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Energy Expenditure of Stair Climbing with Elbow and Axillary Crutches
Professional articles
47 Key Words Axillary crutches, elbow crutches, energy cost, stair climbing.
Energy Expenditure of Stair Climbing with Elbow and Axillary Crutches
by Rufus Adesoji Adedoyin Adeoye Joshua Opayinka Zacchaeus Olawale Oladokun
Summary The purpose of this study was to investigate the energy cost of stair climbing using axillary and elbow crutches. The cardiovascular responses of 60 normal male undergraduate subjects were studied during unassisted and non-weight-bearing staircase ambulation with axillary crutches and elbow crutches. The subjects climbed 13 steps 7.1 metres long and 1.95 metres high, at their preferred speed. The cardiovascular parameters measured were systolic blood pressure, diastolic blood pressure and heart rate. The rate pressure product was calculated from the product of systolic blood pressure and heart rate. The analysis of variance demonstrated a significant result (p < 0.01). Post hoc analysis showed differences between unassisted stair climbing and both axillary and elbow crutch conditions. However, there was no difference in energy expenditure between axillary and elbow crutch ambulation.
Adedoyin, R A, Opayinka, A J and Oladokun, Z O (2001). ‘Energy expenditure of stair climbing with elbow and axillary crutches’, Physiotherapy, 88, 1, 47-51.
Introduction The use of crutches is widespread in rehabilitation. Clinically the need for restricted weight-bearing is often indicated in lower extremity pathologies such as fractures, joint replacements, rheumatoid conditions, immediate fittings and lower extremity vascular disorders (Kathrins and O’Sullivan, 1984). For patients who need to be nonweight-bearing the choice of assistive ambulatory devices is limited to crutches and walkers, but because of the greater mobility they afford, crutches are generally chosen over walkers for both young and older patients with adequate balance (Hinton and Cullen, 1982). Many rehabilitation patients depend on crutches for mobility especially when normal walking is compromised by mechanical or neurological disability and the lower limbs are capable of withstanding the stress imposed by conventional gait patterns (Hall and Clarke, 1991; Fisher and Patterson, 1981). Gait training with various assistive
devices has been described as vigorous, and brief intense exercise has long been studied in terms of stress on the heart of an individual per forming such a task (Amundsen, 1979; Cordrey et al, 1958). Examples of patients who could benefit from crutches include those who have become deconditioned because of prolonged bed rest, those with chronic disabilities who cannot bear weight for long periods or permanently, those with unilateral lower extremity amputations, and those with chronic respiratory or cardiovascular problems (Hinton and Cullen, 1982). Since all walking aids impose an additional burden on patients, those with an orthopaedic and underlying cardiovascular disease are at risk during a rehabilitative programme involving crutch walking (Wagstaff, 1984; Annesley et al, 1990). Kathrins and O’Sullivan (1984) also reported that the cardiovascular response to non-weight-bearing crutch walking is a factor that can affect patients’ ability to return to their premorbid life style. It then follows that patients, especially older clients and those with debilitating illnesses, must be instructed in the mode of crutch walking that is least fatiguing. Although crutch walking involves a combination of upper and lower extremity work, the fact that the upper extremity is more involved may explain why blood pressure (BP) response during crutch walking is significantly greater than during unassisted ambulation. Patterson and Fisher (1981) showed that the energy cost of walking with crutches was double that of normal walking. At a slow speed of 30 m.min-1, level crutch walking VO2 was reported to be 40% of maximum upper extremity testing and heart rate (HR) was 62% of maximum. Underarm and forearm crutches have Physiotherapy January 2002/vol 88/no 1
48
been compared for crutch use in walking and stair climbing (Patterson and Fisher, 1981). No significant difference at the 95% confidence limit was noted on level walking between underarm and forearm crutches either in terms of VO2 or HR; in stair climbing there was a statistical difference at 95% confidence level in both HR and VO2. In Nigeria the most commonly available crutches are the elbow and axillary crutches. Axillary crutches are used when walking is started and weight-bearing on the limb is contra-indicated as in the case of fracture. Elbow crutches are used when balance and confidence are required (Stallard, 1978). Some patients may use only one of these crutches, and for stair climbing patients may be advised to use only one crutch while the other hand is firmly on the rail. Many of our patients may not be able to climb a staircase in this way because staircases with rails are uncommon in Nigeria. Therefore patients who need to climb stairs regularly must be taught how to use a pair of crutches. The purpose of this study was to investigate the cardiovascular responses of normal subjects to using elbow and axillary crutches for stair climbing. It was designed to answer the following question: Is there any difference in energy expenditure between using elbow and axillary crutches during stair climbing? It was anticipated that:
that would have given them experience of walking with crutches. Subjects were asked not to take food and drink other than water for at least two hours before testing. Smoking was prohibited for at least 30 minutes before exercise. Instrumentation Equipment An aneroid sphygmomanometer was used to measure BP over the brachial artery. HR was monitored by palpating the radial artery and counting the number of beats per minute. A stadiometer (Seca, Prazision Furdic Gesundheit, West Germany) and bathroom weighing scale were used to measure the height and weight respectively. Two types of crutches were used in this study (see figure). The axillary crutches were made of lightweight material and weighed 0.108 kg. The elbow crutches were made of aluminium and weighed 0.100 kg.
