Abstract
In elderly individuals balance disorders and muscle weakness can lead to prescribing a walker. There are several different models. According to the very poor effort tolerance in this population, the energy cost necessary to operate walking technical aids should be taken into account when making a choice.
Objective
Compare two types of walker in regards to energy cost produced during gait in weakened elderly individuals.
Method
Thirty subjects over the age of 65 (six men and 24 women, mean age 81.9 years) were admitted in geriatrics care. They all required a walker and performed the same 10-m course with a fixed walker, then with a model bearing front wheels. The walking speed (S) was computed, heart rate at rest (HRrest) and maximum heart rate (HRmax) were recorded during the test. The physiological cost index (PCI = HRmax − HRrest/S) was calculated. Finally a timed get-up-and-go (TGUG) test was performed with each of these technical aids.
Results
With a rollator walker, HRmax was lower ( P < 0.05) and S higher ( P < 0.001). It was 2.01 with a fixed walker versus 1.23 with a rollator walker ( P < 0.01). We found this speed difference during the TGUG test (72.26 sec vs. 82.93 sec, P = 0.001).
Discussion and conclusion
There are very little studies on the evaluation of physiological energy cost produced during gait with a walker. The characteristics of our population did not allow us to conduct our test without a technical aid. The use of a fixed walker leads to a major increase in gait PCI, probably due to the required repeated efforts for lifting the walker. This model must be avoided in case of cardiac or respiratory disorders.
Résumé
Les troubles de l’équilibre et la faiblesse musculaire de la personne âgée peuvent conduire à la prescription d’un déambulateur. Il en existe plusieurs modèles. Compte tenu de la mauvaise tolérance à l’effort de cette population, le coût énergétique lié à l’utilisation de l’aide technique de marche devrait entrer en compte dans son choix.
Objectif
Comparer le coût énergétique de la marche de personnes âgées fragiles avec deux modèles de déambulateur.
Méthode
Trente sujets de plus de 65 ans (six hommes et 24 femmes, 81,9 âge moyen) admis en soins de suite gériatriques et nécessitant l’utilisation du déambulateur ont réalisé le même parcours de 10 m avec un cadre de marche fixe, puis un modèle avec roulettes antérieures. La vitesse de marche (V) était calculée, les fréquences cardiaques de repos (FCR) et maximales (FCM) étaient enregistrées pendant l’épreuve. L’indice de coût physiologique (ICP = FCM − FCR/V) était calculé. Enfin un timed get up and go test était réalisé avec chacune des aides techniques.
Résultats
Avec un rollator , la fréquence cardiaque maximale est inférieure ( p < 0,05) et la vitesse supérieure ( p < 0,001). L’ICP est de 2,01 avec un cadre fixe contre 1,23 avec un cadre à roulette ( p < 0,01). On retrouve cette différence de vitesse au get up and go (72,26 seondes contre 82,93 secondes, p = 0,001).
Discussion et conclusion
On compte peu de travaux portant sur l’évaluation du coût énergétique de la marche avec déambulateur. Les caractéristiques de notre population ne nous ont pas permis de réaliser une épreuve sans aide technique. L’utilisation du cadre fixe entraîne une élévation importante du coût physiologique du déplacement, sans doute du fait des efforts répétés de soulèvements qu’il nécessite. Ce modèle doit être évité en cas de problèmes cardiaques ou respiratoires.
1
English version
The best physiological cost index (PCI) is obtained when the subject walks at a spontaneous comfortable speed. Speed is a determining element and there is a linear correlation between speed and energy cost. In healthy adults, there is a hyperbolic relationship between oxygen uptake (VO2) and walking speed with a level of maximum efficiency at around 80m/min and the energy production decreases with age .
Mac Gregor based on the parallel evolution between VO2 and heart rate (HR), defined during a walking test a PCI reflecting the heart function and thus indirectly the O 2 consumption . The PCI presents several advantages: simplicity in performing the test and analyzing the results, very limited needs for material thus cost-efficient, as well as good functional aspect .
The PCI notion yields a discussion around the prescription of a walking technical aid in elderly individuals. There are several indications for prescribing a walking technical aid, related to the aging process on one hand, and neurological or osteoarticular pathology on the other hand. The arthritis-induced joint limitations, static spine disorders, motor command deficits from the central or peripheral nervous system, balance disorders caused by vestibular, proprioceptive or central affections, just like fatigability can generate walking disorders. The proposed walking technical aid must be based on the patient’s residual capacities. When a unilateral aid such as simple cane or English cane is not enough to limit the risk of falls and facilitate the patient’s gait, it is quite common to prescribe a walker.
