Health Benefits of Nordic WalkingA Systematic Review

Marcus Tschentscher, MSc, David Niederseer, MD, PhD, BSc,Josef Niebauer, MD, PhD, MBA

Context: Modern lifestyle, with its lack of everyday physical activity and exercise training, predis-poses people to chronic diseases such as diabetesmellitus, obesity, hypertension, and coronary arterydiseases. Brisk walking as a simple and safe form of exercise is undisputedly an effective measure tocounteract sedentary lifestyle risks even in the most unft and could lead to a reduction of theprevalence of chronic diseases in all populations. The purpose of this review is to systematicallysummarize, analyze, and interpret the health benefts of Nordic walking (walking with poles), and tocompare it to brisk walking and jogging.

Evidence acquisition: A systematic and comprehensive literature search was performed betweenNovember 2010 and May 2012. Data were analyzed between April 2011 and May 2012.

Evidence synthesis: Sixteen RCTs with a total of 1062 patients and 11 observational studies with831 patients were identifed. The current analysis revealed that with regard to short- and long-termeffects on heart rate, oxygen consumption, quality of life, and other measures, Nordic walking issuperior to brisk walking without poles and in some endpoints to jogging.

Conclusions: Nordic walking exerts benefcial effects on resting heart rate, blood pressure, exercisecapacity, maximal oxygen consumption, and quality of life in patients with various diseases and canthus be recommended to a wide range of people as primary and secondary prevention.(Am J Prev Med 2013;44(1):7684) 2013 American Journal of Preventive Medicine

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Context

Modern lifestyle, with its lack of everyday physicalactivity and exercise training, predisposes peopleto chronic diseases including diabetes mellitus,obesity, hypertension, and coronary artery diseases.1 De-spite the fact that the benefts of regular physical activity arewidely known, the choice of a sedentary lifestyle is increas-ing inprevalence.2,3 Therefore, identifying formsofphysicalactivity that are easily accessible is warranted and can beperformedby a large number andwide range of people for asuffcient amount of time andwith an appropriate intensityto induce ftness and health effects.Brisk walking as a simple and safe form of exercise is

undisputedly an effective measure to counteract seden-tary lifestyle risks even in themost unft and could lead toa reduced prevalence of chronic diseases in all popula-

From the University Institute of Sports Medicine, Prevention and Rehabil-itation, ParacelsusMedical University of Salzburg; Institute of Sports Med-icine of the State of Salzburg; Sports Medicine of the Olympic CenterSalzburg-Rif, Salzburg, Austria

Address correspondence to: JosefNiebauer,MD, PhD,MBA,UniversityInstitute of Sports Medicine, Prevention and Rehabilitation, ParacelsusMedical University of Salzburg, Lindhofstrasse 20, Salzburg, Austria 5020.E-mail: j.niebauer@salk.at.

0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2012.09.043

76 Am J Prev Med 2013;44(1):7684 2013 Amer

tions.4 However, it is not considered very fashionable andhas not been adopted by a meaningful proportion of thepopulation. Nordic walking (walking with poles) was de-veloped in Scandinavia and introduced in central Europenearly 20 years ago. People of all ages quickly were at-tracted by it.5 Nordic walking proved to be a simple andeasible form of physical activity that can be done byearly everybody, everywhere, and at almost any time. Its the same as brisk walking except for the additional usef specially designed poles that provide the advantage ofctively involving the upper body and arms (Figure 1).The purpose of this review is to systematically summa-

ize, analyze, and interpret the health benefts of Nordicalking in general, and to compare it to briskwalking andogging with regard to its effects on heart rate, maximalxygen consumption, quality of life, and other health-elated measures.

Evidence AcquisitionLiterature Search: Inclusion and Exclusion Criteria

To cover the wide range of possible Nordic walking articles, thefollowing databases were searched: ISI Web of Knowledge,PubMed, CENTRAL, CINAHL, and PEDro. The main search

items included Nordic walking, pole walking, pole striding,

ican Journal of Preventive Medicine Published by Elsevier Inc.

