WALKING IMPROVEMENT
Admission to a nursing home often coincides with older
adults losing their independence with mobility and
becoming more dependent on assistive devices and/or
wheelchairs. As many as half of the nursing home residents
who are wheelchair dependent have a history of falls and
up to 25% of residents who could walk were issued a
wheelchair as a result of a fall (Pawlson et al., 1986). It is
also estimated that almost two-thirds of nursing home
residents require assistance with transfers and walking
(Resnick, 1998). Immobility can be a serious problem faced
by nursing homes as it can cause limitations in activities of
daily living, “pressure ulcers, pneumonia, urinary stasis,
constipation and fatigue” (Norman & Gibbs, 1991).
Causes of Decreased
Ambulation
Healthy younger adults typically perform
ambulation at an energy efficient level while
older adults who are generally weaker and
have decreased endurance have increased
energy expenditure during mobility tasks.
Prosthetics,
orthopedic
impairments,
weakened lower extremities, and assistive
devices can also add to the metabolic output
in addition to the effect of aging resulting in
further
difficulty
with
ambulation
(McGibbon et al., 2001; Annesley et al.,
1990). Although the alterations in gait of
older adults indicate a progression toward a
more safe, secure, and stable gait pattern, the
cost of energy output can be significant.
As older individuals become more
physically or psychologically impaired their
mobility performance and skills tend to
decrease. Further, physical impairments
such as loss of bone and muscle mass can
often occur as a result of decreased mobility,
causing even less mobility: therefore a spiral
decline begins.
Significant differences in biomechanical
walking patterns are found between healthy
older and younger adults (Winter et al.,
1990; Ferrandez et al., 1990). Older adults
have:
Risk factors for decreased ambulation and
related falls can be categorized into two
groups: intrinsic and extrinsic. Intrinsic
factors are those specific to the individual
resident and include:
 A shorter step length;
 Decreased velocity;
 Increased double-support stance period
(the stage of walking in which both feet
are touching the floor);
 Decreased push-off power, a more flatfooted landing, and a reduction in their
index of dynamic balance.
Walking Improvement
 Advanced age;
 Medication use (antidepressants,
antihypertensives, and antipsychotics);
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 Chronic diseases (chronic obstructive
pulmonary disorder, arthritis, congestive
heart disease, and Parkinson’s disease);
 Daily alcohol consumption;
 Impaired cognition;
 Decreased visual acuity;
 Incontinence;
 Self-reported decline in health status;
 Factors related to muscle strength,
mobility, flexibility, cardiovascular
conditioning, and balance; and/or
 Additional factors may include falls
resulting in fractures or fear of falling,
decreased endurance due to acute illness,
infections, or psychological changes.
residents not carried out correctly or not
addressed at all. Basic daily needs such as
feeding, medications, and toileting become
the primary concern and there isn’t
additional time to address activities such as
walking or exercise. When facilities are
understaffed, caregivers may assume it is
more efficient to transport residents by
wheelchair rather than supervised walking.
This may be realistic as an immediate
solution; however over time, if the residents
were able to become independent
ambulators the caregivers would spend less
time transporting residents within the
facility.
High staff turnover rates can also be
detrimental to existing programs designed
for individuals in nursing homes. New staff
members are often not educated on
individual programs and can be unaware of
their role in walking improvement. Therapy
teams also share this frustration as they
work individually with the residents to gain
progress and then have concerns regarding
the follow through and support that will be
available after discharge. Staff education
and training must be very comprehensive
during orientation, and must be continual
thereafter. Strong leadership and support
must also be given to these programs by
supervisors and administrators.
Extrinsic factors include:
 Social issues such as living alone;
 Personal factors such as level of risktaking behaviors (Nowalk et al., 2001);
and/or
 Environmental hazards that pose risks
for falls include: cluttered hallways or
living spaces, wet floors, presence of
loose carpets or rugs, lack of grab bars,
poor furniture arrangement, and lack of
adequate lighting (Jensen et al., 2002).
Motivation can have significant impact on a
resident’s physical functioning. Resnick
(1998) suggests that residents who are
motivated to improve had increased
participation and improved functional
outcomes. The presence of depression was
found to have a significant correlation to a
decline in functional abilities, however it
may be because it has an impact on
motivation.