1. The energy cost during unassisted stair climbing would be similar to that of elbow or axillary crutches. 2. The energy cost would be similar during stair climbing with elbow or axillary crutches. Methods Subjects Subjects for this study consisted of a convenience sample of 60 healthy male undergraduates of Obafemi Awolowo University, with no history of chronic or acute musculoskeletal, cardiovascular or respiratory disorders. The average age of the subjects was 23.4 years (sd 3.1); weight 59.2 kg (sd 5.5); height 1.72 m (sd 0.01). Informed consent was obtained from all subjects. A brief past medical history was obtained from each subject to ascertain that the subjects had not had any disorder Physiotherapy January 2002/vol 88/no 1
Elbow and axillary crutches as used in the study
Measurement The subjects’ systolic BP and HR were recorded and their rate pressure product (RPP) was computed using the formula: RPP = systolic BP x HR The RPP has been shown to be a valid predictor of myocardial VO 2 for measurement per formed at rest and during exercise (Kispert, 1987).
Research report
On arrival, the subjects’ ages, heights and weights were recorded. Resting HR and BP were measured. The subjects walked up a staircase 7.1 m long and 1.9 m high, with a total of 13 steps. BP and HR were measured on completion of each mode of ambulation, with a ten-minute rest between each condition. Analysis of Data Data were analysed using SPSS/PC+, the statistical package for the IBM PC. Analysis of variance (ANOVA) statistical procedure was used to determine if there were significant differences in RPP between the resting condition, unassisted stair climbing, and the response during the use of the two types of crutches. Where a significant difference was found, the specific differences between the group means were further analysed using Duncan’s post hoc analysis. A 1% level of significance was set for all tests. Procedure On their arrival at the testing area, the procedure was explained to the subjects and consent forms were signed. They were told that if at any time during the climbing they felt short of breath, excessive fatigue, or discomfort, the experiment would be terminated immediately and they would be under no obligation to complete the task. The crutches were adjusted according to the height of the subjects, to make the elbow flexion at 30˚ when the hands were placed on the handpieces and shoulders were relaxed. Each subject acted as his own control, hence all subjects were measured under four conditions: at rest, during unassisted stair climbing, using axillary crutches and using elbow crutches. Subjects were trained on the use of each type of crutch with 10 minutes rest before measurements were taken. They were randomly assigned to start with any of the three modes of walking. Results The physical characteristics of the subjects are presented in table 1. The result of the ANOVA for the mean RPP during resting, unassisted, elbow and axillary crutch conditions revealed a significant F ratio at the 1% level of significance (table 2). The result of the Duncan’s post hoc analysis (table 3) revealed that the RPP
49
Table 1: Physical characteristic of subjects (N = 60) Range Variables
Mean
SE Mean Std Mean Min
Max
Age (years)
23.40
0.40
–3.09
17
30
Weight (kg)
59.22
0.71
–5.52
45
74
1.72
0.01
–0.06
Height
1.57
1.85
Table 2: Summary of the analysis of variance for RPP during stair climbing unassisted and with elbow and axillary crutches Sources Between groups Within groups Total
DF 33.40 23622 239
SS
MS
419756102.1 870255604.4
F ratio F prob
139918700.7
37.9438
0.00
3687523.747
1290011706
Table 3: Summary of Duncan post hoc test for RPP in the four experimental conditions Mean RPP 8.216
Resting
Unassisted
Elbow
Resting
9.330
Unassisted
10.862
Elbow
* *
*
11.620
Axillary
*
*
*
* Significant difference at 0.01 alpha level
increased progressively from the resting condition to unassisted climbing, and further during the two crutch conditions. The test demonstrated significant differences between the resting and unassisted conditions, and between the elbow crutches and unassisted conditions. Likewise, significant differences were found between resting and axillary crutch walking, and between unassisted and axillary crutch walking. However, no difference was found in RPP during the elbow and axillary crutch assisted stair climbing. Discussion Crutch walking is used by many older patients after a fracture or because of musculoskeletal problems of the lower extremities, although it has been reported that crutch walking requires approximately twice as much oxygen uptake as normal walking and it was speculated that all available types of crutches demand additional energy during walking (Fisher and Patterson, 1981). Before this study it was not known Physiotherapy January 2002/vol 88/no 1
50
