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Nordic Walking: A new training for frail elderly
Sabrina Figueiredo, B.Sc (Physiotherapist)
School of Physical and Occupational Therapy
Faculty of Medicine McGill University, Montreal, Quebec, Canada
August, 2009
A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the
requirements for the degree of Master of Science in Rehabilitation Science
© Sabrina Figueiredo, 2009
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ABSTRACT
The elderly are the fastest growing proportion of the world population. Additional
increase in longevity, brought about by improved medical technology, will impact significantly
on the health care system as, with advancing age comes a variety of acute and chronic health
conditions. No matter how fit, advancing age leads to reduction in mobility and physical
function, and these changes, affect quality of gait and the capacity for functional and safe
ambulation. With the frail elderly, gait impairments are often severe and impact on health and
quality of life. Given that improving walking capacity among the elderly is a desired goal, a
structured review was conducted - Manuscript 1 - to derive a global estimate for elderly people of
the effectiveness of walking training in improving walking related outcomes. The review
included publications on MEDLINE, Embase, CINAHL and the Cochrane Library published in
English or Portuguese in peer-reviewed journals. Effect sizes of walking programs in these
articles were estimated and forest plotted; there was no overall significant effect of walking
training on walking distance or gait speed. Some individual studies showed large effect sizes but
were underpowered; others showed small effect sizes. Heterogeneity in population and the
nature, frequency and intensity of training indicates that this important question is not yet
answered and further research is needed.
The second manuscript presents the results of a pilot study designed to provide supporting
data for a future trial testing a novel walking training strategy - Nordic style pole walking. The
purpose of the pilot study was to estimate, for frail elderly persons undergoing physical
rehabilitation, the relative efficacy in improving functional walking capacity of two gait training
interventions: Nordic Walking and Overground Walking. A randomized controlled trial of 30
participants from two rehabilitations centers of the Greater Montreal Area was carried out: 14
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randomized to Nordic Walking and 16 randomized to Overground Walking. Effect sizes for
Nordic Walking were moderate for 6MWT (ES = 0.5), large for gait speed (ES = 0.9), and small
for fear of falling (E.S = 0.4). Overground Walking showed moderate effects sizes for 6MWT
(ES = 0.5) and small ones for gait speed (E.S = 0.4) and fear of falling (E.S = 0.3). After
calculating the effectiveness ratio of both interventions, Nordic Walking was 125% more
effective in improving gait speed than regular Overground Walking among a frail elderly
population. Future trials with large sample sizes are needed to corroborate these results.
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ABRÉGÉ
Les personnes âgées forment la tranche de la population mondiale dont la croissance est la
plus rapide. De plus, l‟augmentation de l‟espérance de vie grâce aux avancées technologiques en
médecine va affecter de façon considérable le système de santé. En effet, le vieillissement de la
population implique une diminution des fonctions physiques. Ces diminutions influence la
marche et la capacité de se déplacer de façon fonctionnelle et sécuritaire. Une intervention,
destinée à améliorer la marche pourrait améliorer la santé et la qualité de vie des personnes âgées
fragiles. En premier lieu, une revue structurée de la littérature a été effectuée (Manuscrit 1) afin
d‟évaluer l‟efficacité des programmes couramment utilisés afin d‟améliorer la marche chez les
personnes âgées. Les banques de données MEDLINE, Embase, CINAHL et Cochrane Library ont
permis de trouver des articles anglais ou portugais publiés dans des journaux révisés par les pairs.
La taille d‟effet de ces programmes de marche ont étés estimés puis illustrés dans un graphique
en arbre. Aucun programme de marche n‟améliorait significativement l‟endurance ou la vitesse
de marche. Dans ces études, les programmes avec une taille d‟effet importante avaient une
puissance statistique faible et les autres programmes avaient une taille d‟effet réduite. Afin
d‟identifier et d‟estimer l‟efficacité d‟interventions destinées à améliorer la marche chez les
personnes âgées, d‟autres études sont nécessaires.
Le second manuscrit a évalué l‟efficacité de deux interventions destinées à améliorer la
capacité fonctionnelle de marche chez les personnes âgées fragiles. Un projet pilote de type essai
clinique randomisé a comparé la marche nordique au programme « overground walking ». Trente
participants en provenance de deux centres de réadaptation de la région de Montréal ont été
aléatoirement placés dans la marche nordique (n=14) et dans le « overground walking » (n= 16).
Pour la marche nordique, la taille d‟effet pour le 6MWT était modérée (ES=0.5), celle de vitesse
v
de marche était importante (ES=0.9), et celle pour la peur de chuter était petite (ES=0.4). Pour le
« overground walking », la taille d‟effet pour le 6MWT était modéré (ES= 0.5). La taille d‟effet
pour la vitesse de marche était petite (E.S. = 0.4) tout comme celle pour la peur de chuter (E.S =
0.3). Les ratios d‟efficacité pour les deux interventions ont démontré qu‟en comparaison avec le
« overground walking » la marche nordique est 125% plus efficace pour améliorer la vitesse de
marche chez les personnes âgées fragiles. D‟autres études avec de plus large échantillons sont
nécessaires pour corroborer ces résultats.
vi
ACKNOWLEDGMENTS
I would like to express my deepest gratitude to my supervisor, Dr. Nancy Mayo. Your
mentorship and guidance provided me the opportunity to develop strong research skills. Besides,
your passion for research and teaching is an inspiration to all of us. I feel honored for being
supervised by you.
A very special mention goes to Dr. Lois Finch. Thank you so much for your immense
support and recommendations. Your research and clinical knowledge were fundamental during
this entire process.
I would also like to acknowledge Lyne Nadeau. I truly appreciate your assistance with the
statistical language and programming.
I thank you all the staff from the Geriatric Day Hospital of the Royal Victoria Hospital
and from the Richardson Hospital. You always had the door open for me, and this partnership
was essential for finalizing the pilot trial.
To my family, even far away, you are close. Your belief in me, your encouragements and
love made me aim up high, and for that I‟m truly grateful!
To my friends and the staff in the Division of Clinical Epidemiology and in the School of
Physical and Occupational Therapy, you have all been amazing!
Finally, Avi, Chloe, Tal, Lu, Marcia, the Katz family, and all my friends, your love and
friendship made this journey much easier. Thank you for making me laugh!
vii
TABLE OF CONTENTS
Abstract………………………………………………………………………………………… I ii
Abregé……………………………………………………………………………………….….. iv
Acknowledgements…………………………………………………………………………….. vi
Table of Contents………………………………………………………………………………. vii
Index of Tables……………………………………………………………………………..….. ix
Index of Figures………………………………………………………………………….….… x
Preface…………………………………………………………………………………..…….. xi
CHAPTER 1: AGING, AGE-RELATED CHANGES, AND FRAILTY ....................................... 1
1.1. Age-related changes: An overview ....................................................................................... 2
1.1.1. Age related changes affecting mobility .......................................................................... 3
1.2. Frailty .................................................................................................................................... 5
1.2.1. Markers of frailty ............................................................................................................ 7
1.2.2. Identifying frailty ............................................................................................................ 7
1.2.3. Measuring frailty............................................................................................................. 8
1.2.4. Consequences of Frailty................................................................................................ 10
1.2.5. Intervening in frailty: prevention and treatment ........................................................... 11
CHAPTER 2: MOBILITY TRAINING IN FRAIL ELDERLY .................................................... 17
2.1. Overground Walking Training ............................................................................................ 19
2.2. Intensive Walking Training ................................................................................................. 21
2.2.1. Treadmill Training ........................................................................................................ 21
2.2.2. Nordic Walking............................................................................................................. 23
2.2.2.1. History of Nordic Walking .................................................................................... 23
2.2.2.2. The Effects of Nordic Walking .............................................................................. 25
2.2.2.2.1. Nordic Walking for People with Health Conditions ....................................... 25
2.2.2.2.2. Fitness Studies on Nordic Walking ................................................................. 27
CHAPTER 3: RATIONALE AND OBJECTIVES ....................................................................... 35
CHAPTER 4: MANUSCRIPT 1 .................................................................................................... 38
viii
4.1. A structured review and meta-analysis on the effectiveness of walking training in the
elderly ......................................................................................................................................... 38
Abstract ...................................................................................................................................... 39
Introduction ................................................................................................................................ 40
Methods ...................................................................................................................................... 41
Results ........................................................................................................................................ 42
Discussion .................................................................................................................................. 45
Conclusion .................................................................................................................................. 48
References for Manuscript 1 ...................................................................................................... 53
CHAPTER 5: INTEGRATION OF MANUSCRIPT 1 AND MANUSCRIPT 2 .......................... 55
5.1. Primary research objective of manuscript 1 and 2 .............................................................. 55
5.2. Integration of manuscript 1 and 2 ........................................................................................ 55
CHAPTER 6: MANUSCRIPT 2 .................................................................................................... 56
6.1. Nordic Walking For Frail Elderly: A Randomized Pilot Trial ............................................ 56
Abstract ...................................................................................................................................... 57
Introduction ................................................................................................................................ 59
Methods ...................................................................................................................................... 60
Results ........................................................................................................................................ 67
Discussion .................................................................................................................................. 70
Conclusion .................................................................................................................................. 73
References for Manuscript 2 ...................................................................................................... 80
CHAPTER 7: SUMMARY AND CONCLUSION ....................................................................... 84
REFERENCE LIST ........................................................................................................................ 87
APPENDICES ............................................................................................................................. A01
A.1. Conceptual Model ............................................................................................................... A01
A.2. Outcomes Measures ............................................................................................................ A02
A.3. Ethics Approval ................................................................................................................... A21
A.4. Consents Forms ................................................................................................................... A21
ix
INDEX OF TABLES
Table Title Page
Table 1.1 Disabilities in the Canadian Population by age group and sex 14
Table 2.1 Summary of the randomized control trial on Nordic Walking 33
Table 4.1 Summary of studies on walking capacity of the elderly 50
Table 6.1 Characteristics of study subjects at baseline 75
Table 6.2 Characteristics of the study subjects on all outcomes at baseline
(pre) and after intervention (post) and on change from pre to post
76
Table 6.3 Counts of persons sustaining and changing activities after the
intervention period
77
Table 6.4 Interventions‟ effects size and the ratio between Nordic Walking
(NW) and Overground Walking (OW)
78
x
INDEX OF FIGURES
Figures Title Page
Figure 1.1 Elderly as a fraction of the Canadian population over time 13
Figure 1.2 Hospital Admissions per 100,000 populations 15
Figure 1.3 Percentage of homecare services use by age group 15
Figure 1.4 Prevalence of frailty among the elders 16
Figure 2.1 Nordic Walking sequence 31
Figure 2.2 Nordic Walking equipment: poles and hand grip 31
Figure 2.3 Nordic Walking and its social myths 32
Figure 4.1 Effects Size of walking training on walking distance 52
Figure 4.2 Effects Size of walking training on gait speed 52
Figure 6.1 Flow of participants through the trial 79
xi
PREFACE
The first step in writing this manuscript based thesis was the development of a research
protocol approved by the School of Physical Therapy and Occupational Therapy in June, 2008.
This protocol was written by Sabrina Figueiredo under the guidance of Dr. Nancy Mayo. Then, a
literature review was conducted by Sabrina Figueiredo with support from Diana Dawes and Miho
Asano. The following steps: obtaining ethics approval, data collection, development of a database
and statistical analyses were performed by Sabrina Figueiredo. In addition, Lois Finch was of
assistance to obtaining the ethics approval and Lyne Nadeau to statistical difficulties. The thesis
was written by Sabrina Figueiredo with extensive editing by Dr. Nancy Mayo and Dr. Lois Finch.
Organization of thesis
The two primary objectives of this thesis were to perform a structured review on the
effectiveness of walking training in the elderly and to estimate the relative efficacy in improving
functional walking capacity of two gait training interventions - Nordic Walking and Overground
Walking – among frail elderly. Each objective is independently addressed in two separate
manuscripts. These manuscripts will later be submitted to scientific journals for publication.
Additional chapters have been included in the thesis in order to follow the regulations of the
Graduate and Postdoctoral Studies (GPS).
Chapter 1 is an introduction to aging and frailty. It highlights frailty‟s prevalence and its
consequences to the health care system. Furthermore, this chapter relates the age-related walking
changes and its implication to the functional capacity on the elderly. Additionally, a conceptual
model based on the ICF framework was presented as a possible way of intervention.
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Chapter 2 reports the walking strategies used nowadays in the rehabilitation environment.
It also presents a differentiation between the regular walking training and pole walking, also
known as, Nordic Walking.
Chapter 3 provides a general rationale for using Nordic Walking as a strategy to improve
functional capacity among the elderly. It also outlines the main objectives in the two manuscripts.
Chapter 4 consists of the first manuscript. It includes the text, the figures, the tables, and
the references. The contents of this manuscript are related to performing a structured review on
the effectiveness of walking training on gait speed and walking distance among the elderly.
Chapter 5 presents the link or the connection between the conclusion of the first
manuscript and the objective of the second manuscript.
Chapter 6 consists of the second manuscript. It includes the text, figures, tables and
references. This manuscript presents the randomized pilot trial carried out to estimate the relative
efficacy of Nordic Walking and Overground Walking training in improving functional walking
capacity among a frail elderly population. Originally, the protocol for this trial stipulated training
over an 8 week period. Due to organizational constraints, following subject identification,
consent and evaluation, it was possible to offer training for only 6 weeks prior to discharge.
Finally, Chapter 7 summarizes the findings and conclusions of both manuscripts.
The appendices contain information that is not normally presented in a manuscript to be
submitted for publication. A complete list of appendices is presented in the table of contents.
1
CHAPTER 1
AGING, AGE-RELATED CHANGES, AND FRAILTY
The aging process has important physiological, psychological and societal consequences.
Increasing age is characterized by progressive degenerative changes in all bodily tissues and
functions. Because aging is the forerunner of a progressive decline in function, the aging process
needs to be understood to be modified or delayed.
Moreover, the elderly are the fastest growing proportion of the population. In 1997, 6.6%
of the world population was over 65 years. This proportion is expected to increase to 10% by
2025, amounting to 800 million seniors worldwide 1. In Canada, this proportion is currently
13.7% and increasing at a rate of 2.7% per year; by 2025, the proportion of people aged over 65
is expected to reach 20% and 33% by the year 2150 2. The growth of the elderly sub-groups can
be seen in Figure 1.1.
Advances in medical care and new health technology undoubtedly have contributed to the
increase in longevity and an increase in the numbers of people surviving into old age.
Techniques that range from advanced diagnostics to surgical approaches are more effective and
feasible, enhancing treatment for a greater number of people. The changes in health care,
including rehabilitation, have led to greater survival rates 2. The subsequent increase in longevity
will impact significantly on the health care system, as the rise in survival rates is accompanied by
an elevation in morbidity rates 2.
Twenty-five percent of the Canadian elderly population have a disability and its
prevalence rises with advancing age: 18% in persons 65 to 74 years of age to 53 % in those aged
2
85 and over (Table 1.1) 2. Moreover, approximately 70% of the Canadian health care system
budget is attributed to people over 65 years of age. The cost of treating people over the age of 85
is 15 times greater than for those under the age of 55 2. The highest rates of hospital admissions
and use of homecare services are found among the elderly (Figure 1.2 and 1.3). In addition this
population claims the longest length of stay in acute care hospitals and the greatest rate of
institutionalization 2.
The aging process is characterized by greater comorbid and chronic conditions 3.
Although major age-related changes can be found in all physiological, sensory and cognitive
functions many elderly can experience a healthy aging process without significant impairment 4.
1.1. Age-related changes: An overview
It is commonly accepted that increasing age is associated with a loss of cognitive and
motor functions 5. These losses in cognitive and physical function leads to compromised static
and dynamic balance, loss of muscle strength, and diminished vestibular and visual function,
which will affect the quality of gait and the capacity for functional and safe ambulation 6 7.
Although age-related changes have diverse consequences among the elderly, they are, not
a synonym for disability. Many elderly experience what has been termed “healthy aging” 8.
Only one fourth of Canadian elderly can expect adverse age-related changes and
consequently will present with some level of disability. Despite this, the prevalence of disability
and impairments rises with age from 18% in persons 65 to 74 years old to 53% in those aged 85
and over 2. This level of disability is similar to that observed with mobility limitations: with
advancing age, mobility restrictions are amplified as are their impact.
3
Based on the magnitude of age-related changes elders can be divided into four groups:
middle age includes people from 45 to 64 years old; for people older than 65 years, the following
categories are recognized 9:
Young-old – aged 65 to 74 years;
Middle-old – aged 75 to 84 years;
Late-old - aged 85 years and older.
The changes related to age are multiplied in the late old age group 9.
For this thesis only the age-related changes affecting mobility will be described further.
1.1.1. Age related changes affecting mobility
Decreased muscle strength and muscular atrophy are characteristically observed with the
aging process and are considered the major causes of loss of mobility, reduced gait speed,
increased frailty and increased incidence of falls in the elderly 10
. Loss of mobility increases with
advancing age and its prevalence ranges from 14% among people with 65 to 74 years to 50%
among those older 85 years old 5. Impaired mobility and falls are, after cognitive disorders, the
major cause of diminished quality of life.
Focusing on age related changes affecting gait, alterations in spatial and temporal
parameters have been reported as early as age 60 11
. Several studies have reported significant
changes in stride length and cadence 6;12
. Marigold & Patla, (2008) 13
found that the elderly take
shorter steps, resulting in a reduced stride length. There is also decreased coordination between
pelvis and trunk seen as a reduction in pelvic obliquity and rotation in the axial and sagital planes
12. A reduction in all three planes of these counter-movements impacts on gait stability and
4
results in increased trunk rigidity when walking. A general reduction in range of motion of all
lower extremity joints can be observed 14
.
Functional walking capacity, as indicated by distance walked and gait speed will
deteriorate with age. The time taken to walk a well-defined distance increases with age. Among
this population a phenomenon called psychomotor slowing is often observed 15
. Grimby and
Saltin (1983) 16
and Pollock et al. (1974) 17
reported that in the early part of the seventh decade
the decline in gait speed is accelerated. The distance walked in a set time, as well as capacity to
walk on uneven surfaces and up inclines or stairs, were found to decrease with age 6;11;18
.
