Emily Gordon pushes intensely and deliberately on the armrests of her wheelchair as she begins to stand for her gait training session. With much effort and no assistance, she smiles with a sense of accomplishment as she comes to standing.  She is now ready to attempt walking. She takes four; uneven, cautious, shuffling steps and asks if she is done.  Does Emily exhibit ‘normal’ gait changes that occur with age?  It is important to know which gait changes are considered normal aging, what tests are available to examine these gait changes.  We will discuss this as well as what aspects of gait will be detrimental to the patient and what new treatment techniques exist in the rehabilitation milieu.  

The literature abounds with articles on gait changes that occur with age.  Older people consistently demonstrate reduced hip extension¹, knee extension², and a shorter stride length² during ambulation, which may affect walking performance.  These characteristics are present regardless of the persons risk for falls.  Researchers have found four alterations of gait in the elderly that contribute to falls.  They are increased hip flexion in stance, decreased hip extension, decreased knee swing in the pre-swing phase and decreased knee power absorption in the pre-swing phase³.  In older people that fall⁴, the characteristics of fallers versus non fallers is that they have slower speed, shorter step, narrow stride width, wide range of stepping frequencies, and a large variability of step length. 

The influence of lower extremity (LE) joint torque can also affect gait characteristics. In a study of elderly men, hip extension torque was found to be the only significant predictor of gait velocity⁵.  DeVita⁶ found that age causes a redistribution of joint torques and powers during gait.  Specifically, older people generate more hip torque than knee or ankle plantar flexors but the amount generated was still less than younger people.  Hausdorff⁷ noticed an increased gait unsteadiness in community dwelling elderly and found that fallers had more stride-to-stride temporal variance.  Older persons have less control of their momentum and they may be unable to control lateral momentum during gait⁸.  This could explain why older persons decrease their gait speed.  In a comparison of slow walking speeds in healthy young and elderly females, Gillis⁹ found that older persons’ cautiousness may be a feature of the gait that is not symptomatic of pathology but just a result of very slow walking speeds.  For example, if one tries to do an arm swing at a slow walking speed it either doesn’t happen or appears forced like a marching step.  At a faster speed, arm swing will come in naturally.  Cress¹⁰ studied the relationship between physical performance and self-perceived physical function and determined that gait speed was the strongest independent predictor of self-perceived physical function.

Gait speed is a useful indicator of activities of daily living (ADL) function.  So what is normal gait speed?  According to Potter¹¹, gait speeds of less than .25 m/second means that the person will be dependent in one or more ADLs whereas gait speeds of .35 to .55 m/second means the person will be independent in all ADLs.  Muscle strength and mobility are also predictive and related to gait speed according to Laukkanen¹².  The mean value of the 10-meter walking test for those aged 75 to 80 was 7.7 seconds.  Wolfson¹³ hypothesized that strength is a major factor in gait and found that there is a strong relationship between the qualities of gait as measured by stride length and walking speed and falls.  Specifically, he found that fallers had a stride length of .53 meters or less with a walking speed of .45 meters/second or less.  Bohannon¹⁴ determined walking speed reference values and correlations in older adults. He established that the comfortable gait speed for men was 94.3 to 200.1 centimeters per second while for women it was 71.3 to 188.4 centimeters per second.

 Turning as a part of walking is also an interesting phenomenon and should be looked at carefully.  Not only as a characteristic that changes with age but a powerful indicator of falling.  Elderly adults, age 65 or older with difficulty turning took more steps to make a turn, had no pivot and took more time to complete the turn than older persons without difficulty¹⁵.  When an unexpected turn must be made, older subjects had lower success in completing the turn as compared to younger subjects¹⁶. 

