A randomized trial of two forms of therapeutic activity to improve walking: effect on the energy cost of walking

Effects of a Physical Therapist Intervention on GPS Indicators of Community Mobility in Older Adults: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

The authors compared the effects of a standard strength and endurance intervention with a standard plus timing and coordination training intervention on community mobility measured using global positioning systems (GPS) among community-dwelling older adults in this secondary analysis of a randomized controlled trial.

METHODS

Participants were randomized to a standard or a standard plus timing and coordination training program. Community mobility was measured using the Life Space Assessment (LSA) and GPS indicators of community mobility at baseline, as well as at 12 (immediately after the intervention), 24, and 36 weeks. Linear mixed models were used for analysis.

RESULTS

There were 166 participants with GPS data at baseline, including 81 in the standard plus group and 85 in the standard group. The groups did not differ in participant characteristics or GPS measures at baseline. There were no significant within-group changes in GPS indicators of community mobility or LSA score over time, nor between-group differences of the same.

CONCLUSION

There were no significant changes in community mobility with either intervention or between-intervention differences. These findings suggest that interventions targeting physical function alone may not be sufficient to improve community mobility or participation in older adults. Future research should focus on the development of multifaceted interventions targeted to improve real-world participation.

IMPACT

The studied interventions did not significantly change community mobility measured using GPS-derived community mobility measures or self-report measures in older adults, suggesting that more comprehensive interventions may be needed to target improvements in community mobility.

An innovative rehabilitation program for the veterans affairs post-acute skilled nursing setting: Preliminary results

BACKGROUND

Skilled nursing rehabilitative care plays a critical role in older adults' functional recovery impacting post-discharge outcomes. Variations across post-acute rehabilitative care services and patient outcomes indicate a need to improve rehabilitative care in this setting. We adapted a successful outpatient care program (Live Long Walk Strong-LLWS) to address this need in post-acute care settings within the Veterans Health Administration. LLWS differs from standard PT care by treating impairments linked to functional decline that are not traditionally targeted by standard care, providing formalized coaching to optimize behavior change, and providing post-discharge case management to optimize long-term outcomes. The purpose was to adapt, refine and implement the LLWS program for the Community Living Center (CLC), determine its acceptability and feasibility, and evaluate its preliminary effectiveness among older adults.

METHODS

The design of the program was adapted from the original outpatient LLWS program to the CLC setting through quality improvement methods and the Replicating Effective Programs (REP) framework. Primary outcomes included measures of feasibility and acceptability of >80% enrollment and completion of sessions as well as preliminary effectiveness using performance-based and patient-reported measures of function including the Short Physical Performance Battery (SPPB), AM-PAC, a Global Rating of Change questionnaire, and a satisfaction survey.

RESULTS

After 18 months, 51 Veterans had enrolled in the LLWS program, with 94.1% maintaining enrollment. We observed >80% completion of the inpatient and home follow-up sessions. Most patients were highly satisfied with care. Improvements in the SPPB (2.3 (SD 2.2) points), gait speed (0.17 (0.14) m/s) and the AM-PAC (6.5 (SD 5.7)) surpassed clinically meaningful thresholds.

CONCLUSIONS

This novel care program is feasible and acceptable to Veterans, demonstrating preliminary effectiveness with improving functional outcomes. Future research is needed to further examine the program's impact on other important outcomes relative to standard modes of care.

Energetic Cost of Walking and Brain Atrophy in Mid-to-Late Life

BACKGROUND

Higher energetic costs for mobility are associated with declining gait speed, and slow gait is linked to cognitive decline and Alzheimer's disease. However, the physiological underpinnings of gait and brain health have not been well explored. We examined the associations of the energetic cost of walking with brain volume in cognitively unimpaired adults from the Baltimore Longitudinal Study of Aging.

METHODS

We used brain magnetic resonance imaging (MRI) data from 850 participants (mean baseline age 66.3 ± 14.5 years), of whom 451 had longitudinal MRI data (2.8 ± 1.0 MRI scans over 4.0 ± 2.0 years). The energetic cost of walking was assessed as the average energy expended (V̇O2) during 2.5 minutes of customary-paced overground walking. Multivariable linear mixed-effects models examined the associations between baseline energetic cost of walking and regional brain volumes adjusting for covariates.

RESULTS

At baseline, higher energetic cost of walking was cross-sectionally associated with lower gray and white matter volumes within the frontal, parietal, and temporal lobes, as well as hippocampal, total brain, and larger ventricular volumes (all false-discovery rate [FDR] p < .05). A baseline energetic cost of walking × time interaction demonstrated that participants with higher energetic cost of walking had faster annual decline in hippocampal volume (FDR p = .02) and accelerated annual increase in ventricular volumes (FDR p = .02).

CONCLUSIONS

The energetic cost of walking is associated with gray and white matter volumes and subsequent hippocampal atrophy and ventricular enlargement. Collectively, these data suggest the energetic cost of walking may be an early marker of neurodegeneration that contributes to the gait brain connection.

Total Ankle Replacement Provides Symmetrical Postoperative Kinematics: A Biplane Fluoroscopy Imaging Study

BACKGROUND

In vivo measurements of tibiotalar and subtalar joint motion following TAR are unavailable. Using biplane fluoroscopy, we tested the hypothesis that the prosthetic tibiotalar joint and adjacent subtalar joint would demonstrate kinematic and range of motion differences compared to the contralateral untreated limb, and control participants.

METHODS

Six patients of 41 identified candidates that all underwent unilateral Zimmer TAR (5.4 ± 1.9 years prior) and 6 control participants were imaged with biplane fluoroscopy during overground walking and a double heel-rise activity. Computed tomography scans were acquired; images were segmented and processed to serve as input for model-based tracking of the biplane fluoroscopy data. Measurements included tibiotalar and subtalar kinematics for the TAR, untreated contralateral, and control limbs. Statistical parametric mapping quantified differences in kinematics throughout overground walking and the double heel-rise activity.

RESULTS

Patients with this TAR performed walking and heel-rise activities symmetrically with no significant kinematic differences at the tibiotalar and subtalar joints between limbs. Compared to control participants, patients exhibited reduced dorsi/plantarflexion range of motion that corresponded to decreased peak dorsiflexion, but only in the late stance phase of walking. This reduction in tibiotalar dorsi/plantarflexion range of motion in the TAR group became more apparent with double heel-rise activity.

CONCLUSION

Patients with a Zimmer TAR had symmetric kinematics during activities of walking and double heel-rise, but they did exhibit minor compensations in tibiotalar kinematics as compared to controls.

CLINICAL RELEVANCE

The lack of significant kinematic compensation at the subtalar joint may explain why secondary subtalar osteoarthritis is reported as being relatively uncommon in patients with some TAR designs.

Effect of Timing and Coordination Training on Mobility and Physical Activity Among Community-Dwelling Older Adults: A Randomized Clinical Trial

Importance

Standard exercise interventions targeting underlying physiologic system impairments have limited success in improving walking. Augmenting standard interventions with timing and coordination training, which incorporates the principles of motor learning and integrates multiple systems, may be more successful.

Objective

To determine whether a standard strength and endurance program incorporating timing and coordination training (standard-plus) improves gait speed more than strength and endurance training alone.

Design, Setting, and Participants

The Program to Improve Mobility in Aging (PRIMA) study was an assessor-blinded, randomized, 2-group intervention trial that included a 12-week intervention and 24-week follow-up period. The trial was conducted at a university research clinic from 2016 to 2020. Participants included 249 community-dwelling older adults (aged ≥65 years) with gait speed between 0.60 and 1.20 m/s. Statistical analysis was performed from December 2020 to March 2021.

Interventions

Participants were randomized to standard strength and endurance (n = 125) or standard-plus, including timing and coordination training (n = 124), 50 to 60 minutes, twice a week for 12 weeks.

Main Outcomes and Measures

Primary outcome of gait speed and secondary outcomes representing components of the intervention (leg strength and power, 6-minute walk test, chair sit-and-reach test, and figure of 8 walk test) and activity and participation (Late Life Function and Disability Instrument and daily physical activity measured by accelerometry) were measured at 12, 24, and 36 weeks.

Results

Among 249 randomized participants, 163 (65.5%) were female, 22 (8.8%) were Black, 219 (88.0%) were White; mean (SD) age was 77.4 (6.6) years; mean (SD) gait speed was 1.07 (0.16) m/s; and 244 (98.0%) completed the intervention. The 2 groups did not have significantly different improvements in gait speed or secondary outcomes representing the components of the intervention at any time point. For gait speed, individuals in the standard-plus group had a mean (SD) improvement of 0.079 (0.135) m/s over 12 weeks, 0.065 m/s (0.141) over 24 weeks, and 0.059 (0.150) m/s over 36 weeks; individuals in the standard group improved gait speed by 0.081 (0.124) m/s over 12 weeks, 0.051 (0.129) m/s over 24 weeks, and 0.065 (0.148) m/s over 36 weeks.