There are several types of walkers. In this study we evaluated the walking energy cost in weakened elderly individuals with two types of walker: fixed walker and rollator walker. The main advantage of the fixed walker is its great stability but it requires adequate muscle and joint functions in the upper limbs and a good motor coordination in order to lift the walker and walk. The rollator walker, on the other hand, can be used for patients with postural disorders, painful syndromes of the belt muscles or spinal cord, but has the inconvenient of being heavier and less easy to handle during maneuvers, especially for half-turns.
The study aims at comparing the walking energy cost with these two technical aids in elderly individuals with several pathologies that depend on a technical aid for walking. There are very few studies reporting the indications of technical walking aids in elderly people. Our results will allow for validating the indications guiding the choice of a walking technical aid in our population.
1.1
Material and method
The same examiner evaluated 30 patients admitted in geriatrics care. The inclusion criteria were: age above 65, dependent on a technical aid for walking, mini mental state (MMS) over or equal to 24/30.
Exclusion criteria were: ischemic stroke in the past 6 months, orthopedics surgery of the upper or lower limbs in the past 3 months, impaired cognitive functions (MMS < 24).
Materials used were a walker with a fixed frame (FW) ( Fig. 1 ), a walker with anterior (front) wheels rollator walker (RW) ( Fig. 2 ), a HR monitor, an armless chair.
We conducted the measures in the following manner:
- •
evaluation of the heart rate at rest (HRrest), subject sitting down in a chair with a HR monitor;
- •
measure of the timed get – up-and-go (TGUG) test with FW;
- •
recovering until the subject gets back to HRrest;
- •
measure of the TGUG test with RW after a resting period specific to each subject;
- •
HR recovery measurements until HRrest is reached;
- •
set 10-m course (inside) with FW, at comfort speed, measures were recorded once the comfort speed was reached: walking time measurement (in seconds) and simultaneous measures of the HRmax during effort and 30 sec after (HR30);
- •
HR recovery up to HRrest;
- •
set 10-m course (inside) with RW at comfort speed, measures were recorded once the comfort speed was reached: walking time measurement (in seconds) and simultaneous measures of the HRmax during effort and 30 sec after (HR30).
Before the beginning of the study, patients had the opportunity to try the two different types of walkers, for a few steps, in front of the physiotherapist in order to validate their proper use and adjust the height according to each patient.
PCI was our main evaluation criteria. It was calculated for each course with each walker.
PCI = HRmax in heartbeat per minute during the walking test–HRrest in heartbeat per minute/S in meter per minute R.
Speed (S) = walking distance (in meters) × 60/time in seconds.
The other evaluation criteria were HRmax, speed during the 10-m course and the TGUG test.
1.2
Statistics
The computing was done using the paired t -test for comparison of means. The significant threshold was set at P < 0.05.
According to the great variety of HRrest measures and the lack of norms for PCI in this population, we were not able to determine “a priori” the number of subjects necessary for the study.
1.3
Results
1.3.1
Population
Thirty patients hospitalized in a rehabilitation center including six men, aged 69 to 93 were evaluated. The mean age was 81.7 years. The underlying pathologies are listed in Table 1 . No patient was able to be evaluated with a walking aid during his/her hospital stay. Table 2 lists the repartition of the technical walking aids prior to the subjects’ hospital stay. These patients’ walking perimeter was extremely limited; it was impossible to perform the 6-min test.
| Affection | Pathology | Number (%) |
|---|---|---|
| Neurological | Moderate affection of the upper functions with or without psychiatric disorders | 10 (33.33) |
| Parkinsonian syndrome | 4 (13.33) | |
| Sequelae of an ischemic stroke | 6 (20) | |
| Cardiovascular | Arrhythmia | 8 (26.67) |
| Pathology of the coronaries | 7 (23.33) | |
| Arteriopathy of the lower limbs | 3 (10) | |
| Respiratory | Chronic respiratory insufficiency | 3 (10) |
| Recent acute respiratory distress | 5 (16.67) | |
| Osteoarticular | History of fractures with or without implanted material | 12 (40) |
| Joint pain, inflammatory or not | 10 (33.33) | |
| Metabolic | Diabetes and/or dyslipidemia | 10 (33.33) |
| Tumors | Progressing cancer | 3 (10) |
| Technical walking aid | Number (%) |
|---|---|
| None including | 12 (40) |
| Patients not walking anymore | 3 (10) |
| One English cane | 6 (20) |
| Two English canes | 3 (10) |
| Walker | 4 (13.33) |
| Unknown | 5 (16.67) |
1.3.2
Functional tests
The mean PCI was 2.01 with a fixed frame versus 1.23 with a rollator walker ( P < 0.01) ( Table 3 ).