Benefits of Effective Walking
Improvement Programs
Benefits from programs or interventions
producing walking improvement include
“increased
socialization,
greater
independence in functional areas, improved
posture, balance, coordination, cardiac
conditioning, and relief from stress”
(Norman & Gibbs, 1991). “Progressive
resistive strength training interventions can
improve lower extremity strength, balance,
and performance in nursing home residents”
Barriers to Successful
Walking Programs
Nursing departments are often under staffed
resulting in individualized programs for
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(Resnick, 1998). Jivorec (1991) reports
multiple benefits identified in a literature
review of various exercise regimens as:
“increased physical work capacity, increased
muscle strength, improved aerobic capacity,
increased joint flexibility, improved body
image, and increased life satisfaction.” Also,
“increases in range of motion and flexibility
and decreases in recovery heart rate, aches,
and pains.” Psychologically, residents
“demonstrated significant improvement in
morale and attitude toward their own aging”
(Jivorec, 1991).
 Balance training with beanbags, balls,
and balloons;
 Flexibility exercises; and
 Walking.
Research of Walking
Improvement Programs
Program #2: A Six-Month Walking
Program
Koroknay (1995) conducted a six-month
walking program in order to promote
functional mobility in the frail nursing home
population. Twenty residents who would not
or could not ambulate without the assistance
of staff were identified based on initial
assessments completed by the nursing unit
manager and the gerontological clinical
nurse specialist (GCNS). The goal was “to
establish a nursing procedure that focuses on
the resident’s need to walk, and to improve
or maintain the ambulatory status of the frail
elderly… this goal was accomplished by
making walking a regular part of the day’s
activities rather than an additional ‘task,’
and by holding a nursing assistant
accountable for walking residents.” Their
program included the following key points:
The FFLTC demonstrated greater functional
outcomes than standard seated ROM
exercise programs and it can be
individualized to the resident’s abilities. The
program also has additional benefits, as it
can be safely implemented by nursing home
staff, caregivers, or volunteers with minimal
education and low cost.
The majority of nursing homes offer
exercise and walking programs for their
residents, but recent research shows that
how the program is organized makes a big
difference in resident outcomes. Here are
some ideas about how to make your
program successful from a series of studies
that have improved outcomes for residents:
Program #1: The Functional Fitness for
Long-Term Care (FFLTC) Program
The FFLTC (Lazowski et al., 1990) was
designed not only to maintain upper and
lower extremity range of motion (ROM), but
also to improve strength, balance, flexibility,
mobility, and function. It requires simple
equipment and minimal training. Families,
volunteers, or nursing home staff can
administer the program. Nursing home
residents were randomly assigned to 2
groups: ROM exercises only, or FFLTC.
Each program was conducted for 45
minutes, three times per week, for four
months. Key components of the FFLTC
program included:
 Nursing assistants assured that residents
ambulated;
 The focus was on maintaining mobility
in frail nursing home residents who
required assistance with walking;
 Schedules and goals were coordinated
with the nursing unit’s activities (meals)
and the residents’ daily activities (using
the restroom); and
 The residents who were participants in
the program experienced an increase in
 Progressive strengthening with resistive
exercise bands and ankle/wrist weights;
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3
 “The exercise should be designed both to
gradually extend the resident’s exercise
tolerance and to be performed on a
schedule that maximizes the efficient use
of staff time.”
their functional ambulation and a
decrease in falls.
Staff was educated regarding the objective
of the program, benefits of walking and
exercise, and the dangers of immobility. The
environment was adapted to reflect banners
and distance markers for encouragement and
motivation. New residents were assessed
upon admission, existing residents were
continually reassessed, and goals revised if
needed. Results of the program reflected a
significant improvement in ambulatory
status, and the percentage of residents who
fell decreased from 25% to 5%. Koroknay
also found that the residents with cognitive
impairments benefited as much as the
residents who were cognitively intact.