Conclusions and Relevance

This randomized clinical trial found no difference in gait speed change between the standard and standard-plus intervention groups, and both groups showed sustained improvements in mobility 24 weeks after the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT02663778.

The Association of Mobility Determinants and Life Space Among Older Adults

BACKGROUND

It is important to understand the factors associated with life space mobility so that mobility disability can be prevented/treated. The purpose of this study was to identify the association between mobility determinants and life space among older adults.

METHODS

This study was a cross-sectional analysis of 249 community-dwelling older adults (mean age=77.4 years, 65.5% female, 88% white) who were recruited for a randomized, controlled, clinical intervention trial. Associations between cognitive, physical, psychosocial, financial, and environmental mobility determinants and the Life Space Assessment (LSA) at baseline were determined using Spearman's correlation coefficients and one-way analysis of variance. Multivariate analysis was performed using multivariable linear regression models.

RESULTS

The mean LSA score for the sample was 75.3 (SD=17.8). Personal factors (age, gender, education, comorbidities), cognitive (Trail Making Test A and B), physical (gait speed, lower extremity power, Six Minute Walk Test, Figure of 8 Walk Test, tandem stance, energy cost of walking, and Late Life Function and Disability Function Scale), psychosocial (Modified Gait Efficacy Scale), and financial (neighborhood socio-economic status) domains of mobility were significantly associated with LSA score. In the final regression model, age (β=-0.43), lower extremity power (β=0.03), gait efficacy (β=0.19), and energy cost of walking (β=-57.41) were associated with life space (R 2=0.238).

CONCLUSIONS

Younger age, greater lower extremity power, more confidence in walking, and lower energy cost of walking were associated with greater life space. Clinicians treating individuals with mobility disability should consider personal, physical, and psychosocial factors assessing barriers to life space mobility.

Methodology of a home-based motor control exercise and ergonomic intervention programme for community-dwelling older people: The McHeELP study

The aim of this research (Motor control Home ergonomics Elderlies' Prevention of falls; McHeELP study) was to develop a novel intervention combining motor control home-based exercises and a home ergonomic safety-improvement strategy in order to reduce falls in frail ambulatory older adults. A randomized controlled trial of a novel intervention is proposed including motor control exercises and home ergonomic assessment and modification in older adults who have at least one fall experience. Participants are randomized to control or intervention group in a 1:1 ratio. Participants will be assessed three times: at baseline, at 3rd month (end of intervention period) and again at 6th month (follow-up measurement). The primary outcome is of the effect on functional mobility using the Timed Up and Go test. Secondary outcomes include assessments of functionality, fear of falling and quality of life. This will be the first study to develop an exercise intervention approach that combines home-based motor control exercise intervention with home assessment and modification. This study is expected to explore a low-cost, easy-to-popularize, and effective exercise intervention approach for improving functional mobility and prevent falls among older adults.

ENHANCED ACTIVE CONTRACTION OF THE TRANSVERSUS ABDOMINIS DURING WALKING

ABSTRACT Introduction: We applied three-dimensional gait analysis to assess the effects of enhanced active contraction of the transversus abdominis (EACTA) during walking. We sought to evaluate the effect of EACTA during walking in order to improve walking quality. Methods: Thirty college students were recruited and trained to perform EACTA during walking. We examined gait parameters under different conditions, including EACTA and habitual ACTA (natural walking with mild contraction of the feedforward mechanism of ACTA, HACTA) during walking using three-dimensional gait analysis. We compared differences in gait parameters under the two walking conditions using SPSS 16.0 statistical software. Results: The following gait parameters were significantly lower under EACTA conditions than under HACTA conditions (P < 0.05): stance phase, 59.151% ± 1.903% vs. 59.825% ± 1.495%; stride time, 1.104 s ± 0.080 s vs. 1.134 s ± 0.073 s:; stance time, 0.656 s ± 0.057 s vs. 0.678 s ± 0.053 s; and swing time, 0.447 s ± 0.028 s vs. 0.454 s ± 0.031 s, respectively. Gait parameters single support phase and mean velocity were significantly higher for EACTA than for HACTA conditions (both P < 0.05). Conclusions: Overall, the results revealed that EACTA during walking can improve gait. This method is simple, and EACTA training during walking to improve gait quality in daily life could provide a positive basis for people to strengthen the transverse abdominal muscle. Level of evidence III; Retrospective comparative study .

Association Between Improved Mobility and Distal Health Outcomes

BACKGROUND

We examined the association between improved mobility and distal health outcomes in older adults using secondary analysis of data from a cluster-randomized controlled group exercise trial.

METHODS

Participants were 303 men and women aged ≥65 and older in 32 independent living facilities, senior apartments, and community centers who participated in 12-week group exercise interventions. Included were those who completed ≥1 follow-up phone call regarding outcomes assessment in the following year. Gait speed and 6-minute walk distance (6MWD) were assessed at baseline and immediately after 12-week interventions to determine mobility performance change status. Falls, emergency department (ED) visits, and hospitalizations were assessed monthly for 12 months following the end of interventions via interactive voice response phone calls. Incident rate ratios (IRRs) were calculated to quantify incidence of adverse outcomes with respect to mobility performance change.

RESULTS

Each 0.05 m/s increase in gait speed resulted in an 11% reduction in falls (IRR = 0.89; 95% confidence interval [CI], 0.84-0.94; p < .0001); a similar decrease was seen for each 20 m increase in 6MWD (IRR = 0.89; 95% CI, 0.83-0.93; p = .0003). Those who improved gait speed had 61 falls per 1,000 person-months versus 135 in those who had no change/a decline. Those who improved 6MWD had 67 falls per 1,000 person-months versus 110 per 1,000 person-months in those who had no change/a decline. Differences in ED visits and hospitalizations were not statistically significant.

CONCLUSION

Improvements in mobility performance are associated with lower incidence of future falls. Given the exploratory nature of the findings, further investigation is warranted.

What is the Minimum Step Rate Required to Achieve Moderate-Intensity Walking Overground in Adolescent Girls?

BACKGROUND

In order to promote walking, researchers have sought to identify the required step rate to maintain a health-enhancing walking intensity However, there is limited evidence regarding the stepping rate required to promote moderate-intensity walking in adolescent girls.

PURPOSE

To identify the step rate equivalent to moderate-intensity physical activity (MPA) in adolescent girls and to explore the influence that different anthropometric measures may have on the step rate equating to MPA in this population.

METHODS

A total of 56 adolescent girls (mean age = 13.8[0.7] y) were recruited to the study. Anthropometric variables and resting metabolic rate were assessed, followed by 3 overground walking trials on a flat surface at approximately 2, 3, and 4 mph, each lasting a minimum of 4 minutes. Oxygen uptake was assessed using a portable gas analyzer and subsequently converted into metabolic equivalents (METs). Step count was assessed by real-time direct observation hand tally.

RESULTS

Employing the linear regression between step rate and METs (r2 = .20, standard error of estimates = 0.003) suggests that 120 steps per minute was representative of an MPA (3 METs) equating to 7200 steps in 60 minutes. Multiple regression and mixed-model regression confirmed weight-related variables and maturity were significant predictors of METs (P < .01).

CONCLUSION

The results suggest that, at population level, a step rate of 120 steps per minute may be advocated to achieve MPA in adolescent girls; although, due to the small sample size used, caution should be applied. At an individual level, other factors, such as age and weight, should be considered.

Advances in the rehabilitation of intensive care unit acquired weakness: A case report on the promising use of robotics and virtual reality coupled to physiotherapy

INTRODUCTION

Traditional physiotherapy is currently the best approach to manage patients with intensive care unit acquired weakness (ICUAW). We report on a patient with ICUAW, who was provided with an intensive, in-patient regimen, that is, conventional plus robot-assisted physiotherapy. Aim of this case study was to assess the efficacy of a combined approach (conventional plus robot-assisted physiotherapy), on muscle strength, overall mobility, and disability burden in a patient with ICUAW in post-ICU intensive rehabilitation setting.

PATIENT CONCERNS

A 56-years-old male who was unable to stand and walk independently after hospitalization in an Intensive Care Unit. He initially was provided with daily sessions of conventional physiotherapy for 2 months, with mild results.

DIAGNOSIS

The patient was affected by ICUAW.

INTERVENTION

Given that the patient showed a relatively limited improvement after conventional physiotherapy, he was provided with daily sessions of robot-aided training for upper and lower limbs and virtual reality-aided rehabilitation for other 4 months, beyond conventional physiotherapy.

OUTCOMES

At the discharge (6 months after the admission), the patient reached the standing station and was able to ambulate with double support.

