ISSN 1748-3107 print/ISSN 1748-3115 online Disabil Rehabil Assist Technol, Early Online: 1–7 ! 2014 Informa UK Ltd. DOI: 10.3109/17483107.2014.926568


The impact of rollator loading on gait and fall risk in neurorehabilitation – a pilot study Disabil Rehabil Assist Technol Downloaded from by University of Toronto on 02/03/15 For personal use only.

Tobias Braun1,2, Detlef Marks2, Daniel Zutter2, and Christian Gru¨neberg1 1

Hochschule fu¨r Gesundheit, University of Applied Sciences, Department of Applied Health Sciences, Physiotherapy Program, Bochum, Germany and Rehaklinik Zihlschlacht, Neurorehabilitation Center, Zihlschlacht, Switzerland




Purpose: Rollator loading is an application used clinically sometimes to improve functional integrity and security of the patients’ gait. As empirical evidence supporting this intervention is equivocal, the purpose of this study was to examine the effects of rollator loading on several gait parameters and fall risk. Methods: An explicatory experiment with a follow-up cohort study of falls was conducted. In the experimental part of the study, participants (n ¼ 25) were evaluated three times by means of different gait and fall risk assessments, whereby each trial was carried out with different rollator loading (0, 4.5 and 9 kg, respectively). Participants were blinded towards the applied load. In addition, the odds ratio of falls with respect to rollator loading in all-day rehabilitation life was determined. Results: No changes in spatio-temporal gait parameters and fall risk in relation to a particular load could be identified by clinical measures in the tested sample. A separate sub-group analysis (Parkinson’s disease, hemiparesis and ataxia) showed only little impact of the load in each case. Rollator loading had no impact on the odds ratio of inpatient fall risk. Conclusion: On the basis of our findings, weighting of rollators can neither be discouraged nor recommended.

Accidental falls, ataxia, mobility limitations, Parkinson’s disease, rehabilitation, walker History Received 20 January 2014 Revised 16 May 2014 Accepted 18 May 2014 Published online 6 June 2014

ä Implications for Rehabilitation  

Unless more research is has been conducted on this topic, rollator loading can neither be recommended nor discouraged in individuals suffering from neurologic diseases. There is more research needed to examine the impact on ambulation in distinct conditions such as severe ataxia and fear of falling.

Introduction Gait and balance disturbances are common issues in patients undergoing neurorehabilitation and are directly associated with a significantly increased fall risk [1,2]. The reduction of fall risk is of immense concern since falls have a negative impact on quality of life, morbidity and mortality [3–6]. One starting point for fall risk abatement is improvement of gait [7,8]. From a physical therapist’s point of view, therefore, the ability to walk safely and independently constitutes the focal point of the treatment of patients with central nervous diseases [9]. To improve ambulation in patients with neurologic conditions, assistive devices can be very useful [10]. There is a huge assortment of walking aids on the market which can temporarily support relearning or improvement of ambulation or permanently compensate for missing motor skills [11–13]. The most common

Address for Correspondence: T. Braun, Hochschule fu¨r Gesundheit, University of Applied Sciences, Department of Applied Health Sciences, Physiotherapy Program, Universita¨tsstr. 105, 44789 Bochum, Germany. Tel: +49-234-77727625. Fax: +49-234-77727825. E-mail: [email protected]

devices used are undoubtedly canes, crutches, orthotic foot devices and walkers [11]. Over the last three decades, significant changes have occurred in walker construction. Wheels have been added, so that we can now talk about a 3- or 4-wheeled walker or rolling walker. The terminology used in the literature has not been standardized [14]. Referring to the ISO 9999 classification of technical aids for people with disabilities [15], we can say that the denotation ‘‘rollator’’ is the most popular one in Europe. We will use this term in this article, standing for a 4-wheeled walker with two front wheels that swivel. The rollator is a relatively cheap assistive device, easy to use and for this reason favored by users [14,16], and employed frequently in neurorehabilitation [11,17–20]. It consists of a metal base frame on four wheels (inflated or of hard rubber), two highadjustable bar ends with hand brakes, and usually a seat and a basket. The dead weight lies between 7 and 12 kg [21]. Wheels have been the decisive design modification distinguishing rollators from walkers; they allow for better mobility and a more physiological gait pattern [17,22–24]. For this reason, rollators have now widely replaced walkers as a bimanual walking aid. They are widely recommended for patients who would derive too much support from a wheelchair but too little from a cane.


