BJMB
Brazilian Journal of Motor Behavior
Research Article
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Calve, Barela
2021
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The use of a non-pedal tricycle to promote physical activity in nursing home residents: a
pilot study
TATIANE CALVE
1,2
| ANA M. F. BARELA
2
1
Escola de Educação – Centro Universitário Internacional – UNIINTER, Curitiba, PR, Brasil.
2
Instituto de Ciências da Atividade Física e Esporte, Universidade Cruzeiro do Sul, São Paulo, SP, Brasil.
Correspondence to: Profa. Dra. Ana Maria Forti Barela, Universidade Cruzeiro do Sul, Rua Galvão Bueno, 868, Liberdade, São Paulo, SP, Brazil, 01506-000.
email: ambarela@gmail.com
https://doi.org/10.20338/bjmb.v15i2.194
HIGHLIGHTS
• Non-pedal tricycle enables inactive elderlies to
move around safely.
• The sessions with a non-pedal tricycle
promoted improvement in walking resistance.
• The sessions with a non-pedal tricycle
promoted improvement in walking speed.
• The use of non-pedal tricycle promotes
benefits to elderlies living in nursing homes.
ABBREVIATIONS
CG Control group
IG Intervention group
ANOVAs Analyses of variance
PUBLICATION DATA
Received 02 09 2020
Accepted 09 02 2021
Published 01 06 2021
BACKGROUND: Elderly individuals living in nursing homes are usually inactive and do not seem motivated to
engage in physical activity. Therefore, it is important to investigate new possibilities that enable them to be active
in these environments.
AIM: To investigate the feasibility of a protocol using a non-pedal tricycle in elderly individuals living in nursing
homes and its effects on improving endurance, walking speed, and functional mobility.
METHOD: Fourteen nursing home residents aged from 60 to 93 years were included in the study protocol. They
were randomly allocated into two groups: control (CG) and intervention (IG). The CG kept their routine during the
engagement in the study, and the IG, in addition to the routine, used a non-pedal tricycle to move around the
nursing home twice a week for 12 weeks. Participants from both groups underwent the 6-minute walk, 10-meter
walk, and timed-up and go tests, one week before the first practice session and one week after the last practice
session provided to the IG.
RESULTS: Before the intervention, there was no group difference in any test, and after the intervention, only IG
participants presented an increase in walking distance and walking speed. Both groups did not change their time
to conclude the timed-up and go test.
CONCLUSION: The use of a non-pedal tricycle seems appropriate in stimulating physical activity in individuals
living in nursing homes. Besides the motivation to move around, walking resistance and speed improved.
KEYWORDS: Older people | Gait speed | Gait distance | Intervention
INTRODUCTION
Aging is a complex and natural phenomenon that no one can avoid, and it is
characterized by biological, physiological, and psychosocial alterations in all living beings.
1
Those living in nursing homes usually present different needs and dependence degrees.
Actually, older people with no family or those who are mistreated, suffer abuse or violence,
or with no self-care capacity, more often live in nursing homes.
2
For those living in nursing
homes, physical dependence and the inability to perform daily living activities are more
pronounced than their peers, mainly because of a higher incidence of illness, physical
impairment, and psychological, social, and affective issues.
3
Elderly individuals living in
nursing homes are usually inactive and have less interaction with each other as they often
spend their time watching TV or laying down around in their dorms, and this behavior might
be due to the routine of most nursing homes.
4
It has been reported that unstimulated elderly individuals, such as those living in
nursing homes, are provided with fewer opportunities for moving around; consequently, they
present increased muscle weakness, fall risk, gait impairment, depression, and cognitive
decline.
5,6
Therefore, it seems reasonable to develop strategies that could motivate inactive
elderly adults to be active instead of sitting or laying down around on their beds for long
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periods. A strategy adopted in this study involved the use of a non-pedal tricycle, which is
based on equipment used mainly in Europe, known as the “PETRA RaceRunning” tricycle.