CONCLUSIONS

Our case suggests that patients with ICUAW should be intensively treated in in-patient regimen with robot-aided physiotherapy. Even though our approach deserves confirmation, the combined rehabilitation strategy may offer some advantage in maximizing functional recovery and containing disability.

Effect of Community-Based Group Exercise Interventions on Standing Balance and Strength in Independent Living Older Adults

BACKGROUND AND PURPOSE

Many interventions to improve mobility in older adults often include exercises to address underlying impairments such as strength deficits. Task-oriented exercise interventions that focus more on walking and stepping tasks that may be encountered in the community have been considered for improving mobility in older adults. The main purpose was to examine the effect of task-oriented and impairment-based group exercise interventions on standing balance and lower extremity muscle strength.

METHODS

This is an ancillary study to a cluster-randomized clinical trial. Participants included 107 older adults. Participants were randomized by facility to 1 of 2 different interventions, or a waitlist control group. The On the Move (OTM) task-oriented intervention consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and stretching exercises. The standard of care impairment-based exercise intervention (STD) consisted of warm-up, strength, endurance, and stretching exercises. Postural sway and balance measures were recorded before and after the 12-week interventions. An accelerometer was used to collect postural sway for 6 different standing balance conditions. A portable load cell was used to assess lower extremity muscle strength for 3 muscle groups.

RESULTS AND DISCUSSION

The OTM group had a significant reduction in sway acceleration during most of the balance conditions over the 12-week period, whereas the STD had smaller, nonsignificant reductions. Both exercise interventions had a significant reduction in sway compared with the waitlist control group in at least 1 balance condition. The OTM and STD groups had significant increases in hip abduction strength during the intervention and the STD group also had an increase in knee extension strength. The waitlist group had a significant reduction in strength in all muscle groups during the 12-week period. Strength changes in both exercise groups were significantly different from the waitlist group but not from each other.

CONCLUSION

Both exercise intervention groups had an improvement in standing balance and lower extremity strength when compared with a waitlist group that did not receive exercise. Although the exercise groups did not significantly differ from each other, the OTM exercise group showed a trend toward improvement in static standing balance conditions.

Potential long-term impact of "On The Move" group-exercise program on falls and healthcare utilization in older adults: an exploratory analysis of a randomized controlled trial

Background

Wellness program participation may reduce the risk of falling, emergency department-use, and hospitalization among older adults. “On the Move” (OTM), a community-based group exercise program focused on the timing and coordination of walking, improved mobility in older adults, but its impact on falls, emergency department-use, and hospitalizations remains unclear. The aim of this preliminary study was to investigate the potential long-term effects that OTM may have on downstream, tertiary outcomes.

Methods

We conducted a secondary analysis of a cluster-randomized, single-blind intervention trial, which compared two community-based, group exercise programs: OTM and a seated exercise program on strength, endurance, and flexibility (i.e. ‘usual-care’). Program classes met for 50 min/session, 2 sessions/week, for 12 weeks. Older adults (≥65 years), with the ability to ambulate independently at ≥0.60 m/s were recruited. Self-reported incidence of falls, emergency department visitation, and hospitalization were assessed using automated monthly phone calls for the year following intervention completion. Participants with ≥1 completed phone call were included in the analyses. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated (reference = usual-care).

Results

Participants (n = 248) were similar on baseline characteristics and number of monthly phone calls completed. Participants in the seated exercise program attended an average of 2.9 more classes (p = .017). Of note, all results were not statistically significant (i.e. 95% CI overlapped a null value of 1.0). However, point estimates suggest OTM participation resulted in a decreased incidence rate of hospitalization compared to usual-care (IRR = 0.88; 95% CI = 0.59–1.32), and the estimates strengthened when controlling for between-group differences in attendance (adjusted IRR = 0.82; 95% CI = 0.56–1.21). Falls and emergency department visit incidence rates were initially greater for OTM participants, but decreased after controlling for attendance (adjusted IRR = 1.08; 95% CI = 0.72–1.62 and adjusted IRR = 0.96; 95% CI = 0.55–1.66, respectively).

Conclusion

Compared to a community-based seated group exercise program, participation in OTM may result in a reduced risk of hospitalization. When OTM is adhered to, the risk for falling and hospitalizations are attenuated. However, definitive conclusions cannot be made. Nevertheless, it appears that a larger randomized trial, designed to specifically evaluate the impact of OTM on these downstream health outcomes is warranted.

Trial registration

Clinical trials.gov (NCT01986647; prospectively registered on November 18, 2013).

Assessing gait efficacy in older adults: An analysis using item response theory

BACKGROUND

Assessing confidence in walking in older adults is important, as mobility is a critical aspect of independence and function, and self-report provides complementary information to performance-based measures. The modified Gait Efficacy Scale (mGES) is a self-report measure used to examine confidence in walking.

RESEARCH QUESTION

What are the psychometric properties of the mGES at the item level? Are there opportunities for improvement?

METHODS

We performed a secondary analysis of baseline data from a cluster randomized trial of 424 community-dwelling older adults and reliability data from 123 participants. We fitted a graded response model to dissect the mGES to the item and individual response level and examined opportunities to improve and possible shorten the mGES. We examined psychometric characteristics such as internal consistency, test-retest reliability and construct validity with respect to other relevant measures.

RESULTS

Mobility tasks such as navigating stairs and curbs with separate items for going up and down largely provide the same information on confidence, with downward direction providing slightly more. It may be reasonable to consider removal of walking 1/2 mile, stepping down and/or stair tasks with railings items due to little or duplicate information contributed compared to other items. The shortened scales proposed by removing the above items had similar psychometric properties to mGES.

SIGNIFICANCE

The mGES has good psychometric properties, but can be potentially shortened to substantially reduce responder burden. The upward direction curb and stairs items can be removed to result in a 7-item scale with virtually no loss of desirable psychometrics. An alternative 3-item version, level surface walking, stepping down curb and climbing up stairs without a railing items, entails only a minimal loss in psychometric properties.

Effect of investigator observation on gait parameters in individuals with stroke

Improvements in gait speed following various training paradigms applied to patients post-stroke does not always lead to changes in walking performance, defined as gains in daily stepping activity. We hypothesized that testing conditions, specifically the presence of an observer, influences patient behaviors and resultant outcomes may overestimate their true walking capacity. This potential Hawthorne effect on spatiotemporal and biomechanical measures of locomotor function in individuals post-stroke has not been assessed previously. Fifteen ambulatory individuals with chronic stroke wore instrumented insoles and performed two separate normal-pace walking assessments, including unobserved conditions during which participants were unattended and unaware of data collection, and observed conditions with an investigator present. Gait analysis was conducted outside of a laboratory setting using instrumented insoles equipped with a 3D accelerometer and pressure sensors which captured the spatiotemporal kinematics, vertical ground reaction forces and foot acceleration. Data were compared using paired comparisons, with subsequent correlation and stepwise regression analyses to explore potential associations between Hawthorne-induced changes in walking strategies, gait speed and locomotor performance (daily stepping). Except for cadence, other measures of spatiotemporal parameters and swing kinematics (acceleration) were not significantly different between observed vs unobserved conditions. However, analyses of ground reaction forces revealed significantly greater paretic limb loading (Δ1st peak = 1.5 ± 1.6 N/kg Δ2nd peak = 1.4 ± 1.8 N/kg; p < 0.01) and increases in weight bearing symmetry (11-24%, p < 0.01) during observed vs unobserved conditions. This potential Hawthorne effect was greater in those with slower walking speeds and shorter stride lengths but was not related to daily stepping. The present findings suggest that biomechanical parameters of walking function may be related to the presence of an observer and highlight the need to separately measure locomotor capacity (gait speed) and performance (daily stepping).

Program to improve mobility in aging (PRIMA) study: Methods and rationale of a task-oriented motor learning exercise program

Walking difficulty is a common and costly problem in older adults. A potentially important yet unaddressed strategy to enhance walking ability through exercise intervention is to add a timing and coordination component in gait training (i.e. task specific timing and coordination exercise intervention) to the usual strength, endurance, and flexibility training. We describe the methods and rationale of a randomized single-blind, physical therapist supervised, exercise intervention trial to compare the effects of a standard strength, endurance, and flexibility program to a standard plus timing and coordination program in community-dwelling older adults walking slower than the desired gait speed of 1.2 m/s. Exercise sessions are twice weekly for 12 weeks. Participants are assessed at baseline, 12 weeks (post intervention), 24 weeks and 36 weeks. The primary outcome is gait speed, secondary outcomes represent components of the interventions (strength, endurance, flexibility, timing and coordination), and tertiary outcomes are measure of activity and participation (Late Life Function and Disability Instrument and physical activity). The findings of this trial will (1) establish if a standard-plus task specific timing and coordination program is superior to a standard strength and endurance program in improving mobility, activity and participation and (2) determine if the improvements are sustained over time. The information derived from this project will provide valuable insight into the prevention and management of walking difficulty, which is so common in older Americans.

