The Effects of Laparoscopic Sleeve Gastrectomy Surgery on Gait,Physical Activity,Flexibility,and Quality of Life

Abstract

Background/Aim:

There are little data on changes occurring after bariatric surgery. This study aimed to analyze gait speed, other spatiotemporal parameters (STPs) of gait, physical activity level, flexibility, and quality of life in patients before and 3rd month after laparoscopic sleeve gastrectomy surgery (LSGS).

Materials and Methods:

The study included 30 obese individuals aged between 18 and 66 years. Outcome measures on gait speed, other STPs of gait, flexibility, level of physical activity, and quality of life were measured before and 3rd month after LSGS.

Results:

After LSGS, the STPs of gait (speed p < 0.001, cadence p < 0.05, and stride length p < 0.001), physical activity levels (p < 0.001), muscle flexibility parameters (p < 0.05), and quality of life (p < 0.001) increased. The average weight of individuals before surgery and 3rd month after LSGS was calculated as 128.10 ± 16.22 kg and 100.43 ± 12.59 kg, respectively. Body mass index was 47.13 ± 4.87 before surgery and 37.01 ± 4.61 3rd month after surgery.

Conclusion:

Improvements were observed in gait speed, cadence, stride length, physical activity levels, some flexibility parameters, and quality of life in obese individuals in the 3rd month after LSGS. Studies examining the long-term effects of LSG are needed.

Introduction

According to the World Health Organization, obesity is an excessive or abnormal fat accumulation in the body.¹ Obesity is a common nutritional disorder and causes serious health problems reducing life expectancy, such as type 2 diabetes mellitus, cancer, osteoarthritis, and cardiovascular disease.²

In obese individuals, low levels of physical activity and sedentary behaviors often coexist.³ Weakness in major muscles that play a critical role in locomotor tasks, musculoskeletal injuries or pathologies, and an abnormal gait pattern may occur.⁴ Obese individuals adopt different walking strategies such as increased step width, slower gait speed, and increased gait cycle time to increase postural stability.^5,6 In addition, obesity and low physical activity affect motor performance negatively by reducing flexibility.⁷ Therefore, obese patients suffer from an impairment of physical function, and they may not be able to perform simple tasks such as daily activities and participating in sports. Overall physical, psychological, and social impacts of obesity cause impaired quality of life.⁸

Diet, exercise, medication for weight loss, and bariatric surgery are among the treatment methods for obesity. Bariatric surgery is applied in individuals whose body mass index (BMI) ≥40 kg/m² or 35–40 kg/m² and who have obesity-related comorbid diseases for at least 6 months.^9,10 It is reported that bariatric surgery is a safe procedure due to low postoperative morbidity and mortality rates. Bariatric surgery techniques include jejunoileal bypass, vertical banded gastroplasty, laparoscopic adjustable gastric banding procedures, Roux-en-Y gastric bypass (RYGB), and laparoscopic sleeve gastrectomy.¹¹ Laparoscopic sleeve gastrectomy surgery (LSGS), one of the bariatric surgery methods, is advantageous in terms of short operation time, low complication rate, high weight loss, and good comorbidity resolution. Therefore, LSGS is currently the most commonly performed bariatric surgery.¹²

The effect of obesity on gait biomechanics can be minimized by weight loss following bariatric surgery. This is assumed to result from enhanced postural stability and increased range of motion in the lower extremities. These changes may motivate obese individuals to adopt a more active lifestyle. The weight loss resulting from bariatric surgery and the altered lifestyle subsequent to surgery may enhance gait, physical activity level, flexibility, and quality of life. Despite potential improvements in gait parameters and flexibility, there are little data on the changes that occur after bariatric surgery.¹³ Therefore, we hypothesized that the weight loss caused by LSG would improve spatiotemporal parameters (STPs) of gait, physical activity levels, flexibility of the lower extremities, and quality of life. The aim of the study was to assess changes in these parameters in obese patients before and 3rd month after LSGS.