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Tschentscher et al / Am J Prev Med 2013;44(1):7684 77

and exerstriders. In a second step, all items were amended byeach of the cited diseases. If an article included more than onesearch item, it was counted only once during further analysis. Thesearch was limited to articles written in English and German and atime range of 1950 to the present. Data collection took place be-tween November 2010 and May 2012, and data analysis was per-formed between April 2011 and May 2012. References of all in-cluded articles were checked for further relevant publications.Only RCTs and observational studies were included, matching the

search criteria referring to health topics. If studies did not apply aproper Nordic walking technique or did not use specially designedNordic walking poles, they were not considered. Because exerstrid-ing was one of the frst commercial forms of Nordic walking with anidentical technique, articles on that topic were included and assessedalong with all other papers specifcally on Nordic walking.

Selection Process and Data Extraction

A total of 211 articles included the search terms used. Of these, 141had to be excluded on the basis of title and abstract, because theydealt with Nordic walking in a context other than health. Next,search results obtained from the fve databases were compared

Figure 1. Nordic walking, an outdoor sport

January 2013

or coincidingmatches. The remaining 27 articles were acceptedor fnal analysis, including 16 RCTs and 11 observational trialsFigure 2). Two independent reviewers read all abstracts, andisagreements on eligibility were later solved by consensus.rticles were then checked for relevant data, which were ex-racted twice and compared for accuracy. Two reviewers per-ormed statistical analyses and citation handling.

Evidence SynthesisOverall, 16 RCTs were identifed with a total of 1062patients (Nordic walking group, n559; control group,n503), representing the long-term health effects of Nordicwalking. Mean study duration was 324 (13.17.3) weeks(Table 1). Additionally, the data of 11 observational trialswith 831 patients were included in the analyses, to dem-onstrate the short-term health effects of the sport (Table 2).In all reviewed articles, maximum heart rate and/ormaximal oxygen uptake were typically measured by amaximum incremental test.

Healthy SubjectsIn 1995, the frst observational study to demonstrate su-perior short-term effects of Nordic walking as comparedto brisk walking without poles was carried out in tenfemale subjects. It found that 30 minutes of Nordicwalking at a submaximal intensity (6.7 km/hour [i.e.,1.9 m/second]) led to an 11% greater mean oxygen con-sumption (VO2); 8% higher peak heart rate; a raisedrespiratory exchange ratio of 5%; and an 18% higherenergy expenditure as brisk walking at same pace (allp0.05).6 Similar increases (VO2: 23%; peak heart rate:8%; energy expenditure: 22%; all p0.05) were foundyears later in another observational study by Porcarit al.7 in 16 women and 16 men on two separate 20-inute walking protocols at submaximal pace. Jordant al.8 (n10) as well as Church et al.9 (n22)were able toonfrm these fndings on VO2, heart rate, and energy ex-penditure in separate observational studies (Table 2). In afurther observational study, Aigner et al.10 observed in tenwomen and tenmen that Nordic walking resulted in higherarterial blood lactate (12%) and higher peak heart rate (4%;all p0.01) than brisk walking on a treadmill.Schiffer et al.11 assessed cardiorespiratory parameters in

15 healthy women during Nordic walking, walking, and

211 articles identified 141 excluded based on title and abstract

70 matched specific inclusion criteria

27 articles included in review16 RCTs11 observational studies

43 excluded as duplicates

Figure 2. Selection of articles

78 Tschentscher et al / Am J Prev Med 2013;44(1):7684

Table 1. Overview of RCTs on the effects of Nordic walking on chronic diseases

Study State of health N Intervention Intensity Results

Breyer (2010)22 COPD 60 Int: n30; 60 minutes,three times per weekNW, 12 weeks

Con: n30; sedentary

NW: 75% HRmax 1 walking time (p0.01)1 6MWT (p0.01)2 sedentary behavior

(p0.01)

