The Effect of the Use of a Walker in Infancy on the Musculoskeletal System and the Level of Physical Activity

Abstract

Background
The study aimed to compare the lower extremity muscle strength, postural disorders, and physical activity levels of children who used and did not use a walker during infancy.

Method
The study included 39 children between the ages of 8 and 15. The demographic information of the children, their motor development stages and walker use situations, the age at which they started to use it, and the duration of use was questioned. The New York Posture Analysis Questionnaire and the Physical Activity Assessment Questionnaire Scale (PAQ-C) were given to the children. Muscle strength was measured with a digital muscle strength meter.

Results
For the left hip abductor, right hip adductor, right foot plantar flexor, both lower extremity dorsiflexor muscles, and PAQ-C weekend item parameters, a statistically significant difference was found between the two groups (p˂0.05).

Conclusion
We believe that future age periods should be followed up to examine the effect of the use of walkers in children in the developmental period, and the predicted possible effects may yield findings, especially at later ages. The lack of statistical differences in posture and muscle strength necessitated the association of childhood with adulthood.

Full text

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The Effect of the Use of a Walker in Infancy on the
Musculoskeletal System and the Level of Physical
Activity
Ozden Gokcek (  ozden.gokcek@ege.edu.tr )
Ege University
Yagmur Tugral
Izmir Democracy University
Mıne Argalı Denız
Suleyman Demırel University Research and Application Hospital
Esra Doğru Huzmelı
Hatay Mustafa Kemal University
Mehmet Ozkeskin
Ege University
Mıray Baser
Ege University
Arzu Hurrıyetoglu
Hatay Mustafa Kemal University
Baran Yıldırım
Hatay Mustafa Kemal University
Cigdem El
Tayfur Ata Sökmen Medicine Faculty Hatay Mustafa Kemal University
Research Article
Keywords: Baby equipment, physical activity, muscle strength, posture, walker
Posted Date: March 3rd, 2023
DOI: https://doi.org/10.21203/rs.3.rs-2638700/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Abstract
Background
The study aimed to compare the lower extremity muscle strength, postural disorders, and physical activity
levels of children who used and did not use a walker during infancy.
Method
The study included 39 children between the ages of 8 and 15. The demographic information of the
children, their motor development stages and walker use situations, the age at which they started to use
it, and the duration of use was questioned. The New York Posture Analysis Questionnaire and the
Physical Activity Assessment Questionnaire Scale (PAQ-C) were given to the children. Muscle strength
was measured with a digital muscle strength meter.
Results
For the left hip abductor, right hip adductor, right foot plantar exor, both lower extremity dorsiexor
muscles, and PAQ-C weekend item parameters, a statistically signicant difference was found between
the two groups (p0.05).
Conclusion
We believe that future age periods should be followed up to examine the effect of the use of walkers in
children in the developmental period, and the predicted possible effects may yield ndings, especially at
later ages. The lack of statistical differences in posture and muscle strength necessitated the association
of childhood with adulthood.
Introduction
Although the negative effects of baby walkers are recognized, they continue to be widely used worldwide.
(1). Baby walkers are known worldwide as a fun piece of equipment used for babies aged 4–12 months
(2).
Most parents, who see that children who start to move in infancy cannot stand on their feet, think that
they speed up walking by placing their baby on a walker (3). Studies have found that mothers think the
walker supports the baby's walking and having fun (4).
In the healthy development of the musculoskeletal structure of children, the importance of environmental
factors such as age-appropriate physical activity as well as genetic structure cannot be denied (5).