Methods

Study design and participants

This is a prospective descriptive observational study with a 3-month follow-up, conducted in Keçiören Training and Research Hospital. This study was conducted between May 2017 and May 2019. The study followed the Declaration of Helsinki on medical protocol and ethics. Ankara Yıldırım Beyazıt University Ethics Committee 10.05.2017 dated 18 number necessary permission was obtained. The study protocol was registered in the Clinical Trials database. The aim and content of this study were explained to all individuals. All participants signed an “informed consent form.”

The inclusion criteria were age >18 years, diagnosis of obesity, having a BMI ≥ 35 (indication for surgery), and indication of the LSGS decision given by the surgeon. The exclusion criteria were history of orthopedic surgery in lower extremities, musculoskeletal disorder, urinary stress syndrome, systemic or rheumatologic disease or psychiatric illness, having varicose vein, having cardiorespiratory insufficiency that will prevent the individual from walking, and not being willingness to take part.

Procedures

All participants underwent LSGS. Surgical procedures were performed by the same surgeon in the operating setting of the hospital. Patients scheduled for surgery were admitted to the hospital 1 day before the operation. Although the duration of hospitalization after the operation varies according to the recovery status of the patient, the patients were generally discharged after 2 days. The diet program suitable for the patients before and after surgery was explained by the dietician.

Variables

The sociodemographic data, duration and family history of obesity, medical/surgical history, smoking/alcohol use, and medications were recorded at baseline. Gait speed, other STPs, physical activity levels, flexibility, and quality of life parameters were evaluated before and 3rd month after surgery. The primary outcome was gait speed as meter/minute (m/min), assessed using a BTS G-Walk^® sensor (BTS Bioengineering S.p.A., Garbagnate Milanese, Italy). The secondary outcomes were other STPs (cadence, step length, stride length, percentage of stride length/height, gait cycle duration, percentage of swing and stance duration, and double support and single support duration), levels of physical activity, flexibility, and quality of life.

The BTS G-walk has a sensor that transfers the parameters obtained during the individuals’ self-selected gait speed to the computer through a Bluetooth^® 3.0 connection. The computer, which had the BTS G-Studio software program installed, ran the software, and this was monitored by the researcher. The gait analysis started from the moment the participant began walking until they reached the end of the route. The sensor was attached to the lumbar 4–5 region with a semielastic belt. The sensor is a reliable and valid tool.¹⁴ Individuals walked at normal gait speed on the 8 m long path. Other STPs were recorded during the same gait assessment.

The International Physical Activity Questionnaire-Short Form (IPAQ-SF) was used to assess physical activity level. With the IPAQ-SF, information regarding mild–moderate–vigorous physical activities and sitting is recorded during the past week. A score in metabolic equivalent (MET)-minutes is obtained using the duration and frequency of mild (e.g., walking) and moderate–vigorous activities. Accordingly, less than 600 MET-min of activity per week is inactive; 600–3000 MET-min per week is moderate activity, and more than 3000 MET-min per week is classified as very active. The Turkish version of the IPAQ was found reliable and valid to assess physical activity by Saglam et al.¹⁵

To assess the flexibility of the gastrocnemius–soleus, hamstrings, and lumbar extensor muscle groups, the Sit and Reach Test (SRT) was used. Individuals were asked to sit with their legs and knees straight and feet at 90°. Individuals were asked to reach out to their toes with their hands without bending knees and to wait for at least 2 s in this position. The test was repeated three times, and the maximum value was recorded in centimeters.^16,17

The modified Thomas test was used to evaluate the flexibility of iliopsoas and rectus femoris muscles. After the participants sat on the edge of the bed, they were told to lie back and pull both knees toward their chest. Participants were asked to keep the tested lower limb straight without lifting it off the ground while performing maximal hip flexion on the contralateral side. Measurements were repeated three times for each extremity, and the average value was recorded. Measurements were made with a goniometer.¹⁸

Shortness of the hamstring muscles was evaluated with the measurement of the popliteal angle with a universal goniometer. While the participant was lying on their back, the goniometer was aligned on the lower half of the anterior edge of the tibia, and the hip was stabilized at 90° of flexion. Popliteal angle was measured by asking the individual to bring the knee to maximum extension. The measurement was repeated two times, and the mean value was recorded. A popliteal angle of more than 20° was considered as hamstring shortness.¹⁹