Walking distance and gait speed are important for participation in personal, family and
societal roles. Additionally, these two variables are predictors of hospitalization,
institutionalization, and perceived and diagnosed health status 19-21
. Purser at al., 21
suggested that
for every 0.10 m/s reduction in baseline gait speed, when all other variables are constant, overall
health status as measured by the SF-36 would decrease by 4.5 units (beta = 4.5 ; 95% CI = 2.8 to
6.1), the physical functioning would decrease 2.1 units (beta = 2.1; 95% CI = 6.9 to 14.8),
disability level would increase by 0.6 units (beta = 0.63, CI = 0.53 to 0.73) and the number of
visits to rehabilitation centers would increase by 2.0 units (beta = 2.0; CI = 1.4 to 2.5).
An inability to ambulate adequately can lead to de-conditioning and a sedentary life style.
A sedentary life style has pathological consequences; including muscle atrophy, impaired
balance, orthostatic hypotension and decreased cardio respiratory function as well as apathy,
depression and cognitive decline 22
. These conditions combine to perpetuate a cycle resulting in
an even greater decrease in mobility.
Interestingly, a decrease in walking capacity correlates with an increased fear of falling 11
which is defined as the avoidance or restriction of activities due to the fear of falling. The
perpetual concern about falling may prevent someone from performing even usual activities of
5
daily living and from venturing out into the community. The prevalence of fear of falling in the
elderly is high: between 12% and 65%, and is greater in women than men. Approximately one
out of four elders complains about it. This fear begins commonly after a fall, but is also observed
in people without a history of falls 11
.
Persistent fear of falling among the elderly is in itself associated with slower gait speed,
shorter stride length, increased stride width and prolonged double support time 11
. Other studies
also reported that elderly with fear of falling avoided reaching and walking most often.
Additionally, fear of falling is a strong predictor of restriction in social activities 23;24
and is
associated with frailty and decreased quality of life 25
. However, an association between changes
in walking capacity and falls has not been established 25
. This may be because people restrict
their activity rather than risk a fall.
1.2. Frailty
With advancing age also comes the onset of disabling health conditions such as
cerebrovascular, cardiac and oncologic diseases. The illness and associated disabilities can lead
to a complex state recently denominated as frailty 3. Based on the extent of the age-related
changes, elders can be further categorized into a pre-frail or a frail state 26
.
Frailty, originally defined exclusively as a biological syndrome, is characterized by a
physiological imbalance between demand imposed and reserve or capacity. Nowadays, although
there is a consensus that the concept of frailty should be multidimensional, covering disease,
function, cognition, and nutrition, the definition of frailty still lacks consensus. Regardless of this
lack of consensus on concepts and definitions, differentiating frailty from comorbidity and
disability may improve the understanding of the aging process 27
.
6
Many authors provided different definitions for frailty. The most accepted definition is
the one provided by Fried 27
, where frailty is considered a multidimensional construct that
implies a vulnerability that emerges when health stressors overwhelm the individual‟s
physiological, psychological and social reserves. Against a background of the physiological
changes of aging, an acute or chronic health event or condition can precipitate the frailty process
or it may be initiated by lack of activity, inadequate nutritional intake, and/or stress. Furthermore,
frailty is a state of high vulnerability for adverse health outcomes, including disability,
dependency, falls, need for long term care, and mortality 27
.
Disability is defined as a difficulty or dependency in carrying out activities essential to
independent living, including essential roles and tasks needed for self-care and living
independently in a home, and desired activities important to one‟s quality of life 28
.
Comorbidity is the concurrent presence of two or more medically diagnosed diseases in
the same individual, with the diagnosis of each contributing disease based on established, widely
recognized criteria. In this sense, the concept of comorbidity could be viewed as an interface
between the geriatric paradigm of health and the more traditional medical definition of disease 3.
Frailty is distinct from, but overlapping with, both comorbidity and disability, as reported
by Fried et al. 3. This same study showed that 98% of geriatricians from six academic medical
centers across USA and England deemed frailty to be a different concept than disability and 97%
of them agreed that frailty encompasses the concurrent presence of more than one characteristic.
At least 50 % of those geriatricians cited under nutrition, functional dependence, prolonged bed
rest, pressure sores, gait disorders, generalized weakness, aged > 90 years, weight loss, anorexia,
fear of falling, dementia, hip fracture, delirium, confusion, decreased frequency on outdoor
activities and polypharmacy as characteristics observed in association with frailty 3.
7
1.2.1. Markers of frailty
Frailty is considered age related but not age caused. Only 3% to 7% of the early old (65 to
75 years) are classified as frail but the incidence of frailty increases with age, reaching 20% to
26% among people in their 80‟s and 32% among those aged more than 90 years 26
.
Those characteristics that define a person as frail are referred to as frailty markers and can
be divided into three main groups: biological, demographic and social.
Biological markers include sarcopenia, decreased strength, decreased balance, lower gait
speed, decreased visual acuity, cardiovascular disease, hypertension, diabetes, glucose
intolerance, increased c-protein reactive and fibrinogen, and decreased serum levels of insulin-
like growth factor-1 26;29
. Some of these markers such as glucose intolerance, increased c-protein
reactive and fibrinogen, have been shown to activate inflammation and sarcopenia 26
, enhancing
the frailty cycle.
Demographic markers include female sex, African-American race, lower educational
level, and lower income 4;26;30
.
Social markers include a decrease in the level of outdoor activities with increased
isolation 4;26;30
.
Some individuals are more susceptible to factors that trigger frailty. Experts speculate that
certain environments, medications, age-related changes, diseases and their associated treatments
may combine with a particular phenotype to enhance vulnerability to frailty 26
.
1.2.2. Identifying frailty
The early disabilities distinctive in the frailty process may be clinically undetectable as
individuals compensate to achieve a balance between reserve and demands. However, this
unstable equilibrium can be easily disrupted by minimal environmental challenges 3;4
. For
8
example, when the loss of reserve reaches an aggregate threshold that leads to serious
vulnerability, the syndrome may become detectable by examining clinical, functional,
behavioural, and biological markers. To be classified as frail at least three of the following five
characteristics need to be identified:
Decreased gait speed,
Decreased grip strength,
Decreased physical activity,
Exhaustion,
More than 10 pounds or 5% of weight loss in the past year.
In the presence of fewer than 3 frailty markers, an individual is considered in the pre-frail
stage 3.
Not everyone who appears to be frail really is. When frailty is under investigation
diseases such as congestive heart failure, polymyalgia rheumatic, Parkinson disease, rheumatoid
arthritis, occult malignancy, and infection 26
need to be further investigated. Since these
conditions are treatable they should be identified and treated before classifying a person as frail.
1.2.3. Measuring frailty
Due to the lack of agreement and the largely subjective definition, frailty is a concept that
cannot be accurately measured. Despite the difficulty in measuring frailty several attempts have
resulted in a considerable number of specific indices.
Additionally, a variety of generic outcome measures are used in place of specific indices
of frailty to assess impairments, activity limitations, participation restriction, personal and
environmental barriers, and quality of life.
9
The specific measures of frailty developed thus far are:
1) The Frailty Measure was developed in 1994 by Strawbridge as an initial screening
tool to identify frail elderly individuals who warrant extensive functional evaluation.
It encompasses physical and nutritive functioning, cognition and sensory problems
divided in 16 items 31
.
2) The EPIC Assessment System was developed by the European Prototype for
Integrated Care to be used primarily with community dwelling elderly. Its 31 items
cover health, mental and social functioning, ADL/IADL, well being, and goal setting
32.
3) The Edmonton Frail Scale is comprised of cognition, general health status, functional
independence, social support, medication use, nutrition, mood, continence, and
functional performance items. It is a bedside test with 10 items only 33
.
4) The Frailty Index was developed by the Canadian Study of Health and Aging research
group. It is composed of 70 items including the presence of diseases, ability to
perform ADL, physical signs, and laboratory abnormalities. It counts the various
deficits and calculates the relative frailty of an individual as a percentage difference
from the average score for people of that age 34
.
5) The Clinical Frailty Scale is a measure of frailty based on clinical judgment. It
classifies elderly patients accordingly to their degree of vulnerability 35
.
6) The Functional Autonomy Measurement System (SMAF) aims to measure functional
performance in elderly people. Based on the ICF model, it includes 29 items, divided
into activities of daily living, mobility, communication mental status and activities of
domestic life 36
.
10
On investigating the psychometrics properties of these measures, the SMAF, the
Edmonton Scale and the Clinical Frailty Scale are reliable, valid, responsive and feasible
measures. The Frailty Index has shown good psychometric properties but calculating a frailty
index is time-consuming. Studies on the Frailty Measure have shown that this is a measure for
elderly in the pre-disability stage. Finally, the psychometric properties of the EPIC Assessment
System have not yet been estimated.
As previously mentioned, measures that address frailty indicators such as mobility and
vitality are commonly used clinically. These measures include: the Mini-Mental State
Examination, the Barthel Index 37
, the Berg Balance Scale 38
, the Timed up & Go 39
, the Geriatric
Depression Scale (GDS) 40
, the Functional Independence Measure (FIM) 41
, among many others.
Unfortunately, an ultimate consequence of the lack of definition that evolves from frailty
is the inconsistency among outcome measures used across scientific communities and health care
specialties throughout the world.
1.2.4. Consequences of Frailty
Once an individual becomes frail, there is often a rapid, progressive, and self-perpetuating
downward spiral toward failure to thrive and death 26
. Frailty is a risk factor for rapid functional
decline, morbidity, institutionalization, and mortality 42
.
In a study by Fried et al., (2001) of 5,317 Americans of varying ages from 65 to 101
years, frailty (identified by the presence of at least three characteristics like decreased gait speed,
decreased grip strength, decreased physical activity, exhaustion, major weight loss) predicted a 3-
year greater incidence or progression of disability in both mobility and activities of daily living
(ADL‟s), independent of comorbid diseases, health habits, and psychosocial characteristics.
11
Those who were frail were less likely to be socially active 3. Moreover, the authors demonstrated
that after adjusting for age, race, sex, smoking and pre-existing comorbidity, patients who were
frail had a 1.2 to 2.5 fold increased in their risk for falls, decreased mobility, worsening ADL,
institutionalization and death. Additionally, due to the many complications a person normally
will face with aging, frailty has a huge impact on the cost to the health system 3.
Cacciatore and colleagues (2005) followed 120 persons with chronic heart failure and
1139 without it. After a 12 year follow-up period they reported that mortality among the elderly
increased with level of frailty. In this study frail was measured by the presence of three out of
five characteristics aforementioned. Being frail was more predictive of long-term mortality in
persons with chronic heart failure than those without it 43
.
1.2.5. Intervening in frailty: prevention and treatment
As there are limited treatments available to decrease frailty, interventions should address
the five major components that characterize a person as frail.
The ideal treatment for a frail individual should involve a multi-centered team. The initial
goal is to optimally manage all medical and or psychiatric illnesses that may be contributing to
the frailty process. Physical and occupational therapy interventions should focus on reducing
sarcopenia and improving strength, balance and functional walking capacity. Dieticians need to
be involved to optimize protein and caloric intake. Apart from disease-specific preventive
measures, other strategies should focus on broadening social network to enhance social and
cognitive stimulation and prevent isolation 30
. Unfortunately interventions to treat and reduce the
burden of frailty in the elderly are hampered by our poor understanding of the biological basis of
this age-associated syndrome. Clearly, more research is needed in this area 44
.
12
A more important and possibly more effective intervention would be to prevent frailty.
Studies have shown that interventions initiated in the pre-frail stage can reverse the downward
spiral into a full blown frailty syndrome 26
. It is imperative that the populations at risk be
screened in order to identify earlier those in the pre-frailty stage.
Studies suggest that the prevention of disabilities is feasible and potentially effective 44
.
Among the possible interventions that could prevent a person from becoming frailty, physical
exercise might be the most obvious. Exercise strengthens muscles, reduces levels of
inflammatory factors and increases IGF-1 levels. This is important as those two markers can act
as percipients in the frailty chain. Moreover, exercising increases the level of anabolic hormones
such as testosterone and dehydroepiandrosterone (DHEAS), reducing substantially the circulating
levels of inflammatory biomarkers and stimulates the production of free radical scavengers and,
in some instances, improves the function of the autonomic system 45
.
However, as health professionals, we cannot fix what we cannot measure. In order to treat
a condition adequately, it is necessary to identify first those who are at risk of being classified as
frail. The identification process is extremely important, and must be done at the earliest stage. An
early detection will allow initiating preventive interventions, which have been shown to be most
effective in this population.
13
Figure 1.1 - Elderly as a Fraction of the Canadian Population over Time
Source: Statistics Canada - Health Canada, 2009 2
14
Table 1.1 - Disabilities in the Canadian Population by age group and sex
Both Sexes Males Females
number % number % number %
Total - all ages 3,601,270 12.4 1,640,120 11.5 1,961,150 13.3
Total - less than 15 years
180,930 3.3
113,220 4.0
67,710 2.5
0 to 4 years 26,210 1.6 16,030 1.9 10,180 1.3
5 to 14 years 154,720 4.0 97,180 4.9 57,530 3.0
Total - 15 years and over 3,420,340 14.6 1,526,900 13.4 1,893,440 15.7
15 to 64 years 1,968,490 9.9 921,020 9.4 1,047,470 10.4
15 to 24 years 151,030 3.9 74,500 3.8 76,530 4.0
25 to 44 years 626,610 7.1 288,590 6.6 338,030 7.5
45 to 64 years 1,190,850 16.7 557,940 15.9 632,910 17.5
65 years and over 1,451,840 40.5 605,880 38.5 845,970 42.0
65 to 74 years 649,180 31.2 296,310 30.2 352,860 32.0
75 years and over 802,670
53.3 309,570
52.1 493,100
54.1
Notes: - The Canada total excludes the Yukon, Northwest Territories and Nunavut. - The sum of the values for each category may differ from the total due to rounding.
Source: 2001 - Statistics Canada, Participation and Activity Limitation Survey 2
15
Figure 1.2 - Hospital admissions per 100,000 populations
Source: 2002/2003 Hospital Morbidity Disease 2
Figure 1.3 - Percentage of homecare services use by age group
Source: 2003 Canadian Community Health Survey 2
0
5000
10000
15000
20000
25000
30000
< 65 65-74 75-84 > 85
0
5
10
15
20
25
30
35
40
45
< 65 65-74 75-84 > 85
Age groups
100,000
habitants
Percentage
Age groups
16
Figure 1.4 - Prevalence of frailty among the elders.
Source: 2003 Canadian Community Health Survey 2
0
5
10
15
20
25
30
35
65-74 75-80 >85
Age Groups
Percentage
17
CHAPTER 2
MOBILITY TRAINING IN FRAIL ELDERLY
One of the main markers of frailty is slow gait speed. Functional walking capacity,
defined as the walking distance and gait speed needed for everyday activities in and outside home
can be greatly limited in elderly people and the likelihood of developing walking disorders
limitations increases with the lack of physical stimulation. Walking limitations are also
accompanied by an increase in the use of walking aids which further restrict participation
particularly in activities outside the home 22
.
From the clinical perspective decreased gait speed is so prevalent among this population
that it is considered one of five indicators of frailty that can be used to identify those most likely
to benefit from interventions 3. (The other indicators are decreased grip strength decreased
physical activity, exhaustion, and major weight loss.) From the person‟s perspective, elders
attending geriatric rehabilitation centers or living in senior‟s residences report that a decrease in
mobility was one of the main components of frailty 46
confirming Fried‟s concept. From the
societal perspective, the activity limitations and participation restrictions that arise from mobility
limitations impact on morbidity and mortality and lead to frequent use of health care services.
As previously mentioned (see Chapter 1), one of the most effective ways to address frailty
is with an increase in physical activity and exercise. Currently, the positive effects of exercise in
the elderly are well established 47-49
. There is also persuasive evidence for the positive effects of
exercise on neurocognitive function in the elderly. Also, exercising appears to lead to an increase
in metabolic proteins and neurotransmissions, revealing it to be a potential intervention for
treating and modulating some diseases 47
.
18
More specifically, Lazowsky et al. (1999) 48
, after randomizing 68 frail elderly individuals
into range of motion or functional fitness exercises, reported that mobility and balance
significantly improved after performing the later. Additionally King et al., (2000) 49
found that
community based programs focusing on endurance and strengthening exercises resulted in
significant functional and improvements in well being among 103 adults aged 65 years and older.
Based on previous evidence, rehabilitation programs should aim to improve function by
increasing tolerance to walking long distances, gait speed, balance and the capacity to change
position safely and quickly. To accomplish these objectives a wide range of rehabilitation
interventions are available. These interventions can consist of gait training, walking practice,
strengthening of lower limbs muscles, task specific training, stretching and, proprioceptive
training, among others. For the purposes of this thesis, it is essential to differentiate gait training
from walking training.
The MeSH term from Pub Med 50
(the U.S. National Library of Medicine's controlled
vocabulary used for indexing articles for MEDLINE/PubMed) defines gait as the manner or style
of walking, while gait training is defined as helping a patient relearn to walk safely and
efficiently. The professionals most involved with gait training are rehabilitation specialists,
typically physical therapists. They evaluate the abnormalities in a person's gait and employ
treatments such as strengthening and balance training to improve stability and function as these
pertain to the patient's environment. As part of gait training rehabilitation strategies often
incorporate the use of assistive devices such as parallel bars, walkers or canes to promote safe
and proficient ambulation.
Once again using the MeSH term from Pub Med 50
, walking is defined as an activity in
which the body advances at a slow to moderate pace by moving the feet in a coordinated fashion,
one in front of the other. This includes, but is not restricted to, walking for purpose, recreational
19
walking, walking for fitness, and competitive race-walking. The main concern of walking
training is to ensure a person can walk for a pre-determined established time, usually a minimum
of 20 minutes. Quantity, not quality, is the main objective of walking training.
Nevertheless, gait training is important for improving the quality of the walking patterns
which are clearly affected with specific pathologies such as stroke or Parkinson‟s disease.
However, when concentrating on a geriatric population with limitations in functional walking
capacity without specific pathology altering gait, walking training might be a more appropriate
strategy to add to other strategies targeting impairments and limitations in other domains.
The following is a brief review of the most recognized approaches used by rehabilitation
professionals to improve walking capacity regardless of health condition.
2.1. Overground Walking Training
Overground walking training is a safe and feasible technique, that can be performed
anywhere. It consists of walking at a preferred comfortable speed on an even surface. It is a
popular form of moderately intense physical activity for the elderly. A number of studies have
been published on the effects of walking training on body composition and aerobic capacity 51;52
.