So what are some of the tests that can be used to assess gait.  An interesting test is whether the patient can walk and talk at the same time. This article^17-18 found 95% of residents who stopped to talk sustained a fall within the six-month follow-up. This is a good predictive tool for fall risk. Another good tool is the timed ‘Up and Go’. The subject is timed to rise from a chair; walk 3 meters; turn; walk back to the chair; and sit down. Fallers take 21.5 seconds to complete this test while Nonfallers only take 11.3 seconds^19-20. The GARS – Gait Abnormality Rating Scale²¹ has a short version and a long version. This tool is very descriptive regarding gait. If the person scores over an 18 on the long version they are at risk for falls or if they score an 8 on the short version they are at risk for falls.  This test also provides a precise description about the patient’s gait. The only drawback for this test is that it has not been validated for patients requiring the use of an assistive device, which eliminates a large portion of the geriatric population. 

Finally, let’s talk about treatment.  Mary Tinetti has conducted numerous studies on interventions to reduce the risk of falling among elderly people living in the community. Her multi-risk factor intervention²² resulted in a significant reduction in the risk of falling among older persons in the community and saved approximately $2000 per patient. This figure includes paying for the cost of the care and shows that the number of people who fell and did not receive the intervention was exponential as compared to those who did.  Her intervention program worked on gait, transfer training and progressive resistive exercises (PREs). Patients were seen on an average of 8 visits.

Campbell²³ developed a protocol, which is most likely the mainstay of many rehabilitation programs and validates physical therapists’ chosen interventions.  This program is shown below. Patients were required to perform the exercise protocol three times a week in addition to a home exercise program.

Hauer’s²⁴ exercise training program for patients with a history of injurious falls consisted of a 10 minute warm-up, PREs to the lower extremity 3X/wk (Hip abduction, extension, knee extension, plantarflexion), stepping forward, backward, balance challenges with ball throw, tai chi, chair sits, one-legged stance training, and progressive functional training. Nishimoto²⁵ increased gait performance in the elderly using a stepping exercise program.  Her very inventive step training program had patients go up and down steps 5 times, 5 times a day for 8 weeks. (See Figure)  Other suggestions include stretching¹ and strengthening⁴ exercises for the hip flexors to improve walking ability.

 The most innovative and easiest treatment technique was the one described by Hausdorff²⁶ in discussing the power of ageism on the physical function of older adults.  Reversibility of age related gait changes, exposure to either positive or negative reinforcement subconsciously resulted in a significant increase in walking speed and swing time.  In this randomized controlled study, older people were working at a computer while subliminally receiving either positive words or negative words. They tested both groups pre and post with a gait task and found that the group that received the positive comments did much better in their walking speed and swing time.  As we work with our patients it is important to remember to give positive reinforcement. The positive comments used during the study were ‘wise’, ‘astute’, and ‘accomplished’ while the negative comments were ‘senile’, ‘dependent’, and ‘diseased’. We wish all of you wise, astute, and accomplished therapists the best of luck improving the gait of your patients, like Emily Gordon.

References

1.        Kerrigan DC, Lee LW, Collins JJ, Riley PO, Lipsitz LA. “Reduced hip extension during walking: healthy elderly and fallers versus young adults.” Arch Phys Med Rehabil, 2001;82(1):26-30.

2.        Ostrosky KM, Van Swearingen JM, Burdett RE, Gee Z.  “A Comparison of Gait Characteristics in Young and Old Subjects.”  Phys Ther, 1994 Jul;74(7):637-646.

3.        Kerrigan DC “Kinetic alteration independent of walking speed in elderly fallers.” APMR, 2000 Jun;81(6):730-735.

4.        O’Brien K, Culham E, Pickles B.  “Balance and Skeletal Alignment in a Group of Elderly Female Fallers and Nonfallers.”  Journal of Gerontology: Biological Sciences, 1997; 52A(4): B221-B226.

5.        Burnfield JM, Josephson KR, Powers CM, Rubenstein LZ. “The influence of lower extremity joint torque on gait characteristics in elderly men.” Arch Phys Med Rehabil. 2000 Sept; 81:1153-1157.

6.        DeVita P, Hortobagyi T. “Age causes a redistribution of joint torques and powers during gait.” J Appl Physiol, 2000;88:1804-1811.