T. Braun et al.

Disabil Rehabil Assist Technol, Early Online: 1–7

Table 1. Characteristics of study participants. Characteristics

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Number Age Sex female/male (n) Body weight (kg) Duration of rehabilitation (days) Days since onset Years since onset Rollator in RC at TM since (wk) Rollator loaded? yes/no (%) FAC TM without rollator FAC TM with rollator


Parkinson’s disease



25 60.2 ± 18.7 (15.0–83.0) 14/11 71.0 ± 13.0 (52.0–102.0) 40.8 ± 24.5 (18.0–135.0) 49.1 ± 19.2 (31.0–86.0)a 12.8 ± 10.9 (2.0–46.0)d 2.4 ± 1.9 (0.5–8.0) 52/48 2.1 ± 0.9 (1.0–4.0) 3.5 ± 0.8 (2.0–5.0)

11 68.7 ± 10.1 (47.0–79.0) 5/6 71.6 ± 14.1 (52.0–99.0) 30 ± 8.8 (18.0–40.0) # 8.9 ± 4.8 (2.0–16.0)a 2.1 ± 1.6 (0.5–5.0) 55/45 2.3 ± 1.0 (1.0–4.0) 3.5 ± 0.9 (2.0–5.0)

6 67.2 ± 16.4 (38.0–83.0) 4/2 74.5 ± 4.0 (68.0–78.0) 44.2 ± 15.7 (29.0–74.0) 46.0 ± 20.3 (31.0–86.0)b # 2.9 ± 2.6 (1.5–8.0) 67/33 2.2 ± 1.0 (1.0–3.0) 3.2 ± 0.4 (3.0–4.0)

7 37.4 ± 12.8 (15.0–51.0) 5/2 62.9 ± 9.5 (52.0–77.0) 53.4 ± 37.3 (28.0–135.0) 57.3 ± 18.7 (40.0–78.0)c 27 ± 16.5 (17.0–46.0)e 1.7 ± 0.8 (0.5–2.5) 57/43 2.1 ± 0.9 (1.0–3.0) 3.9 ± 0.9 (3.0–5.0)

RC rehabilitation center; TM time of measurement; wk weeks; FAC Functional Ambulation Categories, # not applicable. Values are mean ± standard deviation (range) or numbers. a n ¼ 11; bn ¼ 6; cn ¼ 4; dn ¼ 14; en ¼ 3.

Like all assistive devices, a rollator must be adapted to the constitution, functional capacity and needs of each patient [25,26]. Rollators permit only small changes in their structure. Next to a selection of slightly different model types, in most cases the height of the hand grip and the rotation of the bar in the transverse plane are the only possible ‘‘intrinsic’’ modifications. Another option for structural alteration is loading, i.e. the application of an additional load [27]. In practice, this is accomplished by placing sandbags, water-filled plastic bottles, barbell elements, stones and similar items in the rollator’s basket. These additional loads vary between 2 and 20 kg, as observed by the authors and elicited during initial interviews with physical therapists working in neurorehabilitation. They are utilized for different conditions, but primarily for ataxia. Astonishing to mention is that rollator loading operates in opposition to the rollator’s proper positive characteristics, e.g. its light weight and simple maneuverability. Brand et al. [14] reported on the satisfaction with rollators among users living in the community and postulated that the high-dead load was even the predominant point of criticism in the geriatric cohort. However, to our best knowledge, there is no evidence to support or refute adding additional weight to a rollator. In the context of evidence-based physiotherapy [28], the value of employing the technique of rollator loading in neurorehabilitation to improve gait and decrease fall risk still has to be demonstrated by empirical data. The aim of this study is to examine the impact of rollator loading on gait and fall risk in individuals with neurologic diseased. Results of this study could indicate if ambulation can be improved by rollator loading or not. An experimental, singleblind, case–control study design was used to evaluate gait and fall risk parameters in relation to three different rollator loadings. Furthermore, the odds ratio of falls was evaluated prospectively with respect to a loading condition.