whether axillary or elbow crutches needed less energy expenditure although these types of crutches are commonly prescribed by Nigerian physiotherapists. The result of this study disagreed with our hypothesis that there would be no significant difference between unassisted RPP and with axillary crutches and also between unassisted RPP and elbow crutches. This is in agreement with other reports (Hinton and Cullen, 1982; Annesley et al, 1990). The significant difference noticed here may be due to the fact that crutch walking requires more upper extremity work than normal walking (Davis et al, 1976). It is not surprising that we found significant differences between the RPP of baseline (resting) and those of the three modes of walking, because HR and BP do increase with skeletal muscle exercise (Magel et al, 1978; Stramford et al, 1978). The effect of gravity on cardiovascular responses also cannot be ruled out. The use of elbow and axillary crutches is similar in terms of energy expenditure. In line with our speculation, there was no significant difference between the energy expended during the use of both crutches, despite differences in the design and material used in constructing the crutches. The elbow crutches are lighter, being made of aluminium with upright supports; and they cannot, like the other type, press on axillary vessels. The axillary crutches were made of lightweight metal with double uprights. Fisher and Patterson (1981) found a statistical difference in both HR and VO 2 when underarm and forearm crutches were compared during the stair climbing tasks, but they found no difference during level walking between the two crutches either in terms of VO2 or of HR. They reported that there is no apparent practical importance to this statistical curiosity. They did not, however, show the strength of relationship between the underarm and forearm crutches. One factor we thought might cause higher energy expenditure in the use of axillary crutches is that much pressure is imposed on the axillary vessels which leads to constant contraction and dilation of the vessels and thereby increases HR. With elbow crutches the upper limbs bear the weight of the body with little or no support from the trunk. The contraction and relaxation of the upper limb muscles Physiotherapy January 2002/vol 88/no 1
might also increase blood flow and therefore increase HR. Furthermore, crutch walking is more or less an isometric exercise which usually leads to increase in diastolic BP. Annesley et al (1990) speculated that differences in cardiovascular responses are likely to be the result of differences between subjects in the rate at which they attain a steady state and are not caused by differences in crutch design. The larger sample employed in our study is likely to minimise the influence of subjects’ variability and strengthen the conclusions. Hinton and Cullen (1982) related their own difference to the work required to perform an isometric hand grip, stabilise the scapula on thorax, balance, and lift or extend the elbow during push-off. None of our subjects complained of exhaustion during the training as they were instructed to climb at a comfortable but steady pace. The use of a naturally selected speed will provide data for comparison of results with those of physically disabled people who can only walk at self-selected rates (Baruch and Mossberg, 1983). The results of this investigation are valid for normal young adults but cannot be generalised to elderly people and those who have cardio-respiratory problems. Baruch and Mossberg (1983) reported that excessive amounts of cardiac work are demanded of elderly individuals during walker use. Clinical Implications The majority (67%) of road traffic accident (RTA) victims reported in Nigeria sustain fractures, most commonly to the lower limbs (Balogun and Abereoje, 1992). In the USA almost 80,000 patients are disabled as a result of head injuries each year and will remain disabled for the rest of their lives, and about 6,000 new cases of paraplegia or tetraplegia similarly occur each year as a result of injury to the spinal column, with RTAs as the leading cause of these problems (WHO, 1991). It was equally observed that RTAs constitute the single most important cause of accidental death with increased mortality rates for both sexes in all countries and higher incidence in males than females (WHO, 1991). The majority of these patients may have to depend on walking aids for some time.
Research report
In his unpublished data on the patterns of complications of fracture in RTAs in the Western part of Nigeria, Igbinovia (1992) found out that the 20-40-year age group had highest incidence of RTAs (45%) and 91% of the fractures involved lower limbs, with males having higher incidence. He equally found out that majority of the patients used walking aids, especially axillary and elbow crutches,
51
during their rehabilitation. The findings from this study, employing healthy young male adults, suggest that both axillary crutches and elbow crutches may be prescribed for this age group during the ambulatory phase of their management. Follow-up studies should replicate this study with patients using both types of crutch for walking, and the stability of both types should be determined.