Aging Back Clinics-a Geriatric Syndrome Approach to Treating Chronic Low Back Pain in Older Adults: Results of a Preliminary Randomized Controlled Trial

OBJECTIVE

Treating chronic low back pain (CLBP) with spine-focused interventions is common, potentially dangerous, and often ineffective. This preliminary trial tests the feasibility and efficacy of caring for CLBP in older adults as a geriatric syndrome in Aging Back Clinics (ABC).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinics of two VA Medical Centers.

SUBJECTS

Fifty-five English-speaking veterans aged 60-89 with CLBP and no red flags for serious underlying illness, prior back surgery, dementia, impaired communication, or uncontrolled psychiatric illness.

METHODS

Participants were randomized to ABC care or usual care (UC) and followed for six months. ABC care included 1) a structured history and physical examination to identify pain contributors, 2) structured participant education, 3) collaborative decision-making, and 4) care guided by condition-specific algorithms. Primary outcomes were low back pain severity (0-10 current and seven-day average/worst pain) and pain-related disability (Roland Morris). Secondary outcomes included the SF-12 and health care utilization.

RESULTS

ABC participants experienced significantly greater reduction in seven-day average (-1.22 points, P = 0.023) and worst pain (-1.70 points, P = 0.003) and SF-12 interference with social activities (50.0 vs 11.5%, P = 0.0030) at six months. ABC participants were less likely to take muscle relaxants (16.7 vs 42.3%, P = 0.0481). Descriptively, UC participants were more likely to experience pain-related emergency room visits (45.8% vs 30.8%) and to be exposed to non-COX2 nonsteroidal anti-inflammatory drugs (73.1% vs 54.2%).

CONCLUSIONS

These preliminary data suggest that ABC care for older veterans with CLBP is feasible and may reduce pain and exposure to other potential morbidity.

Real World, Real People: Can We Assess Walking on a Treadmill to Establish Step Count Recommendations in Adolescents?

BACKGROUND

Currently, it is not known how much walking should be advocated for good health in an adolescent population. Step count recommendations for minimum time in moderate-intensity activity have been translated predominantly from treadmill walking.

PURPOSE

To compare the energy cost of walking on a treadmill with overground walking in adolescent girls.

METHODS

A total of 26 adolescent girls undertook resting metabolic measurements for individual determination of 1 metabolic equivalent using indirect calorimetry. Energy expenditure was subsequently assessed during treadmill and overground walking at slow, moderate, and fast walking speeds for 4 to 6 minutes. Treadmill step rates were matched overground using a metronome.

RESULTS

The energy cost of treadmill walking was found to be significantly greater than and not equivalent to overground walking at 133 steps per minute; (equivalent to the fast walking pace): V˙O2 3.90 (2.78-5.01), P < .001, mean absolute percentage error (MAPE) = 18.18%, and metabolic equivalent 0.77 (0.54-1.00), P < .001, MAPE = 18.16%. The oxygen cost per step (V˙O2 mL·step-1) was significantly greater and not equivalent on the treadmill at 120 and 133 steps per minute: 0.43 (0.12-0.56), P < .05, MAPE = 10.12% versus 1.40 (1.01-1.76), P < .001, MAPE = 17.64%, respectively.

CONCLUSION

The results suggest that there is a difference in energy cost per step of walking on a treadmill and overground at the same step rate. This should be considered when utilizing the treadmill in energy expenditure studies. Studies which aim to provide step recommendations should focus on overground walking where most walking activity is adopted.

Progressive Multicomponent Intervention for Older Adults in Home Health Settings Following Acute Hospitalization: Randomized Clinical Trial Protocol

BACKGROUND

Hospitalization is a profound contributor to functional loss for older adults. Many modifiable risk factors (ie, weakness) may persist after hospitalization, representing portents of poor health, re-hospitalization, or death. Older adults frequently receive home health (HH) care after hospitalization to manage functional deficits that have worsened during hospital stays. However, how best to manage these deficits in HH settings has yet to be determined.

OBJECTIVE

The objective is to determine if a higher intensity, progressive, multi-component (PMC) intervention, initiated upon admission to HH after an acute hospitalization, improves objectively measured and self-reported physical function more than usual care (UC) physical therapy.

DESIGN

This will be a 2-arm randomized controlled clinical trial.

SETTING

The setting will be participant homes.

PARTICIPANTS

A total of 200 older adults with deconditioning following acute hospitalization and referred for HH physical therapy will participate.

INTERVENTION

Participants will be randomized to either a PMC treatment group or a UC group and receive 12 therapy visits over a 60-day period. PMC participants will perform lower extremity resistance training at 80% of a 1-repetition maximum, task-specific activities of daily living training, along with advanced gait and balance training. PMC groups will also receive nutritional supplementation and nursing support during transition from hospital to home. The UC group will receive standard of care HH interventions.

MEASUREMENTS

Physical performance, self-reported function, fatigue, and health care utilization outcomes will be measured at baseline, 30 days, 60 days, 90 days, and 180 days. All measures will be assessed by blinded study personnel.

LIMITATIONS

The limitation is an inability to blind treating therapists to study allocation.

CONCLUSIONS

The authors hope to determine whether higher intensity, multi-component exercise interventions improve outcomes more than UC physical therapy for older adults recovering from acute hospitalization in HH settings.

An observational treatment-based gait pattern classification method for targeting interventions for older adult males with mobility problems: Validity based on movement control and biomechanical factors

BACKGROUND

A reliable and valid observational gait assessment intended to guide clinical intervention for gait deficits in older adults has not been proposed. A quick gait classification method which tailors clinical management for different patterns of gait dysfunction may be useful for clinicians with limited access to apply computer-assisted gait analyses.

RESEARCH QUESTION

This work aims to establish reliability and validity of the Treatment-Based Gait Pattern Classification (TBGPC) that can be used to quickly identify and classify mobility problems of older males, and possibly target interventions for specific gait deficits in clinical settings.

METHOD

Videotapes of 116 older male veterans referred for mobility problems were analyzed in this cross-sectional study. The TBGPC defined by movement control (consistent, inconsistent) and postural biomechanical factors (usual, flexed, extended, crouched) was validated by comparing means of individual items of the Modified Gait Abnormality Rating Scale (GARS-M) across groups.

RESULTS

Kappas for interrater reliability of the TBGPC movement control and biomechanical components were 0.59 and 0.75, respectively; for intrarater reliability, 0.82 and 0.72, respectively. Both movement control and biomechanical components were validated. All GARS-M items were different between older males with consistent and inconsistent gait. Within the consistent and inconsistent group, hip ROM was one of the most differentiating GARS-M item between older males with usual and flexed gait and flexed and crouched group. Total GARS-M score and guardedness were two differentiating factors between the usual and crouched group.

SIGNIFICANCE

Gait patterns of older males were reliably recognized and validated by mean differences in abnormal characteristics of gait across patterns. The TBGPC may be useful to quickly identify and classify mobility problems of older males and to guide clinical intervention.

The Nursing Home Physical Performance Test: A Secondary Data Analysis of Women in Long-Term Care Using Item Response Theory

Background and Objectives

The Nursing Home Physical Performance Test (NHPPT) was developed to measure function among nursing home residents using sit-to-stand, scooping applesauce, face washing, dialing phone, putting on sweater, and ambulating tasks. Using item response theory, we explore its measurement characteristics at item level and opportunities for improvements.

Research Design and Methods

We used data from long-term care women. We fitted a graded response model, estimated parameters, and constructed probability and information curves. We identified items to be targeted toward lower and higher functioning persons to increase the range of abilities to which the instrument is applicable. We revised the scoring by making sit-to-stand and sweater items harder and dialing phone easier. We examined changes to concurrent validity with activities of daily living (ADL), frailty, and cognitive function.

Results

Participants were 86 years old, had more than three comorbidities, and a NHPPT of 19.4. All items had high discrimination and were targeted toward the lower middle range of performance continuum. After revision, sit-to-stand and sweater items demonstrated greater discrimination among the higher functioning and/or greater spread of thresholds for response categories. The overall test showed discrimination over a wider range of individuals. Concurrent validity correlation improved from 0.60 to 0.68 for instrumental ADL and explained variability (R2) from 22% to 36% for frailty.

Discussion and Implications

NHPPT has good measurement characteristics at the item level. NHPPT can be improved, implemented in computerized adaptive testing, and combined with self-report for greater utility, but a definitive study is needed.

Randomized Controlled Trial of Exercise to Improve Walking Energetics in Older Adults

Background and Objectives

Mobility limitation is common and has been linked to high energetic requirements of daily activities, including walking. The study objective was to determine whether two separate forms of exercise could reduce the energy cost of walking and secondary outcomes related to activity and participation domains among older adults with mobility limitation.