In Kubo et al. (2008) 53
a moderate to intense 6-months walking training program or, 15 to 40
minutes, 3 to 4 times a week, resulted in greater muscle thickness and strength, in comparison to
a control group instructed not to change their daily or physical activity level.
In the rehabilitation scenario, overground walking training is often used as warm-up. Due
to environmental and space limitations, most often the client is required to walk back and forth in
a corridor for a pre-determined time established by the therapist.
With the community-dwelling elderly, walking training can be performed in different
locations, indoors or outside. Mall walking is a popular form of exercise for the elderly and
20
combines the capacity to walk for long distances in a safe and weather protected environment 54
.
This variation of the training environment can add interest, motivation and challenge to the
exercise.
Although walking training is simple and feasible, without the appropriate intensity few, if
any, benefits in terms of gait speed or endurance are achieved. A meta-analysis by Lopopolo et
al. (2006) 55
reported that high intensity (effort expended by subjects) exercise and high-dosage
(frequency and duration of exercise sessions) intervention had a significant effect on gait speed,
whereas there were no effects for moderate- and low-intensity exercise or for low-dosage
exercise.
In preparation for the study reported in this thesis, the author (SF) and a physical therapy
colleague (EL) documented the nature of walking training in two different geriatric rehabilitation
settings in the Great Montreal Area. The variety of interventions and the time spent per client
were registered over four full days at each setting. This mapping exercise was performed to assist
in designing the main trial of this study. Typically, walking training preceded other forms of
therapy such as stretching, strengthening and balance exercises. Patients walked in the corridor or
in the gymnasium; they received minimal supervision or stimulation from a therapist. The time
spent practicing walking varied from 4 to 10 minutes and included the time allotted for any
resting. Due to the lack of encouragement most patients rested more than they walked. The
inference from this observation was that walking training is only minimally incorporated into
geriatric rehabilitation in these two settings.
A problem arising from this type of rehabilitation program is related to training
specificity. Although the rehabilitation program included elements to improve walking capacity,
what is the evidence that strengthening, stretching and balance translate into gains in functional
walking?
21
Sipila and Suominen (1995) 56
reported that 18 weeks of strength training induced
hypertrophy in the thigh muscles in 42 elderly women, whereas the effect on walking was
insignificant. Similar results were found by Moriello et al. (2009). In a recent study, 60 elders,
after 6 weeks of core training, showed greater muscle strength but no improvements in gait speed
or walking distance 57
.
These results combine to indicate that a specific exercise that focuses on improving gait
speed and walking distance, with an adequate exercise-dose is needed to achieve positive effects
on walking capacity. That is, a more intensive approach is required to produce positive changes
in functional capacity.
2.2. Intensive Walking Training
2.2.1. Treadmill Training
Treadmill training may be a useful intervention to improve both gait speed and distance.
It can be more intense than regular overground walking training as the speed can be controlled.
Pohl et al. 58
, when studying 60 ambulatory post-stroke patients, showed the importance of
manipulating the speed of the treadmill to achieve increases in overground gait speed. Ada et al.
59, after analysing data from 29 ambulatory stroke survivors living in the community more than 6
months post-stroke, proposed that the motion of the treadmill re-enforced the appropriate timing
between the lower limbs and ensured that the hips are extended during stance phase.
Previous studies in stroke populations demonstrated treadmill training resulted in greater
muscle strength 60
, decreased energy expenditure 61
, as well as improved gait speed, walking
capacity and gait symmetry 62
.
Among twenty-one persons with Parkinson‟s disease, with a mean age of 71 years old, an
eight-week exercise program using incremental speed-dependent treadmill training appeared to
22
lead to improved mobility and reduced fear of falling, in comparison to a non-exercise control
group of 10 participants 63
.
Nevertheless, there is a concern that walking on a treadmill differs from overground
walking.
Pearce et al, 1983 64
reported that, among 42 middle aged men, age and body mass
significantly (P < 0.05) affected treadmill gait speed, while only age significantly affected floor
speed. In addition, significantly greater energy expenditure was found for floor walking in
comparison to treadmill walking. At the normal gait speed of 1.3 m/s, the energy cost for the
floor was 1.04 ml. kg/1/9 in (P < 0.05) and for the treadmill (age 55-66 years) was 0.58ml/kg/1/
min. These findings indicate that gains achieved by treadmill walking may not translate to gains
over ground as floor walking requires greater energy.
A study including healthy persons over 65 years of age suggested evident difficulties in
adapting to treadmill training among this population 65
. Even after a period of habituation on a
treadmill their gait pattern differs from what was expected as normal for this population. One
possible reason for this was the fear experienced by the elderly when they were required to walk
on the treadmill. This fear acts as a barrier to training.
From the previous studies it is possible to infer that a difference exists between treadmill
and overground walking, although the extent of this difference is still debated among researchers.
Based on the difficulty in adapting to treadmill, overground walking training seems more
appropriate for elders. Another intensive method of training should be considered to replace
treadmill training for those who fear it.
One method of promoting intensive overground walking training, without using the
treadmill, is to use ski poles while walking, a technique called Pole Striding (PS). More recently
this nomenclature has been changed to Nordic Walking (NW) 66
.
23
2.2.2. Nordic Walking
Nordic Walking is a form of walking that uses the muscles of the upper and lower body in
a continuous motion movement (Figure 2.1). The poles are similar to those used in cross country
skiing but have rubber tips and modified hand grips designed to provide a better platform for the
hand during the push phase of poling 66-68
(Figure 2.2.). The walking pattern while using the poles
is the same pattern as walking without them. In other words, the reciprocal pattern between upper
and lower extremity is maintained. That is when the right hand moves forward, it is accompanied
by the left foot. When the arm is finishing its swing phase, the poles, which are at an inclination
of approximately 60 degrees, are pushed against the floor. At this point is important to keep the
elbow extended, as flexing this joint would interrupt the forces being transmitted from the floor
to the body. The hands should constantly be in a "grip-n-go" state with the pole. The pole is
griped every time it hits the ground, and then released as it is drawn back behind the body,
finishing up with an open hand. As the arms continue to move the poles, the torso and hips are
involved in a counter-swinging motion from the lower body 67
.
When anyone with a balance problem uses the poles, the pole‟s inclination does not need
to be backwards. In this case, the person positions the poles in front of their body, aligned with
the opposite foot at a 90 degree angle against the floor. As the person using the poles masters this
initial technique the poles can be moved progressively backwards 69
.
The flexible technique of Nordic Walking can be adapted to clients with different needs.
2.2.2.1. History of Nordic Walking
The popularity of this intervention is increasing, especially among middle age and elderly
people. Nordic Walking has spread from Finland, where 20% of the population are now regular
Nordic Walkers, to Germany and Austria, where there are recognized training programmes and
24
systems for accreditation for walking instructors. In the European countries, this technique is
suggested for middle age and elderly persons as a fitness program by preventive medicine
practitioners 70
. The health benefits are believed to be of such a level that health insurance
companies pay for Nordic Walking classes 71
.
However, Nordic Walking has a very short history. It was developed in the 70‟s to allow
professional cross-country skiers to continue training during summer time. When the first book
about Nordic Walking was published the authors did not expect that Nordic Walking would be
such a success in the outdoor leisure industry or that it would feature as one of the centrepieces of
the 2003 International Tradeshow for Sports (ISPO) 71
.
The unique feature of this walking technique is the way in which familiar elements such
as assisted devices, social and physical skills and the idea of walking for fun are linked together.
The idea of walking for fun is already well established, but not with sticks (poles). They have a
long history but not one that is associated with fun. Walking sticks are usually associated with
frailty and disability 71
.
Overtime, the Nordic Walking industry started working with physiotherapists to design
better walking poles adapted for different populations, with the aim of getting people to use sticks
not because they were injured but to prevent themselves from becoming so 71
.
Although the concept of Nordic Walking is spreading, its full acceptance depends on
breaking down a few myths. First, depending on the way people face the use of the poles, some
would say that Nordic Walking is for frail people, as they associate the poles with assistive
devices. Others see Nordic Walking practitioners as very fit skiers. The second myth is related to
the social acceptance: people are afraid of looking silly using the poles, as depicted in the carton
(Figure 2.3). In a review by Shove and Pantzar (2009) 71
, many Nordic Walking practitioners
were reported to prefer to start using the walking technique with a group of friends. Only after
25
they were confident in their ability and satisfied with the results of group exercise would they
start doing Nordic Walking alone in the streets. One would think that the proven positive effects
of Nordic Walking would be enough to overcome personal vanity and a misplaced concerned
with appearance.
2.2.2.2. The Effects of Nordic Walking
The annotated bibliography on Nordic Walking is comprised of 57 studies from 1992 to
2009. Amongst those studies, 23 are English peer reviewed publications and 34 are from the
“grey literature”. The peer reviewed publications were obtained online and the information on the
grey literature was obtained from the International Nordic Association via email (office@inwa-
nordicwalking.com.)
The quantitative studies related to Nordic Walking can be divided into three main fields:
1) health, where the studies include patients with pathological conditions; 2) fitness, in which
participants are physically active individuals and 3) sports performance that includes only
athletes. Few qualitative studies have estimated the safety or popularity of the technique.
2.2.2.2.1. Nordic Walking for People with Health Conditions
Eight studies involved populations with a variety of health conditions. Common findings
were that NW improved aerobic and muscular endurance as well as an increase in metabolic
markers and health-related life outcomes.
Three pre-post studies of Nordic Walking and Health Sciences were annotated in the
bibliography.
Baatile et al. (2000) 72
, in a pre-post study including 16 elderly males with Parkinson‟s
disease, suggested that Nordic Walking performed three times a week for eight weeks, improved
26
quality of life and perceived functional independence. The time spent doing the walking
intervention was not reported.
Schottoer et al. (2005) 73
studied 150 patients with orthopaedic problems performing
Nordic Walking for three times a week. Although the length of the program was not reported,
93% of participants reported increased endurance and 63% of them reported an improvement on
resistance to stress.
Nineteen elderly persons with type 2-diabetes performed Nordic Walking for 90 minutes,
twice a week, for one year in a study by Nischwitz et al. (2006) 74
. Results indicated
improvements in all diabetes-related metabolic indicators and significant reduction in daily
medication dosage.
As summarized in Table 2.1, there have been four randomized controlled trials (RCT):
Three involving people with health conditions and one in a sedentary population.
Collins et al., (2002;2005) 67
;68
studied 52 clients with peripheral vascular diseases
performing 30 to 45 minutes of Nordic Walking, three times a week, for 6 months. The
researchers concluded that walking with poles effectively improved both the exercise tolerance
and perceived quality of life in those patients. In another publication using the same population,
68 the researchers found a significant impact on cardiovascular fitness, improved perception of
health related quality of life, and decreased pain during exertion. Langbein et al. (2002) 75
in
secondary analysis of their data reported a significant improvement in perceived distance walked
and perceived gait speed in those performing Nordic Walking.
In Sprod et al. (2005) 76
, 12 middle aged women with breast cancer were randomized to
Overground Walking or Nordic Walking, where exercises were performed for 20 minutes, twice
a week, for 8 weeks. They found no improvements in the control group. The Nordic Walking
group had improved endurance of the upper body.
27
Strombeck et al. (2007) 77
analyzed the data from 21 middle aged women with rheumatic
disease, randomized into Nordic Walking or stretching exercises. The duration of intervention
was 45 minutes, three times a week, for 12 weeks. Significant improvements in oxygen
consumption, fatigue and depression were found among participants in the intervention group.
Kukkonen-Harjula et al. (2007) 70
randomized 121 middle aged healthy women to either
40 minutes of Nordic Walking or Brisk Walking, four times per week, for 13 weeks. The only
muscular endurance of the quadriceps muscle from participants performing Nordic Walking was
the only outcome that showed significant improvement.
A study by Walter et al. (1996) 66
, on a population who had undergone coronary artery
bypass surgery (CABG) will be discussed below as there was no training protocol involved.
These RCT‟s studies aimed to estimate the effectiveness of a Nordic Walking intervention
on physiological and health related quality of life and demonstrated significant effects on these
two variables. Unfortunately, the remaining publications were either too underpowered to detect
a clinically meaningful change, were biased or were limited in their generalizability through the
recruitment of a selected population. Another point elicited in reviewing these RCT‟s is the
considerable variation among the interventions used in these trials.
2.2.2.2.2. Fitness Studies on Nordic Walking
The studies that estimated the effects of Nordic Walking on fitness were associated with
improvements in physiological changes suggesting this type of exercise is potent enough to
produce a training effect 66;78-83
. Eight cross-over designs were carried out at one point in time in
order to assess physiological responses.
28
.In the study by Walter et al. (1996)
66 14 patients with coronary artery diseases who
walked with poles showed greater energy consumption and heart rate compared to walking on the
treadmill.
Porcari et al. (1997) 78
examined, in 32 healthy individuals the physiological response to
walking with and without poles. The Nordic Walking participants showed, on average, 23 %
higher oxygen uptake, 22% higher caloric expenditure and 16 % higher heart rate responses when
compared to participants walking on the treadmill.
Church et al. 2002 79
analyzed the effects of walking on an outdoor track with and without
the poles in 22 young participants. Although perceived exertion did not differ between groups,
the participants with the poles had, on average, 20% greater oxygen consumption, caloric
expenditure and heart rates.
In Wilson et al. (2001) 80
data from 13 healthy adults were analyzed during overground
walking with and without the poles. It was reported that the use of walking poles enabled
participants to walk at a faster speed with reduced vertical ground reaction forces, vertical knee
joint reaction forces and a reduction in the knee extensor angular impulse and support moment.
Thus, people using poles are able to walk faster with less impact on their lower extremity joints.
Parker et al. (2002) 84
compared the metabolic responses to graded exercise walking with
and without poles in 14 physically active young subjects. No differences were found in the heart
rate or metabolic parameters regardless of walking group.
Rodgers et al. (1995) 82
examining walking in a healthy group of women (n = 10) found
that oxygen consumption, heart rate and caloric expenditure were significantly greater when
walking with the poles than what was observed during Overground Walking. Once again,
perceived exertion was not significantly different between the two trainings groups.
29
Schiffers et al. (2006) 83
compared the physiological responses during walking, Nordic
Walking and jogging in fifteen healthy middle-aged women. The authors concluded that sub-
maximal lactate level was lower in Nordic Walking compared to walking or jogging.
In Knight and Caldwell (2000) 85
participants walked on an inclined treadmill carrying a
backpack weighting 30% of the participant‟s body mass. Those using the poles showed longer
stride length, higher heart rate and lower rating of perceived exertion. A similar study was
performed by Jacobson et al. (2000) 81
where 22 healthy volunteers walked with and without
poles caring a backpack of 15 kg. Among heart rate, oxygen consumption, caloric expenditure,
and rating of perceived exertion, the latter was the only that showed any significant differences in
those walking with poles.
The studies related to Nordic Walking and sports performance were not summarized as
their results are not applicable to the objectives of this thesis.
Few studies were published in European journals in languages other than English 86-88
. All
these studies used a cross-over design at one point in time and are not reported in here.
In summary, benefits of Nordic Walking are seen in greater cardio respiratory workload
without an increase in the rate of exertion 70;78;79
. Subjects are able to exercise longer and harder
compared to traditional walking 79
. Furthermore, poles provide additional stability and help
reduce the mechanical load on the musculoskeletal system 79;80;88
. This intervention is
inexpensive, does not require complex apparatus or skilled practitioners, which contributes to its
increased feasibility 79
. Additionally, there have been fewer complaints and side effects reported
among Nordic Walking practitioners compared to traditional walking practitioners 72;89
.
The essential physiological difference between Nordic Walking and traditional walking is
the increase in the total exercising muscle mass 68
. The reason for this is because the poles act as
a force transmitter. The force of the poles against the floor is transmitted to the upper extremity,
30
principally the dorsalis major muscle 72
. Additionally, individuals with good poling technique
may have better blood perfusion of the leg muscles 75.
It is possible to infer that Nordic Walking is more intensive than Overground Walking
training and appears to be effective in improving physiological responses of the human body. As
yet no study on the efficacy of this intervention has addressed the needs of a frail elderly
population.
Although studies on Nordic Walking show positive results in various populations, the
interventions implemented thus far have been lengthy, resembling fitness programs. Nordic
Walking has not been adequately studied as a potential rehabilitation technique. The only study 76
using Nordic Walking with a duration shorter than 30 minutes had a small sample size and was
unpowered to detect changes.
The absence of studies on Nordic Walking as a rehabilitation technique as well as use of
Nordic Walking by an elderly frail population and the need for a more intensive and safe way to
train walking are the stimuli for further studies on Nordic Walking in an elderly population.
31
Figure 2.1 - Nordic Walking sequence
Source: Intraspec.ca at http://intraspec.ca/nordic-walking.php
Figure 2.2 – Nordic Walking equipment: poles and hand grip
Source: Intraspec.ca at http://intraspec.ca/nordic-walking.php
Terminal phase
Initial phase
Mid-phase
Hand grip Poles
32
Figure 2.3 - Nordic Walking and its social myths
Source: Garry Parsons Illustrations, 2008
33
Table 2.1- Summary of the Randomized Controlled Trials on Nordic Walking.