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Correct walking is provided by a healthy nerve and musculoskeletal system. The deterioration in these
systems and functions of the body causes pathological walking. Pathological walking leads to a
decrease in physical activity levels and the development of problems in people's daily lives (6). Between
1990 and 2014, 230,676 children younger than 15 months treated for walker-related injuries in emergency
departments were reported to the National Electronic Injury Surveillance System of the US Consumer
Product Safety Commission (7). For this reason, the American Academy of Pediatrics has declared the
necessity of prohibiting the production and sale of portable walkers (8). In our country, there is no deposit
or policy for the use of baby walkers yet (9). However, in a study conducted in our country, it was reported
that while the rate of use of walkers was 74.5% in 2009, it was 57.5% in 2014 (1, 10).
This study aims to determine the lower extremity muscle strength, postural disorders, and the differences
in physical activity levels between the two groups between walker users and non-users during infancy.
Method
This study included 39 children aged 8–15 years who applied to Hatay Mustafa Kemal University, Tayfur
Ata Sökmen Health Practice and Research Hospital, Department of Pediatrics. Volunteer-participating
children and parents without idiopathic and serious orthopedic problems and chronic diseases were
included in the study. The study did not include children with neurological and neuromuscular disease
and mental retardation. Demographic information of the children, gender, weight, height, body mass
index, resume, surname, and a number of siblings was recorded. Their parents were asked about their
stage of motor development and their use of walkers, the age at which they started using a walker, and
the length of time they used it. The New York Posture analysis questionnaire was used to assess
children's posture, and the physical activity rating scale for children (PAQ-C) was used to assess physical
activity. Muscle strength was measured with a digital muscle strength meter. A consent form was
obtained from parents and children who agreed to participate in the study. The study was approved by
Mustafa Kemal University Tayfur Ata Sökmen Medical Faculty Clinical Research Ethics Committee with
decision number 03 dated 23.12.2021.
New York Posture Analysis
This analysis consists of 13 separate bodily parts and examines posture changes. In the scoring system;
correct posture is recorded as ve points, a moderate amount of deformity posture as three points, and
severe deformity posture as one point. The total score calculated at the end of the questionnaire is taken
as a maximum of 65 and a minimum of 13 points. The results of the analysis are evaluated as ≥ 45
points very good, 40–44 points good, 30–39 points moderate, 20–29 points poor, and a total score of ≤
19 points bad (11).
Physical Activity Questionnaire for Children (PAQ-C)
This questionnaire, administered to children aged 4–14, evaluates the activities done during a week. (12).
The questionnaire consists of 9 questions, each of which is evaluated over 5 points. 1 point indicates low

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and 5 points high physical activity level. Dividing the total score of the selected items by the number of
items gives the summary score of the PAQ-C questionnaire (13, 14).
Digital Muscle Strength Meter
Our study measured muscle strength objectively with the JTech Commander PowerTrack Muscle
Dynamometer. Right and left in muscle test; hip exors/hyperextensors/adductors/abductors/internal
rotators/external retractors, knee exors/extensors, foot plantar exors/dorsiexors were evaluated.
Values were recorded in Newtons. Measurements were made in triplicate and averaged.
Statistical Analysis
The data obtained from the research were evaluated in the SPSS statistical package program. Frequency
(n) and percentage (%) were given within the scope of descriptive statistics. Intergroup Mann Whitney U
Test and within-group Wilcoxon Test were used to determine whether the difference between the means
of variables was statistically signicant. The signicance level was accepted as p < 0.05.
Results
Among the children included in our study, the mean age of those who used a walker was (10.87 ± 1.69)
years, while the mean age of those who did not use a walker was (10.13 ± 1.88) years. In the study,
gender distribution was found to be 41.7% male and 58.3% female using a walker, while the rate of
females not using a walker was 33.3% and males were 66.7%. The mean body mass ratio of those using
walkers was (19.27 ± 4.15) and those who did not use a walker (16.82 ± 2.26) (Table1).
Table 1
Demographic Data of Children
Group Using Walker Walker-Free Group
Girl/Boy (n/%) 10/14 (41,7/58,3) 5/10 (33,3/66,7)
Age (years) 10,83 ± 1,65 10,13 ± 1,88
Height (cm) 147,25 ± 15,50 135,00 ± 13,41
Body Weight (kg) 43,02 ± 15,33 31,13 ± 9,51
Body Mass Index (kg/m2) 19,27 ± 4,15 16,82 ± 2,26
When the motor development stages of children using a walker and the duration of using a walker are
evaluated; The average of the periods when he started using the walker was (7.083 ± 1.69) and the
average of the period he used was (3.04 ± 1.26) months. The motor development stages of children using
a walker are head holding (3.20 ± 1.10), sitting without support (6.29 ± 1.23), crawling (7.50 ± 1.61), and
independent walking (12.33±) in months. 2.38); head holding (2.73 ± 0.59), sitting without support (5.33 ±
1.04), crawling (7.33 ± 1.63), and independent walking (13.20 ± 3.80) months in non-walker users
determined (Table2).

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Table 2
Evaluation of Motor Development Stages of Children Using Walkers
Motor Development Stages (months) Group Using Walker
Mean ± Std
Walker-Free Group
Mean ± Std
P Value
Head Holding 3,20 ± 1,10 2,73 ± 0,59 0,208
Unsupported Seating 6,29 ± 1,23 5,33 ± 1,04 0,022
Crawling Independent 7,50 ± 1,61 7,33 ± 1,63 0,546
Walking 12,33 ± 2,38 13,20 ± 3,80 0,683
When the muscle strength values of children using and not using a walker were compared; There was a
statistical difference between the groups in right hip adductors, right plantar exors, and right-left foot
dorsiexors (p > 0.05). The lower extremity muscle strength of the children using a walker was higher than
the ones not using a walker, and there were signicant differences between the right and left extremity
muscle strengths. In addition, a signicant difference was observed in the right and left hip
hyperextension muscles of the children using walkers (p = 0.024) (Table3).

