Improving Motor Control in Walking: A Randomized Clinical Trial in Older Adults With Subclinical Walking Difficulty

doi:10.1016/j.apmr.2014.10.018

Archives of Physical Medicine and Rehabilitation

Volume 96, Issue 3, March 2015, Pages 388-394

Presented in part to the American Physical Therapy Association, January 22, 2013, San Diego, CA.

https://doi.org/10.1016/j.apmr.2014.10.018 Get rights and content

Abstract

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.

Section snippets

Overview

The study protocol was approved by the University of Pittsburgh Institutional Review Board, and all subjects provided informed consent. The study was registered at ClinicalTrials.gov (PRO09080228). The Program to Improve Mobility in the Elderly (PRIME study) was a 12-week, single-blind randomized clinical trial that compared 2 exercise interventions in older adults with subclinical gait dysfunction. Details of the methods and the main study outcomes have been published elsewhere.⁷

Participants and inclusion criteria

Briefly, the

Results

Of 110 people initially screened by telephone, 64 underwent on-site screening. Forty-one participants met all criteria, and 40 were randomized (1 subject deferred); 38 of these individuals completed the study.⁷ All 38 completers participated in at least 22 exercise sessions, with 37 participants (97%) completing all 24 sessions. The 2 dropouts developed unrelated medical conditions and walked more slowly than those who completed the study. Participants had a mean age of 77.1 years, near-normal

Discussion

Older adults with normal gait speed and subclinical gait deficits who participated in a task-oriented motor learning exercise program demonstrated greater improvements in some indicators of the motor control of walking than those who participated in a standard impairment-based exercise program. Individuals in the motor learning program had greater improvements in 1 measure of gait variability (double-support time variability) and smoothness of walking (HR_AP and HR_V during narrow and dual-task

Conclusions

Suppliers

a.
SAS Institute Inc.
b.
Magnum Fitness Systems.
c.
EQ, Inc.
d.
BIOPAC Systems, Inc.