The Impact of Weight on Quality-of-Life Questionnaire (IWQOL-Lite) was used to assess the participants’ quality of life. IWQOL-Lite assesses the quality of life in five subgroups: bodily functions, self-confidence, sexual life, social pressure, and work. The scale consists of 31 items in total, and each item is scored on a 5-point Likert scale. High scores on the scale indicate high quality of life.²⁰

Sample size

For gait speed and cadence measurements, a posthoc power analysis was performed for the change observed after the surgery compared with the presurgery. The calculated power (1-β) based on the Wilcoxon signed-rank test (matched pairs) was 0.997, considering type I error (α) of 0.05, sample size of 30, effect size of 0.937, and two-sided alternative hypothesis (H1). The posthoc power analysis of the study was determined using the G*Power 3.1. program.

Statistical analysis

The Shapiro–Wilk test was used to investigate the distributions of variables such as age, BMI, and pre- and postoperative measurements. Normally distributed variables are expressed as mean ± standard deviation (SD), nonnormally distributed variables as median (min–max), and categorical variables as number (%).

When comparing pre and postoperative measurements, the paired t-test and Wilcoxon test were used depending on the distribution of these measurements and differences. The statistical significance level was accepted as p < 0.05. The statistical analysis was performed on the IBM SPSS Statistics 22.0 software (IBM Corp. Released 2013, IBM SPSS Statistics for Windows, Version 22.0; IBM Corp., Armonk, NY, USA).

Results

The study was completed by 30 participants. Figure 1 shows the study flow diagram. Twenty-four participants (80%) were females, 9 (30%) had diabetes mellitus, 5 (16.7%) had hypertension, and the duration of obesity was 14.55 ± 10.03 years. Demographic characteristics and anthropometric parameters are given in Tables 1 and 2, respectively. Regarding the diseases in the families of the individuals, a family history of obesity and diabetes was found in 70% (n = 21) and 46.7% (n = 14) of the individuals. The average weight of individuals before surgery and 3rd month after LSGS was calculated as 128.10 ± 16.22 kg and 100.43 ± 12.59 kg, respectively. BMI was 47.13 ± 4.87 before surgery and 37.01 ± 4.61 3rd month after surgery.

FIG. 1.

Study flow diagram.

Table 1.

Demographic Characteristics of Participants

	Mean ± SD	Median (min–max)
	N	%
Age (years)	38 ± 12.33	37 (18–66)
Gender (M/F)	6/24	20/80
Height (cm)	164.87 ± 7.26	165 (155–180)
Education status
Primary school	7	23.3
Secondary school	5	16.7
High school	13	43.3
College	3	10
University	2	6.7
Marital status (married/single)	18/12	60/40
Working Status
Housewife	12	40
Officer	1	3.3
Self-employment	7	23.3
Worker	5	16.7
Retired	2	6.7
Student	3	10
Smoking	5	16.7
Alcohol	2	6.7
Surgical operations
None	13	43.3
Gall bladder	6	20
Cesarean	6	20
Umbilical hernia	3	10
Tonsillectomy	2	6.7
Exercise habit	2	6.7
Obesity in the family	21	70
Dominant side (right/left)	27/3	90/10
Drug use	12	40
Obesity time (year)	14.55 ± 10.03	11.5 (1.5–40)

F, female; M, male; max, maximum; min, minimum; N, number; SD, standard deviation.

Table 2.

Anthropometric Parameters

	Preop Mean ± SD	Month 3 Mean ± SD	p
Weight (kg)	128.10 ± 16.22	100.43 ± 12.59	<0.001^*
BMI (kg/m²)	47.13 ± 4.87	37.01 ± 4.61	<0.001^*
Chest circumference (cm)	131.33 ± 10.36	115.00 ± 8.83	<0.001^*
Waist circumference (cm)	123.42 ± 10.04	104.44 ± 11.94	<0.001^*
Hip circumference (cm)	137.35 ± 11.92	117.37 ± 8.38	<0.001^*
Right thigh circumference (cm)	67.25 ± 8.33	59.85 ± 7.32	<0.001^*
Left thigh circumference (cm)	67.26 ± 8.46	59.66 ± 7.24	<0.001^*

p < 0.05.