7
Overall, the adopted device contains a saddle, a support to lean on the trunk anteriorly, an
open rear frame that allows movement of the lower limbs in different modes, one front, and
two back wheels, and no pedals (the propulsion being generated by the foot contacting the
ground). This device can maintain users’ motivation and adherence to move around,
independently of their fitness level. According to its inventor, the benefits of a non-pedal
tricycle are promoting balance and locomotion,
7
to avoid motor impairments. Through
locomotion, the users of a non-pedal tricycle could improve muscle strength, balance, and
resistance, which in turn improve their quality of life.
8
Previous investigators have described how younger and older adults use the non-
pedal tricycle as they move along a pathway.
9
Overall, they found that both younger and
older adults could perform the proposed task at the same speed, although older individuals
presented more motion with the hip and less with the knee joints compared to younger ones.
As older adults could transport themselves with a non-pedal tricycle, which seemed a safe
way to exercise, it would be appropriate to test this in individuals living in nursing homes. To
our knowledge, there is no information about the use of non-pedal tricycles by inactive
elderly individuals. However, due to the general characteristics of individuals living in nursing
homes, the goal of this study was twofold: to investigate the feasibility of a protocol using a
non-pedal tricycle in older individuals living in nursing homes and its effects on improving
endurance, walking speed, and functional mobility.
METHODS
Participants
A convenience sample of 24 individuals aged from 60 to 93 years (11 females, 13
males), who lived in two different public nursing homes in Caraguatatuba, SP, Brazil, was
randomly allocated into two groups: control group (CG) and intervention group (IG). The
inclusion criteria were as follows: understand simple verbal commands, walk with or without
assistance, and present medical clearance for participation. The exclusion criteria were
neurological, physical, and/or mental impairment that could compromise their participation
in the study.
All procedures were performed with adequate understanding and written signed
informed consent was obtained from all participants or their legal guardians. The institutional
research ethics committee approved this study.
Procedures
All participants were instructed to keep their routine at their nursing homes during
engagement in the study, which included medical and physical therapy, and nutritionist and
psychologist attendances. Participants from IG, in addition to the routine, received practice
sessions using a non-pedal tricycle to move around the nursing home, under the supervision
of at least one experienced physical education instructor and a nurse from the nursing home.
The intervention sessions were offered twice a week, with at least one day between sessions,
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for 12 weeks, summing a total of 24 sessions. Each session lasted up to 45 min, with resting
intervals provided according to the individual needs.
At the beginning of each practice session, the saddle and the wheels were adjusted
according to the participant’s height to accommodate her/him on the non-pedal tricycle
(Figure 1). All participants wore comfortable clothes and shoes and were instructed to move
at a self-selected speed and make turns as necessary around the area. One instructor was
constantly next to the participant, providing verbal instructions and motivating them to move
around.
Figure 1. Illustration of a participant from the intervention group on the non-pedal tricycle.
During all practice sessions, the blood pressure of each participant was assessed
by a nurse at the beginning and end of each session and after 10 min of rest as a safety
precaution. The progression of the sessions was achieved by increasing the effective
duration of movement with the non-pedal tricycle and decreasing the time for resting.
Outcome measures
All participants were assessed one week before the first training session and one
week after the last training session provided to IG. One experienced researcher took the
lead on all assessments and provided standardized instructions for each test to ensure
consistency in test administration. Participants from both groups (CG and IG) underwent the
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following evaluations: 6-minute walk test,
10
10-meter walk test,
11
and timed-up and go test.
12
Rest intervals were provided between tests according to individual needs.
Endurance was measured during the 6-minute walk test. Participants were
instructed to walk at a comfortable speed along a 30-m-long pathway, turning around a cone
at each end. The total distance covered during the 6-min period was recorded for each
participant.
Gait speed was measured during the 10-meter walk test, as participants were
required to walk 10 m at a comfortable speed. A stopwatch was used to measure the time
required to cover the intermediate 6 m, excluding the periods of acceleration and
deceleration.
Finally, functional mobility was measured during the timed-up and go test, wherein
the participant had to rise from a chair, walk 3 m, turn around a cone, return to the chair, and
sit down. One researcher tracked the time taken to complete the task using a stopwatch.
It is important to note that the researcher who did the randomization and data
analysis was not involved in any assessment or training session. Conversely, complete
blinding was not possible for the researcher who performed the intervention sessions and
the assessment due to personnel constraints.