Author Population Sample Size Intervention Outcome
Kukonen Harjula,
2007 72
Middle aged
women
IG: n = 54
age = 54 ( 3)
IG: Nordic Walking (40 min)
4x/week; 13 weeks
VO2 max
Neuromuscular test (one leg squat)
CG: n= 53
age= 54 ( 3)
CG: Brisk walking (40 min)
4x/w; 13 weeks
Heart Rate
Muscle-skeletal pain region
Lactate level
Collins, 200267
Peripheral Vascular
Disease
G1: n = 13
age = 67 (6)
G1: Nordic Walking + Vit. E
45-60 min; 3x/week; 24 wks VO2 max
Arterial Blood Flow to the leg
G2: n = 14
age = 64 (8)
G2: Nordic Walking with oil pill
45-60 min; 3x/week; 24 wks Perceived distance walked
Perceived leg pain
G3: n = 13
age = 67 (9)
G3: Vit. E without exercise HRQOL
Perceived gait speed G4: n = 12
age = 70 (8)
G4: Oil pill
Collins, 2005 68
Peripheral Vascular
Disease
IG: n = 27
age = 65 (7)
IG: Nordic Walking, 30 to 60
minutes; 3x/week; 24 weeks VO2 max
Arterial Blood Flow to the legs
CG: n = 25
age = 68 (8)
CG: measurement of Ankle
Brachial Index (ABI) biweekly Exercised time/oxygen uptake
HRQOL
Langbein,200275
Peripheral Vascular
Disease
IG: n = 27
age = 65 (7)
IG: Nordic Walking, 30 to 60
minutes; 3x/week; 24 weeks
Perceived leg pain
Exercise symptoms-free
CG: n = 25
age = 68 (8)
CG: Measurement of Ankle
Brachial Index (ABI) biweekly Perceived distance walked
Perceived gait speed
Strombeck, 2007 77
Rheumatic Disease IG: n =9
age = 60 (41-65)
IG: Nordic Walking (45 min)
3x/week; 12 weeks VO2
Fatigue CG: n = 10
age=56 (42-63)
CG: Range of motion exercises
3x/week; 12 weeks
Anxiety
Depression
34
Author Population Sample Size Intervention Outcome
Sprod, 200576
Breast Cancer IG: n= 6
age = 50 (3)
IG: Pole walking (20 min) +
resistance training (30 min) +
stretching; 2x/week; 8 weeks
Shoulder ROM
Upper body muscular endurance
CG: n= 6
age = 59 (5)
CG: Walking (20 min) + resistance
training (30 min) + stretching
2x/week; 8 weeks
Outcomes in bold are statistically significant. IG = Intervention group; CG = Control group; G1 = group one; G2 = group 2; G3 = group
three; G4 = group four; VO2 = oxygen consumption; HRQOL = Health related quality of life; ROM = Range of Motion
35
CHAPTER 3
RATIONALE AND OBJECTIVES
Based on the World Health Organization‟s (WHO)
International Classification of
Functioning, Disability and Health (ICF), age related impairments among the elderly, poor
cardio-respiratory function, muscle weakness, dynamic instability, and fear of falling, would lead
to limitations in basic activities, such as walking capacity and performance, which would lead to
restrictions in role participation, and affect overall quality of life. This ICF model would suggest
that intervening to improve walking capacity would favourable impact on the health and quality
of life of frail elders (See appendix A.1 for details on the theoretical model).
Nordic Walking provides a number of advantages as a rehabilitation technique. With
Nordic Walking, the presence of poles may be seen as exercises aids, which might encourage
greater compliance with walking training. Second, the longer stride length and pelvis counter
movement provided by Nordic Walking are likely to stimulate a more physiological gait, instead
of the shuffling one observed in this population. Third, without a shuffling gait, better heel strike
occurs providing the necessary impact to stimulate necessary to bone remodelling. As ground
reactions forces are smaller with Nordic Walking, the impact from Nordic Walking will benefit
those people with lower extremity joint pathology. Fourth, Nordic walking might strengthen
lower extremity and core muscles. Finally, Nordic Walking training might improve cardio-
respiratory conditioning in the frail elderly. When all these factors are combined, Nordic Walking
has the potential to positively affect elderly mobility, resulting in an improved walking capacity.
36
Additionally, balance and self confidence may increase, leading to a decrease in the fear of
falling.
Based on positive results in VO2 max seen in various populations after Nordic Walking 90-
92, we might expect improvements in walking capacity in an elderly population after a Nordic
Walking intervention.
The frail elderly pose other challenges beyond poor walking capacity, such as balance
deficits necessitating the use of walking aids. However, using walking aids such as canes or
walker is not compatible with good gait patterns as many people adopt a stooped posture when
using them. As a consequence, the frail elderly are prone to adopt slow gait and restricted use of
walking beyond that required for fulfilling basic needs which will affect negatively their cardio-
respiratory condition.
In summary, Nordic Walking appears promising as a rehabilitation technique. Studies in
the field have been methodologically divergent, especially in the timing, duration and intensity of
the interventions. Furthermore, evidence is lacking on the efficacy or effectiveness of Nordic
Walking on functional outcomes such as capacity to do distance walking and gait speed. This
study will be the first to directly compare Nordic Walking with traditional walking training
through a randomized controlled trial among frail elderly. A pilot trial will be performed, before
embarking on a large randomized controlled trial of this intervention.
The primary objective of this pilot study was to estimate for frail elderly persons the
relative efficacy in improving functional walking capacity of two gait training interventions:
Nordic Walking and Overground Walking.
A secondary objective was to explore the impact of walking training with poles on self-
perceived fear of falling.
37
We hypothesize that people receiving Nordic Walking, after 6 weeks of intervention, will
show a clinically meaningful improvement in their distance walked in 6 minutes, in gait speed
and perceived fear of falling, while persons in the usual walking group will not show meaningful
changes.
38
CHAPTER 4:
MANUSCRIPT 1
4.1. A structured review and meta-analysis on the effectiveness of walking training
in the elderly
Sabrina Figueiredo, B.Sc., PT1; Diana Dawes, M.Sc
1.; Miho Asano, M.Sc
1.;
Nancy E. Mayo, Ph.D1,2,3
.
1. Faculty of Medicine, School of Physical and Occupational Therapy, McGill University,
Montreal, Quebec, Canada
2. Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada
3. Faculty of Medicine , Department of Geriatrics, McGill University, Montreal, Quebec,
Canada
Manuscript prepared for submission to the journal entitled JAGS
Running title: Effectiveness of walking training in the elderly
Name and address for communications and reprint requests:
Nancy E. Mayo,, PhD
Royal Victoria Hospital
Division of Clinical Epidemiology
687 Pine Avenue West, Ross 4.29
Montreal, Quebec, Canada
H3A 1A1
Email: [email protected]
39
Abstract
Objectives: To derive a global estimate of the effect of walking training as an strategy to
improve distance walked and gait speed in the elderly.
Design: A structured review of publications on MEDLINE, Embase, CINAHL and the
Cochrane Library using the following terms MeSH walking, MeSH gait, MeSH ambulation,
MeSH rehabilitation, MeSH physical endurance, gait velocity, gait speed, six minute walk test,
5MWT, 6MWT. Effects sizes of each intervention were estimated and forest plotted; a meta-
analysis estimated and overall effect size.
Results: Seven studies were retrieved from an initial pool of 1387 articles. Treadmill and
Overground walking were the main strategies used to train walking. No consistency regarding
intensity, duration and frequency of training was found. Effectiveness of the walking program on
distance walked was small in all studies, ranging from 0.03 to 0.4. The overall effect size for
walking distance was 0.26 (95% CI: 0.01 to 0.51). The effectiveness of walking programs for
improving gait speed ranged from small effects sizes (ES = - 0.2 to 0.4) to large ones (ES = 2.2
and 3.0) with the latter arising from studies with very small sample sizes. The overall effect size
was 0.35 (95% CI: -1.89 to 2.60).
Conclusions Among the 7 studies reviewed only two were designed rigorously enough to
detect effectiveness. Despite the reported significant statistical differences in two studies, the
effects sizes were small for treadmill or regular overground walking training, performed 2-3
times a week for 6 weeks. The overall effect size was non-significant.
Keywords: structured review; walking program; walking distance; gait speed; elderly.
40
Introduction
The elderly are the fastest growing proportion of the population. In 1997, 6.6% of the
world population was over 65 years. This proportion is expected to increase to 10% by 2025,
amounting to 800 million seniors worldwide 1
Functional independence is often jeopardized among aged people. Accompanying the
physiological aging process are declines in cognitive and physical function which leads to
compromised static and dynamic balance, loss of muscle strength, and diminished vestibular and
visual function. These in turn will affect the quality of gait and the capacity for functional and
safe ambulation2;3
. These limitations are more pronounced when associated with other
comorbidities and exacerbations of disease 4.
Reduced gait speed and incapacity to walk long distances are common impairments
among the elderly. Functional walking capacity, reflected by distance walked and gait speed, are
related to community mobility and participation in personal, family and societal roles 5. Gait
speeds of 1.2 m/s and 0.8m/s are necessary for an individual to safely cross a 4- and 2- lane street
6. Furthermore, these two variables are predictors of hospitalization, institutionalization, and
perceived and diagnosed health status 5;7;8
. For these reasons improving the walking capacity of
the elderly is a common objective among rehabilitation professionals.
As a structured review, the aim of this paper is 1) to derive an estimate of the overall
effect of walking training as a strategy to promote improvement in either walking distance or gait
speed in the elderly and 2) to provide a comprehensive review of the literature for practitioners,
managers and researchers.
41
Methods
Data source and extraction
The literature published in English or Portuguese between 1997 to 2008 in MEDLINE
(using PubMed and Ovid); Embase and the Cochrane library was searched. The terms used in the
search were:
MeSH walking, MeSH gait, MeSH ambulation, MeSH rehabilitation, MeSH physical
endurance, gait velocity, gait speed, six minute walk test, 5MWT, 6MWT.
References from the acquired articles were also searched for further relevant studies. The
last date for this search was December 25, 2008.
Study Selection
Inclusion criteria for the analysis were (1) participants 65 years or older; (2) walking
training strategy clearly described; (3) gait speed and walking distance as an outcome; (4) clearly
reported mean changes and standard deviations of the main outcomes; (5) studies done with
humans, randomized controlled trials and systematic reviews. Excluded were studies if (1) it was
impossible to extract or calculate the appropriate data from the published results or (2) there was
a secondary analysis of results from the same data set.
Statistical Analysis
Stats Direct Software was used to calculate the effectiveness of each intervention by
calculating their effect sizes. This software uses g (modified Glass statistic with pooled sample
standard deviation), to calculate an effect size. The formula for calculating g is:
where μi is mean of the intervention group and μc is mean of the control group 9.
42
Random effects model was used due to the heterogeneity of the treatment plans. Estimates
of effect sizes and corresponding 95% confidence intervals were derived from the parameters
arising from these models. A random effects model make inferences about the parameters of a
population of studies that is larger than the set of observed studies. This model assumes that these
studies are a random sample of studies that would be done in this area, therefore this model is
more generalizable 9.
Results
Using the search key-words and limiting the search to studies done in humans,
randomized controlled trials and systematic reviews 1387 articles were retrieved.
Based on the inclusion criteria, 296 studies were retained. On reviewing the titles 39
publications were selected, from which an in-depth review excluded 32 studies due to age of
participants, walking training was not the intervention and absence of a control group. The final
analysis included 7 studies summarized in Table 4.1.
[Insert Table 4.1 about here]
Walking Training
Among the 7 RCT‟s, there was no consistency as to the content of walking training.
Treadmill walking was used in three studies 10-12
and overground walking was used in another
four 13-16
. The frequency and intensity varied greatly across studies. The frequency ranged from 1
to 5 times a week and program length from 4 to 48 weeks. The only similarity among the studies
was the duration of walking. As expected in all studies, walking was performed for at least 20
minutes, an inclusion criterion of this review.
43
In four of the studies strengthening exercises were also used to improve walking capacity
10;11;13;16.
In the following analysis only the walking part of the intervention group was outlined and
included.
Effectiveness of walking training on distance walked
Four studies 10;13-15
had distance walked as the outcome of walking training. In each of the
studies, the effect size for the intervention group was calculated and summarized.
In Holland et al. (2008) 15
30 participants with Interstitial Lung Disease performed
walking training for 30 minutes, twice a week, for 8 weeks. Distance walked significantly
improved 35 meters (p<0.001). The effect size for the intervention was 0.4.
In Salbach et al. (2004), 10
44 participants recovering from a stroke, exercised 10 minutes
on the treadmill and another 15 minutes speed walking, 3 times a week for 6 weeks. The 40m
change in distance walked in 6 minutes in the intervention group was significant (95% CI 29 to
51m). The effect size for the intervention was 0.3.
Moffet and colleagues (2004) 13
analyzed 38 participants after a knee arthroplasty, who
walked for a maximum of 20 minutes, twice a week, for 6 weeks. The authors reported
significant improvement in their distance walked measured with the 6MWT (p = 0.04), with an
effect size of 0.2.
In Mangione et al. (2005) 14
, 12 participants, after a hip fracture, performed Overground
Walking for 40 minutes, once or twice a week, for 4 months. Distance walked, measured at
baseline and post-intervention was reported as significantly improved after the intervention,
although no statistical values were reported. The effect size for the study of Mangione et al.
(2005) was 0.03.
44
In each of these studies, the control groups differed; however, there were no changes in
gait and walking measures under the control circumstances 10-16
.
Due to the heterogeneity of the interventions, outcome measures and units of
measurement, effect size (ES) was used to compare effectiveness of each intervention. ES was
used because it is unit-less rendering within and cross-study comparisons meaningful. As
classified by Cohen 17
, values < 0.5 are indicative of a small effect; values ranging from 0.5 to 0.8
are indicative of a moderate effect, and values greater than 0.8 are indicative of a large effect.
In contrast to the statistical significant results reported by each author, the effects sizes
calculated here for the studies were small (< 0.5). Furthermore, in all 4 studies the 95%
confidence interval of the effects sizes included the null value. The effects sizes and their
confidence intervals were graphically reported in Figure 4.1. The overall effect size was 0.26
(95% CI: 0.01 to 0.51).
[Insert Figure 4.1 about here]
Effectiveness of walking program on gait speed
Five studies had comfortable gait speed as an outcome of walking training 10-12;14;16
.
Salbach et al. (2004) 10
and Mangione et al. (2005) 14
were the only authors who measured
both distance walked and gait speed. The interventions of both studies were mentioned in the
previous section. Both these studies reported significant changes in gait speed. Salbach et al.
(2004) 10
reported a mean change in comfortable gait speed of 0.14 m./sec (95% CI: 0.073 to
0.17). No statistical values were mentioned in Mangione et al. (2005) 14
. The effects sizes were
0.3 and -0.2, respectively.
45
Park et al. (2008) 16
, analyzed results of 25 elderly that walked, at least 20 minutes, thrice
a week for 48 weeks, and reported significant improvement in gait speed (p < 0.05). The effect
size was 0.4.
Tong et al. (2006) 12
, analyzed data from 30 participants with stroke using an
electromechanical gait trainer for 20 minutes, 5 times a week for 4 weeks. The authors reported a
significant improvement on gait speed when measured before and after intervention (p < 0.001).
The effect size was 2.2.
In Shimada et al. (2004) 11
, 18 frail elderly walked once or thrice a week for 6 months for
at least 20 minutes. Despite no significant difference was detected in gait speed between baseline
and post-intervention evaluations (p = 0.06), the effect size for this study was large (E.S = 3.0).
The studies of Salbach et al. (2004) 10
, Mangione et al. (2005) 14
and Park et al. (2008) 16
had a
small ES‟s with 95% CI of the effect sizes including the null value. The studies from Shimada et
al. (2004) 11
and Tong et al. (2006) 12
with 15 and 25 subjects respectively, showed large ES‟s.
The overall effect size for gait speed was 0.35 (95% CI: -1.89 to 2.60). These effects are
presented in Figure 4.2.
[Insert Figure 4.2 about here]
Discussion
A structured review of the literature with a meta-analysis was performed to characterize
the type of walking strategies used for the elderly and the accumulation of evidence on the
effectiveness of walking strategies.
46
The results of this review suggest that specific walking training is being used sparingly
among elderly clientele. Moreover it confirms the results of Lopopolo 18
, where the effects of
exercise intervention were rated as small or non-existent.
Walking Training Strategies
Among these studies no consistency existed between the walking strategies used.
Although many authors reported a statistically significant improvement 10;12-16
only studies
related to improvements on gait speed achieved large effect sizes 11;12
. The studies of
interventions targeting walking distance were ineffective, with small effects sizes 10;13-15
.
A recent systematic review 18
suggested that to improve walking distance and speed
among the elderly, a substantial dose of walking intensity and frequency is required. Most
participants walked at a low intensity, less than daily, and any changes seen had little or no carry-
over into function.
For clinicians, the treadmill appears to be more feasible than regular walking training as it
is more easily “dosed” to achieve a therapeutic effect and allows the therapist to perform multiple
activities at the same time although close supervision would be required for safety. However, the
use of a treadmill is not well accepted among the elderly. Many of them consider the apparatus as
a physical barrier and this resistance impacts negatively on their performance 19
. Overground
walking training with longer duration should be encouraged. It is safe, feasible and involves one
of the main activities of daily living. Unfortunately, this can be boring and without continued
stimulation, psychomotor slowing can result in suboptimal gait speed and early termination.
Many of the excluded articles presented the results of strengthening exercises to achieve
gains in walking. Although lower limb strengthening may positively affect the kinematic and
47
kinetic patterns of gait, these gains may not necessarily transferred into functional capacities such
as walking distance and speed. Due to the specificity of physical training, it makes clinical sense
to incorporate walking strategies into rehabilitation treatments.
The impact of a study design and statistics
Five publications demonstrated small effects sizes 10;13-16
. A small ES may be explained
by a weak intervention or a small sample size used in these studies, and this same effect size may
not be seen on repeated testing in a larger sample.
The magnitude of ES is related to sample size. For instance, a study with two independent
samples, with an alpha level of 0.05, and 90% power to detect an ES between 0.10 and 0.60
requires a sample size ranging from 60 to 2100 persons per group 9;17
. In this review, the two
studies reporting large ES for gait speed had a sample size of either 15 12
or 25 persons per group
16. Clearly, these sample sizes were not designed to detect the acclaimed ES. Studies with enough
power need to be carried out or studies need to be designed to fit into a meta-analysis. In which
case, an a priori establishment of inclusion and exclusion criteria, outcomes and time points for
assessment is needed.
A difference exists between a statistically significant difference and a clinically
meaningful difference. With a large sample size, even small differences may achieve
significance. The intervention may only have a small effect on improving gait speed and walking
distance, despite the significant statistical difference observed between the baseline and post-
interventions assessments 20
. With small sample sizes, the confidence intervals around the
estimate include the null value and are labeled “not significant”. Unfortunately, clinically
meaningful changes may be disregarded as unimportant.
48
Interestingly, in the study by Shimada et al 11
no statistical difference was reported. Yet a
large effect size was observed. One possible reason for this is the very small standard deviation of
4.4 m/s at baseline. This small denominator would lead to a large effect size regardless of the
value of the mean differences in the numerator.
Conclusion
Improvement in walking capacity is a common end-point in rehabilitation. However no
specific walking training program has shown effective results for walking distance or gait speed.