References Amundsen, L R (1979). ‘Assessing exercise tolerance: A review’, Physical Therapy, 59, 534-437. Annesley, L A, Almada, N M, Avnall, D A and Cornwell, M W (1990). ‘Energy expenditure of ambulation using the Sure-gait crutch and standard axillary crutch’, Physical Therapy, 70, 1. Balogun, J A and Abereoje, O K (1992). ‘Pattern of road traffic accident cases in a Nigerian university teaching hospital between 1981 and 1990’, Journal of Tropical Medicine and Hygiene, 995, 23-29. Baruch, I M and Mossberg, K A (1983). ‘Heart rate response of elderly women to non-weightbearing ambulation with a walker’, Physical Therapy, 63, 2, 1782-87. Cordrey, L F, Ford, A B and Ferrer, M T (1958). ‘Energy expenditure in assisted ambulation’, Journal of Chronic Diseases, 7, 228-233. Davis, J A, Vodak, P, Wilmore, J H, Vodak, J and Kurtz, P (1976). ‘Anaerobic threshold and maximal aerobic power for three modes of exercise’, Journal of Applied Physiology, 41, 544-550. Fisher, C V and Patterson, B P (1981). ‘Energy cost of ambulation with crutches’, Archives of Physical Medicine and Rehabilitation, 62, 2550-56. Hall, J and Clarke, A K (1991). ‘An evaluation of crutches’, Physiotherapy, 77, 156-160. Hinton, C A and Cullen, A K (1982). ‘Energy expenditure during ambulation in ortho crutches and axillary crutches’, Physical Therapy, 62, 813-819.
Igbinovia, O F (1992). ‘Patterns of complication in road traffic accidents: A fiveyear retrospective study at Obafemi Awolowo University Teaching Hospitals Complex’, dissertation. Kathrins, B P and O’Sullivan, S O (1984). ‘Cardiovascular responses during non-weightbearing and touch-down ambulation’, Physical Therapy, 64, 14-17. Kispert, C P (1987). ‘Clinical measurement to assess cardiopulmonary function’, Physical Therapy, 67, 1886-90. Magel, J R, McArdle, W D, Toner, M and Delio, D J (1978). ‘Metabolic and cardiovascular adjustment to arm training’, Journal of Applied Physiology, 45, 75-79. Patterson, R and Fisher, S V (1981). ‘Cardiovascular stress of crutch-walking’, Archives of Physical Medicine and Rehabilitation, 62, 257-260. Stallard, J (1978). ‘Lower limb vertical ground reaction forces during crutch walking’, Journal of Medical Engineering and Technology, 2, 4, 201-202. Stramford, B A, Cuddilee, R W, Moffatt, R J and Rowland, R (1978). ‘Task specific changes in maximal oxygen uptake resulting from arm versus leg training’, Ergonomics, 21, 1-9. Wagstaff, P S (1984). ‘The ergonomics of walking: Axillary crutches and prototype of a new design termed Dublin crutch’, Physiotherapy, 70, 1, 422-424. World Health Organisation (1991). Accidents in Childhood and Adolescence: The role of research, WHO, Geneva.
Key Messages ■ Older clients and those with debilitating illness must be instructed in the mode of crutch walking that is least fatiguing. ■ Crutch walking is more or less an isometric exercise which usually leads to increase in diastolic blood pressure.
■ The use of elbow and axillary crutches is similar in terms of energy expenditure. ■ All available types of crutches demand additional energy during walking.
Authors R A Adedoyin MSc(PT) MNSP is a member of the academic staff in the Department of Medical Rehabilitation, and a PhD student in Obafemi Awolowo University, Ile-Ife, Nigeria. He provided the concept and research design, and also prepared the manuscript and analysed the data. A J Opayinka BMR(PT) MNSP and Z O Oladokun BMR(PT) MNSP were Youth Corper physiotherapists at the time of this report. Both participated in the data collection and review of literature. This article was received on May 1, 1999, and accepted on January 25, 2001. Address for Correspondence Mr R A Adedoyin, Department of Medical Rehabilitation, Obafemi Awolowo Univerity, Ile-Ife, Osun State, Nigeria. E-mail Pacman@Physiobase. com Acknowledgements The authors wish to thank Dr Femi Olomola of the department of economics at Obafemi Awolowo University for his help during the data analysis, and also Mr B M Salami of the medical illustration unit for his help in photographing the crutches used.