Residents were given individualized goals
for mobility and for standing tolerance. The
average walk time of ambulatory residents
involved in the FIT program increased from
30 minutes a week to 55 minutes. The
average sit to stands performed in a day
improved from 3.4 to 10. The control group
did not change significantly for either
activity. Designing the FIT program to be
implemented by nurses aides while
performing other care routines has the
advantage of time management as it only
required an average of six minutes more per
session than the PV only.
Program #3: Functional Incidental
Training (FIT)
The FIT program walking is integrated with
prompted voiding (PV), which is a
behavioral intervention shown to decrease
the severity of incontinence. Seventy-six
residents participated in the program for
eight weeks. The subjects were randomly
divided into two groups, one integrated the
FIT program with PV and the other was PV
only. Every two hours between 8:00 a.m.
and 4:00 p.m. five days a week the residents
were approached for toileting needs. The
subjects receiving the FIT protocol were
encouraged to participate in transfers,
ambulation, and standing activities along
with toileting assistance. The control group
was given socialization and toileting
assistance. The FIT program was developed
around three principles:
Program #4: Walking Program
The residents walked five days a week for
four weeks. The intervention lasted
approximately 30 minutes per day and the
residents were verbally encouraged to walk
as far as they could without taking a break.
At the beginning of the study the subjects
walked an average of 50 feet before they
were fatigued. After the study the residents
walked an average of 73 feet. Only two of
the 15 subjects could rise independently out
of a chair before the intervention opposed to
six after daily exercise. Three residents
could walk unassisted before the program
compared to five at the end of the fourth
week. The frequency of urinary incontinence
was significantly decreased during the day
shift from an average of 2.33 incontinent
episodes to an average of one. The
prevalence of urinary incontinence can be
impacted by the interventions of caregivers,
and is related to muscle atrophy and loss of
function such as walking that often occurs in
a nursing home setting (Jivorec, 1991).
 “The exercise should be integrated into
the PV incontinence care routine”;
 “Emphasis should be placed on the
repetition of exercises that are specific to
the functional skills involved with
toileting and other activities of daily
living”; and
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social group had individual social visits for
30 minutes. The results showed significant
progress. The subjects in the walking
program increased their maximal walk
endurance time by 77%, and distance by
92% (MacRae et al., 1996).
Program #5: Walking Programs for
Residents with Alzheimer’s Disease (AD)
One of the barriers identified by Tappen et
al. (2000) of an effective ambulation
program for individuals with AD is
compliance with the intervention. In their
study, 65 residents with AD were randomly
assigned to treatment groups of assisted
walking,
walking
combined
with
conversation,
and
conversation-only.
Interventions were provided for 30-minute
intervals three times a week for 16 weeks.
Residents in the assisted walking group
declined with functional mobility by 20.9%,
the conversation-only group declined by an
average of 18.8%, and the combined
walking and conversation group declined
only 2.5%. Residents in the conversationonly group had a compliance rate of 90%,
the combined group averaged 75%
compliance, and the ambulation only
achieved a compliance rate of 57%. The
conversation element of the intervention
appears to have improved compliance of the
residents. Based on the results of this study,
Tappen et al. (2000) suggest that assisted
walking with conversation can contribute to
maintenance of functional mobility,
specifically ambulation, for individuals with
Alzheimer’s disease in nursing homes.
Summary of Key Elements to
a Successful Walking
Improvement Program
Many
interventions
for
walking
improvement have been initiated since the
Omnibus Budget Reconciliation Act
(OBRA) of 1987, which emphasized the
necessity for long-term care facilities to
maintain and promote higher levels of
functioning. Programs require support by the
entire interdisciplinary team and are
typically implemented by physicians,
restorative
personnel,
therapists,
gerontological clinical nurse specialists, or
nursing unit managers. Responsibilities of
the team should include:
 Making initial assessments of functional
mobility status
 Determining the potential of walking
improvement
 Developing goals consistent with
residents’ needs and capabilities
 Assessing current medications that may
affect balance or ambulation potential
and adjust or delete as needed
 Providing continual education and
communication with the resident and
family or caregivers regarding status and
plan of care
 Implementing and maintaining the
program on a daily basis
Program #6: A Walking Improvement
Program
MacRae et al. (1996) conducted a 12-week
walking program to determine the effects on
walk endurance capacity, physical activity
level, mobility, and quality of life in
ambulatory nursing home residents who had
been identified as having low physical
activity levels and low walk endurance
capacities. The subjects were divided into
two groups, a walking program or a social
program. The residents in the walking
program ambulated five times a week up to
30 minutes a day for 12 weeks. The control
Walking Improvement
Staff members must be aware of the goals,
purpose, and design of the program in order
to be effective and accountable. The
elements of successful treatment according
5
to Tinetti (1986) are: “correct exercise
prescription, good supervision, continuity
and persistence, and stepwise progression.”
