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ORIGINAL ARTICLE: EPIDEMIOLOGY,
CLINICAL PRACTICE AND HEALTH
Assessment of rolling walkers
used by older adults in
senior-living communities
Hao (Howe) Liu
Department of Physical Therapy, University of Central Arkansas, Conway, Arkansas, USA
Aim: Rolling walkers (RW) are among the most common ambulatory devices used in
senior-living communities. However, many observational studies have associated RW use
with an increased risk of falling. Studies on how older RW users obtain and use their RW
are lacking. Therefore, this study’s purpose was to provide information about RW use that
can aid clinical professionals in understanding how to educate RW users.
Methods: Data was gathered from 158 RW users (365 years old) who had used their RW
for an approximate mean of 24 months. Assessment utilized questionnaires, inspections
and demonstrations.
Results: Almost 80% of all participants obtained an RW without consultation with a
medical professional (61% through their own means; 19% through medical professionals
without receiving instruction or demonstration). The most common misuse was incorrect
RW height (55%). Maintenance problems were observed in approximately 17% of the RW.
All users admitted that their walkers had not been rechecked by medical professionals
since they had obtained them. Forward-leaning posture was apparent in participants
during static standing (40%) and during ambulation (50%). Forward-leaning posture
during ambulation seemed to be more problematic in causing falls.
Conclusion: Lack to consult a medical professional when obtaining an RW, incorrect
RW height, poor RW maintenance and forward-leaning posture were problems commonly
identified. This knowledge could assist medical professionals in implementing strategies to
address these problems.
Keywords: ambulatory device, balance, falls, gait, physicians.
Introduction
Each year, approximately one-third of adults aged
65 years and older fall.1Among the elderly, falls are the
second leading cause of accidental death and 70% of the
physical injuries caused by accidents are related to fall-
ing.2,3 The frequency of falls is even higher among indi-
viduals living in institutions.4The severity and number
of fall-related injuries seems to increase with age.1,5 In
2005 in the USA, almost 16% of these older adults
reported falling at least once during the preceding
3 months. Of these, one-third saw a doctor or experi-
enced restricted activity for at least 1 day due to injuries
from the fall.6In most cases, stability deficits resulting in
fall-related injuries cannot be treated medically or sur-
gically.7Therefore, assistive ambulatory devices (AAD)
are the main form of treatment for many older individu-
als with balance deficits.7,8
There are 9.1 million AAD users in the USA,9and
among those are 1.5 million walker users.10 Walkers are
often used by older adults who would otherwise be
dependent on others, allowing improved mobility and
independent performance of mobility-related tasks.3–5,11
However, a large number of walker owners experience
Accepted for publication 25 November 2008.
Correspondence: Dr Hao (Howe) Liu MD PhD PT, Department
of Physical Therapy, University of Central Arkansas, 201
Donaghey Avenue, Conway, AR 72035, USA. Email: hliu@
uca.edu
Geriatr Gerontol Int 2009; 9: 124–130
124 兩doi: 10.1111/j.1447-0594.2008.00497.x © 2009 Japan Geriatrics Society
problems related to walker use, and the number of
walker-caused injuries seems to increase at a faster rate
than the number of users.3The most commonly reported
mechanism of walker-related accidents is a fall. Fractures
are the most common type of injury that occur as a result
of a fall.3Studies have identified several factors that may
be responsible for the correlation between ambulatory
devices and risk of fall and injury. These include atten-
tional and neuromotor demands imposed by the mobility
aid, destabilizing biomechanical effects, interference
with limb movement during balance recovery, and meta-
bolic and physiological demands.10
Many cross-sectional and observational cohort
studies comparing fallers and non-fallers among older
adults with low functional levels have found that use of
an assistive ambulatory device has been associated with
an increased risk of falls.10,12 More specifically, use of a
rolling walker (RW) has been identified as a possible
indicator of falling in older adults13,14 and has been
associated with falls and related injuries.3,15 To our
knowledge, there is no current scientific published
work investigating the cost of walker-related injuries.
However, there is an annual upward trend in the
number of estimated walker-related injuries (primarily
due to falls) since 1987.3Therefore, it is important for
health-care providers to find ways to reduce the risk
of falls among walker users in order to minimize the
potential cost for the individual, the individual’s family
and the nation. Thus, the purpose of this study was to
provide information to medical professionals on how
RW are obtained and used and what clinicians can do to
reduce falls in RW users.