Collins (2005)21 Peripheral arterialdisease

49 Int: n25; 3 times perweek NW, 24 weeks

Con: n24; sedentary

N/A 1 HRmax (p0.04)1 VO2peak (p0.016)1 perceived pain (p0.02)2 BP (p0.001)

van Eijkeren (2008)28 Parkinsonsdisease

19 Int: n10; 60 minutes,two times per weekNW, 6 weeks

Con: n9; sedentary

NW: individualspeed

1 6MWT (p0.01)1 QoL (p0.01)

Figard-Fabre (201015 Obesity 11 Int: n6; three times perweek NW, 4 weeks

Con: n5; 3 times perweek walking, 4 weeks

NW and walking:4 km/h (1.1 m/s)

1 HRmax (p0.001)1 VO2peak (p0.001)1 energy consumption

(p0.022)2 RPE (p0.031)

Figard-Fabre (2011)16 Obesity 23 Int: n12; 45 minutes,three times per weekNW, 12 weeks

Con: n11; 45 minutes,three times per weekwalking, 12 weeks

NW and walking:individual speed

1 VO2peak (p0.005)1 adherence (p0.011)2 body fat (p0.011)2 BP (p0.001)

Gram (2010)14 Diabetes mellitustype 2

68 Int1: n22; 45 minutes,two times per weekNW, 8 weeks

Int2: n24; exercisegroup

Con: n22; sedentary

NW and exercise:40% VO2peak

2 Fat tissue mass(p0.021)

(2) HbA1c (n.s.)

Hagner (2009)13 Healthy 168 Int: n168; 12 weeks NW(65 pre-, 53 peri-,53 postmenopausal)

Con: none

NW: individual,moderate speed

1 HDL (p0.01)2 LDL (p0.01)2 triglycerides (p0.01)2 BMI (p0.01)

Hartvigsen (2010)5 Low back and/orleg pain

136 Int1: n45; 45 minutes,two times per weekNW, 8 weeks

Int2: n45; self-controlled NW;

Con: n46; physicalactivity counseling

N/A n.s.

Henkel (2008)24 Neck pain 85 Int1: n28; two times perweek NW, 12 weeks

Int2: n30; one time perweek walking withMBT shoes

Con: n27; two times perweek spine training

N/A 1 QoL (p0.043)2 Neck pain (p0.001)2 functional spine

impairment (p0.011)

Kocur (2009)18 Post acutecoronarysyndrome

80 Int1: n40; 30 minutes,four times per weekNW, 3 weeks

Int2: n20; 30 minutes,four times per weekwalking

Con: n20; standardrehabilitation

NW and walking:individualwalking speed

1 exercise capacity(p0.025)

(continued on next page)

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jogging in an observational feld test on separate days. Theirdata indicate higher VO2 for Nordic walking than for walk-ng and jogging at 6.57.2 km/hour (1.82 m/second;0.05). At a comparable speed (up to 8.5 km/hour [i.e.,.4 m/second; p0.05), VO2 and heart rate during Nordicwalking compared well with that during jogging.In an RCT, Kukkonen-Harjula et al.12 investigated the

ong-term effects of Nordic walking (n60) and walkingn61) during self-guided training intervention for 12eeks (40 minutes, four times per week), similar for bothroups, in previously sedentary women at 50% of thendividual maximum heart rate. Maximum heart rate,

Table 1. (continued)