falls, and tracked when the falls normally
occurred. They determined the majority of
falls occurred between 11:00 a.m. - 3:00
p.m. The staffing schedule was adjusted and
a new position titled “Special Care C.N.A.”
was created with the redistributed hours.
This new position “concentrates on residents
who require special attention at the busiest
times of the day with tasks such as
showering, walking to events, or assistance
with one-on-one activities” (Crotty, 1999).
In the following quarter the fall rate
decreased by 15%. Additional approaches
included individualized prevention programs
following changes in psychotropic drug
plan, and reviewing resident care plans
during morning interdisciplinary meetings
the day after a fall. An interdisciplinary
focus was important to ensure staff
awareness
to
residents
at
risk.
Documentation of data such as time of fall,
date, and injuries sustained, is essential in
identifying results of the program and areas
of improvement.
Norman and Gibbs (1991) also support a
model of an interdisciplinary team approach.
In this model physical therapists make
referrals to nursing for residents currently on
therapy caseload who could benefit from
additional ambulation practice on the unit
with supervision by the nursing staff.
Therapists provide education and training to
the nursing staff regarding the resident’s
potential and functional skills, and provide
gait and balance assessments to measure
baseline status and progress throughout the
course of stay in the facility. Nursing staff
that recognize a change in condition of the
resident’s mobility status request an
evaluation by a physical therapist. The
gerontological clinical nurse specialist offers
initial and reassessments for appropriateness
of admission into the program, and
medication adjustments are made through
collaboration with the physician. Volunteers
assist by providing incentives such as
certificates or awards, and providing
refreshments for the program. Further
responsibilities include environmental or
maintenance personnel to help with marking
the distances in the hallways or
environmental modifications, the activities
department to keep a record of progress in a
main area with the resident’s consent, social
services to inform families and caregivers of
the resident’s progress, and dietary to
recommend supplemental nutrition to
increase energy.
Walking interventions should include
components such as: strength and balance
training, endurance training, cardiovascular
conditioning, and motivational persuasion.
According to Norman and Gibbs (1991),
intervention strategies should involve
reassurance, praise, encouragement, verbal
goal reminders, and incentives for
participation.
Residents
should
be
encouraged to set their own goals. The more
control they have over their own progress
the more motivation and ownership they will
exhibit throughout the program. Residents
may develop their treatment plan to include
when they walk, how far, time of day, which
route to take and offer suggestions for the
program (Norman and Gibbs, 1991).
Determining underlying causes of decreased
mobility can also be an important aspect.
Norman and Gibbs suggest beginning by
identifying residents who ambulate and do
According to Crotty (1999), one long-term
care facility was able to turn their falls
prevention program into a best practice with
individualizing the program according to
their facility’s needs. The quality
improvement team reviewed residents’
records and identified all residents at risk for
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6
not use a wheelchair, those who are unable
to ambulate, and those who can ambulate
but use a wheelchair. Pawlson et al. (1986)
interviewed 50 residents who used
wheelchairs but could ambulate and found
the three reasons cited most often were fear
of falling, they could get around faster, and
they get too tired when they walk,
respectively. Further investigation from that
point may assist in reducing dependent
mobility patterns.
Ferrandez AM, Pailhous J, and Durup M.
Slowness in Elderly Gait. Experimental
Aging Research. 1990; 16: 79-89.
Jensen J, Lundin-Olsson L, Nyberg L, and
Gustafson Y. Fall and Injury Prevention in
Older People Living in Residential Care
Facilities: A Cluster Randomized Trial.
Annals of Internal Medicine. 2002; 136:
733-741.