BMI, body mass index; cm, centimeter; kg, kilogram; kg/m², kilogram/square meters; SD, standart deviation.

The median speed was 56.80 m/min (26.20–90.60 m/min) before surgery and 67.80 m/min (36.40–122.50 m/min) 3rd month after surgery. There was a significant increase in cadence, stride length (right and left step length), and percentage of stride length/height. There was a significant decrease in gait cycle duration and right and left step duration values (p = 0.029; p < 0.001; p = 0.001). No significant difference was observed in the values of stance duration (right and left stance duration), swing duration (right and left swing duration), double support duration, and single support duration (p > 0.05). Mean gait speed increased by ∼19% in 3rd month after surgery. The difference in gait speed between assessments before and 3rd month after surgery was statistically significant (p < 0.001). The changes of STPs are given in Table 3.

Table 3.

Spatiotemporal Parameters of Gait

	Preop Mean ± SD Median (min–max)	Month 3 Mean ± SD Median (min–max)	p
Speed (m/min)	56.80 (26.2–90.6)	67.80 (36.40–122.50)	<0.001^*
Cadence (strides/min)	48.25 (29.20–60.20)	51.20 (37.30–59.20)	0.009^*
Stride length (m)	1.17 ± 0.18	1.38 ± 0.26	<0.001^*
Right step length (m)	0.60 ± 0.10	0.71 ± 0.13	<0.001^*
Left step length (m)	0.56 (0.42–0.99)	0.68 (0.46–1.19)	0.001^*
Stride length/height (%)	70.56 ± 10.35	83.92 ± 15.11	<0.001^*
Gait cycle duration (s)	1.24 (1.00–2.06)	1.17 (1.01–1.61)	0.029^*
Right step duration (s)	0.62 (0.50–1.00)	0.59 (0.49–0.85)	0.029^*
Left step duration (s)	0.62 (0.46–1.07)	0.59 (0.45–0.76)	0.014^*
Stance duration (% of gait cycle)	63.83 ± 2.94	63.57 ± 2.93	0.697
Right stance duration (%)	63.33 ± 3.29	64.06 ± 3.10	0.326
Left stance duration (%)	64.88 ± 4.56	63.06 ± 3.41	0.052
Swing duration (%) (% of gait cycle)	34.53 ± 3.11	35.03 ± 1.94	0.427
Right swing duration (%)	35.66 ± 3.92	34.36 ± 2.62	0.093
Left swing duration (%)	34.39 ± 3.62	35.72 ± 2.33	0.067
Double support duration (% gait cycle)	14.32 ± 3.08	14.23 ± 2.02	0.881
Single support duration (% of gait cycle)	34.84 ± 3.09	34.92 ± 2.11	0.894

p < 0.05; m, meter; max, maximum; min, minumum; m/min=meter/minute; strides/min, strides/mimute; s, second; SD, standart deviation.

According to the IPAQ-SF results, a significant increase in physical activity score was observed after surgery (p < 0.001) (Table 4). When muscle shortening/flexibility measurements were examined, differences were observed in SRT, right/left hamstring, and iliopsoas values (p < 0.05). While the SRT mean value before surgery was −4.85 ± 12.09 cm, it was −0.47 ± 11.93 cm 3 months after surgery (p = 0.003). A significant increase in hamstring length measurements (p < 0.001 for the right side, p = 0.001 for the left side) and a significant decrease in iliopsoas length measurements (p = 0.024 for the right side, p = 0.027 for the left side) were observed. In the rectus femoris length measurements, no statistical significance was detected (p > 0.05) (Table 5).

Table 4.

Physical Activity Levels and Quality of Life

	Preop Median (min–max)	Month 3 Median (min–max)	p
IPAQ MET (min\week)	1129.50 (0–7812)	3431.00 (33–13173)	<0.001^*
IWQOL-Lite
Physical function	29.00 (9–70)	77.00 (39–100)	<0.001^*
Self-esteem	25.00 (0–89)	80.50 (14–100)	<0.001^*
Sexual life	25.00 (0–100)	81.00 (0–100)	<0.001^*
Public distress	30.00 (0–85)	87.50 (20–100)	<0.001^*
Work	9.00 (0–50)	44.00 (0–50)	<0.001^*
IWQOL-Lite total	29.50 (3–86)	71.00 (33–92)	<0.001^*

p < 0.05.