Study State of health N Inte

Kukkonen-Harjula(2007)12

Sedentary 121 Int: n60;four timeNW, 13 w

Con: n61four timewalking,

Langbein (2002)20 Peripheral arterialdisease

52 Int: n27;minutes,week NW

Con: n25

Mannerkorpi(2010)23

Fibromyalgia 67 Int: n34;two timesNW, 15 w

Con: 33; 20times pe15 weeks

Reuter (2011)29 Parkinsonsdisease

90 Int: n30;three timNW, 24 w

Con I: n3Con II: nexercise

Sprod (2005)26 Breast cancerrehabilitation

12 Int: n6; 2two timesNW, 8 we

Con: n6;two timeswalking,

Suija (2009)30 Depressed 21 Int: n16;30 minuttimes pe24 weeks

Con: n5;30 minuttimes pe24 weeks

Total 1062

Note: 95% CIs are between groups.BP, blood pressure; Con, control group; COPD, chronic obstructive pInt, intervention group; N/A, not available; n.s., not significant; NW, Nlife; RER, respiratory exchange ratio; RPE, rate of perceived exertioconsumption; 1, increase; 2, decrease

espiratory exchange ratio, peak oxygen consumption,

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and lactate threshold improved over the training periodbut there was no difference found between the groups(Table 1 shows group-difference CIs).Hagner et al.13 divided 168 women into three age

groups according to their menopausal stage for anRCT. After 12 weeks of Nordic walking, results showeddecreases (all p0.01) in BMI, total fat mass, low-density lipoproteins, triglycerides, and waist circum-ference and an increase in high-density lipoproteins inpre-, peri- and post-menopausal women. No group differ-ences were reported, and there was no control group.In summary, these observational studies and RCTs

ion Intensity Results

inutes,week

minutes,week

eeks

NW and walking:50% HRmax

1 HRmax(95% CI2.3, 1.7)1 RER

(95% CI0.1, 0.03)1 VO2peak

(95% CI1.1, 0.9)1 lactate

(95% CI0.5, 0.5)

5times perweeksentary

NW: 70%80%HRmax

1 exercise tolerance(p0.001)2 claudication pain

(p0.001)

inutes,week

utes, twok walking,

NW: RPE 12walking: RPE

1011

1 6MWT (p0.009)

inutes,r week

lking;flexibility

N/A 1 walking speed(p0.001)1 walking distance

(p0.02)2 BP (p0.004)

nutes,week

inutes,week

eks

NW and W: 40%50% HRR

1 upper extremity strength(p0.046)

ssed,hreek NW,

hy,hreek NW,

N/A n.s.

nary disease; HRmax, maximum heart rate; HRR, heart rate reserve;walking; PDQ-39, Parkinson Disease Questionnaire; QoL, quality of

g., significant; 6MWT, 6-minute walking test; VO2peak, peak oxygen

rvent

40 ms pereeks

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70 mes peeeks

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demonstrate that the short-term as well as long-term

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80 Tschentscher et al / Am J Prev Med 2013;44(1):7684

effects of Nordic walking are equal or superior to briskwalking and (in one study) to jogging, in healthy subjects.

Subjects with Selected Diseases

Diabetes mellitus type 2. Only one RCT14 examined

Table 2. Overview of observational studies on the short-te

Study State of health NTeint

Aigner (2004)10 Healthy 20 Incretre

Baatile (2000)27 Parkinsons disease 8 8 we

Church (2002)9 Healthy 22 1600tes

Jordan (2001)8 Healthy 10 1600tes

Knobloch (2006)31 Healthy 137 Totalho

Leibbrand (2010)25 Breast cancer 563 3 we

Oakley (2008)19 Peripheral arterialdisease

20 Tread

Porcari (1997)7 Healthy 32 20-mtimtes

Rodgers (1995)6 Healthy 10 30-mwa

Schiffer (2006)11 Healthy 15 Incretes

Walter (1996)17 Coronary arterydisease

14 8-mintes

Total 831

HRpeak, peak heart rate during walking test; N/A, not available; n.s.,exchange ratio; VO2, oxygen consumption; 1, increase; 2, decreas

he effects of Nordic walking in patients with diabetes g

mellitus type 2. The Nordic walking group (n22)trained for 2 months (45 minutes, twice per week),followed by for an additional 2 months (45 minutes,once per week; n22). Results were compared to aedentary control group (n22) and a second exercise

effects of Nordic walking on health

andntion Intensity

Results: NWcompared to walking

talll test

NW and walking: untilexhaustion

1 HRpeak (p0.01)1 arterial blood

lactate (p0.01)