Statistical analysis
As normality (Shapiro-Wilk tests) and homogeneity (Levene tests) of variance were
confirmed, parametric tests were employed. Four analyses of variance (ANOVAs) were
employed using the groups (CG and IG) as a factor. The dependent variables for each test
were age, body mass, height, and duration of stay in the nursing homes. Three two-way
ANOVAs were employed using the groups and time of assessment (pre and post) as factors,
the latter was treated as repeated measures. The dependent variables were distance walked
(6-minute walk test), mean walking speed (10-meter walk test), and duration (timed-up and
go test). When necessary, Tukey’s post hoc tests were conducted. An alpha level of 0.05
was adopted for all statistical tests, which were conducted using Statistical Package for the
Social Sciences software.
Within- and between-group effect sizes were calculated as the difference in mean
values from each assessment divided by the pooled standard deviation. Effect sizes were
defined using Cohen’s classification (d=0.2, small; d=0.5, medium; d=0.8, large).
13
RESULTS
Ten participants were excluded from the final analysis due to Parkinson’s disease
(n=2), Alzheimer’s disease (n=1), death (n=2), incomplete assessment in one or more tests
because of weakness (n=3), and pain not related to their participation in the study (n=2).
Table 1 presents the general information of the remaining participants. ANOVA revealed no
difference between groups for age (F
1,12
=0.01, p=0.91), body mass (F
1,12
=1.14, p=0.31),
height (F
1,12
=0.32, p=0.58), and duration of stay in the nursing home (F
1,12
=0.19, p<0.66).
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Figure 2 presents the results of each participant as well as the mean (standard error)
for participants from the CG (left panel) and IG (right panel) at pre-and post-assessment.
ANOVA for the distance covered during 6 min did not reveal a significant effect for both
groups (F
1,12
=0.7, p=0.79) but revealed a significant effect for assessment (F
1,12
=6.31,
p=0.027, d=0.35) and interaction between groups and assessment (F
1,12
=10.81, p=0.007,
d=0.47). Post hoc tests indicated no difference between both groups at pre-assessment and
demonstrated that only participants from IG increased the distance at post-assessment
(d=0.45).
ANOVA for the mean walking speed did not reveal a significant effect for the groups
(F
1,12
=0.77, p=0.39) and assessment (F
1,12
=3.28, p=0.09) but revealed an interaction
between the groups and assessment (F
1,12
=9.01, p=0.011, d=0.43). Post hoc tests indicated
no difference between both groups at pre-assessment and revealed that only participants
from IG increased the mean walking speed at post-assessment (d=0.75).
ANOVA for the duration to complete the “timed-up and go test” did not reveal
significant effects for the groups (F
1,12
=4.11, p=0.06), assessment (F
1,12
=0.89, p=0.36), or
interaction between the groups and assessment (F
1,12
=3.89, p=0.07).
Table 1 – General characteristics of participants from control and intervention groups related to age, body mass, height, and
duration of stay in nursing home.
ID
Sex
Age
(yrs.)
Mass
(kg)
Height
(m)
Nursing home
(yrs.)
Control group
1
F
78
78.0
1.53
1
2
F
69
50.0
1.51
8
3
M
66
59.0
1.70
3
4
M
67
61.6
1.69
7
5
F
81
38.4
1.52
19
6
F
70
60.5
1.61
3
7
F
93
49.6
1.50
45
Mean
74.6
56.7
1.58
12.3
Standard error
3.3
4.4
0.03
5.9
Intervention group
1
M
84
65.5
1.55
4
2
M
72
77.3
1.51
3
3
M
81
55.3
1.49
3
4
M
69
60.2
1.60
5
5
F
64
48.4
1.46
23
6
M
83
60.2
1.67
20
7
F
74
76.3
1.61
7
Mean
75.2
63.3
1.56
9.3
Standard error
3.3
4.4
0.03
3.2
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Figure 2. Individual and mean (standard error) values for distance (top), mean walking speed (middle), and time spent
to conclude test (lower) of participants from the control (left panel) and intervention (right panel) groups at pre (white
bars) and post (grey bars) assessments.
