The impact of walker height positions and their influence on triceps activity and energy conservation: a pilot study

Background/Aims

Millions of adults use walkers for functional mobility. Inappropriate walker use is associated with incorrect height, forward-leaning posture, and increased energy expenditure. Few studies have investigated the impact of walker positions and their influence on triceps activity. The present study assessed walker height and baseline positioning for individuals with a 50% weight bearing restriction of the lower extremity, and implications for energy conservation.

Methods

A total of 38 young adults (mean age = 24.95 years; 84.2% female; 15.8% male) participated in this study with a two-wheeled walker. Participants executed five walker positions while maintaining 50% weight bearing of the lower extremity to determine the effect on triceps electromyography activity.

Results

Triceps electromyography activity did significantly change across the five walker positions assessed (X2 [df=37, P<0.001]). This study showed that the median electromyography activity for positions B (median=0.268) and A (median=0.280) was significantly less than the median electromyography activity for position E (median=0.452; P<0.001). The effect sizes for comparisons of positions B and E (r=0.49) as well as A and E were the largest (r=0.53).

Conclusions

These findings suggest an elbow angle of 26–35° (position B), followed by an elbow angle of 15–25° (position A), with the walker in line with the heels of the participant, to be superior in minimising exertion of the triceps.

Postural effect on gait characteristics by using rolling walkers

This study was to examine the effect of leaning-forward posture (LFP) on gait parameters while using a rolling walker (RW). A cross-sectional study was conducted in which 23 older female adults were asked to walk with a RW on the GaitRite walkway in two posture situations: upright posture, and LFP caused by pushing the RW forward and then following the RW. The temporal and spatial gait parameters were obtained for data analysis. Results showed that compared with the upright posture, participants with LFP demonstrated significantly increased cadence, decreased velocity and gait cycle time (both swing and stance time decreased). Of spatial parameters, both step and stride length significantly decreased, but the base of support increased significantly. These indicate that LFP during ambulation with a RW could lead participants to a shuffling-like (many steps on short distance) gait pattern. They may help clinicians find proper rehabilitation interventions and appropriate patient education for this specific postural presentation.

Clinical and Physiological Effects of Rollators in Individuals With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW

PURPOSE

To determine the effects of using a rollator in people with chronic obstructive pulmonary disease (COPD).

METHODS

Studies were systematically identified from literature searches of MEDLINE, CINAHL, PEDro, PubMed, EMBASE, and the Cochrane Library databases and the reference lists of included studies. Two reviewers independently selected randomized controlled or crossover studies examining the effects of rollator usage compared with no aid in individuals with COPD. Methodologic quality was assessed by 2 reviewers independently using the Cochrane Risk of Bias tool. Two reviewers also used a customized form to extract characteristics of and outcomes for subjects related to exercise capacity, symptoms, health-related quality of life (HRQOL), physiological, and gait parameters. Weighted mean differences (WMD) with 95% CI were calculated using a fixed-effects model.

RESULTS

A total of 7 studies (126 participants) were included. Use of a rollator during a 6-Minute Walk Test (6MWT) improved distance walked (WMD = 13 m; 95% CI, 5-22) and lowered end-6MWT dyspnea rating (WMD = 0.97; 95% CI, 0.63-1.32). Longer-term use did not appear to impact exercise capacity or HRQOL, although this may be related to the frequency of use.

CONCLUSIONS

When used in the short-term, rollators resulted in a small increase in 6MWT and a reduction in dyspnea. Details on patient adherence are required to accurately evaluate the longer-term effects of rollator usage.

Exercise for reducing fear of falling in older people living in the community

BACKGROUND

Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls.

OBJECTIVES

To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses.

MAIN RESULTS

We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling.Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes.Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an extreme outlier study with 73 participants (SMD 0.24 favouring exercise, 95% CI 0.12 to 0.36). None of our subgroup analyses provided robust evidence of differences in effect in terms of either the study primary aim (reduction of fear of falling or other aim), the study population (recruitment on the basis of increased falls risk or not), the characteristics of the study exercise intervention or the study control intervention (no treatment or alternative intervention). However, there was some weak evidence of a smaller effect, which included no reduction, of exercise when compared with an alternative control.There was very low quality evidence that exercise interventions may be associated with a small reduction in fear of falling up to six months post intervention (SMD 0.17, 95% CI -0.05 to 0.38; four studies, 356 participants) and more than six months post intervention (SMD 0.20, 95% CI -0.01 to 0.41; three studies, 386 participants).Very low quality evidence suggests exercise interventions in these studies that also reported on fear of falling reduced the risk of falling measured either as participants incurring at least one fall during follow-up or the number of falls during follow-up. Very low quality evidence from four studies indicated that exercise interventions did not appear to reduce symptoms of depression or increase physical activity. The only study reporting the effects of exercise interventions on anxiety found no difference between groups. No studies reported the effects of exercise interventions on activity avoidance or costs. It is important to remember that our included studies do not represent the totality of the evidence of the effect of exercise interventions on falls, depression, anxiety or physical activity as our review only includes studies that reported fear of falling.

AUTHORS' CONCLUSIONS

Exercise interventions in community-dwelling older people probably reduce fear of falling to a limited extent immediately after the intervention, without increasing the risk or frequency of falls. There is insufficient evidence to determine whether exercise interventions reduce fear of falling beyond the end of the intervention or their effect on other outcomes. Although further evidence from well-designed randomised trials is required, priority should be given to establishing a core set of outcomes that includes fear of falling for all trials examining the effects of exercise interventions in older people living in the community.