Methods
After the letters of support were received from six re-
tirement centers and two assisted-living facilities in the
central Arkansas area, the study proposal was then
approved by the author’s Institutional Review Board.
Before each assessment, the Mini-Mental Status Exam
(MMSE) was conducted among the participants. Based
on the scores, either informed consent (324) or assent
(<24) was signed to each participant or the participant’s
direct family members, respectively. A total of 158 RW
users presented their RW for assessment.
The RW assessment sheet consisted of the patient’s
demographic data (name, sex, age, number of months
of RW use). Questions asked included: “Where did you
receive the RW?”, “Has anyone instructed and/or dem-
onstrated to you how to use the RW?”, “If yes, who and
what is his/her specialty?”, “Has your RW been assessed
by any physicians since you have had your RW?”, “If yes,
who?” and “Have you fallen since using your rolling
walker?”. The RW assessment by the investigator
included: the RW height, maintenance (handgrip, prop-
erly tightened wheels or joints, rubber caps, tennis balls,
and/or slide guards for the tips of posterior legs of the
two-wheeled RW, and brakes for the four-wheeled RW),
posture during standing and walking, gait pattern while
walking in a straight line, and during making turns. A
video camera was used during posture and gait evalua-
tion. The fall data were also collected from those whose
MMSE scores were 24 points or more. Considering the
decline in memory commonly seen in older adults, the
recalled frequency of falls in last 12 months might not be
accurate.16 Therefore, in this study; we only reported
how many people had fallen instead of how many times
they had fallen. A fall was defined as any body part above
the ankle joint touching the floor unintentionally.
Assessments were conducted from 15 June to 15
December 2007 in eight facilities. Residents in the facili-
ties were informed of this assessment opportunity by
bulletin poster, announcement by the facility activity
directors and information fliers. To avoid time conflicts
with some subjects’ personal schedules and to assess as
many RW as possible, the investigator conducted the
assessments at least two different times at each facility.
Ac2-test was used to determine if the frequency of
forward-leaning posture among people using RW at an
incorrect height differed from that among people using
RW at a correct height during ambulation and at stand-
ing, respectively. Multiple one-way ANOVA were applied
for comparison of numbers of people falling under the
following three conditions of using an RW with versus
without: (i) incorrect RW height; (ii) forward-leaning
posture during ambulation; and (iii) forward-leaning
posture at standing. The level of statistical significance
was set at 0.05. All data from this study were processed
with SPSS ver. 15.0 software (SPSS, Chicago, IL, USA).
Results
During the assessment period, there were 634 residents
living in the six retirement centers, among whom 25%
were RW users (157 residents); and 202 residents living
in the two assisted-living facilities, among whom 42%
were RW users (85 residents). RW users were defined
as residents who had to use their RW for ambulation
inside the facility every day. A total of 158 residents
presented their RW for assessment. Their ages ranged
65–98 years (mean, 85.4) and 150 of the participants
were female and eight male. On average, each subject
had four past medical diagnoses, with the most
common being hypertension (43.2%), osteoarthritis/
osteoporosis or post-orthopedic surgery (32.7%),
urinary tract infection (21.2%) and stroke (16%).
The participants used their RW for a mean of
approximately 24 months (range, 1–120 months). The
variations in RW included 50 two-wheeled RW (32%),
101 four-wheeled RW (64%, see Fig. 1 for illustration)
and 7 three-wheeled RW (4%). For data analysis pur-
poses, three-wheeled RW were categorized with the
Roller walker assessment in elderly
© 2009 Japan Geriatrics Society 兩125
four-wheeled RW. No other walkers were presented by
the residents for assessment during the period of study.
Data dependant on the subject’s ability to recall infor-
mation, such as duration of walker use and whether
he/she had experienced falling since using the RW, were
collected only from the 121 (out of total 158) subjects
whose MMSE scores were 24 or more, because this
information required a certain level of cognitive func-
tion to recall.
Data from this study can be divided into three differ-
ent areas concerning RW use. The first area is the role of
medical professionals in helping RW users obtain and
use RW (Table 1). The questionnaire found that the
RW users obtained their RW through physicians’ pre-
scription, physical therapist or nurse recommendation
(39%), or purchase by non-medical professionals (e.g.
self, family members, friends, residential facility, sales-
persons) (61%). When these users obtained their RW,
20% of them received education on how to use an RW
from medical professionals, but the remaining 80%
received neither instruction nor demonstration, includ-
ing 61% obtaining their RW through their own means
and 19% obtaining their RW through medical profes-
sionals. Eighty-one percent of these subjects said that
they had seen their family physicians at least once since
obtaining their RW. However, almost all of these sub-
jects reported that their RW had never been reassessed
by physicians, nor had they been referred to a physical
therapist (PT), nurse or occupational therapist (OT) for
reassessment.