As few studies aiming to improving gait speed and distance in the elderly were randomized
controlled trials, the level of evidence on walking training for the elderly remains unclear.
One of the purposes of this review was to provide evidence for better practice. We would
encourage researchers to increase their sample size to have enough power to detect change and
clinicians to use a more focused walking training program with an adequate dose as far as
intensity and frequency.
Potential limitations
The literature search was only performed in English and Portuguese. Peer reviewed
publications in other languages were excluded.
Acknowledgments
The authors thank Dr. Lois Finch for her extensive support.
Conflict of interest:
The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of the paper.
49
Author Contributions
Sabrina Figueiredo was responsible for conducting the scoping review, analyzing the data
and writing the manuscript. Miho Asano provided guidance on the scoping review and statistical
analyses. Diana Dawes was an advisor on the performance of a scoping review. Nancy Mayo
edited the paper.
Sponsor’s Role
Operating funds were provided by the MUHC – Geriatrics Funding.
50
Graphics
Table 4.1 – Summary of studies on walking capacity of the elderly
Author Population Age Sample Size Intervention Outcome
Salbach, 2004 10
Stroke 71 12 WG = 44
CG = 47
3x/w – 6 weeks
WG: 10 functional task to strengthen
lower limbs (including treadmill
and speed walk)
Walking distance
Gait speed Berg Balance
Timed up and go
CG: upper extremity activities
Moffet, 2004 13
Knee arthroplasty 66 8 WG = 38 60-90 min; 12 sessions; 6-8 weeks Walking distance
CG = 39 WG: stretching; strengthening; task
oriented exercises, walking
Lower Extremity Pain
SF-36
CG: post-operative standard care
(home visits)
Shimada 2004 11
Frail elderly 66 ± 9 WG = 18 1-3 x/week - 6 months Gait speed
CG = 14 WG: Treadmill gait training +
Usual care (stretching,
resistance training, group
training, and outdoor gait
training) (frequency not
reported)
Reaction time
Balance (one-leg standing
time)
Functional Reach Test
Number of Falls
CG: Usual care (stretching,
resistance training, group
training, and outdoor gait
training)
Mangione 2005 14
Hip Fracture 78 7 WG =12 40 min – 1-2 x/week- 3 months Walking distance
CG = 10 WG: Regular walking Gait speed CG: Biweekly informational
mailings about physical
activity
Strength
Mental status
51
Author Population Age Sample Size Intervention Outcome
Tong, 2006 12
Stroke 66 ± 9 WG: 15 20-minute - 5 x/w - 4 weeks Gait speed CG = 16 WG: electromechanical gait trainer FIM instrument score
CG: overground gait training Barthel Index
Elderly Mobility Scale
Berg Balance Scale
Functional Ambulatory
Category
Holland,2007 15
Interstitial lung 67 13 WG = 30 30 minutes – 2x/w/ - 8 weeks Walking distance
disease CG = 27 WG: Walking training, upper limb
endurance, strengthening Fatigue
Chronic Disease Questionnaire
CG: biweekly phone follow-up Dyspnea Score
Park, 200816
Elderly 65-70 WG = 25 60 min-3x/w – 48 weeks Gait speed CG = 25 WG = Walking training, stretching;
strength, weight bearing,
balance, posture exercises
Body sway
Bone mineral density
Body fat composition CG = retained sedentary lifestyle Falls experience VO2 Max One leg stand Maximal step length
Outcomes in bold are statistically significant. WG = Walking Group; CG = Control Group; WGF = walking group with FES.
52
Figure 4.1 – Effects Size of walking training on walking distance
Figure 4.2 - Effects Size of walking training on gait speed
Effect size meta-analysis plot [random effects]
-1.0 -0.5 0.5 1.0
Holland, 2008
Moffet, 2004
Salbach, 2004
Mangione, 2005
0
DL pooled effect size = 0.268779 (95% CI = 0.018405 to 0.519153)
Effect size meta-analysis plot [random effects]
-6 -1 4 9 14
Salbach, 2004
Shimada, 2004
Tong, 2006
Mangione, 2005
Park, 2008
0
DL pooled effect size = 0.352758 (95% CI = -1.894506 to 2.600023)
53
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(2) Prince F, Corriveau H, Hebert R, Winter D. Gait in the elderly. Gait & Posture 5, 128-
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(11) Shimada H, Obuchi S, Furuna T, Suzuki T. New intervention program for preventing falls
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separated treadmill. Am J Phys Med Rehabil 2004;83:493-499.
(12) Tong RK, Ng MF, Li LS. Effectiveness of gait training using an electromechanical gait
trainer, with and without functional electric stimulation, in subacute stroke: a randomized
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(13) Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive
rehabilitation on functional ability and quality of life after first total knee arthroplasty: A
single-blind randomized controlled trial. Arch Phys Med Rehabil 2004;85:546-556.
(14) Mangione KK, Craik RL, Tomlinson SS, Palombaro KM. Can elderly patients who have
had a hip fracture perform moderate- to high-intensity exercise at home? Phys Ther
2005;85:727-739.
(15) Holland AE, Hill CJ, Conron M, Munro P, McDonald CF. Short term improvement in
exercise capacity and symptoms following exercise training in interstitial lung disease.
Thorax 2008;63:549-554.
(16) Park H, Kim KJ, Komatsu T, Park SK, Mutoh Y. Effect of combined exercise training on
bone, body balance, and gait ability: a randomized controlled study in community-
dwelling elderly women. J Bone Miner Metab 2008;26:254-259.
(17) Cohen J. Statistical power analysis for the behavioral sciences. Academic Press New
York, 1977.
(18) Lopopolo RB, Greco M, Sullivan D, Craik RL, Mangione KK. Effect of therapeutic
exercise on gait speed in community-dwelling elderly people: a meta-analysis. Phys Ther
2006;86:520-540.
(19) Wass E, Taylor NF, Matsas A. Familiarisation to treadmill walking in unimpaired older
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(20) Collins EG, Edwin LW, Orebaugh C et al. PoleStriding exercise and vitamin E for
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55
CHAPTER 5
INTEGRATION OF MANUSCRIPT 1 AND MANUSCRIPT 2
5.1. Primary research objective of manuscript 1 and 2
Manuscript 1:
To derive a global estimate of the effectiveness of walking training on walking distance
and speed in the elderly
Manuscript 2:
To estimate for frail elderly persons the relative efficacy in improving functional walking
capacity of two gait training interventions: Nordic style pole walking and Overground Walking.
5.2. Integration of manuscript 1 and 2
From manuscript 1 it was possible to infer that research is required to identify a
rehabilitation approaches that would be effective, safe, and sustainable in promoting
improvements in functional walking capacity within an elderly population.
A pilot trial was designed to test Nordic Walking. The study was a single blinded,
randomized, pilot trial designed to estimate the amount of change between two programs –
walking with poles and Overground Walking - during 6 weeks. This project is equivalent to a
Phase II trial where safety and efficacy would be estimated.
56
CHAPTER 6:
MANUSCRIPT 2
6.1. Nordic Walking For Frail Elderly: A Randomized Pilot Trial
Sabrina Figueiredo, B.Sc. PT1; Lois Finch, Ph.D
2, Gloria Mjiali, B.Sc. PT
2,
Sara Ahmed, Ph.D1, Alan Huang, M.D
3, Nancy E. Mayo, Ph.D
1,2,3.
1. Faculty of Medicine, School of Physical and Occupational Therapy, McGill University,
Montreal, Qc, Canada
2. Division of Clinical Epidemiology, McGill University, Montreal, Qc, Canada
3. Faculty of Medicine , Department of Geriatrics, McGill University, Montreal, Qc, Canada
Manuscript prepared for submission to the journal entitled JAGS
Running title: Nordic Walking for Frail Elderly: A Randomized Pilot Trial
Name and address for communications and reprint requests:
Nancy E. Mayo,, PhD
Royal Victoria Hospital
Division of Clinical Epidemiology
687, Pine Avenue West, Ross 4.29
Montreal, Quebec, Canada
H3A 1A1
Email: [email protected]
57
Abstract
Objectives: To estimate for frail elderly persons the relative efficacy in improving
functional walking capacity of two gait training strategies: Nordic style pole walking and usual
Overground Walking. A secondary objective was to explore the impact of walking training with
poles on self- perceived fear of falling.
Design: Single blind, site-stratified, randomized, pilot trial designed to estimate the
amount of change with Nordic Walking and with Overground walking.
Methods: Outpatients from a geriatric day-hospital or inpatients from a rehabilitation
hospital were randomized to Nordic Walking (n = 14) or Overground walking (n = 16). The
intervention group consisted of walking with poles while the control group involved walking
with or without a usual walking aid. Participants attended sessions twice a week for a maximum
of 6 weeks. The outcomes were functional walking capacity measured by the distance covered in
six-minute (Six minute walk test - 6MWT) and gait speed over 5 meters; fear of falling was a
secondary outcome. Explanatory variables were age, sex, number of comorbidities, walking aids,
balance, pain, and leg function. Exploratory outcomes were activity and self-reported health.
Results: Nordic and Overground Walking participants improved 41 meters on the 6MWT and
increased their gait speed by 0.21 m/s and 0.08 m/s, respectively. Only improvement in gait
speed in the Nordic Walking group reached statistical significance. Fear of falling decreased 10%
among persons in the Nordic Walking group and 6% for persons in the control group. Nordic
Walking effect sizes were moderate for 6MWT (ES = 0.5), large for gait speed (ES = 0.9), and
small for fear of falling (E.S = 0.4). In contrast, Overground Walking demonstrated moderate
effects sizes for 6MWT (ES = 0.5) and small ones for gait speed (E.S = 0.4) and fear of falling
(E.S = 0.3).
58
Conclusions: Nordic Walking is 125% more effective in improving gait speed among a
frail rehabilitation population than Overground Walking. Although the confidence intervals
around these estimates are wide, these findings can be used to design a future trial to estimate the
impact of Nordic Walking on gait speed, mobility, community participation and quality of life for
frail elders undergoing physical rehabilitation
Keywords: Frail elderly, Nordic Walking, Overground Walking, walking distance, gait
speed.
59
Introduction
The elderly are the fastest growing segment of the population. In Canada they are
increasing at the rate of 2.7% per year and presently comprise 12% of the population 1.
Elders have a number of comorbid health conditions and are often considered frail. In a
study by Fried et al 2 74% of subjects aged 65years and older reported difficulty walking 2 to 3
blocks and 15% were housebound. These participants had, on average, 4 chronic diseases and
28% of them were frail. Unfortunately, this is the population at highest risk of activity limitations
and participation restrictions due to sensory and mobility impairments.
Due to this multifaceted disability, pre-frail or frail elderly require complex health care to
simultaneously minimize the severity of multiple chronic diseases, promote the maintenance of
function, and prevent further frailty, functional decline, and loss of independence 3.
Rehabilitation professionals are increasingly being charged to use evidence-based
practices and there is a need to identify effective strategies and interventions to promote and
maintain mobility and walking capacity in seniors 3. Recent studies have demonstrated that no
single modality is capable of achieving improvements in walking capacity as walking is a
relatively complex activity and the strategies offered are neither intensive nor specific enough 4.
As walking independence is of key importance in the elderly and walking is often the
only form of exercise available to the elderly, strategies to promote walking capacity in the
elderly would be of great benefit to elders and to the health care system.
A promising walking strategy is Nordic Walking (NW). When used by the fit, it is an
intensive form of walking that uses the muscles of the upper and lower body in a continuous and
reciprocal movement. The poles used are similar to those used in cross country skiing but have
rubber tips and modified hand grips designed to provide a better platform for the hand during the
60
push phase of poling. The poles provide balance and promote a more physiological gait pattern 5-
11. There is evidence in healthy populations that Nordic Walking leads to greater cardio
respiratory workload without an increase in the level of exertion 6;7;12
. Subjects are able to
exercise longer and harder compared to traditional walking 7. There is limited evidence for the
use of Nordic Walking in persons with health conditions. The only finding in this population is
increased oxygen consumption and health-related quality of life and decreased fatigue and
depression 13-16
. Moreover, Nordic Walking has never been tested as a rehabilitation strategy.
The ultimate goal of this study is to generate data to be used to design a future trial to
estimate the impact of Nordic Walking on gait speed, mobility, community participation and
quality of life of persons with or at risk for frailty.
The primary objective of this pilot study was to estimate for frail elderly persons
receiving rehabilitation, the relative efficacy in improving functional walking capacity of two gait
training strategies: Nordic style pole walking and Overground Walking.
Based on previous studies 11,23-25
, in which gait patterns improvements positively affected
fear of falling, a secondary objective of this study was to explore the impact of walking training
with poles on self- perceived fear of falling.
We hypothesize that people receiving Nordic Walking, after 6 weeks of intervention, will
show a clinically meaningful improvement in their distance walked in 6 minutes, in gait speed
and in perceived fear of falling, while persons in the usual walking group will not show
meaningful changes.
Methods
Subjects
61
Subjects were recruited from two rehabilitation centers from the Greater Montreal Area.
Eligibility criteria included: (1) 65 years old or more; (2) undergoing rehabilitation program; (3)
medically stable or in their usually state of health. Reasons for exclusions were (1) severe
cognitive impairments (Brief Mini-Mental Score less than 14/22), (2) unable to ambulate a
minimum of 15 meters with or without aids; (3) unrestricted mobility as represented by a gait
speed greater than 1.2 m/s, (4) moderate to severe impairments of upper extremity represented by
a shoulder flexion range of motion (ROM) less than 90 degrees and extension less than 20
degrees; elbow flexion ROM less than 90 degrees; and with a poor grip judged by the ability to
release a can of 5 cm diameter (3) pathological conditions of the upper extremity and (4)
individuals who planned time in rehabilitation was less than six weeks.
Evaluations
Evaluations were conducted by trained evaluators at baseline, and on completion of the
intervention (6 weeks post). Initially, the evaluations were planned to be conducted at baseline,
after 2 and 8 weeks. The intervention was reduced to 6 weeks to adjust for the length of stay of
the participants at both centers. Consequently, an assessment at week 2 would be burdensome for
the participant and would not provide any extra valuable information.
Measurement
Functional walking capacity was represented by a measure of walking distance and gait
speed. The Six Minute Walk Test (6MWT) and comfortable gait speed over five meters (5MGS)
were selected as primary measures. Both walking tests assess components of walking required of
an independent community ambulatory: gait speed, walking distance and balance. Fear of falling
was the third primary measure and reflects self-confidence in walking balance. Explanatory
62
outcomes were the Berg Balance Scale, Visual Analogue Scale (VAS) for pain, and the Lower
Extremity Function Scale (LEFS). Exploratory outcomes were Community Healthy Activities
Model Program for Seniors Activities Questionnaire for Older Adults (CHAMPS), and the
Euroqol-5D (EQ-5D) a generic measure of health. Other explanatory variables, socio-
demographic information, comorbidity, and prescribed medications, were obtained through chart
review.
Six Minute Walk Test (6MWT)
The 6MWT is well established, valid and reliable measure for assessing ambulation in the
elderly 17-19
. It is a safe sub-maximal test, well tolerated and a simple measure of functional
walking capacity in clinical populations 20;21
. In this study it was performed in a 20-m enclosed
corridor and with the outcome being the total distance walked during six minutes 21
. Individuals
were instructed to walk as far as possible in six minutes at their own pace. Rests were taken as
needed but participants were encouraged to resume walking as soon as they were ready to do so.
The number and duration of rests, as well as the total distance ambulated were recorded.
Perceived exertion was assessed before and immediately after testing. Standardized instructions
and encouragements were used. (See appendix A.2 for details).
Five Meter Gait Speed (5MGS)
The 5MGS test was used in this study to compute comfortable gait speed. First subjects
were instructed to walk a 9-m distance at a comfortable pace and were timed using a stopwatch
over the middle 5-m section. (See appendix A.2 for details). The 5MGS test is well established,
valid and reliable measure for assessing ambulation in the elderly 17-19
.
Fear of falling - Visual Analogue Scale (VAS)
Fear of falling was measured with a visual analogue scale. Participants were asked to rate
their fear falling, in which zero represents no fear of falling and a hundred represents the highest
63
fear of falling (See appendix A.2 for details). Poor psychometric properties of more specific fear
of falling measures were the reason for choosing the visual analogue scale instead.
Berg Balance Scale
The Berg Balance Scale was used to measure functional balance which may explain why
gains in the primary outcome were achieved. Participants were required to perform 14
movements required in everyday living 22
. The total score is out of 56 and higher scores reflect a
better level of balance ability. The Berg Balance Scale is well established, valid and reliable
measure 23
(See appendix A.2 for details). A change of 3 points is the clinical meaningful change
in the Berg Balance Scale and a score of 45 is the cut-off for identifying those at risk of falling 24
.
Lower Extremity Functional Scale (LEFS)
In this study, the LEFS was used to measure lower extremity function which may explain
why hypothesized progress was not achieved and to identify adverse effects. Participants were
asked to rate the level of difficulty on performing 20 activities of daily living on a 5-point scale,
with higher scores representing greater lower extremity ability (See appendix A.2 for details).
Pain - Visual Analog Scale (VAS)
The Pain VAS was used to measure upper extremity pain which may be an adverse effect.
Participants were asked to rate their pain, in which the null value represented no pain and a value
of hundred represented the highest level of pain (See appendix A.2 for details).
CHAMPS (Community Healthy Activities Model Program for Seniors Activities Questionnaire
for Older Adults) – Short Form
The CHAMPS – short form was used to assess the overall activity and participation level
of each participant which was hypothesized to change as a result of better ambulation and was an
exploratory outcome. This measure asks the subject to describe the usual activities they did over
the past two weeks. Some examples of activities are housework, hobbies, exercises, reading,
64
watching T.V., among others. Additionally the participant was asked how often during the week
and the number of hours spent performing each activity (See appendix A.2 for details).
EUROQOL-5D (EQ-5D)
In this study, the EQ5D was used to assess health related quality of life (HRQL) of each
participant. This generic measure describes HRQL in terms of 5 dimensions - mobility, self
care, usual activity, pain/discomfort and anxiety/depression. The questionnaire records the
respondent‟s perception of their problems on each of the EQ-5D dimensions, together with an
overall rating of health status on a „feeling thermometer‟ calibrated between 0 (worst
imaginable health state) and 100 (best imaginable health state). It has been widely used in
diverse population (See appendix A.2 for details). It was also an exploratory outcome.