Physiotherapy January 2002/vol 88/no 1
47 Key Words Axillary crutches, elbow crutches, energy cost, stair climbing.
Energy Expenditure of Stair Climbing with Elbow and Axillary Crutches
by Rufus Adesoji Adedoyin Adeoye Joshua Opayinka Zacchaeus Olawale Oladokun
Summary The purpose of this study was to investigate the energy cost of stair climbing using axillary and elbow crutches. The cardiovascular responses of 60 normal male undergraduate subjects were studied during unassisted and non-weight-bearing staircase ambulation with axillary crutches and elbow crutches. The subjects climbed 13 steps 7.1 metres long and 1.95 metres high, at their preferred speed. The cardiovascular parameters measured were systolic blood pressure, diastolic blood pressure and heart rate. The rate pressure product was calculated from the product of systolic blood pressure and heart rate. The analysis of variance demonstrated a significant result (p < 0.01). Post hoc analysis showed differences between unassisted stair climbing and both axillary and elbow crutch conditions. However, there was no difference in energy expenditure between axillary and elbow crutch ambulation.
Adedoyin, R A, Opayinka, A J and Oladokun, Z O (2001). ‘Energy expenditure of stair climbing with elbow and axillary crutches’, Physiotherapy, 88, 1, 47-51.
Introduction The use of crutches is widespread in rehabilitation. Clinically the need for restricted weight-bearing is often indicated in lower extremity pathologies such as fractures, joint replacements, rheumatoid conditions, immediate fittings and lower extremity vascular disorders (Kathrins and O’Sullivan, 1984). For patients who need to be nonweight-bearing the choice of assistive ambulatory devices is limited to crutches and walkers, but because of the greater mobility they afford, crutches are generally chosen over walkers for both young and older patients with adequate balance (Hinton and Cullen, 1982). Many rehabilitation patients depend on crutches for mobility especially when normal walking is compromised by mechanical or neurological disability and the lower limbs are capable of withstanding the stress imposed by conventional gait patterns (Hall and Clarke, 1991; Fisher and Patterson, 1981). Gait training with various assistive
devices has been described as vigorous, and brief intense exercise has long been studied in terms of stress on the heart of an individual per forming such a task (Amundsen, 1979; Cordrey et al, 1958). Examples of patients who could benefit from crutches include those who have become deconditioned because of prolonged bed rest, those with chronic disabilities who cannot bear weight for long periods or permanently, those with unilateral lower extremity amputations, and those with chronic respiratory or cardiovascular problems (Hinton and Cullen, 1982). Since all walking aids impose an additional burden on patients, those with an orthopaedic and underlying cardiovascular disease are at risk during a rehabilitative programme involving crutch walking (Wagstaff, 1984; Annesley et al, 1990). Kathrins and O’Sullivan (1984) also reported that the cardiovascular response to non-weight-bearing crutch walking is a factor that can affect patients’ ability to return to their premorbid life style. It then follows that patients, especially older clients and those with debilitating illnesses, must be instructed in the mode of crutch walking that is least fatiguing. Although crutch walking involves a combination of upper and lower extremity work, the fact that the upper extremity is more involved may explain why blood pressure (BP) response during crutch walking is significantly greater than during unassisted ambulation. Patterson and Fisher (1981) showed that the energy cost of walking with crutches was double that of normal walking. At a slow speed of 30 m.min-1, level crutch walking VO2 was reported to be 40% of maximum upper extremity testing and heart rate (HR) was 62% of maximum. Underarm and forearm crutches have Physiotherapy January 2002/vol 88/no 1
48
been compared for crutch use in walking and stair climbing (Patterson and Fisher, 1981). No significant difference at the 95% confidence limit was noted on level walking between underarm and forearm crutches either in terms of VO2 or HR; in stair climbing there was a statistical difference at 95% confidence level in both HR and VO2. In Nigeria the most commonly available crutches are the elbow and axillary crutches. Axillary crutches are used when walking is started and weight-bearing on the limb is contra-indicated as in the case of fracture. Elbow crutches are used when balance and confidence are required (Stallard, 1978). Some patients may use only one of these crutches, and for stair climbing patients may be advised to use only one crutch while the other hand is firmly on the rail. Many of our patients may not be able to climb a staircase in this way because staircases with rails are uncommon in Nigeria. Therefore patients who need to climb stairs regularly must be taught how to use a pair of crutches. The purpose of this study was to investigate the cardiovascular responses of normal subjects to using elbow and axillary crutches for stair climbing. It was designed to answer the following question: Is there any difference in energy expenditure between using elbow and axillary crutches during stair climbing? It was anticipated that:
that would have given them experience of walking with crutches. Subjects were asked not to take food and drink other than water for at least two hours before testing. Smoking was prohibited for at least 30 minutes before exercise. Instrumentation Equipment An aneroid sphygmomanometer was used to measure BP over the brachial artery. HR was monitored by palpating the radial artery and counting the number of beats per minute. A stadiometer (Seca, Prazision Furdic Gesundheit, West Germany) and bathroom weighing scale were used to measure the height and weight respectively. Two types of crutches were used in this study (see figure). The axillary crutches were made of lightweight material and weighed 0.108 kg. The elbow crutches were made of aluminium and weighed 0.100 kg.