The second area concerned the appropriate mainte-
nance of the RW (Table 1). The most common RW
misuse was incorrect RW height. O’Sullivan and
Schmitz,17 as well as Pierson,18 state that the RW height
for an individual is found by measuring the distance
from the ground (or floor) to the wrist joint line while
the individual maintains an upright standing position
with both upper extremities relaxed at the side of the
body.7,17,18 In this study, 55% of the participants had
their RW at an incorrect height. Also, 21% of the
walkers that were used incorrectly did not have enough
holes to adjust the walker height appropriately. Other
maintenance problems were observed in approximately
17% of the walkers. The problems included: worn-
out or loose rubber caps, tennis balls or sliding guards
covering the tips of the two-wheeled RW legs; worn-out
or loose hand grips on two- and four-wheeled RW;
and loose or excessively tight brake or joint areas on
four-wheeled RW.
The third area focused on the posture and gait pattern
used during ambulation with an RW (Table 1). Upright
posture was defined as both the scapular acromions
aligned with the greater trochanters of the femurs in the
coronal plane; and the forward-leaning posture was
Figure 1 The two most commonly used rolling walkers (left, standard two-wheeled rolling walker; right, four-wheeled
“Rollator”) in the retirement centers and assisted living facilities.
H(H) Liu
126 兩© 2009 Japan Geriatrics Society
defined as a posture in which the line between the
scapular acromions was anterior to the line between the
greater trochanters of the femurs. In order to maintain
an upright posture during standing and ambulation, the
RW user must hold his/her RW at the height of the wrist
joint line with both elbows bent to 20–30° and with both
feet staying between the posterior legs/wheels of the
two-wheeled/four-wheeled RW.17,18 Nearly 40% of the
RW users were observed to have forward-leaning
posture during static standing. Among them were 24%
who could not correct their posture (kyphotic back or
spinal stenosis) and the remaining 16% showed the
forward-leaning posture initially in stance, but were able
to return to upright posture after being asked to “hold
your shoulder up”. In addition, 50% of the RW users
could maintain their feet between the posterior legs/
posterior wheels of the RW at standing before walking,
but later demonstrated a forward-leaning posture
during ambulation. Twenty-seven percent initiated gait
by first pushing the RW too far forward and then
moving their feet behind the RW and the rest (23%) of
them moved their RW faster than their feet at certain
times during ambulation, resulting in the feet moving
too far behind the RW. These improper gait patterns
resulted in a forward-leaning posture or made the origi-
nal forward-leaning posture worse for the duration of
ambulation with the RW. Among the 158 RW users in
this study, 87 of them used their RW at an incorrect
height. Observation found that forward-leaning pos-
tures were identified among the RW users with incorrect
RW height during ambulation (52%) and at standing
(41%) (Table 2). In other words, people using an RW at
an incorrect height may show normal posture, or people
using an RW at the correct height may show abnormal
posture. However, the forward-leaning posture among
people using RW at an incorrect height was significantly
more than that among people using RW at the correct
height during ambulation (P<0.05) rather than at
standing (P>0.05) (Table 2). Also, there were 36 RW
users who used their RW at an incorrect height and
showed forward-leaning posture at standing, among
whom 25 of them also showed forward-leaning posture
during ambulation.
After walking for 15–20 feet along a straight line with
the RW, the participants were then asked to make a turn
to go back to their seats, without being told which
direction (left or right) to turn. Sixty-eight percent of
them made a left turn and the rest (32%) made a right
turn to complete the task. It was observed that a small
number of subjects (3%), using two-wheeled RW, had
to lift the RW in the air to make the turn. It was also
observed that some RW users (5%) almost lost their
balance when making the turn too quickly, resulting in
the RW moving too anterolaterally to the user’s body
(Table 1).
Seventy-five percent of the RW users reported that
they used their RW when walking outside their rooms
or apartments (but not outside the facility building) and
they occasionally used the RW inside their room
(Table 1). If they were asked to go outside the facility
building without using their RW, 97% of them were
afraid of falling.