Randomization
Subjects were stratified by setting and randomized into one of two groups, Nordic
Walking or Overground Walking. Randomization was computer generated using randomization
scheme from the website Randomization.com at http://www.randomization.com. The
randomization was hidden from the investigators and revealed only when a subject had consented
and been evaluated.
Interventions
Subjects in both groups participated, on average, in 6 weeks of training, twice a week,
with a duration of 20 minutes daily. Each program was divided into three phases: warm-up,
walking and cool-down. Six weeks was chosen as this was the realistic amount of time available
for training given the usual length of the rehabilitation programs and the time required for
consent and evaluation.
65
Training sessions were individual and were provided by a physiotherapist who was also a
certified Nordic Walking instructor.
During each session, gait speed was determined by the subject; according to what he/she
felt was a comfortable pace. Perceived exertion was also monitored using the Borg Scale.
Therapists provided encouragement throughout the training session. Intensity, duration and
participant perception of safety were recorded at every session.
In the Nordic Walking Group participants were specifically taught how to use the poles
and were instructed in how to walk in a corridor with a reciprocal gait pattern. The heights of the
poles were calculated for each subject according to 70% of their height. Participants in the
Overground walking group were instructed to walk in a corridor. If necessary, they could use
their walking aids.
In both groups, participants were oriented to perform, outside of training time, a
component of their walking training; for the Nordic Walking group they were instructed to walk
simulating the movements of arms and legs as if using poles; for the control group, they were
instructed to just practice walking as usual. All subjects continued to participate in their regular
physiotherapy and occupational therapy programs.
Sample size
Sample size estimates were based on the premise that the intervention group would
achieve a change in 6MWT distance that was at least 20% greater than the control group (relative
efficacy of 1.20) 25
. Based on previous data from the Institution where the study was held, a
positive change of an average of 28 meters was expected in the control group. An increase of
20% of this change (28 meters) is approximately 6 meters. The estimated sample size with 80%
power, to detect a within-group change of 34 meters with baseline standard deviation of 67, at
66
alpha level 0.05, was 12 subjects completing the study in each group. To allow for a drop-out
margin, 15 participants were recruited for each group.
This approach was chosen because Nordic Walking is a simple and inexpensive approach
that would be of benefit even if it only increased the benefits of gait training marginally (20%) 25
.
Statistical methods
Data were analyzed on intention to treat basis. First, basic descriptive statistics was used
to characterize the participants. Fisher exact and t-tests were used to compare the two groups at
baseline. For each group separately, means of all outcomes were calculated at baseline and
follow-up; mean change was also calculated as were 95% confidence intervals (95% CI) using
the formula:
For categorical variables, proportion of persons participating in different types of
activities pre and post intervention, McNemar‟s test was used.
To calculate the relative efficacy, effect sizes (mean differences/standard deviation at
baseline) for each intervention was calculated and a ratio from the effects sizes of the two
interventions was calculated by:
Missing data represented 14% of the data and was related to grave illness or death.
Participants with missing data were not included in the analysis of this pilot trial.
67
The research ethics committees at both study sites approved the study and all subjects
provided informed, written consent (See appendices A.3 and A.4 for more information on ethics
approval and consent form).
Results
Participant flow and handling of missing data
Between January and June 2009, 30 people were enrolled in the study. 14 subjects were
randomized to the Nordic Walking intervention and 16 subjects to the Overground walking
group. Table 6.1 presents baseline characteristics of the study groups which did not differ
between groups. Despite the apparent greater proportion of previous fallers in the NW group
(21%) compared with the Overground group (12%), this difference was not statistically
significant in a sample of this size.
[Insert Table 6.1 about here]
Figure 6.1 presents a flow diagram of participants in the study and provides details of
recruitment, withdrawals and missing data. Missing data occurring at follow-up were due to
death (n=1), severe illness (n=2) or pain (n=1), the participants were not included in the analysis.
As this study is a pilot one, the true effect of Nordic Walking and Overground walking was
estimated by analyzing the participants who completed all the interventions and assessments
(Nordic Walking =13; Overground Walking = 13).
[Insert Figure 6.1 about here]
68
Outcomes and estimation
Table 6.2 presents the performance of participants on the 6MWT, 5 m. gait speed, VAS-
fear of falling, Berg Balance Scale, VAS-pain, LEFS, EQ5-D. Participants from the Nordic
Walking intervention improved their 6MWT performance by an average of 41 m and reduced the
time needed to comfortably walk 5 meters by 2.2 seconds for an increase in gait speed of 0.22
m/sec. Fear of falling decreased by 10 percent.
The overground walking training participants improved their walking distance by 41 m,
reduced the time to walk 5 meters comfortably by 0.8 seconds (change in gait speed of 0.08
m/sec.), and decreased fear of falling by 6%. For both groups, the changes in 6MWT and Berg
Balance Scale were significant as the 95% CI excluded the null value. Change in comfortable
gait speed was significant only in the Nordic Walking group (95% CI: 0.09 to 0.3).
The CHAMPS questionnaire yields data on intensity of activities; the data are counts of
the number of people participating in hard, moderate and easy intensity exercises pre and post
intervention. The options are: A participated both pre and post; D did participate neither pre nor
post; B participated post but not pre (improvement); C participated pre but not post
(deterioration). Table 6.3 shows the numbers of people who were concordant and discordant for
activities pre and post intervention. The numbers in the A and D columns are counts of people
that did not change activity over time. The numbers in the B column indicate people that
increased activity post-intervention, and the numbers in the C column indicate people that
decreased activity post-intervention. In the Nordic Walking group, there was little change and
some deterioration in moderate intensity activities. In the Overground Walking group, from pre
to post intervention, people reduced their level of activity. The p-value associated with the
McNemar‟s chi-square test was also presented. The only significant p values are for
deterioration.
69
All other variables showed no significant changes.
[Insert Table 6.2 and 6.3 about here]
Table 6.4 shows the effects sizes for each intervention and their ratios. The Nordic
Walking intervention showed a moderate effect size for 6MWT (E.S. = 0.5), a large one (ES =
0.9) for gait speed, and a small one for fear of falling (E.S = 0.4). The Overground Walking
intervention showed moderate effects sizes for 6MWT (ES = 0.5) and small ones for gait speed
(E.S = 0.4) and fear of falling (E.S = 0.3).
The ratio of the effects sizes of Nordic Walking and Overground Walking for 6MWT was
1, for gait speed was 2.25, and for fear of falling was 1.33. Nordic Walking was 125% more
effective than Overground Walking in improving gait speed and is as effective as Overground
Walking in improving 6MWT. The greater efficacy of NW in improving fear of falling is not
significant.
[Insert Table 6.4 about here]
Adverse events
Throughout the study, a total of 234 walking sessions (132 Overground Walking; 102
Nordic Walking sessions) were conducted. No patients experienced an adverse event such as a
fall or injury and there was no increase in pain or deterioration in lower extremity function.
70
Discussion
A randomized pilot trial was performed to estimate, among frail elderly, the relative
efficacy of Nordic Walking in improving functional walking capacity (distance and speed) and
fear of falling.
The results of this pilot trial suggest that for an elderly mobility compromised population
Nordic Walking is 125% and 33% more effective than Overground Walking in improving
comfortable gait speed and fear of falling, respectively. Improvements in 6MWT were similar for
Nordic Walking and Overground Walking.
The gait speed of this population was well below that required for community ambulation
26 at 0.56 m/sec for the Nordic Walking group and 0.61 m/s for the Overground Walking group at
baseline. Only the Nordic Walking group increased gait speed a clinically relevant amount > 0.2
m/sec. However, the final gait speed of 0.77 m/sec is still slower than the minimum needed for
safe community ambulation – 0.8 to 1.2 m/sec 26
.
One explanation for this increased speed in the Nordic Walking group is that the poles act
as a force transmitter, propelling the lower limbs and thus the body forward. This is congruent
with the results from Wilson et al., 2001 who found what exactly 8. The person learns this more
efficient and powerful way of walking even when not using the poles. As there were significant
changes on the Berg Balance Score among subjects in both groups, owing most likely to the
interventions carried out as part of the regular rehabilitation program, the change in gait speed
cannot be attributed only to change in balance.
Although the effectiveness ratio suggests Nordic Walking is 33% more effective in
improving fear of falling than Overground Walking, the 95% CI is not significant. The greater
efficacy of Nordic Walking on fear of falling could be explained by the association between fear
71
of falling and gait speed and balance ability. As shown by Chamberlin et al., 2005 27
greater fear
of falling is highly associated with slower gait speed. The increase in the Nordic Walking
participant‟s gait speed may have directly affected their fear of falling as at the end of the
intervention, participants from this group reported less fear of falling. Also, as shown by Hatch
el., 2003 28
among 50 elderly, aged 65 to 95 years old, balance explained 75 % of the fear of
falling variance. Therefore balance improvements will affect perceived fear of falling.
Nevertheless, the intervention in this study was not long enough to evoke fear of falling
improvements.
Both groups showed equal improvement in 6MWT. As this study measured walking
distance via a sub-maximal text (6MWT) the results in here cannot be comparable with those
from a number of other researchers 29-33
who used maximal oxygen consumption to measure the
impact of Nordic walking. In studies from other authors 34-37
changes in walking distance is
similar, or a little superior, to what was obtained here. Nevertheless, in those studies the
intervention was longer and more frequent. However, both groups showed a greater than
expected change in 6MWT. This is probably due to the enhanced walking practice given to both
groups equivalent to an additional 40 minutes per week. In our preparatory work, we noted that
walking practice was done for only 4 to 10 minutes during a therapy session.
There was little change in HRQL which is not surprising during the short intervention
time and that 65% of the sample were inpatients during the study. HRQL is a construct that takes
time to realize following gains in mobility 38
. Similarly, there was no positive change in activity
level.
Future research involving a longer intervention, and the opportunity to use the poles for
walking and exercise in the community, will address the impact on activity and HRQL.
72
Commentary from the Nordic Walking participants indicated the training was greatly
enjoyed as participants felt they were using sport-related equipment rather than disability focused
assistive devices such as canes and walkers. Some participants went even further by stating they
would now go outside using the poles but would not do so with a walker. This information is
consistent with that reported by others 13-15;39
.
Use of the poles did not increase shoulder or arm pain or disability in the legs which is a
positive finding given that many elderly have concomitant arthritis and the use of the arms in the
walking exercise could increase shoulder pain.
The cost-effectiveness of the Nordic Walking as a rehabilitation strategy is apparent as the
cost of a set of Nordic Walking poles is minimal ranging from 40 to 100 dollars based on hand
grip, materials, and height options. As some poles are height adjustable, this represents a minimal
investment for a rehabilitation unit.
Potential limitations
There are a number of limitations to this study, the main one being its pilot nature with a
small sample size. The frequency and duration of the intervention was short and varied
depending on the duration of stay in the rehabilitation setting which was outside the control of the
study. It was likely not long enough to have the desired impact. And, finally, without a post
intervention follow-up, maintenance of gains is unmeasured. However, the data from this pilot
study is more than adequate to motivate a larger randomized clinical trial to estimate the change
in each outcome.
73
Conclusion
Among a mobility challenged frail elderly population, Nordic Walking is 125% more
effective in improving gait speed than regular Overground Walking. Moreover Nordic Walking is
a safe, feasible and enjoyable technique. Therapists may want use Nordic Walking as a
rehabilitation strategy to improve gait speed in the elderly.
Although the confidence intervals around these estimates are wide, these findings can be
used to design a future trial to estimate the impact of Nordic Walking on gait speed, mobility,
community participation and quality of life of persons with or at risk for frailty.
Acknowledgments
The authors thank Lyne Nadeau and Susan Scott for their assistance with randomization
and data analysis; all the staff from the Geriatric Day Hospital at the Royal Victoria Hospital and
from the Richardson Hospital; Harshida Pattel for contributing with the intervention procedure
and the data collection.
Conflict of interest
The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of the paper.
Author Contributions
Sabrina Figueiredo was responsible for conducting the trial, analyzing the data and
writing the manuscripts. Dr. Lois Finch provided guidance throughout the study and edited the
paper. Gloria Mjiali conducted the evaluations. Dr. Sara Ahmed and Dr. Allen Huang provided
74
theoretical input. Dr. Nancy Mayo supervised all aspects of the project, providing procedural
guidance, edited and reviewed the paper. Lyne Nadeau provided assistance with database
development and management and statistical programming.
Sponsor’s Role
Canadian Nordic Walking Association provided 5 pair of poles and two certified training
courses. The North American Nordic Association provided 5 pair of poles. The study was
supported by MUHC – Geriatric Funding.
75
Graphics
Table 6.1 – Characteristics of study subjects at baseline
Characteristic Nordic Walking (n = 14) Overground Walking (n = 16)
Inpatient/Outpatient Rehabilitation
Age years mean (± SD)[range]
65% / 35%
78 (± 7) [66-88]
63% / 37%
78 (± 7) [65-92]
Women 57% 56%
Previous faller 21% 12%
Walking aid users 93% 94%
Number of Comorbidities
0-5 65% 42%
6-10 21% 44%
11-15 14% 6%
>15 0% 6%
76
Table 6.2 – Characteristics of the study subjects on all outcomes at baseline (pre) and after intervention
(post) and on change from pre to post.
SD = Standard Deviation; LEFS = Lower Extremity Functional Scale; VAS = Visual Analogue Scale;
EQ-5D = Euroqol-5D.
Measure Nordic Walking
(n = 13)
Overground Walking
(n = 13)
Mean SD Range 95%CI Mean SD Range 95%CI
6 Minute Walt Test (m)
Pre 196 77 (120-420) 225 73 (120-367)
Post 237 83 (120-474) 266 84 (164-480)
Change 41 48 (11,70) 41 54 (7,75)
5 Meter Gait Speed (m/s)
Pre 0.56 0.23 (0.36-1.09) 0.61 0.20 (0.31-0.93)
Post 0.77 0.21 (0.60-1.30) 0.69 0.23 (0.14-0.91)
Change 0.21 0.14 (0.09,0.3) 0.08 0.21 (-0.1,0.25)
Fear of Falling (VAS – 0/100)
Pre 35 30 (0-80) 24 24 (0-70)
Post 22 28 (0-80) 18 23 (0-70)
Change -10 23 (-7,21) -6 14 (-3,15)
Berg Balance Scale (0/56)
Pre 44 5 (38-55) 39 6 34-56
Post 46 5 (39-56) 46 5 38-56
Change 2 6 (0,4-8) 7 6 (3,10)
LEFS (0-80)
Pre 38 11 (18-53) 38 15 (18-64)
Post 36 11 (20-60) 39 15 (23-60)
Change -2 9 (-6 , 3) 1 6 (-0.6 , 7)
Pain (VAS- 0/100)
Pre 13 20 (0-60) 15 13 (0-40)
Post 17 20 (0-50) 22 18 (0-50)
Change 4 18 (-7 , 15) 7 20 (-6 , 17)
EQ5D (VAS – 0/100)
Pre 60 12 (40-85) 65 18 (30-90)
Post 63 14 (35-90) 63 15 (25-80)
Change
3 17 (-7 , 13) -2 14 (-11 , 6)
77
Table 6.3 - Counts of persons sustaining and changing activities after the intervention period
Activity Intensity Nordic Walking Overground Walking
AD BC p AD BC P
Easy 12 0 1 0 0.3 10 0 0 3 0.08
Moderate 4 0 0 8 0.005 5 0 0 8 0.005
Hard 11 0 1 1 1.0 9 0 0 4 0.04
Columns A and D indicate the number of persons who sustained the same level of activity; A
participated both pre and post; D did not participate neither pre nor post. Column B indicates the
number of persons participating post but not pre (improvement) and C pre but not post
(deterioration).
78
Table 6.4 – Interventions‟ effects size and the ratio between Nordic Walking (NW) and
Overground Walking (OW)
Measure Effect Size of
Nordic Walking
Effect Size of
Overground Walking
Ratio
NW/OW
Six-minute walk test (m) 0.5 0.5 1
Comfortable gait speed (s) 0.9 0.4 2.25
Fear of Falling (VAS – 0/100) 0.4 0.3 1.33
Berg Balance Scale (0/56) 0.4 1.1 0.4
LEFS (0/80) 0 0 0
Pain (VAS – 0/100) 0.2 0.5 0.4
EQ-5D (VAS – 0/100) 0.2 0.1 2
Nordic Walking = NW; Overground Walking = OW; LEFS = Lower Extremity Functional Scale;
VAS = Visual Analogue Scale; EQ5D = Euroqol-5D
79
Figure 6.1 – Flow of participants through the trial
Assessed for eligibility
(n = 39)
Excluded
(n = 6)
Eligible patients
(n = 33)
Refused
(n = 3; 10%)
Randomized
(n = 30)
Allocated to Nordic Walking (n = 14)
Outpatients (n = 5)
Inpatients (n = 9)
Allocated to Overground Walking (n = 16)
Outpatients (n = 6)
Inpatients (n = 10)
Analysed (n = 13)
Missing data (n = 1)
Discontinued intervention (n = 1)
1 got worse
Analysed (n = 13)
Missing data (n = 3)
Discontinued Intervention (n = 3)
2 got worse
1 passed away
80
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82
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dwelling elderly people. Phys Ther 2003;83:1072-1079.
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83
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had a hip fracture perform moderate- to high-intensity exercise at home? Phys Ther
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(35) Salbach NM, Mayo NE, Wood-Dauphinee S, Hanley JA, Richards CL, Cote R. A task-
orientated intervention enhances walking distance and speed in the first year post stroke:
a randomized controlled trial. Clin Rehabil 2004;18:509-519.
(36) Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive
rehabilitation on functional ability and quality of life after first total knee arthroplasty: A
single-blind randomized controlled trial. Arch Phys Med Rehabil 2004;85:546-556.
(37) Holland AE, Hill CJ, Conron M, Munro P, McDonald CF. Short term improvement in
exercise capacity and symptoms following exercise training in interstitial lung disease.
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of early supported discharge for stroke. Stroke 2000;31:1016-1023.