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Prevalence and Predictors of Ambulatory Care Physicians’ Documentation of Mobility Limitations in Older Adults
2023, Archives of Physical Medicine and Rehabilitation
To determine how often physicians document mobility limitations in visits with older adults, and which patient, physician, and practice characteristics associate with documented mobility limitations.
We completed a cross-sectional analysis of National Ambulatory Medical Care Surveys, years 2012-2016. Multivariate analyses were conducted to identify patient, physician, and practice-level factors associated with mobility limitation documentation.
Ambulatory care visits.
We analyzed visits with adults 65 years and older. Final sample size represented 1.3 billion weighted visits.
Not applicable.
We defined the presence/absence of a mobility limitation by whether any International Classification of Diseases (ICD)-9 or ICD-10 code related to mobility limitations, injury codes, or the patient's “reasons for visit” were documented in the visits.
The overall prevalence of mobility limitation documentation was 2.4%. The most common codes were falls-related. Patient-level factors more likely to be associated with mobility limitation documentation were visits by individuals over 85 years of age, relative to 65-69 years, (odds ratio 2.32, 95% confidence interval 1.76-3.07]; with a comorbid diagnosis of arthritis (odds ratio 1.35, 1.18-2.01); and with a comorbid diagnosis of cerebrovascular disease (odds ratio 1.60, 1.13-2.26). Patient-level factors less likely to be associated with mobility limitation documentation were visits by men (odds ratio 0.80, 0.64-0.99); individuals with a cancer diagnosis (odds ratio 0.76, 0.58-0.99); and by individuals seeking care for a chronic problem (relative to a new problem [odds ratio 0.36, 0.29-0.44]). Physician-level factors associated with an increased likelihood of mobility limitation documentation were visits to neurologists (odds ratios 4.48, 2.41-8.32) and orthopedists (odds ratio 2.67, 1.49-4.79) compared with primary care physicians. At the practice-level, mobility documentation varied based on the percentage of practice revenue from Medicare.
Mobility limitations are under-documented and may be primarily captured when changes in function are overt.
Program to improve mobility in aging (PRIMA) study: Methods and rationale of a task-oriented motor learning exercise program
2020, Contemporary Clinical Trials
Citation Excerpt :
Conceptually, the exercise is intended to achieve its effects by shifting the center of pressure posterior-lateral then forward, encouraging hip extension prior to stepping, loading the trailing limb, coordinating activation of the abductors of the soon to be swing leg with adductors of the stance limb, and shifting the center of pressure in medial stance to unload the stepping limb. Progression is based on first separately increasing the speed, amplitude or accuracy of performance prior to undertaking a more complex task [12,13,18,20]. For example, the progression of stepping patterns is, 1) self-paced step forward and across, 2) increase stepping speed, 3) alternate side of stepping, and 4) alternate forward with backward stepping.
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.
The reliability and validity of the Figure of 8 Walk test in older people with knee replacement: does the setting have an impact?
2019, Physiotherapy (United Kingdom)
Citation Excerpt :
By only reporting time to complete the F8W, essential higher level aspects of gait in an elderly population may have been overlooked with undue emphasis placed on cognitive processing speed and less on overall stability and susceptibility to falling. Thus inclusion of the accuracy component of the F8W may be more important for populations with more frailty and may have clinical relevance particularly in identifying subtle problems with performance, for example during dual activities where the additional challenge of balancing speed with accuracy may bring out performance deficits [27]. To reduce the burden and time commitment for study participant’s different groups of participants were assessed either at home or in clinic.
To determine the reliability and validity of the Figure of 8 Walk test (F8W) for older people after knee replacement surgery in the home setting.
Observational repeated measures.
A specialist orthopaedic hospital and participants homes.
Seventy-four older adults aged over 55 years one year following knee replacement surgery participated in two assessments more than one week apart.
The time to complete, steps, boundary limits and smoothness score from the Figure of 8 Walk test (F8W), the time to complete the Timed Up and Go (TUG) test and the time to complete the Timed Walk Test (TWT).
Overall, on 95% of occasions, the difference between the measurements for intra-rater reliability were within 1.8 second of the two test times. The difference between the measurements for inter-rater reliability were found to be narrower than for intra-rater reliability with scores within 1.2 second overall on 95% of occasions. The time to perform the F8W was highly correlated to the Timed Up and Go (overall sample r = 0.921) and the variability spread within narrow limits (−0.8 to 0.8 z-scores). This was also true for the Timed Walk Test (overall sample r = 0.834) with a narrow limit of variability on almost all of the observations (−1.16 to 1.16 z-scores).
The F8W test has good reliability and validity when used in either a clinical or home setting for patients around one year following knee replacement surgery.
Spatiotemporal variability underlying skill in curved-path walking
2019, Gait and Posture
Daily life walking frequently involves curved paths. While mean gait characteristics and orientation of the body during curved path walking have been described, little has been reported about spatiotemporal variability during curved path walking and its relation to the motor skill of walking in older adults.
Among community-dwelling older adults, is greater spatiotemporal variability during curved path walking related to better curved path walking ability?
Community dwelling older adults (n = 34) completed the Figure-of-8 Walk Test (F8W, a measure of curved path walking ability) and usual straight path walking on an instrumented walkway. Standard deviations for step length, stride width and step time (step length variability, SLV, stride width variability, SWV, step time variability, STV) during both conditions were determined, along with time and number of steps to complete F8W. Associations were examined with Pearson r correlation coefficients, regressions determined contributions of variability during curved path walking to F8W performance, and AUC analyses were used to determine the ability of variability during curved path walking to distinguish better vs poorer F8W performance.
F8W time and steps were negatively associated with both SLV (r’s = −0.37, p < 0.05) and SWV (r’s = −0.67 to −0.82, p < 0.001). Both SLV and SWV independently contributed to F8W performance (SLV βs = −0.26 to −0.29, p < 0.03; SWV βs = −0.74 to −0.76, p < 0.001). The AUC of the ROC curve for SLV was 0.716, and for SWV was 0.765.
Greater spatial variability, particularly SWV, was associated with better motor skill of curved path walking. It is important for clinicians to understand the variables that contribute to successful performance of complex walking tasks as these can be targets for rehabilitation. The findings suggest that practice of adjustment of stride width and step length during walking are important.
Energy Impairments in Older Adults With Low Back Pain and Radiculopathy: A Matched Case-Control Study
2018, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
However, mobility deficits often persist even after pain is effectively managed. Fortunately, prior work has shown that there are effective rehabilitation strategies, such as exercises that focus on the timing and coordination of walking, that improve the energy efficiency of walking among older adults.24 Second, clinicians should consider optimizing chronic disease management to help reduce, or prevent rise in, the energy cost of walking.
To investigate the impact that the presence of chronic low back pain with radiculopathy (CLBPR) may have on (1) energy efficiency and (2) energy capacity among community-dwelling older adults.
Matched case-control study.
Clinical research laboratory.
Included in the analysis were community-dwelling older adults (N=38, 60-85 years) with and without CLBPR. Participants were matched between-groups on age (±5 years), sex, and diabetic status.
Not applicable.
Energy cost of walking at self-selected speed (ie, energy efficiency) and peak volume of oxygen consumed (ie, energy capacity).
Older adults with CLBPR had a higher energy cost of walking at self-selected speed (P=.009) and lower peak volume of oxygen consumed while walking (P=.050), compared to those without pain.
Older adults with CLBPR may benefit from specific rehabilitative interventions that target these potentially modifiable energetic outcomes, thereby reducing the risk of mobility decline. Future studies should identify which mechanisms specifically contribute to diminished energy efficiency and capacity among older adults with CLBPR.
Altered spatiotemporal characteristics of gait in older adults with chronic low back pain
2017, Gait and Posture
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.