IPAQ, International Physical Activity Questionnaire; IWQOL-Lite, The Impact of Weight on Quality-of-Life Questionnaire; MET, metabolic equivalent; max, maximum; min, minimum.

Table 5.

Flexibility Parameters

	Preop Mean ± SD Median (min–max)	Month 3 Mean ± SD Median (min–max)	p
SRT (cm)	−4.85 ± 12.09	−0.47 ± 11.93	0.003^*
Hamstring right (°)	22 (0–45)	0 (0–38)	<0.001^*
Hamstring left (°)	22 (0–42)	0 (0–40)	0.001^*
Rectus femoris right (°)	0 (0–35)	0 (0–35)	0.201
Rectus femoris left (°)	0 (0–40)	0 (0–35)	0.235
Iliopsoas right (°)	0 (0–23)	0 (0–20)	0.024^*
Iliopsoas left (°)	0 (0–20)	0 (0–22)	0.027^*

p < 0.05.

SRT, Sit and Reach Test; cm, centimeter; (°): degree.

When the scores of the IWQOL-Lite questionnaire were examined, a significant improvement was observed in all subparameters of the questionnaire 3rd month after surgery (p < 0.001) (Table 4).

Discussion

The aim of this study was to examine the differences in STPs of gait, physical activity, flexibility parameters, and quality of life before and 3rd month after LSGS. It was found in the examinations performed 3rd month after surgery that there were significant improvements in gait speed, cadence, stride length (right and left step length), percentage of stride length/height, gait cycle duration (right and left step duration), physical activity, SRT results, hamstring and iliopsoas flexibility, and quality of life.

It is known that obesity causes changes in muscle structure and lower extremity biomechanics.^13,21 Obese individuals walk with short, wide, and slow steps.²² The effects of massive weight loss as a result of bariatric surgery on the gait speed of individuals at 3, 8, and 12 months and 5 years after surgery have been reported.^13,23,24 In our study, the evaluations were repeated at 3 months because of the higher probability of rapid weight loss after surgery. Researchers have found improvements in gait speed, stride length, and single support phases after surgery at each time period investigated. In our study, as a result of the massive weight loss achieved by surgery, individuals experienced improvements in gait speed, cadence, stride length (right and left step length), and gait cycle duration (right and left step duration) in 3rd month after LSGS.

Anthropometric measurements, physical activity level, and lower extremity flexibility, which were observed to improve statistically after surgery, may also lead to improvement in gait parameters. Contrary to the studies of Vincent et al. and Gill et al., no significant improvement was observed in the double and single support duration in our study.^13,21 Moreover, in the studies of Summa et al. in which they examined the gait parameters of adolescent individuals after sleeve gastrectomy, no improvement was observed in the double support period compared with the measurements made 1 year later.²⁵ This difference may have resulted from the evaluation of STPs with different devices and the difference in the period of time passed after surgery. In addition, while RYGB surgery has been mostly used as a bariatric surgery type in the mentioned studies, LSGS was applied to all participants in our study. The difference in the type of surgery may have caused our findings to be different from other studies. The types of surgery may differ in terms of factors such as initial body mass index values, comorbidities of the patients, and weight loss in the long and medium term. These factors may be considered as the reason why our study results differ from those reported in the literature.²⁶

It was reported that some of the patients who underwent bariatric surgery cannot reach the target weight, and some of them cannot maintain long-term weight loss.²⁷ From this point of view, physical activity is very important in supporting weight loss after surgery and preventing weight gain in the first 2 years.²⁸ In the literature, it is seen that the methods of assessing physical activity level after bariatric surgery are various and performed at various times. According to the results of a meta-analysis published in 2017, an improvement was observed in the evaluation made with physical activity self-report scales at 3–6 months after surgery.²⁹ In a recent study, it was found that the physical activity levels were statistically higher 3 months after surgery compared with presurgery. Although only suitable diet programs were recommended for all our participants, the increase in physical activity scores may have resulted from the improvement in physical functions and mobility after the surgery and the motivation provided by this improvement.²⁹