W NW: individual speed 1 exercise capacity(p0.025)

alking NW and walking:individual speed

1 HRpeak (p0.01)1 VO2 (p0.001)1 energy expenditure

(p0.001)

alking NW and walking:75% HRmax

1 HRpeak (p0.05)1 VO2 (p0.05)1 energy expenditure

(p0.05)

60W

NW: individual speed Documentation ofinjury rates

W N/A 1 shoulder mobility(pN/A)1 QoL (pN/A)2 sensitivity to pain

(pN/A)

test NW and walking:3.2 km/h at 4%gradient

1 HRpeak (p0.001)1 walking distance

(p0.001)2 perceived leg pain

(p0.002)

, twoalking

NW and walking:submaximal

1 HRpeak (p0.05)1 VO2 (p0.05)1 energy expenditure

(p0.05)

testNW and walking:

submaximal(6.7 km/h, i.e.,1.9 m/s)

1 HRpeak (p0.05)1 VO2 (p0.05)1 RER (p0.05)1 energy expenditure

(p0.05)

tal field NW and walking:1.2 m/s untilexhaustion

Jogging: 1.8 m/s untilexhaustion

1 HbA1c (n.s.)2 fatty tissue mass

(p0.021)

walking NW and walking:1.6 m/s

1 VO2 (p0.05)1 HRpeak (p0.05)

significant; NW, Nordic walking; QoL, quality of life; RER, respiratory

rm

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menadmi

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29,1urs N

eks N

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unsupervised endurance training for 4 months. Therewas no difference between groups with regard toHbA1c and energy expenditure, but fat tissue massdecreased (p0.021).

besity. In an RCT, Figard-Fabre et al.15 examined in11 obese women (mean BMI 33.1) the effect of 4 weeks(12 sessions) of 5-minute walking exercises (four timesper week) with and without poles at 4 km/hour (1.1m/second) and various inclinations. The use of poles ledto an increase in heart rate; VO2 (both p0.001); energyxpenditure (p0.022); and decreased ratings of per-eived exertion (p0.031) compared to walking withoutoles. In a later RCT, Figard-Fabre et al.16 could further

demonstrate in 23 obese women (mean BMI 33.3) thatNordic walking for 12 weeks (30minutes, three times perweek) also led to a decrease in body mass (p0.011) andblood pressure (p0.001) compared to a walking groupwith similar exercise duration.

Coronary artery disease. In a 1996 observationalstudy, Walter et al.17 observed 14 patients in Phase-IIIand Phase-IV cardiac rehabilitation in two separate8-minute walking trials, with and without poles, and theyconfrmedRodgerss6 fndings thatwalkingwith poles ledto an increasedVO2 (21%; p0.05); peak heart rate (13%;p0.05); and slightly higher blood pressure during exer-cise testing. In an RCT, Kocur et al.18 investigated theffects of 3 weeks of Nordic walking in addition to atandardized cardiac rehabilitation program. Eightyen, 23 weeks after an acute coronary syndrome, wereandomized among three groups: (1) cardiac rehabilita-ion plus Nordic walking (n40; 2.5 km, 4 times pereek); (2) brisk walking in addition to cardiac rehabilita-ion (n20; 2.5 km, four times per week); and (3) stan-ard cardiac rehabilitation only (n20). Energy expendi-ure was higher in both the Nordic walking and thealking group compared to the control group (10.81.8;0.01.9; 9.2 2.2 METs, respectively; p0.025). In ad-ition, the Nordic walking group showed an increase inower body endurance and dynamic balance (p0.05).

eripheral arterial disease. In an observational studyn 20 patients with intermittent claudication, Oakley etl.19 confrmed a longer walking distance (p0.001) andess perceived pain (using a Borg CR 10 scale; p0.002)espite a higherworkload. They also recorded an increasen cardiopulmonary work capacity, as indicated by anncrease in VO2 (p0.001). In 2002, Langbein et al.