Research Design and Methods

Community-dwelling older adults with self-reported mobility limitation (n = 72) were randomized to 12 weeks of twice-weekly, group-based, instructor-led timing and coordination, aerobic walking, or stretching and relaxation (active control) programs. The primary outcome was the energy cost of walking (mL O₂/kg/m), assessed by a 5-minute treadmill walking test (0.8 m/s). Secondary outcomes were fatigability, physical activity, endurance, physical function, and life-space. Baseline-adjusted ANCOVAs were used to determine mean differences between exercise and control groups at 12 and 24 weeks.

Results

Exercise session attendance was high: 86% for timing and coordination, 81% for aerobic walking, and 90% for stretching and relaxation. At 12 weeks, timing and coordination reduced the mean energy cost of walking by 15% versus stretching and relaxation (p = .008). Among those with high baseline cost, timing and coordination reduced mean energy cost by 20% versus stretching and relaxation (p = .055). Reductions were sustained at 24 weeks. Aerobic walking had no effect on the energy cost of walking at 12 or 24 weeks. At 12 weeks, there was a trend toward faster gait speed (by 0.1 m/s) in timing and coordination versus stretching and relaxation (p = .074). Fatigability, physical activity, endurance, physical function, and life-space did not change with timing and coordination or aerobic walking versus stretching and relaxation at 12 or 24 weeks.

Discussion and Implications

Twelve weeks of timing and coordination, but not aerobic walking, reduced the energy cost of walking among older adults with mobility limitation, particularly among those with high baseline energy cost; reductions in energy cost were sustained following training cessation. Timing and coordination also led to a trend toward faster gait speed.

Effectiveness of a Timing and Coordination Group Exercise Program to Improve Mobility in Community-Dwelling Older Adults: A Randomized Clinical Trial

IMPORTANCE

Timing and coordination exercises may be an important addition to community-based health promotion exercise programs to improve walking in older adults.

OBJECTIVE

To compare the effectiveness of the On the Move group exercise program, which focuses on the timing and coordination of movement, with a seated strength, endurance, and flexibility program (usual care) at improving function, disability, and walking ability of older adults.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized, single-blind intervention trial. Thirty-two independent living facilities, senior apartment buildings, and senior community centers were randomized to On the Move (16 sites; 152 participants) or usual care (16 sites; 146 participants). Participants were 65 years or older, able to ambulate independently with a gait speed of at least 0.60 m/s, able to follow 2-step commands, and were medically stable.

INTERVENTIONS

Exercise classes were 50 minutes, twice a week for 12 weeks and had 10 or fewer participants per class. On the Move consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and stretching exercises. The usual-care program consisted of warm-up, strength, endurance, and stretching exercises.

MAIN OUTCOMES AND MEASURES

The primary outcomes were self-report of function and disability (Late Life Function and Disability Instrument) and mobility (6-minute walk distance and gait speed) assessed by blinded individuals.

RESULTS

Participants (mean [SD] age, 80.0 [8.1] years) were mostly female (251 [84.2%]) and white (249 [83.6%]) and had a mean (SD) of 2.8 (1.4) chronic conditions. Intervention groups were similar on baseline characteristics. Postintervention, 142 (93.4%) participants in On the Move and 139 (95.2%) participants in usual care completed testing. On the Move had greater mean (SD) improvements than the usual-care group in gait speed (0.05 [0.13] vs -0.01 [0.11] m/s; adjusted difference = 0.05 [0.02] m/s; P = .002) and 6-minute walk distance (20.6 [57.1] vs 4.1 [55.6] m; adjusted difference = 16.7 [7.4] m; P = .03). Attendance was greater in the usual-care program compared with On the Move (95 [65.1%] vs 76 [50.0%] attended ≥20 classes; P = .03). There were no significant differences in any of the other primary or secondary outcomes.

CONCLUSIONS AND RELEVANCE

The On the Move group exercise program was more effective at improving mobility than a usual-care exercise program, despite lower attendance. Additional research examining the impact of the intervention on long-term disability outcomes is needed before recommending routine implementation into clinical practice.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01986647.

Coordination Impairments Are Associated With Falling Among Older Adults

Background/Study Context: Approximately one third of older adults over the age of 65, and over 40% of those over 80 years, fall each year, leading to fractures, morbidity, and mortality. Annual direct medical costs due to falls in the United States are approximately $19.2 billion. The identification of new treatable risk factors for falls has the potential to advance their prevention and rehabilitation.

METHODS

A cross-sectional study of 127 community-dwelling adults aged 67-99 years was conducted. An electronic gait walkway was used to assess gait coordination, measured as the Phase Coordination Index during normal speed walking. A motion capture system was used to assess rhythmic interlimb antiphase ankle coordination, measured as the standard deviation of ankle relative phase. Having fallen in the previous year was self-reported retrospectively. Odds ratios for falling as a function of coordination quartiles were determined using multivariable logistic regression.

RESULTS

Adjusting for age, sex, body mass index, number of chronic conditions, Mini-Mental State Examination score, gait speed, and the variability of step length, time, and width, the odds ratios for falling based upon being in the 4th (the poorest) quartiles of gait or ankle coordination were 5.5 (95% confidence interval [CI]: 1.2-24.7) and 8.2 (95% CI: 2.2-31.3), respectively, and 3.7 (95% CI: 1.0-13.8) for the 3rd quartile of gait coordination, compared with the best (the 1st) coordination quartiles. Similar results were found in regression without adjustment for gait characteristics.

CONCLUSION

The results support the hypothesis that impaired gait and rhythmic interlimb ankle coordination are associated with a history of falls in the past year. Prospective longitudinal research is needed to determine the possible direction of causality between falls and impaired coordination.

Altered spatiotemporal characteristics of gait in older adults with chronic low back pain

Previous studies in older adults have identified that chronic low back pain (CLBP) is associated with slower gait speed. Given that slower gait speed is a predictor of greater morbidity and mortality among older adults, it is important to understand the underlying spatiotemporal characteristics of gait among older adults with CLBP. The purposes of this study were to determine (1) if there are differences in spatiotemporal parameters of gait between older adults with and without CLBP during self-selected and fast walking and (2) whether any of these gait characteristics are correlated with performance of a challenging walking task, e.g. stair negotiation. Spatiotemporal characteristics of gait were evaluated using a computerized walkway in 54 community-dwelling older adults with CLBP and 54 age- and sex-matched healthy controls. Older adults with CLBP walked slower than their pain-free peers during self-selected and fast walking. After controlling for body mass index and gait speed, step width was significantly greater in the CLBP group during the fast walking condition. Within the CLBP group, step width and double limb support time are significantly correlated with stair ascent/descent times. From a clinical perspective, these gait characteristics, which may be indicative of balance performance, may need to be addressed to improve overall gait speed, as well as stair-climbing performance. Future longitudinal studies confirming our findings are needed, as well as investigations focused on developing interventions to improve gait speed and decrease subsequent risk of mobility decline.

Aging, the Central Nervous System, and Mobility in Older Adults: Interventions

BACKGROUND

Research suggests that the central nervous system (CNS) and mobility are closely linked. CNS-mediated mobility impairment may represent a potentially new and prevalent syndrome within the older adult populations. Interventions targeting this group may have the potential to improve mobility and cognition and prevent disability.

METHODS

In 2012, the Gerontological Society of America (GSA) and the National Institute on Aging (NIA) sponsored a 3-year conference workshop series, "Aging, the CNS, and Mobility." The goal of this third and final conference was to (i) report on the state of the science of interventions targeting CNS-mediated mobility impairment among community-dwelling older adults and (ii) partnering with the NIA, explore the future of research and intervention design focused on a potentially novel aging syndrome.

RESULTS

Evidence was presented in five main intervention areas: (i) pharmacology and diet; (ii) exercise; (iii) electrical stimulation; (iv) sensory stimulation/deprivation; and (v) a combined category of multimodal interventions. Workshop participants identified important gaps in knowledge and key recommendations for future interventions related to recruitment and sample selection, intervention design, and methods to measure effectiveness.

CONCLUSIONS

In order to develop effective preventive interventions for this prevalent syndrome, multidisciplinary teams are essential particularly because of the complex nature of the syndrome. Additionally, integrating innovative methods into the design of interventions may help researchers better measure complex mechanisms, and finally, the value of understanding the link between the CNS and mobility should be conveyed to researchers across disciplines in order to incorporate cognitive and mobility measurements into study protocols.

Stakeholder involvement in the design of a patient-centered comparative effectiveness trial of the "On the Move" group exercise program in community-dwelling older adults

BACKGROUND

Group exercise programs for older adults often exclude the timing and coordination of movement. Stakeholder involvement in the research process is strongly encouraged and improves the relevance and adoption of findings. We describe stakeholder involvement in the design of a clinical trial of a group-based exercise program that incorporates timing and coordination of movement into the exercises.