Methods Participants The study was conducted at the Rehaklinik Zihlschlacht, an inpatient neurological rehabilitation center in Switzerland. Inclusion criteria were: (1) rehabilitation because of a central nervous disorder, (2) patient age 418 years, (3) ‘‘ability to walk with a rollator’’ over a distance of three times 60 m with a minimal functional ambulation category (FAC) [29] score of 3, which is equivalent to ‘‘ambulation on a level surface without manual contact of another person but for safety requiring standby guarding of no more than one person because of poor judgment, questionable cardiac status, or the need to verbal cueing to

complete the task’’. The definition ‘‘ability to walk with a rollator’’ was based on the individual appraisal by the physical therapist treating the patient. Thus, the rollator was, at that time of the rehabilitation, the device deemed most appropriate by the therapist. It was imperative that at the time of the examination, the participant was ambulatory either occasionally, always only when guarded, or mainly in therapy. Exclusion criteria were: (1) a non-neurological disturbance of gait due to, for example, a prosthesis, massive foot and leg deformities, acute capsule-ligament injuries, etc., (2) severe disturbance of vision, (3) severe cognitive deficits which would impair the patient’s understanding of instructions or make such understanding impossible, (4) the fact that the participant cannot speak and comprehend German or English, (5) hospitalization in the defined period/absence for miscellaneous reasons, (6) refusal of the participant to participate voluntarily in the study and (7) refusal of the participant to allow video recording of the examination. During a period of 26 consecutive days, all inpatients (n ¼ 186) were screened on the basis of the given inclusion and exclusion criteria. Finally, 25 patients participated in the study. The other patients were excluded because they were not ambulatory, ambulatory with another device than a rollator or ambulatory without a rollator (n ¼ 156), suffered from a non-neurological disturbance of gait (n ¼ 2), were hospitalized during the defined period (n ¼ 1) or did not give informed consent (n ¼ 2). The general and clinical characteristics of the included participants are shown in Table 1. The experiment was performed after a mean of 22 SD 17 (range: 3–72) days after admission to the clinic. The following diagnosis groups were included: (1) Parkinson’s disease (PD) (n ¼ 11), (2) hemiparesis after stroke (ischemic or hemorrhagic) (n ¼ 6) and (3) ataxia, cerebrospinal (symptomatic) after traumatic brain injury, cerebellar stroke, multiple sclerosis or infantile cerebral palsy (n ¼ 7). One participant with a cerebellar stroke exhibited hemiparesis as well as ataxia and was therefore included in both groups. Two participants displayed a somatoform gait disturbance and an incomplete spinal cord injury (SCI), respectively. They were pooled as ‘‘diverse’’ and not analyzed separately, but included in the group ‘‘all’’ (n ¼ 25). Participants with PD had a mean Hoehn & Yahr [30] score of 3.2 SD 1.1 and a mean Unified Parkinson’s Disease Rating Scale [31] score of 14.7 SD 6.0 on admission. Experimental procedure A test battery containing four standard tests was used. Every participant had to pass through this test battery three times, at any

DOI: 10.3109/17483107.2014.926568

Rollator loading application in neurorehabilitation


Disabil Rehabil Assist Technol Downloaded from by University of Toronto on 02/03/15 For personal use only.

with the heavy (i.e. loaded with 9 kg) rollator. Possible bias due to fatigue and training effects should have been equalized in the mean value via randomization. In between test runs, every participant took a 3-min sitting break. Each test run including all assessments took 60 to 90 min. All assessments were performed by the same assessor, who was not blinded to the loading weight. Participants with a FAC value of 3 were guarded by a second physical therapist. For ethical reasons, all participants used a rollator at all times because of the risk of falling associated with not using it. The experimental procedures were carried out in accordance with the ethical standards of the institutional committee on human experimentation and with the Helsinki Declaration on ethical principles for medical research. All participants provided written informed consent. Assessment of gait and fall risk We created a test battery using standardized and widely accepted assessment procedures employed in neurorehabilitation. Four assessments (10MWT, TUG, DGI and POMA) were performed. 10 m Walk Test