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Table 3
Muscle Strength Measurement Results of Children Using and Not Using a Walker
Digital Muscle Force
Measurement Device
(Newton)
Group Using
Walker
Mean ± Std
P* Walker-Free
Group
Mean ± Std
P*
Value P**
Right Left Right Left Right/ Left
Hip Flexors 145,91
± 28,90 141,17
± 28,09 0,071 154,13
± 41,97 147,47
± 42,73 0,151 ,633/0,885
Hyperextensors 140,17
± 22,84 130,21
± 27,24 0,024 129,33
± 28,86 128,33
± 32,04 0,875 ,312/,675
Abductors 116,00
± 20,98 115,33
± 20,02 0,732 106,13
± 20,87 96,67
± 19,46 0,019 ,296/,014
Adductors 115,33
± 20,97 109,38
± 19,08 0,140 94,40
± 20,05 101,47
± 22,54 0,119 ,008/,592
Internal Rotators 98,17
± 16,78 99,92
± 18,50 0,871 82,33
± 25,63 79,60
± 26,77 0,348 ,053/,075
External Rotators 98,33
± 20,77 96,04
± 19,62 0,287 81,60
± 30,74 79,07
± 25,22 0,530 ,102/,092
Knee Flexors 108,50
± 19,59 103,96
± 20,18 0,067 95,60
± 23,77 99,47
± 25,50 0,148 ,160/,862
Extensors 128,50
± 26,34 123,50
± 23,34 0,091 127,20
± 29,41 121,00
± 26,23 0,093 ,784/,318
Foot Plantar Flexors 115,46
± 14,37 110,67
± 14,14 0,064 101,67
± 18,06 101,53
± 22,96 0,814 ,021/,187
Dorsiexors 106,13
± 16,35 102,96
± 15,16 0,360 88,40
± 22,69 80,80
± 19,49 0,036 ,033/,001
** Mann Whitney U Test, *Wilcoxon Test
Posture analysis and physical activity levels (except on weekends, there was no signicant difference
between the two groups (p > 0.05). The weekend activity status of the children who did not use a walker
was 3.53 ± 1.19 on average, while it was 2.54 ± 0.98 for those who used a walker. (Table4).

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Table 4
Posture Analysis and Physical Activity Level Evaluation Results of Children Using and Not Using a Walker
Group Using Walker
Mean ± Std
Walker-Free
Group
Mean ± Std
P Value
Leisure Activity Checklist 25,83 ± 3,82 25,80 ± 6,20 0,919
Physical education 4,04 ± 1,04 3,60 ± 1,54 0,455
Respiration 2,92 ± 1,25 3,40 ± 1,59 0,203
Lunch 2,25 ± 1,22 2,06 ± 1,53 0,499
After School 3,08 ± 1,35 3,33 ± 1,63 0,622
Evenings 2,29 ± 1,37 3,26 ± 1,66 0,079
Weekend 2,54 ± 0,98 3,53 ± 1,18 0,008
What denes you best 2,96 ± 1,08 2,73 ± 1,33 0,539
Activity frequency for each day of the past
week 21,92 ± 5,06 21,53 ± 7,45 0,977
PAQC 67,58 ± 12,06 69,26 ± 19,11 0,762
New York Posture Analysis 52,63 ± 6,82 53,80 ± 6,09 0,581
PAQ-C: Physical Activity Assessment Questionnaire Physical activity Questions for international
children, Mann-Whitney U Test
Discussion
This study aimed to compare the lower extremity muscle strength, postural disorders, and physical
activity level of children using and not using a walker in infancy, and to determine the effects of walker
use. As a result of the study, it was determined that there was a difference in PAQ-C weekend item
parameters with the left hip abductor, right hip adductor, right foot plantar exor, and both lower extremity
dorsiexor muscles.
The walker, whose production and sale have been banned in the world for many years, continues to be
used in our country. In a study conducted by Doğan et al. (1) in Turkey, more than half of the families
reported that they started using walkers for their babies before the 7th month. Clinical physiotherapists
working in the eld of pediatrics inform families that the use of walkers is not healthy. The American
Academy of Pediatrics emphasizes that the walker does not support independent walking and may even
delay normal development and motor control (8). On the other hand, families stated that they used the
baby's walker because they thought it accelerated the acquisition of gait activity and improved lower
extremity muscle strength (1, 15). Although many families believe that babies using walkers start walking