Improvement in flexibility parameters has been reported with weight loss after bariatric surgery in obese individuals.¹⁶ There is still much to learn about the effect of rapid weight loss on the musculoskeletal system. Bennetti et al. studied the flexibility and balance of individuals undergoing bariatric surgery and found that SRT scores increased in the 6th and 12th months after surgery.¹⁶ In our study, a significant change was found in the SRT results and hamstring and iliopsoas flexibility 3rd month after surgery. No change was observed in the rectus femoris muscle measurements. The lack of difference in the measurements of the rectus femoris muscle in our study may be attributed to the fact that the preoperative values were within normal limits. In addition, we think that the significant increase in SRT and hamstring flexibility may be due to the decrease in the waist, hip, and thigh circumferences of the individuals after surgery, and postoperative weight loss from the abdomen leads to an improvement in SRT results.

Bariatric surgeries cause not only weight loss but also an increase in the quality of life.³⁰ In studies, it has been stated that the quality of life of individuals increased 1 year after bariatric surgery.⁸ This increase in the quality of life was explained by the massive weight loss after surgery and individuals’ feeling of the ability to control obesity.³¹ In addition, the positive effects of weight loss on body functions, reduction of joint pain, and control of obesity complications may be among the reasons for the increase in the quality of life.⁸ In accordance with the literature, a significant increase was found in our study after surgery in all subheadings and the general score of the quality of life compared with the preoperative period.

This study is one of the few research projects examining the effects of LSGS on gait, physical activity level, flexibility, and quality of life. Since the musculoskeletal system is affected by obesity, it is important to investigate and demonstrate the positive biomechanical changes in these structures with weight loss.^13,20 Studies have shown massive muscle loss in addition to massive weight loss after bariatric surgery.^32,33 Individuals should be followed up with an exercise program under the supervision of a physiotherapist to maintain the muscle strength of the individuals and to maintain the weight loss process in a healthy way. Therefore, there is a need for studies in which exercise programs are added to the follow-up of the individual.

Our study had some limitations, such as the fact that our results cover a short period of time, most of the participants were women, the variability of the age range, that flexibility measurements were not evaluated objectively, and individuals were not followed up with a regular exercise program. However, all participants had LSGS, this surgery was performed by a single surgeon, and short-term flexibility parameters were evaluated.

In conclusion, improvements were observed in some STPs, physical activity levels, flexibility, and quality of life in obese individuals 3 months after LSGS. It is crucial to investigate and demonstrate the positive biomechanical changes associated with weight loss. Longer-term studies with larger populations are necessary to gain a more comprehensive understanding of the long-term effects of weight loss on biomechanics, physical functions, and quality of life. Controlled studies with long-term follow-up and larger numbers of subjects are essential to elucidate the impact of bariatric surgery on weight loss, gait, STPs, physical activity, and quality of life.

Footnotes

Acknowledgment

The authors would like to thank Dr. Hakan Buluş and the staff of Keçiören Training and Research Hospital.

Author Disclosure Statement

This article was produced from a master’s thesis. This study was presented as an oral presentation at the 10. International Congress of Prosthetics and Orthotics held on October 18–20, 2018.

Ethical Approval

Ankara Yıldırım Beyazıt University Ethics Committee 10.05.2017 dated 18 number necessary permission was obtained.

Informed Consent

The participants included in the study were informed about the study’s methodology, and written informed consent was obtained for participation in the study.

Authors’ Contributions

N.F.: Conceptualization (lead), data curation (lead), formal analysis (supporting), investigation (lead), methodology (equal), project administration (equal), resources (lead), supervision (lead), visualization (equal), writing—original draft (lead), and writing—review and editing (equal). B.A.K.: Conceptualization (supporting), data curation (supporting), formal analysis (lead), investigation (supporting), methodology (equal), project administration (equal), resources (supporting), supervision (supporting), writing—original draft (supporting), and writing—review and editing (equal). S.S.B.: Investigation (supporting), methodology (supporting), project administration (equal), supervision (supporting), visualization (equal), writing—original draft (supporting), and writing—review and editing (equal).

