot and leads to more harm than good in some circumstances.
What can patients and providers do?
Lim: For providers, they have to make sure patients know how to use things like canes and walkers properly while they’re still in a clinic. Even something like crutches can lead to peripheral nerve damage in your shoulder if used improperly. There also needs to be an open dialogue with patients to grasp their needs and their living situation. [Providers] need to understand if [patients] will be using stairs, if there are railings properly installed, how active they are, and other information.
From a patient standpoint, many don't know that when you get a device and it works in the beginning, it can eventually stop being effective in a year or two. For example, if you’re discharged from a hospital and you’re using a cane, your condition may eventually improve. However, the cane won’t be able to support you like it was in the beginning, as your physical needs have shifted, your balance might be different, your living conditions could change, and so on. Patients need to actively understand that because your needs are constantly changing, you need to consult with your doctors and ensure the device still works properly. There is also the commercialization aspect. Patients should understand that the devices you buy online aren’t made specifically for you. You unfortunately can’t buy something like a cane or a walker, set it to a height, and use it with no problems. You still need to get it checked out.
Feller: Patients should absolutely focus on getting sound advice, while asking themselves what some of the features of their illness or condition are. We should be clear that the large majority of physicians or ancillary health professionals do not have training or expertise in the use of MADs. However, they can help patients understand the potential dangers of using these devices without consulting those that do.
Where might the research go from here?
Lim: It would be great to carry out a study within clinics to observe whether or not implementing an educational strategy with specific doctors and patients decrease the amount of fall injuries in elderly people or those using MADs. Results from a study like this can really prove if our hypothesis is correct. With that being said, I think just monitoring the market, seeing how people use these devices, and getting them educated on this topic through simple conversations is a good next step.