Nordic walking, a fairly new form of exercise based on cross-country (Nordic) skiing, is gaining popularity in the U.S.-and has recently been incorporated into physical ­rehabilitation.

When practiced correctly, Nordic walking has been scientifically proven to improve physical condition, health and general well-being.¹Invented in Finland, the physical activity uses specifically-designed Nordic walking poles and combines walking with cross-country skiing upper-body movements.

"Picture cross-country skiing without the skis," said Maurice Dumit, MPT, owner of INVIVO Wellness, Milwaukee WI.

Dumit, along with Sara M. Meeks, PT, MS, GCS, owner of Sara Meeks Seminars, uses Nordic walking to help treat certain patient populations. Paula McLeod, Dip, TR, R/TRO, a recreation therapist for the Rehabilitation Centre at The Ottawa Hospital, Ontario, teaches patients how to Nordic walk with the intent of continuing the exercise once discharged.

All three therapists spoke with ADVANCE about the benefits of Nordic walking and shared tips for fellow PTs looking to incorporate Nordic walking into rehabilitation.

ADVANCE: What types of patients can benefit from Nordic walking?

Dumit: Nordic walking poles can be used in myriad ways to address a number of physical therapy interventions and diagnoses. The poles provide stability and a lower-extremity unloading effect that is beneficial in the later stages of hip, knee and ankle rehabilitation. Because it engages the core during gait (you can feel the abdominals contracting at heel strike/pole plant and the latissimus dorsi/lumbar paraspinals at toe off/push-off), it is also advantageous for lumbar rehabilitation. I especially like to use them with patients who have axial flexion collapse postures (think osteoporosis) as the poles encourage neutral thoracic and head postures.

McLeod: Much of my experience has been with people diagnosed with chronic pain syndrome. The majority of these clients can walk safely with little or no walking aids. Beyond its usefulness as a modality in therapy, a patient who can walk relatively safely without aids and is able to swing their arms with control can benefit from using Nordic walking as a fitness activity.

Meeks: I work with patients with postural problems, back pain, pain and/or limitation of motion secondary to osteoarthritis of the knees and hips, post-surgical (knee, hip, ankle) and neurologically-impaired patients. Patients with osteoporosis, back pain and postural problems can benefit from Nordic walking in many ways:

The walking poles promote a more upright posture and thus will help stimulate more normal weight-bearing forces and muscle contractions on the bones.

For people with back pain, the poles help to un-weight the back and lower extremities, thus helping relieve back pain.

The poles bring a weight-bearing force into the upper extremities.

ADVANCE: What parts of the body does Nordic walking exercise?

Dumit: Along with all the lower-extremity muscles engaged in normal walking, the poles provide recruitment of the axial and upper-extremity muscles. At heel strike/pole plant, the abdominal and pectoralis engage. Throughout the stance phase, the recruitment of muscles shift from anterior axial to posterior axial/upper extremity, with the latissimus dorsi and posterior deltoids being the primary mover. A significant degree of coactivation of anterior and posterior axial muscles exists throughout the entire gait cycle.

McLeod: The same parts of the body used in cross country skiing are exercised in Nordic walking, which is pretty much the whole body. All four limbs (including feet and hands), glutes and trunk are involved, as well as shoulders, back and neck.

Meeks: Nordic walking is what I would call a "total-body" exercise. When one walks with the poles, the arms are used more than in walking without poles, thus increasing weight-bearing forces and flexibility in the upper body. With each pole-plant there is a co-contraction of the abdominals and other core muscles. Use of the poles creates more of a cardiac workout. As the person uses the poles, there is a corresponding increase in heart rate, and the person does not have to walk faster to get a better workout.

ADVANCE: How do you choose which pole will be the right fit for each patient?

Dumit: There are a number of companies that manufacture walking poles with many ­features. Most poles today are made from aluminum, aluminum/carbon fiber or just carbon fiber. My favorite poles are telescoping, which make them portable and versatile for different users. They are made from aluminum alloy and have durable rubber "boot-shaped" tips and ergonomic grips. These features provide shock control and stability while still providing good ground feedback.