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

References

World Health Organization. Obesity and overweight [Internet]. What are obesity and overweight; 2021 [updated 2021; cited. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight [Last accessed: October 30, 2023].

Djalalinia

, Qorbani

, Peykari

, et al. Health impacts of obesity. Pak J Med Sci, 2015; 31(1):239–242; doi: 10.12669/pjms.311.7033

Mendonça

, Noll

, Rodrigues

APDS

, et al. Association of pain, severe pain, and multisite pain with the level of physical activity and sedentary behavior in severely obese adults: Baseline Data from the DieTBra Trial. Int J Environ Res Public Health, 2020; 17(12):4478; doi: 10.3390/ijerph17124478

Lerner

, Board

, Browning

. Effects of obesity on lower extremity muscle function during walking at two speeds. Gait Posture, 2014; 39(3):978–984; doi: 10.1016/j.gaitpost.2013.12.020

Adil

, Jain

, Rashid

, et al. Meta-analysis of the effect of bariatric surgery on physical function. Br J Surg, 2018; 105(9):1107–1118; doi: 10.1002/bjs.10880

Horsak

, Schwab

, Baca

, et al. Effects of a lower extremity exercise program on gait biomechanics and clinical outcomes in children and adolescents with obesity: A randomized controlled trial. Gait Posture, 2019; 70:122–129; doi: 10.1016/j.gaitpost.2019.02.032

Nobre

, de Almeida

, Nobre

, et al. Twelve weeks of plyometric training improves motor performance of 7- to 9-year-old boys who were overweight/obese: A randomized controlled intervention. J Strength Cond Res, 2017; 31(8):2091–2099; doi: 10.1519/JSC.0000000000001684

Hachem

, Brennan

. Quality of life outcomes of bariatric surgery: A systematic review. Obes Surg, 2016; 26(2):395–409; doi: 10.1007/s11695-015-1940-z

Seki

. Current indication. In: Bariatric and Metabolic Surgery. ( Choi

, Kasama

, eds.) Heidelberg New York Dordrecht London: Springer, 2014, pp. 23–28.

10.

Huq

, Todkar

, Lahiri

. Patient perspectives on obesity management: Need for greater discussion of BMI and weight-loss options beyond diet and exercise, especially in patients with diabetes. Endocr Pract, 2020; 26(5):471–483; doi: 10.4158/EP-2019-0452

11.

Arterburn

, Telem

, Kushner

, et al. Benefits and risks of bariatric surgery in adults: A review. JAMA, 2020; 324(9):879–887; doi: 10.1001/jama.2020.12567

12.

Rebibo

, Verhaeghe

, Tasseel-Ponche

, et al. Does sleeve gastrectomy improve the gait parameters of obese patients? Surg Obes Relat Dis, 2016; 12(8):1474–1481; doi: 10.1016/j.soard.2016.03.023

13.

Gill

, Walsh

, Pratt

, et al. Changes in spatiotemporal gait patterns during flat ground walking and obstacle crossing 1 year after bariatric surgery. Surg Obes Relat Dis, 2016; 12(5):1080–1085; doi: 10.1016/j.soard.2016.03.029

14.

De Ridder

, Lebleu

, Willems

, et al. Concurrent validity of a commercial wireless trunk triaxial accelerometer system for gait analysis. J Sport Rehabil, 2019; 28(6):jsr.2018–jsr.0295; doi: 10.1123/jsr.2018-0295

15.

Saglam

, Arikan

, Savci

, et al. International physical activity questionnaire: Reliability and validity of the Turkish version. Percept Mot Skills, 2010; 111(1):278–284; doi: 10.2466/06.08.PMS.111.4.278-284

16.

Mayorga-Vega

, Merino-Marban

, Viciana

. Criterion-related validity of sit-and-reach tests for estimating hamstring and lumbar extensibility: A meta-analysis. J Sports Sci Med, 2014; 13(1):1–14.

17.