View all citing articles on Scopus

: Supported by the Pittsburgh Older Americans Independence Center (grant no. NIA P30 AG024827) and the Beeson Career Development Award (grant no. NIA K23 AG026766).

: Clinical Trials Registration No.: PRO09080228.

: Disclosures: S.P. reports grants from InRange Systems, Inc, during the conduct of the study. The other authors have nothing to disclose.

View full text

Original articleImproving Motor Control in Walking: A Randomized Clinical Trial in Older Adults With Subclinical Walking Difficulty

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Overview

Participants and inclusion criteria

Results

Discussion

Conclusions

Suppliers

Arch Phys Med Rehabil

J Psychiatr Res

Hum Mov Sci

Arch Phys Med Rehabil

Trends Neurosci

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Biomech

Gait Posture

Gait Posture

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Gait Posture

J Biomech

Neurosci Res

Effects of a physical activity intervention on measures of physical performance: results of the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) study

J Gerontol A Biol Sci Med Sci

Exercise training and nutritional supplementation for physical frailty in very elderly people

N Engl J Med

High intensity strength training in nonagenarians. Effects on skeletal muscle

JAMA

Effects of a low intensity exercise program on selected physical performance characteristics of 60- to 71-year olds

Aging (Milano)

Exercise to improve gait velocity in older persons

Arch Phys Med Rehabil

Efficacy of resistance and task-specific exercise in older adults who modify tasks of everyday life

J Gerontol A Biol Sci Med Sci

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

J Am Geriatr Soc

Interventions to improve walking in older adults

Curr Transl Geriatr Exp Gerontol Rep

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

J Gerontol A Biol Sci Med Sci

Exercise to improve gait efficiency: impact on activity and participation in older adults with mobility limitations

Phys Ther

Walking skill can be assessed in older adults: validity of figure-of-8 walk test

Phys Ther

A comparison of straight- and curved-path walking tests among mobility-limited older adults

J Gerontol A Biol Sci Med Sci

Curved path walking predicts 12-month physical function in older adults without mobility limited physical function

J Am Geriatr Soc

Original article
Improving Motor Control in Walking: A Randomized Clinical Trial in Older Adults With Subclinical Walking Difficulty