20 ranan RCT on 52 peripheral arterial disease patients withintermittent claudication. After 24weeks of Nordic walk-ing (3045 minutes, three times per week; n27) at anintensity of 70%80% maximum heart rate, they foundthat training improved peak oxygen consumption as well

as walking duration and decreased perceived level of

January 2013

claudication pain (Walking Impairment Questionnaire;all p0.001) compared to a non-exercising control group(n25).Collins et al.21 included 49 patients with intermittent

laudication into an RCT with an identical study proto-ol. After 24 weeks of training, they were able to demon-trate that total treadmill time (10.34.1 vs 15.14.5inutes; p0.001); peak oxygen consumption (p0.016);

evel of perceived claudication (p0.02) during exertion;nd quality of life (by SF-36 [short-form health surveyith 36 questions] andWalk Impairment Questionnaire;0.031) improved.

hronic obstructive pulmonary disease. Breyer etl.22 enrolled 60 chronic obstructive pulmonary diseaseCOPD) patients into a 12-week Nordic walking RCT.heNordicwalking group (n30) trained for 60minuteshree times per week at an intensity of 75% of maximumeart rate, compared to a sedentary control groupn30). Nordic walking increased daily physical activitynd the distance covered in a 6-minute walk test (both0.01). Further, Nordic walking decreased exercise-nduced dyspnea (Borg dyspnea score) and anxiety andepression (Hospital Anxiety and Depression Scale) andmproved quality of life (SF-36 Physical Componentummary and Mental Component Summary; all0.01). No changes in lung function parameters oredication were reported.

ibromyalgia syndrome. Mannerkorpi et al.23 in anRCT examined the effect of Nordic walking (n34; rateof perceived exertion [RPE] 12) compared to briskwalking (n33; RPE: 1011) on pain in fbromyalgia in67 women, 20 minutes, twice per week for 15 weeks.Nordic walking was found to improve the functionalcapacity in a 6-minute walk test (p0.009) and to de-crease the perceived level of activity limitation (Fibromy-algia Impact Questionnaire Physical Scale; p0.027).Nevertheless, individual severity of pain did not changeduring the intervention period.

Pain in general. In an RCT, Henkel et al.24 studied theffects of twice-per-week Nordic walking for 12 weeks in7 patients with chronic neck pain and observed a reduc-ion in unspecifc, chronic neck pain (p0.001) and in-reased quality of life (SF-36 questionnaire; p0.043). InnotherRCT5 onpatientswith lower back pain and/or legpain (n136), 8 weeks ofNordic walking twice aweek for45 minutes showed a tendency toward reduced lowerback pain, which resulted in a reduction of oral painmedication (for both, see Table 1 for controls).

Breast cancer. In a questionnaire observation on fe-male breast cancer patients, Leibbrand et al.25 found an

improved shoulder mobility and quality of life while

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sensitivity to pain in the upper body was reduced withinthe group. No worsening of existing preconditions tolymphedema was described.Sprod et al.26 showed in a small RCT on 12 femalereast cancer patients that 8 weeks of Nordic walking for0 minutes twice a week led to an increase in muscularndurance of the upper body (p0.046) compared toalking.

arkinsons disease. Baatile et al.27 performed a Nor-dic walking observational study for 8 weeks (40 minutesof walking, three times perweek) in sixmale subjects withParkinsons disease and demonstrated increased func-tional independence and quality of life by disease-specifcquestionnaires (Unifed Parkinsons Disease RatingScale; p0.026); Parkinson Disease Questionnaire39(p0.028)). An RCT by van Eijkeren et al.28 trained 19Parkinsons patients (14 women, 5 men) for 6 weeks (60minutes twice per week). They found an increase in phys-ical activity and quality of life (both p0.01) compared toa sedentary control group. In another RCT, Reuter et al.29

were able to show in 90 Parkinsons patients that anexercise program of Nordic walking for 24 weeks (70minutes three times per week) brought superior effectson walking speed (p0.02) and distance (p0.001) aswell as on blood pressure (p0.004; Table 1 showscontrols).