1. The energy cost during unassisted stair climbing would be similar to that of elbow or axillary crutches. 2. The energy cost would be similar during stair climbing with elbow or axillary crutches. Methods Subjects Subjects for this study consisted of a convenience sample of 60 healthy male undergraduates of Obafemi Awolowo University, with no history of chronic or acute musculoskeletal, cardiovascular or respiratory disorders. The average age of the subjects was 23.4 years (sd 3.1); weight 59.2 kg (sd 5.5); height 1.72 m (sd 0.01). Informed consent was obtained from all subjects. A brief past medical history was obtained from each subject to ascertain that the subjects had not had any disorder Physiotherapy January 2002/vol 88/no 1
Elbow and axillary crutches as used in the study
Measurement The subjects’ systolic BP and HR were recorded and their rate pressure product (RPP) was computed using the formula: RPP = systolic BP x HR The RPP has been shown to be a valid predictor of myocardial VO 2 for measurement per formed at rest and during exercise (Kispert, 1987).
Research report
On arrival, the subjects’ ages, heights and weights were recorded. Resting HR and BP were measured. The subjects walked up a staircase 7.1 m long and 1.9 m high, with a total of 13 steps. BP and HR were measured on completion of each mode of ambulation, with a ten-minute rest between each condition. Analysis of Data Data were analysed using SPSS/PC+, the statistical package for the IBM PC. Analysis of variance (ANOVA) statistical procedure was used to determine if there were significant differences in RPP between the resting condition, unassisted stair climbing, and the response during the use of the two types of crutches. Where a significant difference was found, the specific differences between the group means were further analysed using Duncan’s post hoc analysis. A 1% level of significance was set for all tests. Procedure On their arrival at the testing area, the procedure was explained to the subjects and consent forms were signed. They were told that if at any time during the climbing they felt short of breath, excessive fatigue, or discomfort, the experiment would be terminated immediately and they would be under no obligation to complete the task. The crutches were adjusted according to the height of the subjects, to make the elbow flexion at 30˚ when the hands were placed on the handpieces and shoulders were relaxed. Each subject acted as his own control, hence all subjects were measured under four conditions: at rest, during unassisted stair climbing, using axillary crutches and using elbow crutches. Subjects were trained on the use of each type of crutch with 10 minutes rest before measurements were taken. They were randomly assigned to start with any of the three modes of walking. Results The physical characteristics of the subjects are presented in table 1. The result of the ANOVA for the mean RPP during resting, unassisted, elbow and axillary crutch conditions revealed a significant F ratio at the 1% level of significance (table 2). The result of the Duncan’s post hoc analysis (table 3) revealed that the RPP
49
Table 1: Physical characteristic of subjects (N = 60) Range Variables
Mean
SE Mean Std Mean Min
Max
Age (years)
23.40
0.40
–3.09
17
30
Weight (kg)
59.22
0.71
–5.52
45
74
1.72
0.01
–0.06
Height
1.57
1.85
Table 2: Summary of the analysis of variance for RPP during stair climbing unassisted and with elbow and axillary crutches Sources Between groups Within groups Total
DF 33.40 23622 239
SS
MS
419756102.1 870255604.4
F ratio F prob
139918700.7
37.9438
0.00
3687523.747
1290011706
Table 3: Summary of Duncan post hoc test for RPP in the four experimental conditions Mean RPP 8.216
Resting
Unassisted
Elbow
Resting
9.330
Unassisted
10.862
Elbow
* *
*
11.620
Axillary
*
*
*
* Significant difference at 0.01 alpha level
increased progressively from the resting condition to unassisted climbing, and further during the two crutch conditions. The test demonstrated significant differences between the resting and unassisted conditions, and between the elbow crutches and unassisted conditions. Likewise, significant differences were found between resting and axillary crutch walking, and between unassisted and axillary crutch walking. However, no difference was found in RPP during the elbow and axillary crutch assisted stair climbing. Discussion Crutch walking is used by many older patients after a fracture or because of musculoskeletal problems of the lower extremities, although it has been reported that crutch walking requires approximately twice as much oxygen uptake as normal walking and it was speculated that all available types of crutches demand additional energy during walking (Fisher and Patterson, 1981). Before this study it was not known Physiotherapy January 2002/vol 88/no 1
50