7.        Hausdorff JM, Edelberg HK, Mitchell SL, Goldberger AL, et al.  “Increased Gait Unsteadiness in Community-Dwelling Elderly Fallers.”  Arch Phys Med Rehabil, 1997 Mar;.78(3):278-283.

8.        Kaya BK, Krebs DE, Riley PO. “Dynamic Stability in Elders: Momentum Control in Locomotor ADL. “Journal of Gerontology: MEDICAL SCIENCES, 1998;53A(2): M126-M134.

9.        Gillis B, et al.  “Slow walking speeds in healthy young and elderly females.”  Physiotherapy Canada, 1986Nov-Dec;38(6):.

10.     Cress ME, et al.  “Relationship Between Physical Performance and Self-Perceived Physical Function.”  JAGS, 1995 Feb;43(2):93-101..

11.     Potter JM, et al.  “Gait Speed -and Activities of Daily Living Function in Geriatric Patients.”  Arch Phys Med Rehabil, 1995 Nov;76(11):997-999.

12.     Laukkanen P, et al.  “Muscle Strength and Mobility as Predictors of Survival in 75-84-Year-old People.”  Age and Ageing, 1995 Nov;24(6):468-473.

13.     Wolfson L, Whipple R, Amerman P, Tobin JN.  “Gait Assessment in the Elderly:  A Gait Abnormality Rating Scale and Its Relation to Falls.”  Journal of Gerontology:  Medical Sciences, 1980;45(1):M12-19.

14.     Bohannon RW, et al.  “Walking Speed: Reference Values and Correlates for Older Adults.”  JOSPT, 1996 Aug;24(2):86-90.

15.     Thigpen MT, Light KE, Creel GL, Flynn SM. “Turning difficulty characteristics of adults aged 65 years or older.” PT, 2000 Dec;80(12):1174-1187.

16.     Cao C, Ashton-Miller JA, Schultz AB, Alexander NB.  “Abilities to Turn Suddenly While Walking: Effects of Age, Gender, and Available Response Time.”  Journal of Gerontology: MEDICAL SCIENCES, 1997;52A(2): M88-M93.

17.     Lundin-Olsson L, Nyberg L, Gustafson Y.  “’Stops walking when talking’ as a predictor of falls in elderly people.”  Lancet, 1997 Mar;349(9052):617.

18.     Lundin-Olsson L, Nyberg L, Gustafson Y.  “The Mobility Interaction Fall chart” Physiother Res Int, 2000; 5(3):190-201.

19.     Mathias S, Nayak USL, Isaacs B. “Balance in elderly patients: the ‘Get Up and Go’ test.” APMR, 1986;67:387-389.

20.     Podsiadlo D, Richardson S. “The timed’Up and Go’: a test of basic functional mobility for frail elderly persons.” JAGS, 1991 Feb;39(2):142-148.

21.     Wolfson L, Whipple R, Amerman P, Tobin JN. “Gait Assessment in the elderly: A Gait Abnormality Rating Scale and Its Relation to Falls.” Journal of Gerontology,1990;45(1):M12-19.

22.     Tinetti ME, et al.  “A Multifactorial Intervention to Reduce the Risk of Falling Among Elderly People Living in the Community.”  N Engl J Med, 1994 Sept 29;331(13):821-827.

23.     Campbell AJ, Robertson C, Gardner M, Norton R, Buchner D.  “Falls Prevention over 2 Years: A Randomized Controlled Trial in Women 80 Years and Older.”  Age and Aging, 1999;28: 513-518.

24.     Hauer K, Rost B, Rutschle K, Opitz H, Specht N, Bartsch P, Oster P, Schlierf G. “Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls.” JAGS. 2001;49:10-20.

25.     Nishimoto K, Nakamura S, Imai T et al.  “Increasing Gait Performance in Elderly Women Using a Step Exercise Training Program.”  J Phys Ther Sci, 1999; 11: 71-8.

26.     Hausdorff J, Levy B, Wei J.  “The Power of Ageism on Physical Function of Older Persons Reversibility of Age-Related Gait Changes.”  JAGS, 1999;47(11): 1346-1349.