Depression. In 16 depressed subjects, Suita et al.30 in-estigated in an RCT the impact of Nordic walking (30inutes three times per week) over a period of 24 weeks.ordic walking led to a nonsignifcant increase in pa-ients physical activity and mood.

omplications and injuries. Knobloch and Vogt31 as-sessed the safety of Nordic walking in 137 healthy, skilledNordic walkers (101 women, 36 men; aged 53.5 years;average BMI 25.6) and documented the incidence of re-lated injuries through a questionnaire. After a total of29,160 hours of Nordic walking, the rate of injury wasreported with 0.926 injuries per 1000 hours of training.This is very low compared to other popular sports such asbasketball or squash (each 14 injuries per 1000 hours).Rates of upper body injuries were slightly higher as com-pared to the lower body (0.549 vs 0.344 per 1000 hours).Most common injuries were strains of the ulnar collateralligament; thumb (equivalent to skiers thumb); and upperankle. No data are available on the injury rates of Nordicwalking in patients with specifc medical disorders.

DiscussionResults of this systematic review clearly identify Nordicwalking as a healthy and well-accepted mode of physical

activity. Nordic walking potentially can be incorporated

into patients daily lives and thus help increase their dailyphysical activity. Further, because it exerts benefcial ef-fects on several relevant parameters such as resting heartrate, blood pressure, exercise capacity, maximal oxygenconsumption, and quality of life in a wide range of dis-eases, it is well suited for primary and secondaryprevention.Nordic walking has gained increasing popularity in the

general population of several northern and central Euro-pean countries. Numerous observational studies haveshown that the short-term benefts of Nordic walking incomparison to brisk walking without poles include anincreased VO2 of 11%23%

69,11; peak heart rate of 4%18%611; respiratory exchange ratio of 5%6; lactate con-centration of 12%10; and caloric expenditure of 18%22%.68,10 Nordic walking generates up to 6.37.7 MET7

at brisk paces whereas walking reaches 3.35.0 MET.32

Nordic walking over the long-term leads to superior car-diorespiratory ftness as compared to walking withoutpoles because of the higher amount of muscle mass usedthrough additionalmotor activity of the upper body. Thisresults in an increased cardiovascular and respiratoryresponse when walking at the same pace, causing in-creased energy expenditure.12 Up to a pace of 8.5 km/hour (i.e., 2.4m/second), it even leads to similar or highervalues of VO2 and heart rate than jogging.

11

Therefore, Nordic walking is a suitable form of aerobicexercise for most of apparently healthy male and femalesubjects aged 4060 years who would beneft from train-ing at a proper aerobic exercise intensity between 4 and 8METs, an intensity range that is too high to obtain byregular walking and too low to achieve while running. Inthese subjects, Nordic walking is suitable to close theintensity gap betweenwalking and jogging and thus pres-ents an alternative for everybody seeking a sport thatfulflls the needs of daily physical activity at an optimalintensity that results in gaining health benefts while ex-ceeding personal exertion limits. Previous studies13,16

have shown that 12 weeks of Nordic walking demon-strated a decrease in BMI, total fat mass, low-densitylipoproteins, triglycerides and waist circumference andan increase in high-density lipoproteins in otherwisehealthy postmenopausal women.The preventive arguments for Nordic walking are ob-

vious. As with physical activity in general,3,32 Nordicalking may have similar positive effects on chronic dis-ases such as diabetes or obesity.14,15 As part of cardiacrehabilitation programs, Nordic walking has the sameshort-term and long-term cardiorespiratory effect as reg-ular walking for people suffering from coronary arterydisease.17,18 For patients with peripheral arterial disease,walking on a regular basis is recommended.33 Nordic

walking is a useful exercise strategy for improving

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walking distance, cardiovascular ftness, and quality oflife as well as decreasing the level of perceived claudica-tion pain.1921