McLeod: Some poles have straps for the hands, some don't. Some have telescopic poles. Some are extremely lightweight, others a little heavier. Generally, I like to use the lighter weight ones with adjustable hand straps. The length of pole I recommend depends on a patient's height, physical fitness level and the angle of their arm while holding a pole. Sizing a participant for poles is part of the Nordic walking instructor training, as inappropriate pole length can impact technique. It is important to distinguish the difference between Nordic walking poles and trekking poles. Trekking poles are made for hiking and backpacking and as such their main purpose is for balance and support. The straps are different from Nordic walking pole straps and some trekking poles are spring loaded. Nordic walking poles are designed to help with propulsion. I don't recommend trekking poles for Nordic walking.

Meeks: For patients, I choose Nordic walking poles that are lightweight, have adjustable heights, have cushioned tips or removable cushioned tips for off-road walking, and have easy-use, well-fitting handgrips.

ADVANCE: Do patients typically enjoy this form of exercise over other types of exercise?

Dumit: Patients typically find this to be an energizing experience. When patients concentrate on the proper technique, they tend to focus on function instead of dysfunction. It's a fairly small learning curve, and when they begin to integrate the proper technique they achieve a longer stride and more upright posture and that can be empowering.

McLeod: Patients often tell me that they really like Nordic walking and many have pursued it as a form of exercise post discharge. I don't believe it feels like therapy to them. They feel like it's a fun new way of exercising, a way to walk with less pain, a way to help maintain good posture while walking, a way to be able to walk farther with no increased pain, a way to get an upper-body workout while walking and a way to take walking "up a notch." In addition, the poles can provide some stability for walking outdoors in the winter months: the rubber paws come off the bottom of the poles to expose metal tips.

Meeks: Nordic walking poles promote a more "athletic" appearance. They give bilateral support and thus help support the upper body better. Patients seem to enjoy the idea of this fun way to exercise and so it doesn't seem so much like exercise. More patients than I had ever thought possible have responded well to the use of the poles.

ADVANCE: Would you recommend this form of exercise to other PTs/facilities? Why?

Dumit: Yes, primarily because of the versatility and simplicity of walking with the poles. Using poles can be a valuable tool from developing core and lumbar stability, to un-weighting lower extremities, to improving exercise tolerance for patients with claudication, Parkinson's disease, ataxia and arthritis. In many cases using poles will also have significant psycho-social advantages over the use of walkers, crutches and canes. They can even be used by wheelchair users.

McLeod: Yes, patients seem to be really motivated by this form of exercise, as it enables them to become more involved in fitness activities.

Meeks: I absolutely recommend Nordic walking classes to every PT facility I visit. Therapists can offer classes and this appeals to a lot of patients. Also, PTs are getting more and more into wellness practices and this helps take patients further into that arena.

ADVANCE: What should other PTs keep in mind when incorporating Nordic walking into a treatment plan?

Dumit: Consider first a patient's cognitive and coordination abilities prior to adding a variable such as walking poles to a gait training program. I don't initially use the poles if the primary intent is to unload the lower extremity associated with an orthopedic issue, or if there are significant balance or coordination issues. Canes and walkers are better in those instances. The poles are an excellent tool to progress someone from walkers and canes to unassisted gait.

We also use the poles to progress stability training and plyometric style exercises. Holding the poles out in shoulder abduction and jumping side to side is great for lateral/medial hip/knee stability.

McLeod: If using the poles for fitness, the person working with the patient should have training to instruct Nordic walking. Proper technique maximizes the benefits.

Meeks: Nordic walking offers a more motivational, fun and exciting way for patients to exercise. Walking, in and of itself, while useful and recommended, can be boring. Walking with poles adds elements of support, an increased level of workout, and can also help patients with balance problems that would prohibit them from getting the most out of a walking workout.

Reference

1. International Nordic Walking Association. (2009). What is Nordic Walking? Retrieved from the World Wide Web, www.inwa-nordicwalking.com

Beth Puliti is senior associate editor and web editor of ADVANCE and can be reached at epuliti@advanceweb.com