Table 1 Main results of rolling walker (RW)
assessment
Medical professional involvement in helping select
and instructing how to use an RW (based on 121
subjects whose Mini-Mental State Examination
(MMSE) scores were >24)
1. Users obtained their RW through:
physicians’ prescription/recommendation (26%)
physical therapists (12%)
nurses (1%)
non-medical professional (self, family, friends,
residential facility) (61%)
2. RW users were provided with instruction and/or
demonstration on how to use their RW (20%):
by oral instruction from physician (1%)
by oral instruction and physical demonstration
from physicians (5%)
by physical therapists (14%)
3. Provided RW reassessment or referred for RW
reassessment (1%)
Maintenance of appropriate RW use
1. Incorrect RW height (55%)
too high (48%)
too low (7%)
2. Not enough holes to adjust RW height (21%)
3. Poor mechanic maintenance (17%)
worn-out or loose rubber caps, tennis balls or
sliding guard covering the tips of posterior legs of
the two-wheeled RW (12%)
worn-out or loose handgrips (3%)
loose or excessively tight brake or joint areas (2%)
Posture and gait pattern during standing and
ambulation
1. Forward-leaning posture at standing (40%)
able to correct posture (16%)
unable to correct due to kyphosis/spinal stenosis
(24%)
2. Upright posture at standing but forward-leaning
during ambulation (50%)
3. Making a U-turn by lifting the RW up in the air
(3%) or by walking with body posteriorly and
laterally away from the RW (5%)
4. Use the RW primarily for activity inside their living
facility and occasionally for activity inside
individual room/apartment (75%)
Roller walker assessment in elderly
© 2009 Japan Geriatrics Society 兩127
The incorrect RW height and forward-leaning
posture during ambulation and at standing were
assessed among all 158 subjects including those whose
MMSE scores were under 24 and those whose MMSE
scores were 24 or over (Table 3). Among the 121 people
whose MMSE scores were 24 or more, 42% of them
reported that they had had at least one fall since using
an RW. However, 31% of them had experienced a
minimum of one fall in the last 12 months (Table 3).
For those who used their RW for less than 12 months,
only the falls after they started to use their RW were
counted. Each of the three factors of inappropriate RW
use (incorrect RW height, forward-leaning posture
during ambulation, and forward-leaning posture at
standing) was analyzed in this study to see if these
factors made differences in term of falls (Table 3). RW
users with forward-leaning posture during ambulation
were found to have a statistically significant higher fall
incidence rate (P<0.01) than those who did not show
the posture during ambulation. Incorrect RW height
and forward-leaning posture during standing did not
show a statistically significant difference in fall incidence
rate when compared with those who presented with
these problems and those who did not (both P>0.05).
Discussion
This assessment shows that older RW users experience
falls, despite the use of an RW. Lack to consult a
medical professional when obtaining an RW, incorrect
RW height, poor RW maintenance, improper gait ini-
tiation and forward-leaning posture were problems
commonly identified among RW users. These observa-
tions seem to be in agreement with previous reports that
inappropriate RW selection19 and incorrect RW use11
could result in a poor posture and increased potential of
falls.12,19 More specifically, the results from this study
indicated that incorrect RW height might not lead to
increased fall incidence, but might be an important
factor in causing forward-leaning posture during ambu-
lation. This forward-leaning posture could be a signifi-
cant factor in the higher incidence of falls among RW
users.
Normally, a person ambulating with an upright
posture relies only on his/her feet for a base of support
(BOS). Typically, the center of mass (COM) falls
between both feet and is perpendicular to the BOS. In
this position, the somatosensory input for balance is
received primarily from the lower extremities (LE). Also,
during normal ambulation without using an ambulatory
device, the reciprocal swing of the upper extremities
(UE) could allow them to constantly be in the “ready”
position to help maintain the COM over the BOS when
balance is perturbed. However, using an RW might
change these body mechanics. First, the normal alter-
nating arm swing will be lost by using an RW. Second,
the normal bilateral somatosensory input from the LE
may gradually adapt to quadrilateral somatosensory
inputs from both LE and UE through the RW legs.
Third, the normal BOS is increased from the area
between both feet to the area between both the subject’s
feet and the four legs/wheels of the RW. Under this
condition, the RW users may have a tendency to lean
the body forward to make the COM fall perpendicularly
on the center of this “larger” BOS, which allows the RW
user to walk with more stable dynamic balance. Fourth,
use of an RW allows the UE to compensate for weak LE
muscles during mobility, and allows total bodyweight
to be sustained by UE and LE rather than the LE only.
Thus, RW use will likely result in decreased loading
of the LE which may in turn lead to LE weakness.