In COPD, Nordic walking is associated with increaseddaily physical activity, functional exercise capacity, andquality of life. Further, it decreased exercise-induceddyspnea, anxiety, and depression and is a simple andeffective physical training modality for patients withCOPD.22,34

Even though little research onNordic walking in fbro-myalgia has been published, combined training sets ofaerobic endurance, strength, and flexibility training havebeen shown to bring ease to fbromyalgia pain; increasephysical functioning, muscular endurance, and strength;and improve psychological parameters such as self-esteem and quality of life.23,35

In patients with chronic pain, strength-training com-bined with endurance-training has a positive effect onseveral kinds of nonspecifc neck, shoulder, and low-backpain.36 Nordic walking, in combination with strengthnd mobility training, has been shown to signifcantlyeduce unspecifc, chronic neck and lower back pain,oncomitantly increasing quality of life.24

Regular physical activity positively affects exercise tol-erance and quality of life in breast cancer patients.37,38

Nordic walking additionally improves shoulder mobilityand reduces sensitivity to pain in the upper body, withoutworsening lymphedema and can be recommended forbreast cancer patients to increase their activity index.25,26

Also, patients with progressive neurodegenerativemovement disorders such as Parkinsons disease havebeen shown to beneft from Nordic walking. Results ofsmall trials revealed that patients beneft by improvedmotor skills, impaired functional mobility, walkingspeed, and distance, possibly leading to a reduced rate offalls and an improved quality of life.2729 Regular, mod-rate endurance exercise training is used also therapeuti-ally for moderate to severe depressive disorders, and haseen shown to improve patientsmood.3940With regardo depression scores as well as quality of life, Nordicalking showed trends toward improvement.30 Becauseordic walking is associated with a comparably low ratef injuries, it is suitable not only for the experienced butlso for a wide range of newcomers.31

Taken together, the presented fndings on the healthbenefts of Nordic walking partly derive from small stud-ies that are sometimes inconsistent or not in keepingwiththe fndings of RCTs. Nevertheless, their results can beviewed as hypothesis generating and are of general inter-est. However, conclusions have to be drawn and general-izations have to be made with caution.Overall, Nordicwalking has been shown to be a formof

physical activity with convincing benefts for health in

January 2013

general and has superior short-term and long-term ef-fects on the cardiorespiratory system as compared tobrisk walking. Short-term effects show higher values ofheart rate, VO2, respiratory exchange ratio, lactatehresholds and caloric expenditure,611 as well as a supe-rior lipid profle.13

Current literature unanimously identifes Nordicwalking as a safe, feasible, and readily available form ofendurance exercise training, which exerts a panoply ofbenefcial effects in a wide range of people with variousdiseases and the healthy. Nordic walking can therefore berecommended to those who wish to increase their dailyphysical activity with an effective cardiorespiratory train-ing routine as part of primary or secondary prevention.

T. Rathgeber and M. Niederseer helped with the literaturesearch.No fnancial disclosures were reported by the authors of this

paper.

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www.ajpmonline.org

Health Benefits of Nordic Walking A Systematic ReviewContextEvidence AcquisitionLiterature Search: Inclusion and Exclusion CriteriaSelection Process and Data Extraction

Evidence SynthesisHealthy SubjectsSubjects with Selected DiseasesDiabetes mellitus type 2ObesityCoronary artery diseasePeripheral arterial diseaseChronic obstructive pulmonary diseaseFibromyalgia syndromePain in generalBreast cancerParkinson`s diseaseDepressionComplications and injuries

DiscussionReferences