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earlier than their peers (16), some studies argue that the walker does not show any positive effect to
accelerate locomotor skill acquisition (15, 17, 18).
There are conicting results in studies specic to this subject in the literature. In addition to studies
stating that there is no difference in the toddler age of babies using and not using a walker (17–19),
some studies have found that babies who do not use a walker can walk earlier (17, 20). In terms of gross
motor development, it is stated that the use of walkers has no effect (18, 21, 22, 23), and that it may even
cause a delay in motor skills in children at the age of acquisition (19, 20, 22) and normal locomotor
foundation stones, and its use should be discouraged (24). Has been done. Although this opinion is more
common in the literature, there are also studies stating that babies using walkers have an earlier
independent walking age. In their study with 160 children and their caregivers, Çöl et al. (25) asked the
caregiver about the independent walking time of the baby and found that the babies who used a walker
walked independently earlier. In another study, the current motor development and walking age were
compared between two groups using and not using a walker, and although the walking age was found to
be earlier in the group using a walker, no difference was found between the two groups in terms of motor
development (26). Studies have reported that due to the design of the walker, infants prevent seeing the
extremity movements and cannot obtain visual experience (27), which may cause them to exhibit an
unusually advanced motor movement in the early period by interfering with the natural development
process (28, 29). Badihian et al. (30), in their systematic review on the effect of the walker on motor
development, stated that the results about the effects of the walker on development were insucient and
contradictory, therefore, it should be used carefully until studies with a higher level of evidence on the
subject are conducted.
In our study, the average age of children to start using a walker was 7.083 months, and the average time
they used it was 3.04 months. Although independent walking was on average 1 month earlier in the
walker group in children using and not using a walker, there was no difference between the two groups in
terms of motor development steps, except for the age of sitting without support, in accordance with the
literature (25, 26). It was observed that the right hip adductors, right foot plantar exors, and right-left foot
dorsiexors of the children using a walker were signicantly different from the children who did not use a
walker. The presence of children interested in sports activities in the walker group or some environmental
factors may have affected muscle strength development. For this reason, it was concluded that future
studies can also be viewed and interpreted from this perspective.
With the use of a walker, specic postures and movements not seen in normal independent walking are
practiced. A baby sitting on a walker usually exes his trunk and plantar exes his feet and rises to the tip
of his toes to move (16, 19). When the group that did not use a walker was compared with the group that
used it, it was determined that the rectus femoris muscle exhibited greater muscle action potential, less
muscle activation during walking, and a more straight and vertical posture. They concluded that since
some of the baby's weight is carried by the walker, the walker can minimize the antigravity muscle
contraction and strength development necessary to maintain posture. In the study, more undesirable
lateral movements were observed in the group using a walker compared to those who did not, suggesting

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that there may be a developmental delay in acquiring balance skills in babies using walkers (19).
Because of all these postural alignment problems, the walker may adversely affect the normal gait
pattern and posture development in early childhood, and may cause idiopathic toe gait development (1,
8). However, in the long term, it is thought that walking practices performed with this abnormal postural
alignment will not create a typical gait pattern when the baby starts walking independently (28), and the
motor changes observed due to the walker will be short-lived (19). In our study, there was no difference
between the results of the New York Posture Analysis of the two groups, which may be because an
average of 10 years has passed since the use of the walker, and a possible postural change is reduced or
not observed in the long term.
In order to examine the effect of the use of walkers in the developmental children in the study, we believe
that the future age periods should also be followed and the predicted possible effects will show ndings
especially in later ages.
In the literature, no study has been found on the muscle strength of children using walkers and the effect
of physical activity in older ages. The fact that there was no statistical difference, especially in posture
and muscle strength, made it necessary to associate the childhood period with the adult period.
Conclusion
There are some questions in the literature regarding the achievement of posture, muscle strength, and
motor development steps of walker use. Many families still continue to use walkers for their babies, with
the belief that the walker affects early mobility. Without a clear scientic basis for this issue, it becomes
dicult for clinicians to advise families on using walkers. For this reason, the effect of walker use in
infancy on the school-age period should be claried with studies with a high level of evidence.
Abbreviations
PAQ-C: Physical Activity Assessment Questionnaire Scale
Declarations
Funding Source:none
Conicts of interest:none
Informed consent and Human and Rights: The ethics of the research was approved in accordance with
the Helsinki declaration. the children and their responsible parents were informed and consent was
obtained.


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
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