METHODS

The study was a cluster randomized, single-blind intervention trial to compare the effects on function, disability and mobility of a standard group exercise program and the "On the Move" group exercise program in older adults residing in independent living facilities and senior apartment buildings, and attending community centers. Exercise classes were twice weekly for 12weeks delivered by study exercise leaders and facility activity staff personnel.

OUTCOMES

The primary outcomes function, disability and mobility were assessed at baseline and post-intervention. Function and disability were assessed using the Late Life Function and Disability Instrument, and mobility using the Six-Minute Walk Test and gait speed.

STAKEHOLDERS

Patient and provider stakeholders had significant input into the study aims, design, sample, intervention, outcomes and operational considerations.

SUMMARY

A community-based exercise program to improve walking can be developed to address both investigator identified missing components in current exercise to improve walking and stakeholder defined needs and interest for the activity program. Involvement of stakeholders substantially improves the relevance of research questions, increases the transparency of research activities and may accelerate the adoption of research into practice.

Progressive multi-component home-based physical therapy for deconditioned older adults following acute hospitalization: a pilot randomized controlled trial

OBJECTIVE

To determine whether a progressive multicomponent physical therapy intervention in the home setting can improve functional mobility for deconditioned older adults following acute hospitalization.

DESIGN

Randomized controlled trial.

SETTING

Patient homes in the Denver, CO, metropolitan area.

PARTICIPANTS

A total of 22 homebound older adults age 65 and older (mean ± SD; 85.4 ±7.83); 12 were randomized to intervention group and 10 to the control group.

INTERVENTION

The progressive multicomponent intervention consisted of home-based progressive strength, mobility and activities of daily living training. The control group consisted of usual care rehabilitation.

MEASUREMENTS

A 4-meter walking speed, modified Physical Performance Test, Short Physical Performance Battery, 6-minute walk test.

RESULTS

At the 60-day time point, the progressive multicomponent intervention group had significantly greater improvements in walking speed (mean change: 0.36 m/s vs. 0.14 m/s, p = 0.04), modified physical performance test (mean change: 6.18 vs. 0.98, p = 0.02) and Short Physical Performance Battery scores (mean change: 2.94 vs. 0.38, p = 0.02) compared with the usual care group. The progressive multicomponent intervention group also had a trend towards significant improvement in the 6-minute walk test at 60 days (mean change: 119.65 m vs. 19.28 m; p = 0.07). No adverse events associated with intervention were recorded.

CONCLUSIONS

The progressive multicomponent intervention improved patient functional mobility following acute hospitalization more than usual care. Results from this study support the safety and feasibility of conducting a larger randomized controlled trial of progressive multicomponent intervention in this population. A more definitive study would require 150 patients to verify these conclusions given the effect sizes observed.

Translation of a Motor Learning Walking Rehabilitation Program Into a Group-Based Exercise Program for Community-Dwelling Older Adults

BACKGROUND

Traditional exercise programs for older adults, which focus on aerobic and strength training, have had only modest effects on walking. Recently, a motor learning exercise program was shown to have greater effects on walking compared with a traditional exercise program. Translating this novel motor learning exercise program into a group exercise program would allow it to be offered as an evidence-based, community-based program for older adults.

OBJECTIVE

To translate a walking rehabilitation program based on motor learning theory from one-on-one to group delivery (On the Move) and evaluate multiple aspects of implementation in older adults with impaired mobility.

DESIGN

The translation process involved multiple iterations, including meetings of experts in the field (Phase I), focus groups (Phase II), and implementation of the newly developed program (Phase III). Phase III was based on a one-group model of intervention development for feasibility, safety, potential effects, and acceptability.

SETTING

Community sites, including 2 independent living facilities, an apartment building, and a community center.

PARTICIPANTS

Adults 65 years of age or older who could ambulate independently and who were medically stable. Thirty-one adults, mean age 82.3 ± 5.6 years, were eligible to participate.

METHODS

The group exercise program was held twice a week for 12 weeks.

MAIN OUTCOME MEASUREMENTS

Acceptability of the program was determined by retention and adherence rates and a satisfaction survey. Risk was measured by adverse events and questions on perceived challenge and safety. Mobility was assessed pre- and postintervention by gait speed, Figure of 8 Walk Test, and 6-minute walk test.

RESULTS

Modifications to the program included adjustments to format/length, music, education, and group interaction. The 12-week program was completed by 24 of 31 entrants (77%). Adherence was high, with participants attending on average 83% of the classes. Safety was excellent, with only 1 subject experiencing a controlled, noninjurious fall. There was preliminary evidence for improved mobility after the intervention: gait speed improved from 0.76 ± 0.21 to 0.81 ± 0.22 m/s, P = .06; Figure of 8 Walk Test from 13.0 ± 3.9 to 12.0 ± 3.9 seconds, P = .07; and 6-minute walk test from 246 ± 75 to 281 ± 67 m, P = .02.

CONCLUSIONS

The group-based program was safe and acceptable to older adults with impaired mobility and resulted in potentially clinically meaningful improvements in mobility.

Combining Fast-Walking Training and a Step Activity Monitoring Program to Improve Daily Walking Activity After Stroke: A Preliminary Study

OBJECTIVES

To determine preliminary efficacy and to identify baseline characteristics predicting who would benefit most from fast walking training plus a step activity monitoring program (FAST+SAM) compared with fast walking training (FAST) alone in persons with chronic stroke.

DESIGN

Randomized controlled trial with blinded assessors.

SETTING

Outpatient clinical research laboratory.

PARTICIPANTS

Individuals (N=37) >6 months poststroke.

INTERVENTIONS

Subjects were assigned to either FAST, which was walking training at their fastest possible speed on the treadmill (30min) and overground 3 times per week for 12 weeks, or FAST+SAM. The step activity monitoring program consisted of daily step monitoring with an activity monitor, goal setting, and identification of barriers to activity and strategies to overcome barriers.

MAIN OUTCOME MEASURES

Daily step activity metrics (steps/day [SPD], time walking per day), walking speed, and 6-minute walk test (6MWT) distance.

RESULTS

There was a significant effect of time for both groups, with all outcomes improving from pre- to posttraining (all P values <.05). The FAST+SAM was superior to FAST for 6MWT (P=.018), with a larger increase in the FAST+SAM group. The interventions had differential effectiveness based on baseline step activity. Sequential moderated regression models demonstrated that for subjects with baseline levels of step activity and 6MWT distances that were below the mean, the FAST+SAM intervention was more effective than FAST (1715±1584 vs 254±933 SPD; P<.05 for overall model and ΔR(2) for SPD and 6MWT).

CONCLUSIONS

The addition of a step activity monitoring program to a fast walking training intervention may be most effective in persons with chronic stroke who have initial low levels of walking endurance and activity. Regardless of baseline performance, the FAST+SAM intervention was more effective for improving walking endurance.

The effects of Task-Oriented Motor Training on gait characteristics of patients with type 2 diabetes neuropathy

Background

It is known that general gait training improves lower extremity muscle strength and endurance in Diabetes Neuropathy (DN). But, it is still unknown whether Task-Oriented (TO) gait training would change gait biomechanics and the risk of falling in DN. TO gait training focuses on promoting timing and coordination of lower extremity movements through goal-directed practices with sufficient repetition.

Methods

A group of 14 patients with DN participated in a time-series study. All subjects participated in four sessions of assessments (Initial, Pre, Post and Follow-Up). Training was twice a week for 12 weeks. Vertical and horizontal Ground Reaction Forces (GRF), Time Get up and Go (TGUG) and Fall Efficacy Scale-International (FES-I) were evaluated. Gait training started with stepping patterns that progressively changed to complicated patterns of walking. Then, training continued combining walking patterns with upper extremity activities and then ended with treadmill-paced practice.

Results

DN patients significantly increased Second Vertical Peak Force and Horizontal Propulsive Force in addition decrease in Minimum Vertical Force. TGUG significantly decreased while FES-I reflected significant increase after gait training.

Discussion

Conclusively, training not only improved gait performance, confidence in daily activities and attenuated risk of falling, but also helped DN patients to improve feet biomechanics, muscles timing and coordination.

Conclusions

Gait training with respect to principles of motor learning allowed patients to effectively improve through sessions.

Sensory Enhancing Insoles Modify Gait during Inclined Treadmill Walking with Load

INTRODUCTION

Inclined walking while carrying a loaded backpack induces fatigue, which may destabilize gait and lead to injury. Stochastic resonance (SR) technology has been used to stabilize spatiotemporal gait characteristics of elderly individuals but has not been tested on healthy recreational athletes. Herein, we determined if sustained vigorous walking on an inclined surface while carrying a load destabilizes gait and if SR has a further effect.