Benetti

, Bacha

, Garrido Junior

, et al. Analyses of balance and flexibility of obese patients undergoing bariatric surgery. Clinics (Sao Paulo), 2016; 71(2):78–81; doi: 10.6061/clinics/2016(02)05

18.

Cady

, Powis

, Hopgood

. Intrarater and interrater reliability of the modified Thomas test. J Bodyw Mov Ther, 2022; 29:86–91; doi: 10.1016/j.jbmt.2021.09.014

19.

Shepherd

, Winter

, Gordon

. Comparing hamstring muscle length measurements of the traditional active knee extension test and a functional hamstring flexibility test. Physiother Rehabil, 2017; 2:1.

20.

Kolotkin

, Crosby

. Psychometric evaluation of the impact of weight on quality of life-lite questionnaire (IWQOL-lite) in a community sample. Qual Life Res, 2002; 11(2):157–171; doi: 10.1023/a:1015081805439

21.

Vincent

, Ben-David

, Conrad

, et al. Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery. Surg Obes Relat Dis, 2012; 8(3):346–354; doi: 10.1016/j.soard.2011.11.020

22.

, Tsai

, Clancy

, et al. Weight loss changed gait kinematics in individuals with obesity and knee pain. Gait Posture, 2019; 68:461–465; doi: 10.1016/j.gaitpost.2018.12.031

23.

Froehle

, Laughlin

, Sherwood

, et al. Gait patterns after bariatric surgery. In book: Metabolism and Pathophysiology of Bariatric Surgery: Nutrition, Procedures, Outcomes and Adverse Effects, 2017, p. 553–562.

24.

Shin

, Keegan

, Gill

. Changes in gait self-efficacy, fear of falls, and gait four and eight months after bariatric surgery. Behav Sci (Basel), 2022; 12(8):246; doi: 10.3390/bs12080246

25.

Summa

, De Peppo

, Petrarca

, et al. Gait changes after weight loss on adolescent with severe obesity after sleeve gastrectomy. Surg Obes Relat Dis, 2019; 15(3):374–381; doi: 10.1016/j.soard.2019.01.007

26.

Shoar

, Saber

. Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: A systematic review and meta-analysis of comparative studies. Surg Obes Relat Dis, 2017; 13(2):170–180; doi: 10.1016/j.soard.2016.08.011

27.

Puzziferri

, Roshek

3rd , Mayo

, et al. Long-term follow-up after bariatric surgery: A systematic review. JAMA, 2014; 312(9):934–942; doi: 10.1001/jama.2014.10706

28.

Charansonney

, Vanhees

, Cohen-Solal

. Physical activity: From epidemiological evidence to individualized patient management. Int J Cardiol, 2014; 170(3):350–357; doi: 10.1016/j.ijcard.2013.11.012

29.

Herring

, Stevinson

, Davies

, et al. Changes in physical activity behaviour and physical function after bariatric surgery: A systematic review and meta‐analysis. Obes Rev, 2016; 17(3):250–261; doi: 10.1111/obr.12361

30.

Lindekilde

, Gladstone

, Lübeck

, et al. The impact of bariatric surgery on quality of life: A systematic review and meta‐analysis. Obes Rev, 2015; 16(8):639–651; doi: 10.1111/obr.12294

31.

Raaijmakers

, Pouwels

, Thomassen

, et al. Quality of life and bariatric surgery: A systematic review of short-and long-term results and comparison with community norms. Eur J Clin Nutr, 2017; 71(4):441–449; doi: 10.1038/ejcn.2016.198

32.

Baad

VMA

, Bezerra

, de Holanda

NCP

, et al. Body composition, sarcopenia and physical performance after bariatric surgery: Differences between sleeve gastrectomy and roux-en-y gastric bypass. Obes Surg, 2022; 32(12):3830–3838; doi: 10.1007/s11695-022-06335-y

33.

Pekař

, Pekařová

, Bužga

, et al. The risk of sarcopenia 24 months after bariatric surgery–assessment by dual energy X-ray absorptiometry (DEXA): A prospective study. Wideochir Inne Tech Maloinwazyjne, 2020; 15(4):583–587; doi: 10.5114/wiitm.2020.93463