Jivorec MM. The Impact of Daily Exercise
on the Mobility, Balance, and Urine Control
of Cognitively Impaired Nursing Home
Residents. International Journal of Nursing
Studies. 1991; 28(2): 145-151.
Comprehensive
programs
involving
rehabilitation and discharge from the facility
to a lesser level of care should include
balance and gait training, walking on uneven
surfaces, on carpeted floors, negotiating
stairs, maneuvering through obstacles,
walking outside on sidewalks using curbs,
and practicing car transfers. The best
opportunity to predict success in the
subsequent environment is to perform an onsite evaluation with the resident present. If
family members or other caregivers will be
involved in the follow-up care, it would be
helpful to have them attend for educational
purposes. Further therapy provision by
caregivers or home health therapists may be
needed once the resident is discharged from
the facility to assist the resident with
achieving their highest possible level of
independent ambulation.
Koroknay VJ, Werner P, Cohen-Mansfield
J, and Braun JV. Maintaining Ambulation in
the Frail Nursing Home Resident:
A
Nursing Administered Walking Program.
Journal of Gerontological Nursing. 1995;
21(11): 18-24.
Lazowski DA, Ecclestone NA, Myers AM,
Paterson DH, Tudor-Locke C, Fitzgerald C,
Jones G, Shima N, and Cunningham DA. A
Randomized Outcome Evaluation of Group
Exercise Programs in Long-Term Care
Institutions. Journal of Gerontology:
Medical Sciences. 1999; 54A(12): M621M628.
MacRae PG, Asplund LA, Schnelle JF,
Ouslander JG, Abrahamse A, and Morris C.
A Walking Program for Nursing Home
Residents: Effects on Walk Endurance,
Physical Activity, Mobility, and Quality of
Life. Journal of the American Geriatrics
Society. 1996; 44: 175-180.
References
Annesley AL, Almada-Norfleet M, Arnall
DA, and Cornwall MW. Energy Expenditure
of Ambulation Using the Sure-Gait® Crutch
and the Standard Axillary Crutch. Physical
Therapy. 1990; 70: 18-23.
McGibbon CA, Puniello MS, and Krebs DE.
Mechanical Energy Transfer During Gait in
Relation to Strength Impairment and
Pathology in Elderly Women. Clinical
Biomechanics. 2001; 16(4): 324-33.
Crotty MT. Setting Best Practices in Motion.
Provider. 1999; 25(7): suppl 7,10.
Walking Improvement
7
Norman G and Gibbs J. Why Walk When
You Can Ride? Clinical Ambulation
Incentives for the Immobile Elderly. Journal
of Gerontological Nursing. 1991; 17(8): 2933.
Changes in the Fit and Healthy Elderly.
Physical Therapy. 1990; 70: 340-347.
Nowalk MP, Prendergast JM, Bayles CM,
D’Amico FJ, and Colvin GC. A
Randomized Trial of Exercise Programs
Among Older Individuals Living in Two
Long-Term Care Facilities: The FallsFREE
Program. Journal of the American
Geriatrics Society. 2001; 49(7): 859-65.
Pawlson G, Goodwin M, and Keith K.
Wheelchair Use by Ambulatory Nursing
Home Residents. Journal of the American
Geriatrics Society. 1986; 34(12): 860-864.
Resnick B. Functional Performance of Older
Adults in a Long-Term Care Setting.
Clinical Nursing Research. 1998; 7(3): 230249.
Schnelle JF, MacRae PG, Ouslander JG,
Simmons SF, and Nitta M. Functional
Incidental Training, Mobility Performance,
and Incontinence Care with Nursing Home
Residents. Journal of the American
Geriatrics Society. 1995; 43: 1356-1362.
Tappen RM, Roach KE, Applegate EB, and
Stowell P. Effect of a Combined Walking
and Conversation Intervention on Functional
Mobility of Nursing Home Residents with
Alzheimer Disease. Alzheimer Disease and
Associated Disorders. 2000; 14(4): 196-201.
Tinetti
ME.
Performance-Oriented
Assessment of Mobility Problems in Elderly
Patients. Journal of the American Geriatrics
Society. 1986; 34(2): 119-126.
Winter DA, Patla AE, Frank JS, and Walt
SE. Biomechanical Walking Pattern
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