METHODS

Participants were fitted with a backpack weighing 30% of their body weight and asked to walk at a constant self-selected pace while their feet were tracked using an optical motion capture system. Their shoes were fitted with SR insoles that were set at 90% of the participant's sensory threshold. The treadmill incline was increased every 5 min until volitional exhaustion after which the treadmill was returned to a level grade. SR stimulation was turned ON and OFF in a pairwise random fashion throughout the protocol. Spatiotemporal gait characteristics were calculated when SR was ON and OFF for the BASELINE period, the MAX perceived exertion period, and the POST period.

RESULTS

Vigorous activity increases variability in the rhythmic stepping (stride time and stride length) and balance control (double support time and stride width) mechanisms of gait. Overall, SR increased stride width variability by 9% before, during, and after a fatiguing exercise.

CONCLUSION

The increased stride time and stride length variability may compromise the stability of gait during and after vigorous walking. However, participants may compensate by increasing double support time and stride width variability to maintain their stability under these adverse conditions. Furthermore, applying SR resulted in an additional increase of stride width variability and may potentially improve balance before, during, and after adverse walking conditions.

Neuromotor training in older women living in long-term care setting: a pilot study

This pilot study identified the effect and the feasibility of neuromotor training in a group of ageing women living in a long-term care setting. Thirty-five older women (mean age, 84.18 years; SD = 5.92 years) participated in the study. Twenty women were in the intervention group, and 15 women were in the control group. Data on mobility, activities of daily living (ADL) and fear of falling were collected before and after the 16-week training period. The neuromotor training program was based on concepts from motor control and motor learning. All participants completed the training program, and no adverse events occurred. The intervention group showed steady and significant improvements in mobility, ADL and fear of falling after the intervention, but the control group did not exhibit significant changes. Moreover, mediation analysis demonstrated the role of mobility as a mediator between participation in physical training and fear of falling.

The Impact of a Portable Metabolic Measurement Device on Gait Characteristics of Older Adults With Mobility Limitations

BACKGROUND AND PURPOSE

Increased carriage loads have been found to alter gait biomechanics in young healthy adults and military personnel; however, less is known regarding the influence of added carriage load on the gait characteristics of older adults-especially those with mobility limitations. The purpose of this study was to examine spatial and temporal gait characteristics during instrumented and noninstrumented overground walking in a sample of older adults with slow gait.

METHODS

Forty older adults with slow gait completed 2 bouts of walking (instrumented and noninstrumented) over a computerized walkway during 1 clinic visit. Mean spatial-temporal characteristics, gait variability, and gait speed over 8 passes were recorded. Paired t tests and intraclass correlation coefficients were used to quantify differences.

RESULTS AND DISCUSSION

Nine of the 10 gait variables did not differ statistically between instrumented and noninstrumented gait (P < .05). Intraclass correlation coefficients (ICCs) for mean gait characteristics were excellent (range ICC = 0.94-0.98; 95% confidence interval = 0.89-0.99), and for gait variability ranged from fair to excellent (range ICC = 0.56-0.79; 95% confidence interval = 0.28-0.89). Our study was able to demonstrate no significant impact of instrumentation on gait characteristics in a sample of older adults with slow gait.

CONCLUSION

Our findings begin to fill in the gaps in the literature regarding the impact of added carriage loads on more vulnerable populations and lend support for the use of similar weighted metabolic devices as a component of gait assessment in older adults with confidence that the additional carriage-load will not significantly impact concurrent measures of gait.

Improving motor control in walking: a randomized clinical trial in older adults with subclinical walking difficulty

OBJECTIVE

To test the proposed mechanism of action of a task-specific motor learning intervention by examining its effect on measures of the motor control of gait.

DESIGN

Single-blinded randomized clinical trial.

SETTING

University research laboratory.

PARTICIPANTS

Adults (N=40) aged ≥65 years with gait speed >1.0m/s and impaired motor skill (figure-of-8 walk time >8s).

INTERVENTIONS

The 2 interventions included a task-oriented motor learning and a standard exercise program; both interventions included strength training. Both lasted 12 weeks, with twice-weekly, 1-hour, physical therapist-supervised sessions.

MAIN OUTCOME MEASURES

Two measures of the motor control of gait, gait variability and smoothness of walking, were assessed pre- and postintervention by assessors masked to the treatment arm.

RESULTS

Of 40 randomized subjects, 38 completed the trial (mean age ± SD, 77.1±6.0y). The motor learning group improved more than the standard group in double-support time variability (.13m/s vs .05m/s; adjusted difference [AD]=.006, P=.03). Smoothness of walking in the anteroposterior direction improved more in the motor learning than standard group for all conditions (usual: AD=.53, P=.05; narrow: AD=.56, P=.01; dual task: AD=.57, P=.04). Smoothness of walking in the vertical direction also improved more in the motor learning than standard group for the narrow-path (AD=.71, P=.01) and dual-task (AD=.89, P=.01) conditions.

CONCLUSIONS

Among older adults with subclinical walking difficulty, there is initial evidence that task-oriented motor learning exercise results in gains in the motor control of walking, while standard exercise does not. Task-oriented motor learning exercise is a promising intervention for improving timing and coordination deficits related to mobility difficulties in older adults, and needs to be evaluated in a definitive larger trial.

Aging, motor skill, and the energy cost of walking: implications for the prevention and treatment of mobility decline in older persons

BACKGROUND

Age-associated neural changes profoundly affect the biomechanics and energetics of walking, increase energy cost, and require novel approaches to exercise that focus on motor learning theory.

METHODS

We present a conceptual framework for motor skill in walking, its effect on the energy cost of walking, and the influence of the aging brain.

RESULTS

Motor learning theory and practice can be incorporated into interventions to promote skilled, energy efficient walking in older people.

CONCLUSIONS

An extensive literature on motor skill and motor learning, derived from neuroscience, sports medicine, and neurorehabilitation, can be applied to problems of walking in late life.

Callosal hyperintensities and gait speed gain from two types of mobility interventions in older adults

OBJECTIVE

To assess whether the volume of callosal hyperintensities in the genu and splenium of older adults with mobility impairment is differentially associated with the degree of gain in gait speed after 2 types of gait interventions.

DESIGN

Single-blind randomized controlled trial of 2 types of gait exercises in older adults.

SETTING

Research center in an academic institution.

PARTICIPANTS

Ambulatory adults (N=44) aged ≥65 years with a slow and variable gait.

INTERVENTION

Twelve-week physical therapist-guided trial of a conventional walking, endurance, balance, and strength (WEBS) intervention (n=20) versus a timing and coordination of gait (TC) intervention (n=22).

MAIN OUTCOME MEASURE

Gain in gait speed after the intervention and its relation to callosal hyperintensities in the genu and splenium of the corpus callosum.

RESULTS

Gait speed improved in both the WEBS group (mean change, 0.16m/s) and the TC group (mean change, 0.21m/s; both P<.05). The volume of white matter hypertintensities (WMHs) in the genu was differentially associated with gait speed gain (group × genual WMH interaction, P=.05). Greater genual WMH volume was related to a smaller gait speed gain in the WEBS group (P=.01) but not in the TC (P=.10) group. Splenial WMH volume was not differentially associated with gait speed gain (interaction, P=.90).

CONCLUSIONS

Callosal hyperintensities differentially influence gait speed gain by the type of gait rehabilitation. Mobility impaired older adults with genual hyperintensities may benefit from a rehabilitation program focused on motor skill learning rather than on strength and endurance training.

Walking energetics, fatigability, and fatigue in older adults: the study of energy and aging pilot

BACKGROUND

Slow gait speed increases morbidity and mortality in older adults. We examined how preferred gait speed is associated with energetic requirements of walking, fatigability, and fatigue.

METHODS

Older adults (n = 36, 70-89 years) were categorized as slow or fast walkers based on median 400-m gait speed. We measured VO2peak by graded treadmill exercise test and VO2 during 5-minute treadmill walking tests at standard (0.72 m/s) and preferred gait speeds. Fatigability was assessed with the Situational Fatigue Scale and the Borg rating of perceived exertion at the end of walking tests. Fatigue was assessed by questionnaire.

RESULTS

Preferred gait speed over 400 m (range: 0.75-1.58 m/s) averaged 1.34 m/s for fast walkers versus 1.05 m/s for slow walkers (p < .001). VO2peak was 26% lower (18.5 vs 25.1ml/kg/min, p = .001) in slow walkers than fast walkers. To walk at 0.72 m/s, slow walkers used a larger percentage of VO2peak (59% vs 42%, p < .001). To walk at preferred gait speed, slow walkers used more energy per unit distance (0.211 vs 0.186ml/kg/m, p = .047). Slow walkers reported higher rating of perceived exertion during walking and greater overall fatigability on the Situational Fatigue Scale, but no differences in fatigue.

CONCLUSIONS

Slow walking was associated with reduced aerobic capacity, greater energetic cost of walking, and greater fatigability. Interventions to improve aerobic capacity or decrease energetic cost of walking may prevent slowing of gait speed and promote mobility in older adults.