whether axillary or elbow crutches needed less energy expenditure although these types of crutches are commonly prescribed by Nigerian physiotherapists. The result of this study disagreed with our hypothesis that there would be no significant difference between unassisted RPP and with axillary crutches and also between unassisted RPP and elbow crutches. This is in agreement with other reports (Hinton and Cullen, 1982; Annesley et al, 1990). The significant difference noticed here may be due to the fact that crutch walking requires more upper extremity work than normal walking (Davis et al, 1976). It is not surprising that we found significant differences between the RPP of baseline (resting) and those of the three modes of walking, because HR and BP do increase with skeletal muscle exercise (Magel et al, 1978; Stramford et al, 1978). The effect of gravity on cardiovascular responses also cannot be ruled out. The use of elbow and axillary crutches is similar in terms of energy expenditure. In line with our speculation, there was no significant difference between the energy expended during the use of both crutches, despite differences in the design and material used in constructing the crutches. The elbow crutches are lighter, being made of aluminium with upright supports; and they cannot, like the other type, press on axillary vessels. The axillary crutches were made of lightweight metal with double uprights. Fisher and Patterson (1981) found a statistical difference in both HR and VO 2 when underarm and forearm crutches were compared during the stair climbing tasks, but they found no difference during level walking between the two crutches either in terms of VO2 or of HR. They reported that there is no apparent practical importance to this statistical curiosity. They did not, however, show the strength of relationship between the underarm and forearm crutches. One factor we thought might cause higher energy expenditure in the use of axillary crutches is that much pressure is imposed on the axillary vessels which leads to constant contraction and dilation of the vessels and thereby increases HR. With elbow crutches the upper limbs bear the weight of the body with little or no support from the trunk. The contraction and relaxation of the upper limb muscles Physiotherapy January 2002/vol 88/no 1
might also increase blood flow and therefore increase HR. Furthermore, crutch walking is more or less an isometric exercise which usually leads to increase in diastolic BP. Annesley et al (1990) speculated that differences in cardiovascular responses are likely to be the result of differences between subjects in the rate at which they attain a steady state and are not caused by differences in crutch design. The larger sample employed in our study is likely to minimise the influence of subjects’ variability and strengthen the conclusions. Hinton and Cullen (1982) related their own difference to the work required to perform an isometric hand grip, stabilise the scapula on thorax, balance, and lift or extend the elbow during push-off. None of our subjects complained of exhaustion during the training as they were instructed to climb at a comfortable but steady pace. The use of a naturally selected speed will provide data for comparison of results with those of physically disabled people who can only walk at self-selected rates (Baruch and Mossberg, 1983). The results of this investigation are valid for normal young adults but cannot be generalised to elderly people and those who have cardio-respiratory problems. Baruch and Mossberg (1983) reported that excessive amounts of cardiac work are demanded of elderly individuals during walker use. Clinical Implications The majority (67%) of road traffic accident (RTA) victims reported in Nigeria sustain fractures, most commonly to the lower limbs (Balogun and Abereoje, 1992). In the USA almost 80,000 patients are disabled as a result of head injuries each year and will remain disabled for the rest of their lives, and about 6,000 new cases of paraplegia or tetraplegia similarly occur each year as a result of injury to the spinal column, with RTAs as the leading cause of these problems (WHO, 1991). It was equally observed that RTAs constitute the single most important cause of accidental death with increased mortality rates for both sexes in all countries and higher incidence in males than females (WHO, 1991). The majority of these patients may have to depend on walking aids for some time.
Research report
In his unpublished data on the patterns of complications of fracture in RTAs in the Western part of Nigeria, Igbinovia (1992) found out that the 20-40-year age group had highest incidence of RTAs (45%) and 91% of the fractures involved lower limbs, with males having higher incidence. He equally found out that majority of the patients used walking aids, especially axillary and elbow crutches,
51
during their rehabilitation. The findings from this study, employing healthy young male adults, suggest that both axillary crutches and elbow crutches may be prescribed for this age group during the ambulatory phase of their management. Follow-up studies should replicate this study with patients using both types of crutch for walking, and the stability of both types should be determined.