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84
CHAPTER 7
SUMMARY AND CONCLUSION
Lately, the elderly population has received a great deal of attention in terms of research
and clinical care, mainly because it comprises a large part of the world population, and, because
this portion of the population is increasing at a considerable rate, compared with the other ages
groups. Moreover, the aging process is marked by many age-related changes resulting in
impairments of body functions, activity limitations and participation restrictions. When the
delicate equilibrium of the body is unbalanced, the health and environmental stressors exceed the
person‟s reserve and frailty ensues. Frail persons are characterized by decreased gait speed,
decreased grip strength, decreased physical activity, more exhaustion, and more than a 10 pound
or 5% of weight loss in the previous year 3.
Rehabilitation professionals are best suited to intervene favorably in many of the frailty
indicators, particularly to improve walking capacity.
In Chapter 4, manuscript 1 entitled “A structured review and meta-analysis on the
effectiveness of walking training in the elderly” indicates that there is a lack of rehabilitation
interventions able to promote gains in walking capacity in the elderly. Seven randomized trials
showed small effects sizes with confidence intervals that included the null value. The two studies
which demonstrated larger effects sizes had flaws in their study design namely small samples
sizes and unusually small variation. The results from these studies provided the incentive to find
an intervention that could be used in the rehabilitation environment and would be able to produce
important gains in walking distance and speed.
85
Given the scant literature and inconsistency in the existing interventions to address
walking limitations among the elderly, a pilot study was designed to estimate the relative
efficacy of two interventions: Nordic Walking and Overground Walking. The reason for
choosing these two interventions was because walking is a common and safe technique,
practiced by everyone, and it is required for daily life as well as a form of exercise and
recreation. Although Nordic Walking resembles walking, it is more intense as it also uses the
upper limbs. It also has less of a disability image and more of a fitness image. Nordic Walking
has not been studied as a rehabilitation strategy, indicating that many questions about this
technique need to be answered. An in-depth review of these two techniques was provided in
Chapter 2.
In Chapter 6, manuscript 2 “Nordic Walking for Frail Elders: A Randomized Pilot Trial”
is the first study to directly compare Nordic Walking with Overground Walking, and their
respective effects in walking capacity in frail elderly. The trial was a single-blinded, randomized,
pilot trial equivalent to a Phase II trial where safety and efficacy were estimated. The results
from this trial proved to be optimistic as Nordic Walking, for a frail elderly population, was
125% more effective in improving gait speed than regular Overground Walking. Moreover,
Nordic Walking was as effective as Overground Walking in improving walking distance. Other
positive aspect of Nordic Walking was that participants enjoyed it and it was a pain free
intervention.
In this trial the relative efficacy of both interventions was reported, rather than the mean
differences of each outcome. This approach was chosen, due to the small sample size, but yet
appropriate for this kind of trial. An adequately powered, parallel-group, randomized clinical
trial will be designed based on these results.
86
From these preliminary results is possible to infer that adequate walking training
strategies for the elderly, based on scientific evidence, with proven results are needed.
The main focus for designing this trial was not to design a walking training that would
address all the problems related to walking disabilities, but to provide evidence for a single
strategy that is easy to adopt and would produce small but worthwhile gains in gait speed or
walking distance. This walking training strategy would then be added to the other strategies
therapists use to enhance walking and gait quality. Nordic Walking combined with other proven
strategies should provide therapists with the necessary “pieces” to plan an intervention and
design a complete evidence-based walking program. Therefore, future work is encouraged.
As with any study, this project has limitations that must be considered when examining
the results. In the first manuscript only one abstractor performed the review. This may have had
an impact on the final selection of articles. Additionally, studies other than English and
Portuguese might have been excluded. In the second manuscript, the sample size was small and
there is no follow-up assessment, which prevents verifying the maintenance of the effectiveness
of each intervention.
87
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APPENDICES
A.1- Conceptual model
Shopping
Attending social events
Walking
limitation
•Shorter Stride length
•Decreased pelvis counter
movements
•Muscle weakness
•Static and dynamic instability
•Fear of falling
Personal
factorsNordic Walking
Ageing
A01
A.2 – Outcomes measures
A02
__________________________________________________________________
1. Socio Demographic Information
2. Berg Balance Scale
3. Fear of Falling - VAS
4. CHAMPS – Short version
5. LEFS – Lower Extremity functional Scale
6. Pain – VAS
7. EuroQol-5D
8. Five Meter Walk Test
9. Six Minute Walk Test
Subject Name:________________________________________
Setting:_____________________________________________
Days attending setting:_________________________________
Date (DD/MM/YY):______________________________________
Evaluator:___________________________________________
Nordic Walking Measurements
(English)
Evaluation ___Initial ___ 3 weeks Follow Up ___ 8 weeks Follow Up
A03
SOCIO-DEMOGRAPHIC AND HEALTH-RELATED INFORMATION
_______________________________________________________________________________________
Patient Gender (1) male_______ (2) female________
Patient date of birth: dd/mm/yyyy _____/_______/______ Age:
Past Medical History:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Medications/dosage:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
.
A04
SOCIO-DEMOGRAPHIC AND HEALTH-RELATED INFORMATION
_______________________________________________________________________________________
Height:__________________ Weight*:________________________
*(Date when was taken):________________
DD/MM/YY
What is the average amount of caffeine (COFFE, BLACK TEA, SOFT DRINKS WITH CAFFEINE) intake per
day?
(a) None
(b) One cup per day
(c) 2 to 4 cups per day
(d) More than 4 cups per day
Have you fallen in the past month? (1) yes_______ (2)No_________
If yes, how many times? _______________ Where?______________________________________________
+At the present moment, do you use any type of walking aids? (1) yes_______ (2)No_________
If yes, what type?__________________________ Since when?___________________________________
Where:__________________________________________________________________________________
A05
BERG BALANCE SCALE
_______________________________________________________________________________________
In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are
deducted if the time or distance requirements are not met, if the subject's performance warrants supervision, or if
the subject touches an external support or receives assistance from the examiner. Subjects should understand that
they must maintain their balance while attempting the tasks. The choices of which leg to stand on or how far to
reach are left to the subject. Poor judgement will adversely influence the performance and the scoring.
Equipment required for testing are a stopwatch or watch with a second hand, and a ruler or other indicator of 5, 12
and 25 centimetres. Chairs used during testing should be of reasonable height. Either a step or a stool (of average
step height) may be used for item 12.
1. Sitting to standing
Instructions: Please stand up. Try not to use your hands for support.
( ) 4 able to stand without using hands and stabilize independently
( ) 3 able to stand independently using hands
( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or to stabilize
( ) 0 needs moderate or maximal assist to stand
2. Standing unsupported
Instructions: Please stand for 2 minutes without holding.
( ) 4 able to stand safely 2 minutes
( ) 3 able to stand 2 minutes with supervision
( ) 2 able to stand 30 seconds unsupported
( ) 1 needs several tries to stand 30 seconds unsupported
( ) 0 unable to stand 30 seconds unassisted
If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item 4.
A06
BERG BALANCE SCALE
3. Sitting with back unsupported but feet supported on floor or on a stool
Instructions: Please sit with arms folded for 2 minutes.
( ) 4 able to sit safely and securely 2 minutes
( ) 3 able to sit 2 minutes under supervision
( ) 2 able to sit 30 seconds
( ) 1 able to sit 10 seconds
( ) 0 unable to sit without support 10 seconds
4. Standing to sitting
Instructions: Please sit down.
( ) 4 sits safely with minimal use of hands
( ) 3 controls descent by using hands
( ) 2 uses back of legs against chair to control descent
( ) 1 sits independently but has uncontrolled descent
( ) 0 needs assistance to sit
5. Transfers
Instructions: Arrange chair(s) for a pivot transfer. Ask subject to transfer one way toward a seat with armrests
and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a
bed and a chair.
( ) 4 able to transfer safely with minor use of hands
( ) 3 able to transfer safely definite need of hands
( ) 2 able to transfer with verbal cueing and/or supervision
( ) 1 needs one person to assist
( ) 0 needs two people to assist or supervision to be safe
A07
BERG BALANCE SCALE
_______________________________________________________________________________________
6. Standing unsupported with eyes closed
Instructions: Please close your eyes and stand still for 10 seconds.
( ) 4 able to stand 10 seconds safely
( ) 3 able to stand 10 seconds with supervision
( ) 2 able to stand 3 seconds
( ) 1 unable to keep eyes closed 3 seconds but stays steady
( ) 0 needs help to keep from falling
7. Standing unsupported with feet together
Instructions: Place your feet together and stand 1 minute without holding.
( ) 4 able to place feet together independently and stand safely 1 minute
( ) 3 able to place feet together independently and stand for 1 minute with supervision
( ) 2 able to place feet together independently but unable to hold for 30 seconds
( ) 1 needs help to attain position but able to stand 15 seconds feet together
( ) 0 needs help to attain position and unable to hold for 15 seconds
8. Reaching forward with outstretched arm while standing
Instructions: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. Examiner
places a ruler at end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while
reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in
the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation
of the trunk.
( ) 4 can reach forward confidently > 25 cm (10 inches)
( ) 3 can reach forward > 12 cm safely (5 inches)
( ) 2 can reach forward > 5 cm safely (2 inches)
( ) 1 reaches forward but needs supervision
( ) 0 loses balance while trying/requires external support
A08
BERG BALANCE SCALE
_______________________________________________________________________________________
9. Pick up object from the floor from a standing position
Instructions: Pick up the shoe/slipper which is placed in front of your feet.
( ) 4 able to pick up slipper safely and easily
( ) 3 able to pick up slipper but needs supervision
( ) 2 unable to pick up but reaches 2-5 cm (1-2 inches) from slipper and keeps balance independently
( ) 1 unable to pick up and needs supervision while trying
( ) 0 unable to try/needs assist to keep from losing balance or falling
10. Turning to look behind left and right shoulders while standing
Instructions: Turn to look directly behind you over your left shoulder. Repeat to the right. Examiner may
pick an object to look at directly behind the subject to encourage a better twist turn.
( ) 4 looks behind from both sides and weight shifts well
( ) 3 looks behind one side only other side shows less weight shift
( ) 2 turns sideways only but maintains balance
( ) 1 needs supervision when turning
( ) 0 needs assist to keep from losing balance or falling
11. Turn 360 degrees
Instructions: Turn completely around in a full circle. Pause, then turn a full circle in the other direction.
( ) 4 able to turn 360 degrees safely in 4 seconds or less
( ) 3 able to turn 360 degrees safely one side only in 4 seconds or less
( ) 2 able to turn 360 degrees safely but slowly
( ) 1 needs close supervision or verbal cueing
( ) 0 needs assistance while turning
12. Placing alternative foot on step or stool while standing unsupported
Instructions: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool
four times.
( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds
( ) 3 able to stand independently and complete 8 steps in > 20 seconds
( ) 2 able to complete 4 steps without aid with supervision
( ) 1 able to complete > 2 steps needs minimal assist
( ) 0 needs assistance to keep from falling/unable to try
A09
BERG BALANCE SCALE
_______________________________________________________________________________________
13. Standing unsupported one foot in front
Instructions: (Demonstrate to subject) Place one foot directly in front of the other. If you feel that you cannot
place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the
toes of the other foot. To score 3 points, the length of the step should exceed the length of the other foot and
the width of the stance should approximate the subject's normal stride width.
( ) 4 able to place foot tandem independently and hold 30 seconds
( ) 3 able to place foot ahead of other independently and hold 30 seconds
( ) 2 able to take small step independently and hold 30 seconds
( ) 1 needs help to step but can hold 15 seconds
( ) 0 loses balance while stepping or standing
14. Standing on one leg
Instructions: Stand on one leg as long as you can without holding. The patient needs to get into the position
without using their hands
( ) 4 able to lift leg independently and hold > 10 seconds
( ) 3 able to lift leg independently and hold 5 - 10 seconds
( ) 2 able to lift leg independently and hold = or > 3 seconds
( ) 1 tried to lift leg unable to hold 3 seconds but remains standing independently
( ) 0 unable to try or needs assist to prevent fall.
TOTAL SCORE (Maximum = 56): _____
A10
FEAR OF FALLING (FF) - VAS _______________________________________________________________________________________
To help people say how much fear of falling
they have, we have drawn a scale (rather like a
thermometer) on which the least far of falling is
marked by 0 and the worst fear of falling you
can imagine is marked by 100.
We would like you to indicate on this scale how well
or bad is your fear of falling today, in your opinion.
Your own FF level today
Worst
imaginable
fear of falling
100
90
80
70
60
50
40
30
20
10
0
No FF
A11
CHAMPS – SHORT VERSION _______________________________________________________________________________________
INSTRUCTIONS If the person DID the activity in the past 4 weeks:
Step #1 Record the activity in the box.
Step #2 Ask about how many TIMES a week the person usually does it put the number on the
line
Step #3 write down how many TOTAL HOURS in a typical week he/she did the activity.
Here is an example of how Mrs. Jones would answer: Mrs. Jones usually visits her friends Maria
and Olga twice a week. She usually spends one hour on Monday with Maria and two hours on
Wednesday with Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week.
In a typical week
during the past 4
weeks, did you…
Visit with friends
or family (other
than those you live
with)?
YES How
many TIMES a
week?_____
How many
TOTAL hours
a week did you
usually do it?
Less than
1 hour
1-2½
3-4½
5-6½
7-8½
≥9
List below the activities the person did over the last FOUR WEEKS using the prior CHAMPS interview answers
This Includes
1. Work:
2. Volunteering:
3. Church:
4. Sports:
5. Exercise:
6. Handicrafts:
7. Hobbies:
8. Housework: (LAUNDRY, COOKING, CLEANING, ETC)
9. Visiting
10. also computer, reading watching TV
A12
CHAMPS – SHORT VERSION _______________________________________________________________________________________
List the activities below that the person did typical week during the past 2 weeks as in the CHAMPS
In a typical week during the past 2 weeks, did
you…
How many TOTAL hours a week did you usually do
it?
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
Activity________________
How many TIMES a week?_____
Less than 1 hour, 1-2½ 3-4½
5-6½ 7-8½ ≥9
A13
LOWER EXTREMITY FUNCTIONAL SCALE _______________________________________________________________________________________
We are interested in knowing whether you are having any difficulty at all with the
activities listed below because of your lower limb problem for which you are currently
seeking attention. Please provide an answer for each activity.
Today, do you or would you have any difficulty at all with:
(Circle one number on each line)
ACTIVITIES Extreme
Difficulty
or Unable
to Perform
Activity
Quite a bit
of
Difficulty
Moderate
Difficulty
A Little
bit of
Difficulty
No
Diffi
culty
a. Any of your usual work,
housework or school
activities.
0 1 2 3 4
b. Your usual hobbies,
recreational or sporting
activities.
0 1 2 3 4
c. Getting into or out of the
bath. 0 1 2 3 4
d. Walking between rooms. 0 1 2 3 4
e. Putting on your shoes or
socks. 0 1 2 3 4
f. Squatting. 0 1 2 3 4
g. Lifting an object, like a bag
of groceries from the floor. 0 1 2 3 4
h. Performing light activities
around your home. 0 1 2 3 4
1. Performing heavy activities
around your home. 0 1 2 3 4
j. Getting into or out of a car. 0 1 2 3 4
k. Walking 2 blocks. 0 1 2 3 4
1. Walking a mile. 0 1 2 3 4
m. Going up or down 10 stairs
(about 1 flight of stairs). 0 1 2 3 4
n. Standing for 1 hour. 0 1 2 3 4
A14
LOWER EXTREMITY FUNCTIONAL SCALE _______________________________________________________________________________________
p. Running on even ground. 0 1 2 3 4
q. Running on uneven
ground. 0 1 2 3 4
r. Making sharp turns while
running fast. 0 1 2 3 4
s. Hopping. 0 1 2 3 4
t. Rolling over in bed. 0 1 2 3 4
Column Totals:
Score: _______/80
A15
PAIN - VAS _______________________________________________________________________________________
To help people say how much pain they have,
we have drawn a scale (rather like a
thermometer) on which the least pain is marked
by 0 and the worst pain you can imagine is
marked by 100.
We would like you to indicate on this scale how
good or bad is your pain is today, in your opinion.
Your own pain level today
Worst
Imaginable
pain
100
90
80
70
60
50
40
30
20
10
0
No Pain
A16
EURO-QOL (5D) _______________________________________________________________________________________
Please indicate which statement best describes your own health state today. Do not tick more than one box in
each group.
Mobility
I have no problems in walking about
I have some problems in walking about
I am confined to bed
Self-Care
I have no problems with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
Usual Activities (e.g. work, study, housework,
family or leisure activities)
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities
Pain / Discomfort
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort
Anxiety / Depression
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed
A17
EURO-QOL (5D) _______________________________________________________________________________________
To help people say how good or bad a health
state is, we have drawn a scale (rather like a
thermometer) on which the best state you can
imagine is marked by 100 and the worst state
you can imagine is marked by 0.
We would like you to indicate on this scale how
good or bad is your own health today, in your
opinion. Please do this by drawing a line from the
box below to whichever point on the scale indicates
how good or bad your current health state is.
Your own
health state
today
Best imaginable
health state
100
90
80
70
60
50
40
30
20
10
0
Worst imaginable
health state
A18
GAIT SPEED – 5MWT _______________________________________________________________________________________
Comfortable walking speed is determined over distances of 5. Gait speed is measured in a quiet section of
the hospital corridor, of the rehabilitation department, or of the subject‟s home, using tape to mark the
distances on the floor. Acceleration and deceleration distances, each of 2 m, are marked. Bright pylons are
placed at the outer acceleration lines during testing so that the patient can easily visualize the end of the walk
distance.
The floor should like the following:
I---2 m---I-----------5 m------------I---2 m---I
Confortable gait speed: You should walk along this line in a comfortable pace.
Time spent (seconds): _________________________________________________________
Use of walking aids: Y/N What type: __________________________________
Maximum gait speed: You should walk along this line as fast as safely as possible.
Time spent (seconds): _________________________________________________________
Use of walking aids: Y/N What type: __________________________________
A19
SIX MINUTE WALK TEST
_______________________________________________________________________________
Instructions:
1. The subject should dress in comfortable clothing and wear supportive footwear.
2. The subject may use his/her usual assistive devices (e.g., walker, AFO, etc.). If the subject is
able to perform the test without an assistive device, then allow them to do so. However, be
consistent with previous 6-MWT measures.