Submaximal oxygen cost during incremental exercise in children with developmental coordination disorder

There has been minimal evidence examining the differences in submaximal aerobic power between children with and without probable developmental coordination disorder (pDCD). This is important as most activities of daily living are performed at submaximal levels. The aim of this study was to examine the oxygen cost of work (VO2) performed during an incremental exercise protocol on a cycle ergometer. Subjects with pDCD (n=63) were matched for age and gender to 63 typically developing controls (12-13 years of age) using a nested case-control design. Motor coordination was assessed using the Movement Assessment Battery for Children. Children with pDCD had significantly lower VO2 peak values relative to controls (35.0 vs. 42.9 ml/kg/min, p<0.0001). At the submaximal level, mixed effects modeling demonstrated that, after controlling for relative body fat, and VO2 peak, children with pDCD had consistently greater oxygen cost (VO2 ml/kg/min) compared to controls at any given exercise intensity (p=0.0006). A significant interaction between pDCD and workload indicated that the difference in VO2 at higher workloads is greater than that at lower workloads (p=0.0004). Children with pDCD utilize more oxygen to sustain the same submaximal workload. The implication of these findings is that children with pDCD may experience earlier fatigue than well coordinated individuals when engaging in physical activity.

Interventions to Improve Walking in Older Adults

Interventions to improve walking in older adults have historically been multifactorial (i.e. strengthening, endurance and flexibility programs) focusing on improving the underlying impairments. These impairment-based programs have resulted in only modest improvements in walking. In older adults, walking is slow, less stable, inefficient, and the timing and coordination of stepping with postures and phases of gait is poor. We argue the timing and coordination problems are evidence of the loss of motor skill in walking. Taking a lesson from the sports world and from neurorehabilitation, task-oriented motor learning exercise is an essential component of training to improve motor skill and may be a beneficial approach to improving walking in older adults. In this article we: 1) briefly review the current literature regarding impairment-based interventions for improving mobility, 2) discuss why the results have been only modest, and 3) suggest an alternative approach to intervention (i.e. task oriented motor learning).

Motor learning versus standard walking exercise in older adults with subclinical gait dysfunction: a randomized clinical trial

OBJECTIVES

To compare the effect of motor learning with that of standard exercise on measures of mobility and perceived function and disability.

DESIGN

Single-blind randomized trial.

SETTING

University research center.

PARTICIPANTS

Older adults (n = 40) with a mean age of 77.1 ± 6.0, normal walking speed (≥ 1.0 m/s), and impaired motor skills (Figure of 8 walk time >8 seconds).

INTERVENTIONS

The motor learning program incorporated goal-oriented stepping and walking to promote timing and coordination within the phases of the gait cycle. The standard program employed endurance training by treadmill walking. Both included strength training and were offered twice weekly for 1 hour for 12 weeks.

MEASUREMENTS

Primary outcomes were mobility performance (gait efficiency, motor skill in walking, gait speed, walking endurance); secondary outcomes were perceived function and disability (Late-Life Function and Disability Instrument).

RESULTS

Thirty-eight of 40 participants completed the trial (motor learning, n = 18; standard, n = 20). The motor learning group improved more than the standard group in gait speed (0.13 vs 0.05 m/s, P = .008) and motor skill (-2.2 vs -0.89 seconds, P < .001). Both groups improved in walking endurance (28.3 and 22.9 m, P = .14). Changes in gait efficiency and perceived function and disability were not different between the groups (P > .10).

CONCLUSION

In older adults with subclinical gait dysfunction, motor learning exercise improved some parameters of mobility performance more than standard exercise.

The association between energy cost of walking and physical function in older adults

To assess the association between energy cost of walking and self-report of function, independent of comorbidity and gait speed, in older adults with mobility limitations. This cross-sectional observational study was conducted within an ambulatory clinical research training center. Forty-two older adults, age 65 and older, with slow and variable gait participated. Function was assessed using the Late Life Function and Disability Index-Basic Lower Extremity Subscale, while energy cost of walking was derived by standardizing the mean oxygen consumption recorded during physiological steady state by gait speed. Comorbidity and gait speed were collected as co-variates. Pearson's r correlation coefficient and regression analyses were used to assess the relationship between energy cost and function. Energy cost of walking was significantly correlated with self-reported function (Pearson's r=-0.50, p<0.001); furthermore, energy cost of walking explained an additional 17% (p=0.002) of the variance in self-reported function above and beyond the variance explained by comorbidity and gait speed combined. Energy cost of walking is emerging as another significant factor related to functional performance among older adults, even after controlling for comorbidity and gait speed - robust variables known for their strong contributions to function. Knowledge of and attention to the efficiency of how one moves (high energy cost of walking) may enhance rehabilitation efforts to further reduce "functional burden" in older adults.

A comprehensive assessment of gait accelerometry signals in time, frequency and time-frequency domains

Gait accelerometry is a promising tool to assess human walking and reveal deteriorating gait characteristics in patients and can be a rich source of clinically relevant information about functional declines in older adults. Therefore, in this paper, we present a comprehensive set of signal features that may be used to extract clinically valuable information from gait accelerometry signals. To achieve our goal, we collected tri-axial gait accelerometry signals from 35 adults 65 years of age and older. Fourteen subjects were healthy controls, 10 participants were diagnosed with Parkinson's disease, and 11 participants were diagnosed with peripheral neuropathy. The data were collected while the participants walked on a treadmill at a preferred walking speed. Accelerometer signal features in time, frequency and time-frequency domains were extracted. The results of our analysis showed that some of the extracted features were able to differentiate between healthy and clinical populations. Signal features in all three domains were able to emphasize variability among different groups, and also revealed valuable information about variability of the signals between anterior-posterior, mediolateral, and vertical directions within subjects. The current results imply that the proposed signal features can be valuable tools for the analysis of gait accelerometry data and should be utilized in future studies.

Walking smoothness is associated with self-reported function after accounting for gait speed

BACKGROUND

Gait speed has shown to be an indicator of functional status in older adults; however, there may be aspects of physical function not represented by speed but by the quality of movement. The purpose of this study was to determine the relations between walking smoothness, an indicator of the quality of movement based on trunk accelerations, and physical function.

METHODS

Thirty older adults (mean age, 77.7±5.1 years) participated. Usual gait speed was measured using an instrumented walkway. Walking smoothness was quantified by harmonic ratios derived from anteroposterior, vertical, and mediolateral trunk accelerations recorded during overground walking. Self-reported physical function was recorded using the function subscales of the Late-Life Function and Disability Instrument.

RESULTS

Anteroposterior smoothness was positively associated with all function components of the Late-Life Function and Disability Instrument, whereas mediolateral smoothness exhibited negative associations. Adjusting for gait speed, anteroposterior smoothness remained associated with the overall and lower extremity function subscales, whereas mediolateral smoothness remained associated with only the advanced lower extremity subscale.

CONCLUSION

These findings indicate that walking smoothness, particularly the smoothness of forward progression, represents aspects of the motor control of walking important for physical function not represented by gait speed alone.

White matter hyperintensities, exercise, and improvement in gait speed: does type of gait rehabilitation matter?

OBJECTIVES

To examine whether white matter hyperintensities (WMHs) on brain magnetic resonance imaging (MRI) in tracts in older adults with mobility impairment are linked to outcomes of gait rehabilitation interventions.

DESIGN

Twelve-week randomized controlled single-blind trial.

SETTING

University-based mobility research laboratory.

PARTICIPANTS

Ambulatory adults aged 65 and older with mobility impairment.

INTERVENTION

A conventional gait intervention focusing on walking, endurance, balance, and strength (WEBS, n = 21) and a task-oriented intervention focused on timing and coordination of gait (TC, n = 23).

MEASUREMENTS

Self-paced gait speed was measured over an instrumented walkway before and after the intervention, and WMH and brain volumes were quantified on preintervention brain MRI using an automated segmentation process. A white matter tract atlas was overlaid on the segmented images to measure tract WMH volumes, and WMH volumes were normalized to total brain volume. Aggregate WMH volumes in all white matter tracts and individual WMH volumes in specific longitudinal tracts (superior longitudinal fasciculus, inferior longitudinal fasciculus, and fronto-occipital fasciculus) and the cingulum were measured.

RESULTS

Gait speed gains in the TC group were of the same magnitude, independent of WMH volume measures in all except the cingulum, but in the WEBS group, gain in gait speed was smaller with greater overall tract WMH volumes (P < .001) and with greater WMH volume in the three longitudinal tracts (P < .001 to .02).

CONCLUSION

Gains in gait speed with two types of gait rehabilitation are associated with individual differences in WMHs. Task-oriented therapy that targets timing and coordination of gait may particularly benefit older adults with WMHs in brain tracts that influence gait and cognition.