The inappropriate RW use, such as a forward-leaning
posture during ambulation, might be able to make these
four changes above more evident and put an RW user in
great risk of losing his/her balance. This risk could be
greater if combined with other RW problems, such as
incorrect RW height, loose handgrips, loose rubber tips,
tennis balls and/or sliding guards for two-wheeled RW,
or loose brakes for four-wheeled RW.
Usually a person with poor balance and/or decreased
LE strength may need an ambulatory device in order
to increase the BOS (or to improve the stability) and
decrease load on LE (or to compensate for LE muscle
weakness).7Many factors should be considered to
determine if an older individual may need an ambula-
tory device (e.g. an RW). These include the subject’s
mental status, the functional level of vestibular, visual
and/or LE somatosensory systems, UE and LE strength,
as well as any external factors like the subject’s living
environment.7However, as reported in this study, many
Table 2 Observed forward-leaning posture during ambulation and at
standing
Forward-leaning posture
During ambulation* At standing
Incorrect RW height Yes n=87 52% (45/87) 41% (36/87)
No n=71 34% (24/71) 38% (27/71)
*Significant difference was identified between the incorrect rolling walker (RW)
height and the correct RW height groups.
H(H) Liu
128 兩© 2009 Japan Geriatrics Society
older individuals received little to no medical profes-
sional assistance when selecting an RW. Inappropriate
RW selection could likely result in inappropriate use,
maintenance, and improper posture and gait pattern.
Therefore, it is important and helpful if medical profes-
sionals such as physicians can assist their patients who
are RW users in obtaining, using and maintaining an
RW.
There has been an increase in the role and awareness
of physicians in fall prevention for geriatric patients.12,20
Awareness has also been raised among medical profes-
sionals regarding the lack of professional intervention
for RW selection and education.21–23 However, there is
little evidence that physicians are translating this aware-
ness into their daily clinical practice.24,25 Based on the
results from this study, there is a need for physicians
and their nurses to actually provide the service of RW
assessment and/or reassessment for their patients.
These services should include routine RW maintenance
inspections for appropriate RW height, handle-grips,
tips of RW legs and brakes of wheels. Gait and posture
pattern while using an RW should be evaluated. In
particular, attention should be given to see if: (i) the
patient moves his/her feet behind the RW; and (ii) the
patient is making a turn too quickly and/or lifts the RW
up in the air while turning.
This study also demonstrated that physicians did not
provide RW checkup for their patients during routine
office visits. This may be attributed to the lack of time
for a physician to provide instruction, demonstration
and checkup of the RW for these patients.7A possible
solution is that physicians could make a referral to a
physical therapist for a regular assessment or reassess-
ment for these RW users.7Another solution is the
establishment of an education program to provide RW
users with knowledge concerning appropriate RW use.
This program could be provided by physicians or nurses
as an educational outreach presentation (e.g. demon-
strations with handouts) in senior-living communities.
Four limitations of this study were noted. First, this
study was conducted in assisted-living facilities and
retirement centers. Older RW users living in their own
houses or in nursing homes were not assessed. Second,
subjects participated in this assessment study voluntar-
ily. Some residents did not present their RW for assess-
ment, which could increase or decrease the percentages
described in this study. Third, data regarding falling
were not collected from those whose MMSE scores
were less than 24. Considering these persons’ cognitive
ability, falls might have occurred in a higher percentage
than in this study. Fourth, more than half of these
subjects were old-older individuals (385 years), which
may indicate an increased likelihood that one will need
an RW with advanced age. However, this may also indi-
cate inaccuracies in data based on memory ability from
individuals with advanced age.
Table 3 Demographic data of selected inappropriate rolling walker (RW) use
Total
(n=158)
MMSE Score Falls among those whose MMSE 324
(n=121)
<24
(n=37)
324
(n=121)
Yes
(n=38)
No
(n=83)
Fall incidence
rate
Incorrect RW height Yes 87 19 68 22 46 22/68 =32%
No 71 18 53 16 37 16/53 =30%
Forward-leaning posture during ambulation* Yes 79 24 55 24 31 24/55 =44%*
No 79 13 66 14 52 14/66 =21%*
Forward-leaning posture at stance Yes 63 14 49 18 31 18/49 =37%
No 95 23 72 20 52 20/72 =28%
*Significant difference was identified between people with such postures and people without such posture during ambulation. MMSE, Mini-Mental State Examination.
Roller walker assessment in elderly
© 2009 Japan Geriatrics Society 兩129
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