Figure 1. Loaded rollator.

one time with a variably loaded rollator. The test battery included the 10 m Walk Test (10MWT) [32], the timed up & go Test (TUG) [33], the gait part of the performance-oriented mobility assessment (POMA), also known as the Tinetti Test [34], and the dynamic gait index (DGI) [35]. These tests were administered each time in this consecutive order. During the testing, each participant used the rollator he or she also used during all-day rehabilitation. All rollators used had four wheels with front wheels that swiveled, a basket, functioning brakes and a weight without loading (dead weight) between 7 and 9 kg. Prior to testing, grip height and grip rotation were adjusted individually for each participant. As a general rule, it was stated that grips should be at the height of the styloid process of ulna with the patient in a standing position and with arms hanging besides the body [36]. Rollator loading was achieved with three differently colored bags (yellow, blue and white) (Figure 1). These bags were filled with six 1.5 l plastic bottles in each case. All the bags therefore made the impression of being equally large (‘‘equally heavy’’). Variable weight was simply achieved via the justification ratio of the bottles with tap water. On the basis of clinical empirical values, three different weights were chosen: 0, 4.5 and 9 kg. There was thus a bag weighing about 0 kg (six empty bottles), one weighing about 4.5 kg (three empty and three filled bottles) and one weighing about 9 kg (six filled bottles). Variable bag colors were important mainly for video recording analysis, as described below. The patients were blinded with respect to the bag weight at all times. An empty, evenly and brightly lit gym with a parquet floor was used for the examination. Sturdy shoes had to be worn all the time. The testing procedure was as follows: initially, the POMA balance part was evaluated. Here the unloaded rollator could be used as a hold if necessary. The POMA balance was followed by a non-counted TUG trial run [33]. Subsequently, the test battery was performed three times with the tree loads in a randomized order. In equal parts, one-third of the participants started with the unloaded, one-third with the medium heavy and one-third

The 10MWT is a valid and reliable test for measuring speed, cadence and stride length, which are important components of gait quality. The test was performed as described by Flansbjer et al. [32] using the following standard conditions with respect to rollator use: (1) participants were placed with their feet at a marked line on the ground and both hands placed on the bar end of a non-braked rollator. On command, the participant was requested to ambulate at a comfortable speed and to stop some steps after the marked end line. We made video recordings of the 10MWT to count the steps taken and the time required accurately afterwards. Based on this data, gait speed (distance/time needed; in m/s), cadence (number of steps per min) and the step length (distance/number of steps; in cm) were calculated. Timed up and go test The TUG [33] provides information about a number of activities which constitute high-risk situations for people who are at risk of falling. The participant was sitting on a chair, 46-cm high, with his or her back leaning against the backrest and his or her arms placed on the armrests. A bowling pin was placed at a distance of 3 m from the chair. At the signal ‘‘Start!’’, the participant was requested to walk around the pin at a comfortable and safe walking speed and then sit back on the chair. The time between detachment from the backrest and renewed contact was measured. The rollator was placed in front of the participant. It was left up to the participant whether to stand up with the support of the armrests or the rollator or completely without support. During the tests, no tactile or verbal assistance was provided by the evaluator. Each participant performed an uncounted trial run before the first measurement. We abstained from performing three trials, and using a mean score of these [33], because of potential training and fatigue issues. There is also evidence that the results of a single trial do not differ substantially from the mean, best and worse scores collected within three trials, respectively [37]. Performance-oriented mobility assessment The POMA [34] is divided into two parts: balance and gait. They are evaluated qualitatively and then scored quantitatively on an ordinal scale. The POMA also provides information about fall risk, with higher scores on the total scale of 0–28 points indicating a lower risk.