3. Instructions:
“The object of this test is to walk back and forth as far as possible for 6 minutes. You will
walk back and forth in this hallway. In case you get out of breath or become exhausted, you
are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall
while resting but must resume walking as soon as you are able. Remember that the object is
to walk AS FAR AS POSSIBLE for 6 minutes, but don’t run or jog.”
4. The pace will be determined by the patient. The physiotherapist should walk slightly behind the
patient so as not to pace them.
5. Encouragement must be standardized as it has been shown to increase walking speed.1
Standardized encouragement was given to all subjects in the study conducted by Gibbons et al.
Every 30 seconds the subjects were told :
“You're doing well, keep up the good work.”
6. Total distance walked and the number and duration of rest periods required are noted
Data:
Suppl 02: ______ L 02/min Acc m use: Y / N # Rests: ________
Duration of Rests: (1) ___________ (2) ___________ (3) ___________ (4) ___________
Distance Walked: _______metres
Average Walking Speed (distance/360 sec): _________ metres/sec.
A20
A.3 - Ethics approval
Ethics approval was obtained in December 15, 2008.
A.4 - Consent forms
Subjects will be asked to provide voluntary informed consent and to sign the consent
form. The researcher will explain the random nature of group allocation, and that the efficacy of
the available training program has not been determined yet. Both groups will receive an active
intervention that will be added to their existing program. The 20 minute intervention will not
detract from other therapeutic activities. It offers minimal risk. The slight risk for falls will be
controlled by the training focused at an individual level. A second person will always be in the
laboratory to provide additional security. Neither group is expected to be harmed by having more
exercise. All adverse events will be recorded and in case of injury, subjects will be treated as
required by medical team. Participants will not be paid to participate in the research project.
Although the research team do not expect any subject incurring an expense during the study since
they are either resident or transported to the center, those requiring transportation will be
reimbursed up to a total of $35.00 per visit.
A21
Patient Consent Form
STUDY TITLE: Nordic Walking for Frail Elderly: A Randomized Pilot Trial
INVESTIGATORS: Nancy E. Mayo BSc PT, MSc, PhD.
COLLABORATORS: Sara Ahmed, BSc PT, MSc, PhD; Allen Huang, MD; Dr. R Ludman,
MD; Ms Nancy Cox, BSc PT; Ms Sabrina Figueiredo, BSc PT, MSc candidate.
STUDY COORDINATOR: Ms Sabrina Figueiredo, BSc PT, MSc candidate.
SPONSORS: Pete Edwards and The American Nordic Walking System,
www.skiwalking.com; Canadian Nordic Walking Association.
Introduction
In many elderly people functional independence is often jeopardized. The decline in physical
function leads to compromised static and dynamic balance, loss of muscle strength, and
diminished visual function, which will affect the quality of safe walking. Although there are a
wide range of rehabilitation interventions that aim to improve walking capacity, to date, no
program has used walking poles as a technique to improve walking capacity in an integrated
rehabilitation program.
Studies have shown that Nordic Walking can improve fitness without increasing effort. People
can then exercise longer without feeling as tired. These studies were only done in a healthy,
middle-aged people. The purpose of our study is to see if in an older group of people Nordic
Walking can be used to improve walking, more than a regular walking training program.
We are a group of researchers from McGill University, McGill University Health Center, and the
Richardson Hospital. We are interested in studying the potential benefits of Nordic Walking. If
you agree to participate, we will randomly assign you to one of the two groups. The decision on
which group you will be in is similar to taking names out of a hat. The two groups are (1) an over
ground walking training program and (2) a pole walking training program.
No matter which group you are assigned to, you will receive a walking training program. This
will consist of walking practice (with or without poles), periods of rest as needed, stretching, and
mobility exercises. The walking program will be added to your usual rehabilitation program at
either the Geriatric Day Hospital at Royal Victoria Hospital or at the Richardson Hospital. The
research intervention will not replace your usual treatment. For 8 weeks, a trained research
therapist will guide and supervise you through individual sessions lasting 20 minutes each. There
will be 2 sessions per week.
A22
Benefits
We are evaluating the benefits of the two exercise programs. There is no guarantee that you will
benefit directly from the program. Throughout the training program you will be monitored by
research professionals. In addition, the increase knowledge we gain from the study may help
people in the future.
Procedures
Because you are attending the Geriatric Day Hospital at Royal Victoria Hospital or the
Richardson Hospital, we are asking you if you would be interested in participating in this study.
Your agreement will involve participation in the following:
1. Twice a week, you will train, either with or without the poles. The sessions last 20
minutes each and consist of walking, stretching and mobility exercises. This will last
8 weeks. You will participate in 16 sessions. A research therapist will closely monitor
your exercises and modify them according to your needs and comfort
2. If you are in the group using the poles, a trained research therapist will teach you the
proper way to walk with the poles.
3. A research physiotherapist will assess you, at the Institution you are attending
rehabilitation, at admission, and then after 2 and 8 weeks. These tests consist of a 6-
minute walk test, a gait speed test and simple questionnaires. We will also look at
your balance and ask you how you felt about the training.You will need to fill-in
questionnaires on fear of falling, lower extremity pain, participation and quality of
life. The entire assessment should last approximately one hour.
4. We would also like to ask you questions about demographic information and access
your medical chart regarding concomitant health conditions as well as supporting
laboratory and clinical results of other tests you may have done at your Institution.
Risks and Inconveniences
There are no serious risks involved in participating in this study. If you feel any discomfort while
exercising, we will assist you. If this condition persists, we, the research team, will advise the
hospital. There might be a slight possibility of falling during the training, but we will take every
precaution to prevent this from happening. In the unlikely event that you become physically ill or
injured as a result of participating in this study, necessary medical treatment will be made
available to you as usual. The McGill University Health Centre, the MUHC Research Institute,
the Richardson Hospital, and the investigator would not be able to offer compensation in the
unlikely event of an injury resulting from your participation in this research study. However, you
are not giving up any of your legal rights by signing this consent and agreeing to participate to
this study.
A23
Furthermore, the investigator can terminate your participation in the project without your
consent, if in his/her opinion it would be harmful for you to continue. We will communicate to
you any information or relevant results that may affect your participation.
Confidentiality
Any personal information you provide (name, address, and health information) as well as any
relevant information to this research project that might be collected from your medical file (such
as concomitant health conditions including supporting laboratory and clinical data) will be kept
strictly confidential. This information will be kept safe in a locked filing cabinet within a secure
space in a locked office in the Division of Clinical Epidemiology at Royal Victoria Hospital. We
will put all the information into a computer and remove your name and any personal information.
Then we will assign your file a number, your name will not be on the forms. The information for
the program will be in the form of statistical table and later on summarized into graphs. No
information from any individual will be released. The results of this research may be presented at
meetings or in publications but your identity will not be disclosed. Your name will not appear in
any publication or report from this study. In the future, the information we gather may be used by
other researchers to answer additional research questions about elderly and for this reason all data
will be kept for 15 years.
I agree to allow the data collected from this study to be used for future health research about the
elderly, as long as I am not personally identified, and the same conditions concerning
confidentiality and storage of data agreed to for the present study are adhered to.
Yes No
Voluntary Participation and Right to Withdraw
Your participation in this project is voluntary. You have the right to leave the study at any time.
Leaving the study will not result in any penalty or loss of benefits to which you are entitled.
Compensation
You will not be paid to participate in this research study, but you will be reimbursed for your
travel expenses, up to an amount of $35.00 per visit.
Contact Information
The person in charge of the research project is Dr. Nancy Mayo. The research coordinator is
Sabrina Figueiredo, who can be reached at 514-934-1934 ext. 36906. She is available to answer
any questions you may have about the study. If you have any questions about your rights as a
participant in a research project, you can call the Patient Ombudsman of the Royal Victoria
Hospital at 514-934-1934 ext. 35655.
A24
STUDY TITLE: Nordic Walking for Frail Elderly: A Randomized Pilot Trial
INVESTIGATORS: Nancy E. Mayo BSc PT, MSc, PhD.
COLLABORATORS: Sara Ahmed, BSc PT, MSc, PhD; Allen Huang, MD; Dr. R Ludman,
MD; Ms Nancy Cox, BSc PT; Ms Sabrina Figueiredo, BSc PT, MSc candidate.
STUDY COORDINATOR: Ms Sabrina Figueiredo, BSc PT, MSc candidate
SPONSORS: Pete Edwards and The American Nordic Walking System,
www.skiwalking.com; Canadian Nordic Walking Association
Statement of consent
I, __________________________ have reviewed the material in the consent form. I have
discussed the above information with the researcher and I have had the opportunity to ask further
questions. I consent to participate in this study.
_________________________________
(Printed) name of participant
_________________________________ _________________________
Signature of participant date of signature
_________________________________
(Printed) name of person reading consent
_________________________________ _________________________
Signature date of signature
15/12/2009
A25
Formulaire de consentement
TITRE DU PROJET: La marche nordique pour les personnes âgées fragiles: Un projet
pilote randomisé.
CHERCHEURS: Nancy E. Mayo BSc PT, MSc, PhD.
ASSOCIÉS : Sara Ahmed, BSc PT, MSc, PhD; Allen Huang, MD; R Ludman, MD., Nancy
Cox, BSc PT, Sabrina Figueiredo, BSc PT, MSc candidate
COORDONATRICE: Sabrina Figueiredo, BSc PT, MSc candidate
COMMANDITAIRES: Pete Edwards & The American Nordic Walking System
www.skiwalking.com
Introduction
L‟indépendance fonctionnelle de beaucoup de personnes âgées est compromise. La diminution
de leur fonction physique au niveau de leur balance statique et dynamique, la diminution de leur
force musculaire et leur diminution de leur fonction visuel, ce qui affecte leur qualité de marcher
en sécurité. Même s‟il y a plusieurs exercices de réadaptation qui visent à augmenter la mobilité,
à ce jour, aucun de ces programmes de réadaptation n‟ont utilisé les bâtons de marche comme
outil dans un programme de réadaptation intégré.
Des études ont prouvé que la marche nordique peut augmenter la forme physique sans effort
supplémentaire. Les personnes peuvent donc s‟exercer plus longtemps sans la sensation de
fatigue. Ces études ont toues été réalisé à l‟intérieur d‟une population en santé et d‟âge moyen.
L‟objectif de notre étude est d‟examiné pour voir si un groupe de personnes âgées pourraient
augmenter leur forme physique en utilisant la marche nordique au lieu de d‟un programme de
marche habituel.
Nous sommes un groupe de chercheurs de l‟Université McGill, du Centre de Santé de
l‟Université McGill et de l‟hôpital Richardson. Nous sommes intéressé a étudié les bénéfices
potentiels de la marche nordique. Si vous consentez à y participer, vous serez assigné au hasard à
un des deux groupes. Ces deux groupes consistent en (1) un programme de réadaptation sur le sol
et (2) un programme de réadaptation avec des bâtons de marche.
Que vous soyez dans un groupe ou dans l‟autre, des vous recevrez un programme de d‟exercice.
Les séances d‟exercice (avec ou sans pôles) comprennent des étirements, des entraînements à la
marche, des exercices de mobilisation et des périodes de repos. Ces exercices seront ajoutés à
A26
votre thérapie courante à l‟Hôpital de jour en gériatrie de l‟Hôpital Royal Victoria ou de l‟Hôpital
Richardson. Notre intervention ne remplacera pas les soins que vous obtenez habituellement.
Durant une période de 8 semaines, un(e) thérapeute de la recherche vous guidera et vous
supervisera tout au long des sessions d‟entraînement individuelles qui dureront 20 minutes
chaque. Il y aura 2 sessions par semaine.
Bénéfices
Au cours de cette étude, nous comparerons les avantages de ces deux programmes d‟exercices. Il
n‟est pas certain que votre entraînement vous apportera des bénéfices. Pour la durée du
programme d‟exercice vous aurez un suivi médical complet. De plus, les résultats de cette étude
permettront d‟aider d‟autres individus ultérieurement.
Déroulement du programme
Nous vous invitons à participer à cette étude parce que vous êtes un patient à l‟Hôpital de jour en
gériatrie de l‟Hôpital Royal Victoria ou à l‟Hôpital Richardson. Si vous acceptez de participer,
voici ce qui vous attend :
5. Vous participerez à deux sessions de 20 minutes (incluant de la marche, des étirements et des
exercices de mobilité) chacune par semaine (avec ou sans pôles) et ce, pendant 8 semaines.
Vous participerez à 16 entraînements au total. Le ou la thérapeute de la recherche
supervisera attentivement vos sessions et ajustera l‟intensité des exercices selon vos besoins
et votre confort.
6. Si vous êtes choisi dans le groupe avec pôles, une thérapeute de la recherche entraînée à ce
programme vous montrera comment utiliser les pôles de façon appropriés.
7. Lors de votre première, deuxième et huitième semaine, dans votre centre de réhabilitation
respective, le ou la thérapeute de la recherche évaluera votre vitesse de marche et votre
endurance à marcher pendant six minutes, l‟évaluation « gait speed », ainsi qu‟un
questionnaire simple. Vous répondrez également à des questionnaires écrits. Nous
évaluerons aussi votre balance physique et nous vous demanderons comment vous vous
sentez dans ce programme. Vous répondrez également à des questions sur votre niveau de
douleur, votre équilibre, votre peur de tomber, votre participation à vos activités habituelles
et sur votre qualité de vie en général. L‟évaluation entière devrait durer environ une heure.
8. Nous aimerions également vous posez des questions sur vos informations démographiques
ou médicales et consulter votre dossier médical, pour savoir information sur votre état de
santé et examen physique et résultats de laboratoire que vous pourriez avoir subis à votre
hôpital.
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Risque et inconvénients.
Vous ne courez pas de risques sérieux en acceptant de participer à cette étude. S‟il arrivait que
vous ressentiez quelque inconfort ou douleur qu‟il soit, nous vous apporterons les soins
nécessaires. Si ces malaises devaient persister, nous, le groupe de chercheurs, aviserons l‟hôpital
immédiatement. Il y a un faible risque de tomber lors des entraînements, cependant nous
veillerons à prendre toutes les précautions nécessaires afin d‟éviter une chute. Si jamais, vous
deviez être blessé ou avoir des problèmes physiques dû à votre participation à cette étude, les
traitements médicaux nécessaires seront disponibles. L‟Université McGill, le Centre de Santé de
l‟Université McGill, l‟hôpital Richardson ainsi que les chercheurs ne pourra pas vous offrir une
compensation si jamais vous souffrez d‟une blessure dû à votre participation dans l‟étude.
Cependant, vous n‟abonner pas vos droits légaux en signant ce formulaire de consentement et en
acceptant de participer à cette étude.
En outre, le chercheur peut mettre fin à votre participation sans votre consentement, s‟il a des
raisons de croire qu‟il serait dangereux pour vous de continuer. Toutes informations ou résultats
pouvant affecter votre participation vous sera également transmises.
Confidentialité
Vos informations personnelles (nom, adresse, information médicale) ou toutes informations
nécessaires à cette étude provenant de votre dossier médical (information sur votre état de
historique médical, examen physique, résultats de laboratoire), toutes ces informations seront
traitées de façon confidentielle. Votre dossier sera identifié par un numéro et seulement le
personnel autorisé aura accès aux dossiers. Les dossiers seront gardés dans des filières
verrouillées dans un bureau qui lui aussi est verrouillé dans la Division d‟épidémiologie clinique
de l‟hôpital Royal Victoria dont l‟accès est sécurisé par un code d‟entrée électronique. Toutes
l‟information collectées sera introduites dans un ordinateur, ce faisant, votre information
personnel ne sera pas transférée, seulement votre numéro de dossier. Ces données seront utilisées
pour préparer des tables et des graphiques statistiques pour tous les participants. Aucune donnée
personnelle ne sera publiée de façon individuelle. Les résultats de cette étude pourraient être
présentés lors de conférences ou publiés dans des revues scientifiques, mais aucune identification
individuelle ne sera diffusée. Ultérieurement, l‟information que nous recueillons pour être
utiliser par d‟autres chercheurs pour répondre à des questions additionnelles sur les personnes
âgées, pour cette raison, les données seront gardées pendant 15 ans.
Je permets que les donnés collectées pour cette étude soient utilisées dans autres études futures
sur la santé des personnes âgées, en autant qu‟on ne puisse pas m`identifier personnellement. Les
même conditions par rapport à la confidentialité et la conservation des données de cette étude
s‟appliqueraient aussi aux autres études futures.
Oui Non
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Participation volontaire et droit de se retirer de l’étude
Votre participation à ce projet est entièrement volontaire et vous pouvez décider de vous retirer
de l‟étude à n‟importe quel moment. Si vous décidez de ne pas participer à cette étude ou de
vous retirer avant la fin, cela n‟affectera pas vos soins de santé.
Compensation
Vous ne recevrez aucune compensation pour votre participation à l‟étude. Cependant, vous serez
remboursé pour vos dépenses de voyagement, un montant maximal de $35.00 par visite.
Personnes ressources
La personne en charge du projet de recherche est Dr. Nancy Mayo. Sabrina Figueiredo, la
coordonnatrice de l‟étude peut être rejointe au (514) 934-1934 poste 36906. Elle est disponible
pour répondre à vos questions concernant l‟étude. Si vous avez des questions concernant vos
droits en tant que participant à ce projet d‟étude, vous pouvez parler à l‟ombudsman des patients
au (514) 934-1934 poste 35655.
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TITRE DU PROJET: La marche nordique pour les personnes âgées fragiles: Un projet
pilote randomisé.
CHERCHEURS: Nancy E. Mayo BSc PT, MSc, PhD.
ASSOCIÉS : Sara Ahmed, BSc PT, MSc, PhD; Allen Huang, MD; R Ludman, MD., Nancy
Cox, BSc PT, Sabrina Figueiredo, BSc PT, MSc candidate
COORDONNATRICE: Sabrina Figueiredo, BSc PT, MSc candidate
COMMANDITAIRES: Pete Edwards & The American Nordic Walking System
www.skiwalking.com
Déclaration du participant
Je, ai lu le dépliant d‟informations sur l‟étude. J‟ai
discuté de cette information avec l‟équipe de recherche et j‟ai eu l‟occasion de poser des
questions. Je consens à prendre part à cette étude.
___________________________________________
Nom du patient (lettres moulées)
___________________________________________ ______________________
Signature du patient date
________________________________________
Nom du témoin (lettres moulées)
___________________________________________ ______________________
Signature du témoin date
15/12/2009
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