Rollators are often prescribed for individuals with chronic obstructive pulmonary disease (COPD).1,2 They consist of a frame with handles, a seat, a hand brake, and 3 or 4 wheels.1,2 The rationale for the use of a rollator is to reduce exertional dyspnea during exercise and physical activity.3,4 The underlying mechanism for symptom relief is multifactorial. A forward leaning position stabilizes the upper limb and the rib cage, thereby assisting the accessory respiratory muscles5 as well as reducing work by transferring a portion of the body weight to the rollator.6–8 An increase in maximal voluntary ventilation (MVV) has been described in individuals with COPD when bracing their arms on a rollator, with the hypothesis that this posture improves ventilatory capacity.5,9 In some studies, rollators increased stride length, which improved walking efficiency,10,11 whereas others have noted a reduction in gait speed.12 In the elderly, rollators have been prescribed to improve balance and assist ambulation, with reports of an increased perception of safety,13 especially in the presence of comorbidities such as osteoarthritis or obesity.2,14 Daily use of a rollator, principally for outdoor use, has been reported in 59% of individuals with COPD for whom it was prescribed and assists outdoor walking in those with ambulatory oxygen therapy.15
In COPD, patients are frequently prescribed overground walking exercise (supervised and unsupervised) and undertake field walking tests as a measure of their exercise tolerance, with rollators often used during these activities.16 The effect of rollator use during a field walking test on walking distance and symptoms of dyspnea and fatigue is variable, with several studies reporting improvement3,4,17 but not all studies.11 Increased gait efficiency has also been noted in some11 but not all studies.18 Current indicators for rollator prescription include the need for rests during a field walking test, habitual use of arm bracing during a walking test, supervised walking training, or reports of less dyspnea or achieving an increased walking distance using this aid.19 Given many different indications for rollator use, there is a need to determine the short- and longer-term effects of rollators in individuals with COPD. The aim of this study was to systematically review the effects of rollators in COPD on (1) exercise capacity, (2) symptoms, and (3) health-related quality of life (HRQOL), as well as to comment on any reported physiological changes and the frequency of use. This review was registered with the international database of prospectively registered systematic reviews (PROSPERO; number CRD42016041397) and was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.20
The primary search strategy used the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, PubMed, Cochrane Database of Systematic Reviews, and Physiotherapy Evidence Database (PEDro) electronic databases from inception to November 2015, with an updated search in August 2016. The key terms were “COPD/chronic obstructive disease, pulmonary obstructive lung disease,” “rollator/wheeled rollator/wheeled walker,” “exercise capacity/peak exercise capacity/walking distance, gait parameters, health-related quality of life/quality of life, dyspnea/breathlessness, fatigue, physical activity.” The search strategy used for MEDLINE is shown in Appendix 1 (see Supplemental Digital Content 1, available at: http://links.lww.com/JCRP/A55) and was adapted for use in the other databases. Secondary searches involved hand-searching reference lists from identified articles, citation tracking of included articles, and use of the PubMed-related articles option.
Two investigators reviewed titles and abstracts independently, and potentially relevant articles were identified and retrieved in full text for independent assessment using the inclusion criteria. Inclusion criteria are outlined in Table 1. Any disagreements were resolved by consensus. Abstracts were included if sufficient data could be obtained.
DATA EXTRACTION AND QUALITY ASSESSMENT
Two investigators independently assessed the internal validity of the randomized controlled and crossover studies using the Cochrane Risk of Bias tool.21 Data extraction was performed by one investigator using a standardized template, with data checked by a second investigator. Authors of one included study were contacted and responded to provide additional information.19
Meta-analysis was planned for ≥2 studies considered clinically homogenous (similar model of intervention and outcome tools).22 Data were entered using the Review Manager 5.3 computer program (Cochrane Collaboration Information Management System), with outcomes treated as continuous variables. Data reported as mean ±SE or mean ± SD were pooled; data reported as median (interquartile range) were not able to be pooled. For crossover trials, data were analyzed using mean difference, with SE of the difference calculated from the P value or t-statistic.23,24 Weighted mean difference (same metric scale) using a fixed-effects model was selected when estimating the total effect of pooled data for a given follow-up period, with generic inverse variance used for analysis.24 Forest plots were generated to depict results, and heterogeneity was tested according to the overlap in confidence intervals (CIs), interpretation of the χ2 test, and the I2 statistic, with substantial heterogeneity represented by I2 > 50%.24 For meta-analyses, authors of included studies were contacted for additional information where necessary. When study findings could not be combined, a narrative format was used to report results.