| HRrest Hb/min | HR30 Hb/min | HRmax Hb/min | PCI Hb/m | S meter/min | TGUG seconds | |
|---|---|---|---|---|---|---|
| FW | 79.64 (52–144) | 94.7 (56–155) | 97.77 (58–158) | 2.01 (0.2–10.71) | 13.45 (3.36–40.02) | 82.93 (31–213) |
| RW | 79.83 (52–150) | 88.38 (57–147) | 98.03 (57–150) | 1.23 (0.02–10.45) | 22.78 (3.54–46.14) | 72.26 (24–269) |
| P | NS | <0.05 | NS | <0.01 | <0.001 | <0.001 |
With RW, the maximum HR 30 sec after effort (HR30) is lower ( P < 0.05) than the one with a FW.
With a RW, the 10-m course speed was higher than with a FW ( P < 0.001).
We also found this speed difference during the TGUG test, which was performed more quickly with a RW (72.26 sec vs. 82.93 sec, P = 0.001).
1.4
Discussion
As we observed, with a fixed frame walker PCI was higher in a weakened elderly individual due to HR increase and lower walking speed.
Not very many studies are available in the literature, especially ones evaluating the energy cost when walking with a walker .
Most studies focus on healthy subjects. Holder et al. compared the energy cost and effort perception during assisted gait with axillary crutches, fixed walker or rollator walker. The test lasted 7 min for each condition, and the axillary canes enabled the patients to walk more quickly while spending less energy than with walkers. For the latter the energy cost was identical, but the speed was higher with the RW.
Among studies conducted on sick populations, Probst et al. reported in a population of subjects with respiratory insufficiency that using a RW improved the walking perimeter and oxygen consumption versus walking without a technical aid. The most recent study by Crisafulli validated this impact, especially due to the decrease in weight bearing in 60 oxygen-dependent patients with chronic obstructive pulmonary disease (COPD).
In 19 patients with Parkinson, Cubo et al. compared walking without a technical aid, a FW and a RW. The use of one or the other technical aid slowed down the walking speed.
Studies on elderly populations were conducted on quite autonomous subjects. Baruch et Mosberg asked women, aged 60 to 80, to walk for 3 min with a walker while loading on only one leg. The HR went up to 83% of the HRmax during the test. Foley et al. did a study on the energy cost of walking without a technical aid, with an English cane and with two types of walker. The study population was made of 10 elderly individuals (age: 50 to 74), able to walk for 2 min. With a FW, the oxygen consumption was 212% higher than with a cane, and 104% higher than with a RW. Protas et al. compared spatio-temporal gait parameters and oxygen consumption during gait with three types of walker in 13 autonomous individuals between 70 and 90 years old, their results matched the ones reported in the previous studies regarding the use of FW and RW. We think that when walking with a FW, the major physiological energy cost increase is probably due to the repeated efforts to lift the walker. FW is supposed to be easier to handle especially for changing directions; the wheels of RW cannot change directions slowing down the walk during turns. However, we noticed that TGUG test reported longer duration with a FW even though the test included a half-turn. The common use of a fixed-frame walker seems justified since it is less cumbersome and thus more convenient for small living areas. For rehabilitation, the higher energy cost and greater solicitations for balance can justify its transitory use.
Furthermore, it is possible that in patients hospitalized in a rehabilitation center, there might be a preferential use during rehabilitation for one type or the other which could then have an impact on the results of the functional tests used in our measurement protocol. In our service, before this study, we had a preference for the rollator walker, which could explain in part its better tolerance in our study. We do not know of any study that evaluated the impact of walking with a walker on the cardiac function in a population of elderly individuals with multiple pathologies, as dependent as the population recruited for our study. The walker was essential for our patients who could not walk without this type of technical aid, the walking perimeter was very limited and the walking speed very low, as shown by the long time taken to perform the TGUG test. This population presents the usual prescription criteria for a walker. However, the limits of this study are a very heterogeneous population with an interaction of several cardiac, neurological, respiratory and orthopedics pathologies, varying from one person to the next. It will be difficult to compare our patients with multiple pathologies to other elderly populations if some studies were conducted on the same topic.
1.5
Conclusion
A rollator walker allows the elderly patient, unable to walk without a technical aid, to move faster in a straight line with a lesser energy cost. This model should then be preferred to the fixed-frame walker, especially for people with cardiac and respiratory pathologies limiting the effort tolerance.
Conflict of interest
The authors have not declared any conflict of interest.
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