DISCUSSION
In this study, we investigated the feasibility of a protocol using a non-pedal tricycle
in elderly individuals living in nursing homes and its effects in terms of improving endurance,
walking speed, and functional mobility. In general, the results revealed that it is possible to
employ a non-pedal tricycle in nursing homes, thus promoting the benefits regarding
endurance and walking speed. Thus, the use of a non-pedal tricycle seems appropriate in
stimulating physical activity in sedentary elderly individuals living in nursing homes.
Although IG displayed improved endurance and walking speed, it is important to
note that their overall scores in the 6-minute walk and 10-meter walk tests were very low
when compared to community-dwelling older individuals,
14,15
or even to individuals with
stroke before an intervention protocol.
16
The reason for this can be due to the low levels of
physical activity presented by nursing home residents
17
and their marked diminished
functional abilities.
18
However, improvement in both tests by those who underwent the
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practice sessions can be attributed to the possibility of some physical activity engagement,
which should be aimed at with the elderly population.
It is important to note that even though we failed to keep track of the effective time
that participants moved with the non-pedal tricycle, most of them spent more time resting
than moving around, although they stayed on the tricycle even during the resting intervals.
This fact can justify why they showed no improvement in their duration to complete the timed-
up and go test, which involves standing up from a sitting position and walking with changes
in the direction as fast as possible. We suggest that the way the practice sessions were
conducted in this study enabled IG to improve balance but not the lower limb strength.
However, we should be cautious with this suggestion as these aspects were not directly
measured.
Although we did not employ any instrument for registering motivation and adherence
to the use of a non-pedal tricycle, it is important to mention that even those individuals who
resisted to use the equipment in the first sessions were interested and motivated afterward
to move around the nursing home with it. An employee of one of the nursing homes reported
that one elderly individual was motivated to leave his dorm only for the practice sessions.
Another requested the use of the equipment to move to the opposite end of the nursing home
to observe an instructor of another activity (something he would not do without the non-pedal
tricycle). Based on these facts, it seems that the non-pedal tricycle, besides being able to
promote locomotion in nursing home residents, stimulates physical activity and, most
importantly, it is a tool that can be used even with those presenting gait impairments.
Therefore, the use of a non-pedal tricycle might constitute a different and innovative way of
promoting physical activity for those living in nursing homes.
To our knowledge, this is the first study investigating the viability of using a non-
pedal tricycle to promote the physical activity of nursing home residents. Although this pilot
study is relevant and presents important results, several limitations should be pointed out.
The major limitation was the limited sample size recruited as only two public nursing homes
took part in the study. Thus, this should be taken into consideration while assessing the
results and generalizability of the findings, and future studies should include more
participants from an increased number of nursing homes. We also did not monitor the
exercise intensity and did not keep track of the effective time of practice for each session.
We suggest future studies to use a heart rate monitor and a chronometer during practice
sessions. All tests were performed at the same time for each assessment (pre and post) and
in the same order for all participants. Even though we offered time for resting as necessary,
it would be more appropriate to employ each of the three selected tests on three different
days due to the frailty of these participants and in different orders to avoid possible bias.
Lack of blinding to practicing sessions by the evaluator could also cause bias, although there
were no specific expectations on which test was expected to lead to an improvement in
results between both groups. Last but not least, the assessment should comprise different
aspects other than locomotion, such as the supervision of physical activity level per day,
adherence, and motivation to participate in the practice sessions, among others. It is thus
important to plan a clinical trial, following all the recommendations to conduct it, by
considering the limitations of the present study.
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CONCLUSION
In conclusion, the results of this study revealed that it is possible to employ a non-
pedal tricycle for those residing in nursing homes, independent of their physical activity level.
The use of this device twice a week as a way to promote physical activity contributed to
improving the walking resistance and walking speed of frail individuals.
REFERENCES
1. Kerrigan DC, Xenopoulos-Oddsson A, Sullivan MJ, Lelas JJ, Riley PO. Effect of a hip
flexor-stretching program on gait in the elderly. Arch Phys Med Rehabil. 2003;84:1-6.
2. Prefeitura SP. Serviços para Cidadão (Centros de acolhida especial) - Instituição de
Longa Permanência para Idoso (ILPI), http://www.capital.sp.gov.br/cidadao/familia-e-
assistencia-social/centros-de-acolhida/centros-de-acolhida-especial/instituicao-de-longa-
permanencia-para-idoso-ilpi (accessed February 5th 2020).