An initial search and secondary searches yielded 31 articles, following removal of duplicates. After independent review by 2 researchers, 7 studies, 2 randomized controlled trials,3,19 and 5 crossover trials4,11,25–27 of rollator use met the inclusion criteria (Figure 1). Overall, 124 clinically stable individuals with COPD were included. Two studies reported different information from the same participants.3,4 Two studies explored the impact of integrating rollator use into daily activities over 4 wk19 and 8 wk.3 One study prescribed the rollator in those who had recently completed pulmonary rehabilitation (PR) and were previously naive to rollator use and had a 6-min walk distance (6MWD) of <375 m.3 The second study prescribed a rollator following completion of pulmonary rehabilitation for use during the following tasks: walking activities at home, walking within the home, walking outside, getting to and from the car, walking indoors in a location other than home, and other activities outside the home.19 For use during exercise testing, 4 studies compared the effects of using a rollator with no aid during a 6-Minute Walk Test (6MWT),4,11,25,26 with protocols originating from different sources28–30 and one study explored the immediate effects during a 12-min walk test (12MWT).27 Characteristics of included studies are outlined in Table 2.
The quality assessment for each study is presented in Table 3. There was a high risk of bias with participants, with only 2 studies including a blinded assessor.3,4 Randomization sequence was adequately described in 2 studies,19,25 although allocation concealment was largely unclear. All studies included a complete reporting of results.
EFFECTS OF ROLLATOR ON FUNCTIONAL EXERCISE CAPACITY DURING FIELD WALKING TESTS
Meta-analysis of 3 studies showed that a rollator increased the 6MWD by 13 m (95% CI, 5-22) (Figure 2). Similar findings with a median improvement of 46 m (P = .04) were reported by Probst et al.11 In contrast, there was no significant improvement in 12-min walking distance with a rollator27 (Table 4). Those with a 6MWD of <300 m had a significant improvement with a rollator compared with no aid (mean difference = 22.2; P =.02), but use of a rollator in those with a 6MWD of >300 m had no significant effect (mean difference = −9.9 m; P = .1).25
Effect on symptoms of dyspnea and fatigue
Meta-analysis of data from 3 pooled studies4,25,26 showed that rollator use was associated with a lower Borg dyspnea score at the end of the 6MWT with a mean difference of 0.97 (95% CI, 0.63-1.32) (Figure 2). Rollator use reduced dyspnea in those with a 6MWD of <300 m (mean difference = 1.4; P <.001) and a 6MWD of >300 m (mean difference = 0.5 points; P = .03).25 There were no reports on fatigue or rating of perceived exertion with rollator using during field walking tests.
One study noted that short-term rollator use was associated with an increased peak oxygen uptake11 and an increased ventilatory capacity, tidal volume, and MVV. Rollator use in this study resulted in a faster walking speed of 76.8 m/min.11 Another study noted a lower heart rate (HR) during the 6MWT, with walking speed of 54.4 m/min.25 Rollator use reduced oxygen desaturation in 1 study26 and had no effect in 2 others.11,25
Walking speed was reduced in one study25 and increased in another11 (Table 4), with no changes in stride length being observed.
EXTENDED USE OF ROLLATOR IN THE COMMUNITY
Effects of rollator on functional exercise and symptoms
Only one study reported on functional exercise capacity. Although it was greater with a rollator after 4 and 8 wk, this difference was not significant.3 After 8 wk of use, dyspnea scores at end-6MWT remained less with a rollator than with no aid3 (Table 4).
Effect on HRQOL
Two studies explored the effect of using a rollator within the community upon HRQOL according to the Chronic Respiratory Disease Questionnaire.3,19 Data were pooled for the domains of dyspnea, fatigue, emotional function, and mastery (Figure 3). Use of a rollator did not affect any of these domains of HRQOL compared with no aid after 4 or 8 wk.
Only one study examined the effect of a rollator use on physical activity.19 Its use increased the number of daily steps compared with no aid (mean difference = 732 steps; 95% CI, 139-1325). It also increased the amount of time undertaking moderate-intensity physical activity (9 min; 95% CI, 1-17).19 There was no difference in the amount of time spent walking (Table 4).