T. Braun et al.

Dynamic gait index The DGI [35] assesses the dynamic adaption of gait and is used to evaluate dynamic postural control. It is a valid predictive marker for fall risk in a chronic stroke population [38]. The DGI consists of eight items each of which can be rated on an ordinal scale of 0–3 points. There is thus a maximum of 24 possible points. The worse, i.e. the more insecurely, a participant performs a task, the fewer points are given.

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Fall numbers One of the most valid methods used to assign fall risk in relation to a criterion, in this case rollator loading, is to count the number of falls occurring in a group, classified by this criterion, during a defined period. The result is then compared with the number of falls occurring in a control group without this criterion. In this study, the participants were divided into two groups, but group allocation was not randomized. The first group (unloaded rollator ¼ UnRo) comprised those whose rollator was not loaded during rehabilitation. The second group (loaded rollator ¼ LoRo) comprised those participants who were ambulatory with a clinically loaded rollator. The reasons for rollator loading in the LoRo group were surveyed. The physical therapists treating the patients counted all falls during the complete rehabilitation stay and classified them as ‘‘falls with rollator’’ or ‘‘falls without rollator’’. In addition, the amount of time during which the participant was ‘‘ambulatory with a rollator’’ (time with rollator) was recorded. In both groups, the mean number of falls per week with rollator and the odds ratio for the loading condition were the outcomes. Analysis of criterion groups The complete sample of participants was always analyzed as a whole. Since a specific examination of sub-groups seemed essential, however, three main groups with respect to clinical pictures were also formed: Parkinson’s disease, hemiparesis after stroke and ataxia caused from various diseases. Data analysis All data analysis was conducted using the Statistical Package for the Social Sciences (SPSS, version 14.0). Descriptive statistics were used for characterization of participants and test results with p50.05 considered as statistically significant. To demonstrate differences in the outcomes of the gait and balance assessments between the three paired samples/intervention groups (0, 4.5 and 9 kg), we first applied the non-parametric Friedman Test for more than two paired samples. In the event of a significant Friedman Test result, a Wilcoxon Signed-Rank Test between two paired samples was conducted. For this multiple comparison, the significance level of the Wilcoxon signed-rank test was set at p50.004 according to the false discovery rate procedure described by Curran-Everett [39]. Both tests statistics were used for the numeric and ordinal-based values due to the relatively small sample size. To demonstrate differences in fall numbers per week between both unpaired groups (UnRo and LoRo), a Mann–Whitney U test was performed. Furthermore, the odds ratio for experiencing a fall between both groups was calculated.

Results Assessments of gait and of fall risk Spatio-temporal gait parameters, TUG, POMA as well as the DGI showed no significant differences in the three loading conditions

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in consideration of all 25 participants and the three sub-groups Parkinson’s disease, hemiparesis and ataxia (Table 2). Fall numbers A total of 13 participants used a clinically loaded rollator and 12 participants used a rollator without additional weight. Physical therapists gave nine different reasons for loading, of which the ‘‘doctor’s advice’’, a ‘‘prior loading by the nurses’’, a ‘‘better road adherence’’, a ‘‘better stability’’ and ‘‘ataxia’’ were the most common ones. No loading was justified with six different reasons. In most cases, the ‘‘rollator seemed stable enough without an additional load’’ (n ¼ 6) or ‘‘the patient was not used to a load before’’ (n ¼ 3). Unloaded rollators (UnRo) were loaded with 0 kg, and the loaded rollators (LoRo) were loaded with 6.6 kg on average. In the mean time, the participants ambulated with a rollator were 4.7 SD 2.6 (range: 1.5–10.5) weeks for the UnRo and 4.4 SD 1.3 (range: 3.0–7.0) weeks for the LoRo. During this period, in the UnRo group 5 falls (3 falls without a rollator and 2 with a rollator) and in the LoRo group 12 falls (9 falls without rollator and 3 with rollator) occurred. Closely considered, one participant using an UnRo fell 2 times and one participant using a LoRo fell three times. None of the other 23 participants ever fell when walking with a rollator. In fact, the average number of falls per week was higher with the LoRo (0.042 SD 0.150) than with the UnRo (0.015 SD 0.055). However, these differences were not statistically significant (U ¼ 78; p ¼ 1.00). The odds ratio for experiencing a fall with a loaded rollator in contrast to an unloaded rollator was 0.912.