References Amundsen, L R (1979). ‘Assessing exercise tolerance: A review’, Physical Therapy, 59, 534-437. Annesley, L A, Almada, N M, Avnall, D A and Cornwell, M W (1990). ‘Energy expenditure of ambulation using the Sure-gait crutch and standard axillary crutch’, Physical Therapy, 70, 1. Balogun, J A and Abereoje, O K (1992). ‘Pattern of road traffic accident cases in a Nigerian university teaching hospital between 1981 and 1990’, Journal of Tropical Medicine and Hygiene, 995, 23-29. Baruch, I M and Mossberg, K A (1983). ‘Heart rate response of elderly women to non-weightbearing ambulation with a walker’, Physical Therapy, 63, 2, 1782-87. Cordrey, L F, Ford, A B and Ferrer, M T (1958). ‘Energy expenditure in assisted ambulation’, Journal of Chronic Diseases, 7, 228-233. Davis, J A, Vodak, P, Wilmore, J H, Vodak, J and Kurtz, P (1976). ‘Anaerobic threshold and maximal aerobic power for three modes of exercise’, Journal of Applied Physiology, 41, 544-550. Fisher, C V and Patterson, B P (1981). ‘Energy cost of ambulation with crutches’, Archives of Physical Medicine and Rehabilitation, 62, 2550-56. Hall, J and Clarke, A K (1991). ‘An evaluation of crutches’, Physiotherapy, 77, 156-160. Hinton, C A and Cullen, A K (1982). ‘Energy expenditure during ambulation in ortho crutches and axillary crutches’, Physical Therapy, 62, 813-819.
Igbinovia, O F (1992). ‘Patterns of complication in road traffic accidents: A fiveyear retrospective study at Obafemi Awolowo University Teaching Hospitals Complex’, dissertation. Kathrins, B P and O’Sullivan, S O (1984). ‘Cardiovascular responses during non-weightbearing and touch-down ambulation’, Physical Therapy, 64, 14-17. Kispert, C P (1987). ‘Clinical measurement to assess cardiopulmonary function’, Physical Therapy, 67, 1886-90. Magel, J R, McArdle, W D, Toner, M and Delio, D J (1978). ‘Metabolic and cardiovascular adjustment to arm training’, Journal of Applied Physiology, 45, 75-79. Patterson, R and Fisher, S V (1981). ‘Cardiovascular stress of crutch-walking’, Archives of Physical Medicine and Rehabilitation, 62, 257-260. Stallard, J (1978). ‘Lower limb vertical ground reaction forces during crutch walking’, Journal of Medical Engineering and Technology, 2, 4, 201-202. Stramford, B A, Cuddilee, R W, Moffatt, R J and Rowland, R (1978). ‘Task specific changes in maximal oxygen uptake resulting from arm versus leg training’, Ergonomics, 21, 1-9. Wagstaff, P S (1984). ‘The ergonomics of walking: Axillary crutches and prototype of a new design termed Dublin crutch’, Physiotherapy, 70, 1, 422-424. World Health Organisation (1991). Accidents in Childhood and Adolescence: The role of research, WHO, Geneva.
Key Messages ■ Older clients and those with debilitating illness must be instructed in the mode of crutch walking that is least fatiguing. ■ Crutch walking is more or less an isometric exercise which usually leads to increase in diastolic blood pressure.
■ The use of elbow and axillary crutches is similar in terms of energy expenditure. ■ All available types of crutches demand additional energy during walking.
Authors R A Adedoyin MSc(PT) MNSP is a member of the academic staff in the Department of Medical Rehabilitation, and a PhD student in Obafemi Awolowo University, Ile-Ife, Nigeria. He provided the concept and research design, and also prepared the manuscript and analysed the data. A J Opayinka BMR(PT) MNSP and Z O Oladokun BMR(PT) MNSP were Youth Corper physiotherapists at the time of this report. Both participated in the data collection and review of literature. This article was received on May 1, 1999, and accepted on January 25, 2001. Address for Correspondence Mr R A Adedoyin, Department of Medical Rehabilitation, Obafemi Awolowo Univerity, Ile-Ife, Osun State, Nigeria. E-mail Pacman@Physiobase. com Acknowledgements The authors wish to thank Dr Femi Olomola of the department of economics at Obafemi Awolowo University for his help during the data analysis, and also Mr B M Salami of the medical illustration unit for his help in photographing the crutches used.
Physiotherapy January 2002/vol 88/no 1