Frequency of use
One study separated frequent (minimum use of 3 times per week) from infrequent rollator users.3 Duration of use was 25 to 60 d among 10 frequent users (n = 10) and 5 to 15 d among 8 infrequent users. Frequent users had higher levels of mastery and lower levels of fatigue over the 8 wk than infrequent users.
When used in the short-term, rollators increased 6MWD and reduced dyspnea. Lack of daily use, with 44% of participants using a rollator <3 times per week,3 limits meaningful conclusions regarding its effect on exercise capacity or HRQOL over the longer-term. The effects of rollator use on HR, oxygenation, respiratory rate, and walking speed were variable.
Improvements in mastery and fatigue have been reported among both indoor and outdoor users,3,15 as have increased confidence and greater stability when walking among both frequent and infrequent users.3 However, the studies included in this review evaluating the long-term effects were influenced by actual rather than recommended use. The infrequent practice in one study may account for the lack of a positive effect on exercise capacity or HRQOL.3 Although the second study had a documented frequency of 3 times per wk, the time frame (4 wk) may be too short to realize the benefits.19 Alternatively, difficulty in transferring a rollator to and from a car19 and a limited ability to use indoors at home due to space constraints15 may have imposed some barriers to regular practice.
In contrast, rollator use ≥3 times per week, improved the time spent in moderate-intensity physical activity.19 This change is likely to be attributable to an increased pace of walking rather than a change in stride length.31 The extent of functional limitation due to dyspnea may also be important, with patients designated Modified Medical Research Council (MMRC) class ≥3 experiencing a greater increase in their number of steps per day than those at MMRC class 2.19 In addition to the benefits achieved by the adopted forward leaning posture, being equipped with a seat promotes more opportunities for rests and recovery of symptoms. Despite this, the lack of change in time spent walking suggests that although fear was reduced,19 the rollator does not empower individuals to be more active. However, a rollator may be a useful training adjunct to walking training in clinical practice, enabling those with marked functional limitation an opportunity to increase their walking pace and gain clinical benefit.
When used during a field walking test (6MWT), rollators significantly improved functional exercise capacity by an amount approaching the minimal clinically important difference (MCID) of 25 m suggested for COPD, while the reduction in dyspnea on exertion did reach the MCID for all participants.32,33 This effect was greater in those with baseline walking distances below 300 m,25 while the reduction in dyspnea on exertion did reach the MCID in all participants.33 The need to rest during an unaided 6MWT was predictive of an improved 6MWD and reduced perception of dyspnea when a rollator was used.25 These observations may help inform the decision whether to prescribe a rollator for an individual with COPD and substantial limitations in functional ability.
The exact mechanism beyond the reduction in dyspnea is unclear, with respiratory physiological effects ranging from an increased oxidative capacity and improved ventilation11 to variable effects on oxygenation11,25,26 to no effect on HR or respiratory rate.11,25 The favorable length-tension relationship of the diaphragm may reduce the work of breathing5,25,26 and may account for reduced dyspnea. However, this has not translated into improvements in oxygenation or breathing rate, which have been previously observed.18 In studies including patients of a similar FEV1% (percent forced expiratory volume in the first second of expiration) predicted, the degree of airflow limitation is unlikely to be the reason. Although only one study commented on the occurrence of rests during the test and their duration, the slower walking speed and lower HR lend support that resting during a 6MWT is another possible explanation.25
The effects of a rollator on walking speed were inconsistent11,25 despite studies using similar standardized protocols for the 6MWT. It might be because the improvement in walking associated with the forward lean position might be offset by the increased work associated with pushing the rollator on all but smooth surfaces.6,7,9,13 It may be influenced by the occurrence of rests during a 6MWT, with one study noting rest periods.25
The review was limited by the limited information related to adherence to the rollator prescription even among those identified as frequent users.3 Greater consistencies in reporting prescription adherence among future studies will further enhance interpretation of the clinical effects of using a rollator over the short- and long-term. Information on randomization and concealment was limited, which might have encouraged a risk of bias. Only one study evaluated the important outcome of rollator use on step count and moderate-intensity physical activity.
Short-term use of a rollator improves walking distance and reduces dyspnea. There is insufficient information on rollator adherence to draw conclusions regarding its longer-term impact on exercise capacity or HRQOL. The impact of rollator use on daily activity levels remains to be explored.
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