Discussion The aim of this study was to examine the impact of rollator loading on gait and fall risk in patients with neurologic disorders. An explicatory experiment with a follow-up cohort study of falls was conducted, including 25 participants with gait impairments due to various diseases. In the experimental part of the study, participants were evaluated three times by means of different gait and fall risk assessments, whereby each trial was carried out with different rollator loading (0, 4.5 and 9 kg, respectively). Furthermore, the impact of rollator loading on prospective fall risk in all-day rehabilitation life was determined. Analysis of all outcome measures of gait and fall risk reveals no statistically significant or clinically relevant differences between the three rollator loading conditions. This was also evident in a sub-group analysis of the three different disease groups PD, hemiparesis after stroke and ataxia. Thus, neither fall risk could be reduced through loading nor was there any impact of loading evident on gait parameters such as velocity, cadence and step length, in this study. An examination of falls in relation to clinical loading showed no relevant decrease in the odds ratio between loading and no loading. The fact that only one participant of each group fell when ambulating with a rollator, and the relatively small number of falls in general indicate that the observed differences are due to chance and not impacted by the rollator loading. Limitations The present study has some limitations concerning its external validity. We examined a relatively small sample, which became even smaller after it was divided into three diagnostic groups. That is why these results have to be treated with caution. However, as this was an explicatory experiment, we attached importance to the impact of loading on ambulation in different diagnostic groups.

Rollator loading application in neurorehabilitation

DOI: 10.3109/17483107.2014.926568


Table 2. Results for all participants and the three diagnosis groups.

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Loading 0 kg

All (n ¼ 25) Speed (m/s) 0.75 ± 0.23 (0.28–1.25) Cadence (s/min) 92.6 ± 14.0 (60.0–120.0) Step length (cm) 48.4 ± 11.7 (20.0–67.0) TUG (s) 29.4 ± 13.9 (14.0–80.0) POMA gait 7.4 ± 1.7 (4.0–9.0) POMA total 17.4 ± 4.7 (9.0–25.0) DGI 14.7 ± 3.5 (5.0–20.0) Parkinson’s disease (n ¼ 11) Speed (m/s) 0.81 ± 0.12 (0.28–1.11) Cadence (s/min) 100.3 ± 12.0 (83.0–120.0) Step length (cm) 48.1 ± 12.3 (20.0–63.0) TUG (s) 33.6 ± 18.0 (16.0–80.0) POMA gait 7.6 ± 1.8 (4.0–9.0) POMA total 17.8 ± 4.6 (9.0–25.0) DGI 14.7 ± 3.9 (5.0–19.0) Hemiparesis (n ¼ 6) Speed (m/s) 0.79 ± 0.26 (0.45–1.25) Cadence (s/min) 92.7 ± 12.4 (76.0–113.0) Step length (cm) 50.5 ± 10.8 (36.0–67.0) TUG (s) 24.2 ± 6.8 (14.0–35.0) POMA gait 7.0 ± 2.0 (4.0–9.0) POMA total 16.7 ± 5.4 (9.0–25.0) DGI 14.5 ± 4.0 (9.0–19.0) Ataxia (n ¼ 7) Speed (m/s) 0.72 ± 0.29 (0.31–1.25) Cadence (s/min) 83.7 ± 16.9 (60.0–113.0) Step length (cm) 50.6 ± 13.5 (31.0–67.0) TUG (s) 25.6 ± 10.3 (14.0–44.0) OMA gait 6.9 ± 1.4 (5.0–9.0) POMA total 16.4 ± 3.9 (14.0–25.0) DGI 15.3 ± 2.3 (12.0–19.0)

