Physical inactivity increases cardiovascular risk. The possible adverse effects of regular motorized scooter use, recently popularized for patients with physical limitations, has not been previously examined. We performed a single-center, retrospective cohort study of 102 consecutive patients who had obtained medical approval for, and subsequently received, a motorized scooter during a 6-year period. The clinical data were collected for the 12 months before and after the intervention. Surveys assessing 11 different facets of health-related quality of life were returned by 28% of patients. The patients receiving a scooter were 68 ± 19 years old, and 55% were women. The medical indications for scooter use, by decreasing frequency, were disabling arthritis, chronic lung disease, neurologic disorders, and heart failure. Patients returning the surveys estimated scooter use at a median of 4 hours/day, with walking confined to 30 min/day. Despite significant physical and psychological improvements in all quality-of-life categories (p <0.001), the fasting blood glucose increased from 119 ± 39 to 133 ± 49 mg/dl (p = 0.009), hemoglobin A1c increased from 6.3 ± 0.8 to 6.8 ± 1.2 (p = 0.019), and 18.7% of patients developed diabetes during the follow-up period. No significant changes in blood pressure were noted, although 20% of patients required additional antihypertensive medication. Despite improvements in total and low-density lipoprotein cholesterol over time, 50% of dyslipidemic patients required either an increase medication dose or additional medications during follow-up. In conclusion, interventions, such as scooters, that improve self-perceived quality of life, can have detrimental long-term effects by increasing cardiovascular risk, particularly insulin resistance. Physicians should carefully weigh such risks before approving their use, as well as ensure healthy levels of activity afterward.
In recent years, motorized scooters or platform-motorized wheelchairs have been popularized as a method of improving the quality of life of patients through improved mobility. Physicians regularly prescribe these devices, despite little evidence supporting a benefit and with great expense to patients and the healthcare system in general. A review of MEDLINE from 1969 to the present with the search criteria “motorized wheelchair OR scooter OR platform motorized wheelchair” failed to reveal any studies documenting that these devices were effective in improving the quality of life of the patients who received them. In addition, it is unclear whether by providing platform motorized wheelchairs, physicians are further promoting inactivity and inadvertently increasing patients’ cardiovascular risk. A single-center, retrospective, cohort study was therefore designed to assess the effect of motorized scooter use on patient-perceived quality of life. The study was also designed to examine how these devices, which have the potential to reduce the level of physical activity, affected the well-established cardiovascular risk factors.
Methods
All patients who receive motorized scooters at Wilford Hall Medical Center and Brooke Army Medical Center in San Antonio, Texas require previous approval from the physical medicine and rehabilitation department. All consultations placed to that department for platform motorized wheelchair devices during a 6-year period (June 1998 to June 2004) were reviewed. From this group, a final cohort of 102 patients was identified who had been medically approved and had received a scooter during this period. Our institutional review board fully reviewed and accepted the protocol under exemption status.
An 11-item survey ( Figure 1 ) was mailed to each patient, and they were given the option to withdraw their participation from the study at that time. Because no recognized survey tested for reliability and validity had been previously developed to examine patients receiving platform motorized wheelchairs or other mobility-assist devices, a quality-of-life survey ( Figure 1 ) was created under the guidance of our institutional review board. The survey was intended to evaluate the patients’ self-perceived changes in physical and psychological well-being before and after receiving the motorized scooter. In addition to collecting baseline demographics, the patients were asked why they had required a scooter and how many hours per day they used the device. They were also asked to quantify how many minutes they walked per day and how often they exercised in the year after receiving their scooter.
An intensive electronic and paper medical record review was then conducted of each patient, and data were collected from the 12-month period before and the 12-month period after the date the patient had received a motorized scooter. Relevant cardiovascular data were collected, including body weight and body mass index, cholesterol profile, office blood pressure measurement, and fasting glucose level. Hypertension was defined as actively taking antihypertensive medication and/or a systolic blood pressure of ≥140 mm Hg on ≥2 occasions. Dyslipidemia was defined as a total cholesterol level of 240 mg/dl or the need for lipid-lowering therapy. Renal insufficiency was defined as a creatinine clearance of <60 ml/min.
Because medications can have a major effect on these risk factors, we examined the absolute number of medicines and the dosages of all hypertensive, diabetic, and lipid-modifying drugs during these periods. By collecting data for the 12 months proceeding scooter implementation, we were able to establish a baseline of cardiovascular risk factors and assumed that any changes in the subsequent year would most likely reflect lifestyle changes resulting from use of the device. If more than one measurement was available during the examined periods, the levels were averaged, and the average value was used for the purposes of the analysis.
Electronic and chart data were collected into 2 separate spreadsheets by different reviewers, and any differences were resolved by a re-examination of the raw data. In the rare event of missing data, the analyses were performed only for those patients with paired data (data from blood tests performed both before and after scooter use). The data were compiled and analyzed using a statistical software package (Statistical Analysis Systems, version 8.2, SAS Institute, Cary, North Carolina). A comparison of the continuous variables was performed using paired and 2-sample t testing and a comparison of dichotomous variables using the chi-square test or Fisher’s exact test, as appropriate. A comparison of noncontinuous variables was performed using the Wilcoxon signed rank test. Data are presented as the mean ± SD for continuous variables, as the number (percentage) for dichotomous variables, and as the median and range for noncontinuous variables. p Values <0.05 were considered statistically significant. For multiple comparisons of laboratory values, a Bonferroni adjustment was used.
Results
From June 1998 to June 2004, 102 patients were identified who had received medical approval for, and subsequently received, a motorized wheelchair. The medical indications for scooter use by decreasing frequency were disabling arthritis (39%), chronic lung disease (25%), neurologic disorders (18%), and heart failure (14%). Of the 102 patients in this cohort, 29 returned completed surveys and estimated their scooter use at a median of 4 hours daily (range 1 to 10), with walking confined to 30 min/day (range 0 to 300) and formal exercise to a median of 6 min/day (range 0 to 60). All but 1 patient were still regularly using the scooter at follow-up completion. The baseline clinical characteristics of the population are listed in Table 1 .
| Variable (n = 103) | Value |
|---|---|
| Age (years) | 68 ± 18 |
| Weight (lb) | 184 ± 36 |
| Men | 45% |
| Hypertension | 58% |
| Hyperlipidemia | 30% |
| Diabetes | 38% |
| Active smoker | 14% |
| Previous smoker | 35% |
| Known coronary artery disease | 40% |
| Renal insufficiency | 23% |
Of the 102 patients, 29 (28%) returned the quality-of-life survey sent to their mailing address. On a scale from 1 (“very poor”) to 10 (“excellent”), a statistically significant, self-perceived improvement was noted in all quality-of-life facets tested, with the exception of improvement in the ability to perform their job (all patients surveyed reported they were no longer employed). The results of the survey are summarized in Figure 2 . The patients generally reported a near doubling in their quality-of-life scores, with the most notable improvements seen in overall physical health (improving from a median of 3 to a median of 6, p <0.001), the ability to go shopping (improving from 2 to 7, p <0.001), and overall self-perceived quality of life (improving from 3 to 8, p <0.001). Every patient returning a survey reported that the scooter had improved at least one facet of their quality of life, and no patient reported worsening in any single component of their physical or mental well-being.
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