3. Cuddy AJC, Norton MI, Fiske ST. This old stereotype: the pervasiveness and persistence
of the elderly stereotype. J Soc Issues. 2005;61:267-285.
4. Bessa MEP, Silva MJ. Motivações para o ingresso dos idosos em instuições de longa
permanência e processos adaptativos: um estudo de caso. Texto Contexto Enferm.
2008;17:258-265.
5. Franch-Ubia O. Changes in gait in the elderly. Rev Neurol. 2000;31:80-83.
6. Santos DM, Melo SIL, Carneiro LC, Andrade MC. Características da marcha de idosos
considerando a atividade física e o sexo. Fisioter Mov. 2008;21:137-148.
7. Hansen C. PETRA RaceRunner, https://by-conniehansen.com/product/racerunner-petra-
racerunner/ (accessed August 4th 2020).
8. Rikli RE, Jone CJ. Senior fitness test manual. 2nd ed. Champaign, IL: Human Kinetics;
2013.
9. Calve T, Russo Junior DV, Barela AMF. Strategies adopted by younger and older adults
while operating a non-pedal tricycle. Braz J Phys Ther. 2018;22:64-69.
doi: 10.1016/j.bjpt.2017.10.008.
10. Laboratories ATSCOPSFCPF. ATS statement: guidelines for the six-minute walk test. Am
J Respir Crit Care Med. 2002;166:111-117. doi: 10.1164/ajrccm.166.1.at1102.
11. Bohannon RW, Andrews AW, Thomas MW. Walking speed: reference values and
correlates for older adults. J Orthop Sports Phys Ther. 1996;24:86-90.
doi: 10.2519/jospt.1996.24.2.86.
BJMB! ! ! ! ! ! ! ! Research Article!
Brazilian(Journal(of(Motor(Behavior(
!
Calve, Barela
2021
VOL.15
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12. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail
elderly persons. J Am Geriatr Soc. 1991;39:142-148.
doi: 10.1111/j.1532-5415.1991.tb01616.x.
13. Cohen J. A power primer. Psychol Bull. 1992;112:155-159.
14. Lobo A, Santos P, Carvalho J, Mota J. Relationship between intensity of physical activity
and health-related quality of life in Portuguese institutionalized elderly. Geriatr Gerontol Int.
2008;8:284-290. doi: 10.1111/j.1447-0594.2008.00478.x.
15. Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in
community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up
& Go Test, and gait speeds. Phys Ther. 2002;82:128-137. doi: 10.1093/ptj/82.2.128.
16. Gama GL, Celestino ML, Barela JA, Forrester L, Whitall J, Barela AM. Effects of gait
training with body weight support on a treadmill versus overground in individuals with
stroke. Arch Phys Med Rehabil. 2017;98:748-745. doi: 10.1016/j.apmr.2016.11.022.
17. Marmeleira J, Ferreira S, Raimundo A. Physical activity and physical fitness of nursing
home residents with cognitive impairment: A pilot study. Exp Gerontol. 2017;100:63-69.
doi: 10.1016/j.exger.2017.10.025.
18. Rothera I, Jones R, Harwood R, Avery A, Waite J. Health status and assessed need for a
cohort of older people admitted to nursing and residential homes. Age Ageing.
2003;32:303-309. doi: 10.1093/ageing/32.3.303.
Citation: Calve T, Barela AMF. The use of a non-pedal tricycle to promote physical activity in nursing home residents:
a pilot study. BJMB. 2021. 15(2): 118-126.
Editors: Dr Fabio Augusto Barbieri - São Paulo State University (UNESP), Bauru, SP, Brazil; Dr José Angelo Barela -
São Paulo State University (UNESP), Rio Claro, SP, Brazil; Dr Natalia Madalena Rinaldi - Federal University of
Espírito Santo (UFES), Vitória, ES, Brazil.
Copyright:© 2021 Calve and Barela and BJMB. This is an open-access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives 4.0 International License which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-
profit sectors.
Competing interests: The authors have declared that no competing interests exist.
DOI:!https://doi.org/10.20338/bjmb.v15i2.194