Loading 4.5 kg

Loading 9 kg


0.76 ± 0.26 (0.23–1.25) 92.8 ± 15.3 (60.0–120.0) 48.6 ± 13.2 (16.0–71.0) 32.6 ± 16.8 (13.0–80.0) 7.4 ± 1.8 (2.0–9.0) 17.4 ± 4.7 (9.0–25.0) 15.3 ± 3.2 (7.0–20.0)

0.76 ± 0.27 (0.32–1.25) 93.9 ± 16.8 (62.0–133.0) 48.2 ± 13.0 (20.0–67.0) 33.8 ± 23.7 (12.0–113.0) 7.4 ± 1.7 (2.0–9.0) 17.4 ± 4.7 (9.0–25.0) 14.9 ± 3.0 (8.0–20.0)

0.80 0.81 0.97 0.29 0.65 0.65 0.34

0.85 ± 0.31 (0.23–1.25) 103.3 ± 13.8 (83.0–120.0) 48.8 ± 15.4 (16.0–71.0) 38.0 ± 20.5 (16.0–80.0) 7.5 ± 2.2 (2.0–9.0) 17.6 ± 4.9 (9.0–25.0) 15.3 ± 3.4 (7.0–19.0)

0.80 ± 0.27 (0.32–1.11) 102.0 ± 17.0 (80.0–133.0) 47.5 ± 14.7 (20.0–67.0) 41.2 ± 31.9 (15.0–113.0) 7.4 ± 2.2 (2.0–9.0) 17.6 ± 4.9 (9.0–25.0) 14.5 ± 2.5 (9.0–18.0)

0.90 0.54 0.83 0.65 0.22 0.22 0.08

0.74 ± 0.17 (0.48–1.00) 90.3 ± 7.3 (77.0–96.0) 49.3 ± 9.2 (37.0–63.0) 27.3 ± 10.1 (16.0–46.0) 7.5 ± 1.5 (5.0–9.0) 17.2 ± 5.0 (10.0–25.0) 15.7 ± 4.0 (8.0–19.0)

0.76 ± 0.26 (0.48–1.25) 91.5 ± 12.2 (80.0–113.0) 49.0 ± 10.4 (36.0–67.0) 25.5 ± 9.9 (13.0–42.0) 7.7 ± 1.5 (5.0–9.0) 17.3 ± 5.1 (10.0–25.0) 16.0 ± 4.1 (8.0–19.0)

0.81 0.87 0.50 0.14 0.06 0.06 0.65

0.69 ± 0.24 (0.33–1.00) 79.9 ± 12.3 (60.0–96.0) 50.4 ± 13.4 (33.0–71.0) 26.9 ± 12.8 (16.0–51.0) 7.0 ± 1.3 (5.0–9.0) 16.6 ± 3.8 (14.0–25.0) 15.3 ± 1.7 (13.0–18.0)

0.73 ± 0.30 (0.34–1.25) 84.3 ± 16.6 (62.0–113.0) 50.7 ± 13.4 (33.0–67.0) 27.6 ± 14.6 (13.0–55.0) 7.0 ± 1.3 (5.0–9.0) 16.6 ± 3.8 (14.0–25.0) 15.0 ± 2.3 (12.0–18.0)

0.65 0.28 0.88 0.86 0.37 0.37 0.85

SD standard deviation; TUG timed up and go test; POMA performance-oriented mobility assessment; DGI dynamic gait index *Friedman test. Values are mean ± standard deviation (range) or numbers.

Besides this, the sample displays a high degree of heterogeneity with respect to the participants’ ages, functional handicaps, disease severity (see high standard deviations in Hoehn & Yahr and UPDRS scores) and reasons for rollator use. The small sample size also limits the explanatory power of the fall risk odds ratio. We did not rate the severity of stroke and ataxia, which could have been done, for example, by using the National Institutes of Health Stroke Scale [40] and the Scale for the Assessment and Rating of Ataxia [41], respectively. For patients with ataxia, in particular, it would have been interesting to evaluate the impact of loading with respect to symptom severity. Furthermore, the assessor was not blinded to the amount of the applied load, and no loads heavier than 9 kg were used, although what was observed in practice. During the testing, each participant used the rollator he or she also used during all-day rehabilitation. A stipulation of one rollator model for all participants would have enlarged the study bias in the author’s opinion. This would have forced the participants to re-acclimate, which could have caused fear or distrust of the rollator. That is why we only assessed the impact of a loading, not of the total rollator weight. This might have biased the results, but it was very important for us to examine ‘‘clinical impact’’, as we presupposed patients to present with different rollator models and therapists to be rather not aware of the rollator weight then of the applied loading. Furthermore, the inclusion criteria have to be criticized. It was not relevant why, when, where and for how long a participant had ambulated with a rollator. In particular, the reasons for using a rollator could significantly influence the usefulness of loading.

An individual who uses a rollator because of fatigue issues would probably react to loading in a completely different way than, for example, an individual who needs a rollator because of balance deficits. We can think of many other reasons to use a rollator in neurorehabilitation. Some individuals with PD may use the rollator to reduce the burden on their back muscles and others to transport personal belongings. Some need a ‘‘mobile chair’’ so that they can take a break on longer walks, while others suffer from fear of falling and need a ‘‘psychological backup’’. Yet others may need a rollator to unburden the accessory respiratory muscles. Functional handling is very important and can be affected by loading. For this reason, attention must be paid to the context of rollator usage. Rollator loading may be useful for patients who ambulate only in the indoor corridor of the hospital and disadvantageous for patients who walk outside, where curbs and steps have to be crossed and purchases have to be transported. It would be very important to consider the reasons why rollators are used and the user context when planning further research on rollator loading. As mentioned above, the factor of fear was not examined sufficiently. For reasons of objectivity, participants were blinded to the kind of intervention, but a subjective feeling of safety certainly plays an important role for many individuals with increased fall risk [42,43]. We assume that some participants would have scored better in the fall risk assessments if they had been aware of the rollator loading and a higher stability had been ‘‘sold convincingly’’ to them. Such safety cannot be proved with this study, but loading in line with a physical therapist’s or doctor’s words could create a placebo effect, which could then

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T. Braun et al.

reduce the fear of falling and indirectly promote mobility [44]. A reduction of the fear of falling achieved in this manner could be part of a multifactorial approach to reducing fall risk [45,46]. We can think here of a very small load which would have no objective impact but whose subjective effects could be positive. Freezing of gait is a significant fall risk factor in patients with PD [47] that could potentially be influenced by rollator loading. We did not count the motor blocks occurring during the measurements, as other authors have done [17]. However, the increased occurrence of blocks indirectly expresses itself in longer TUG times. This was shown in many measurements performed under loading conditions. As freezing of gait seems to appear when the performances of individual gait features, e.g. bilateral coordination of gait, gait symmetry and dynamic postural control, deteriorates below a certain threshold [48], the question is whether a heavier rollator has any impact on these parameters. We did not analyze these outcomes. To the best of our knowledge, the impact of rollator loading on freezing of gait in Parkinson’s disease has never been examined, thus it remains unclear if loading might be advantageous or disadvantageous in these patients. Another aspect to consider is post-stroke fatigue [49], which affects 38–77% of stroke survivors during rehabilitation [50]. For patients with fatigue, also due to multiple sclerosis, a heavier rollator could be more challenging to handle. More research is needed to evaluate the potential impact of a heavier rollator on recovery of these individuals, as we did not considered this topic in the present study.

Conclusion This is the first research study done on rollator loading in neurorehabilitation. Apart from the lack of evidence from the literature, the present results show no improvement of gait and fall risk in individuals suffering from neurologic diseases. In conclusion, the results of this study do not give any evidence concerning a recommendation pro or contra rollator loading in neurorehabilitation.

Acknowledgements We thank all participants who attended this study as well as Arnon Berney, Susanne Bru¨hlmann and Nadja Sto¨rk for their support in data analysis and study conduction.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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DOI: 10.3109/17483107.2014.926568

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The impact of rollator loading on gait and fall risk in neurorehabilitation - a pilot study.

Abstract Purpose: Rollator loading is an application used clinically sometimes to improve functional integrity and security of the patients' gait. As ...
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