Gait Assessment & Implications in Geriatric Rehabilitation Therapy Network Seminars, Inc. Nicole Dawson, PT, PhD, GCS Learning Objectives Following completion of this webinar, participants will be able to: Identify normative age related changes in posture and gait Identify functional implications of age related changes in association with functional ambulation Identify multiple assessment tools to examine gait and functional mobility in the older adult patient Identify which assessment tool is ideal for a given patient presentation NORMATIVE AGE- RELATED CHANGES IN POSTURE & GAIT
STATIC POSTURE Increased kyphosis in relaxed and erect posture (Hinman, 2004; Kuo et al., 2009; Singh et al., 2010) Can lead to decreased cervical ROM (Quek et al., 2013) Forward head posture (Kuo et al., 2009) Increased lower cervical flexion Increased upper cervical extension Decreased lumbar flexion (Kuo et al., 2009) FORWARD HEAD & KYPHOSIS FUNCTIONAL IMPLICATIONS Sit to Stand transfer (Kuo et al., 2010) Downward head tilt at lift off Decreased lumbar ROM Large variation between participants Older adults with increased kyphosis had walking disabilities (Hirose et al., 2004) Shorter stride, longer step width Slower speed
POSTURAL CONTROL Center of pressure displacement increased in movement (Huang & Brown, 2013) Worsens with addition of cognitive task (Huxhold et al., 2006) Longer time to return to stable recovery (Kilby et al., 2014) Relationship found with ankle ROM and toe flexor strength (Spink et al., 2011) FUNCTIONAL IMPLICATIONS Older adults use more trunk on pelvis rotation when turning (Baird & Van Emmerik, 2009) Also moved feet more than younger adults Center of mass more anterior at start of forward reaching task (Lin & Liao, 2011) Smaller displacement and greater hip flexion Did not differ in maximum reach distance CHANGES IN GAIT Reduction in speed and stride length (Hollman et al., 2011; Ko et al., 2012; Salzman et al., 2010) Increased stance width with more double support Forward posture Less force at toe off Pelvic rotations and flexion/extension reduced (Van Emmerik et al., 2005) Most gait disorders are multifactorial Pain, cardiopulmonary issues, strength, flexibility, sensory impairment, fatigue Importance of knee extensor strength (Ko et al., 2012) Cognitive performance related to gait speed and stride length (Holtzer et al., 2012)
GAIT CYCLE Forward posture & less trunk movements Increased gait variability Importance of knee extensor strength More double support time Decreased stride length & slower speed Less force at toe off GAIT & COGNITION Cognitive performance related to gait speed and stride length (Holtzer et al., 2012) Executive function related to gait parameters (Ijmker & Lamoth, 2012; Martin et al., 2012) Processing speed associated with variability in gait parameters (Martin et al., 2012) Association between stride variability and lower gray matter volume (Beauchet et al., 2014) FUNCTIONAL IMPLICATIONS Falls (Verghese et al., 2009) Slower gait speed Increased double support time Stride length variability Gait speed needs to be adequate for completion of functional tasks (Fritz & Lusardi, 2009) Multi tasking during walking tasks
ASSISTIVE DEVICE USE Most commonly used assistive device is straight cane 70% use cane; 30% use walker USE OF MOBILITY DEVICES LaPlante & Kaye, 2013 Adults older than 65 years old, prevalence of assistive device use 146.5 per 1,000 EXERCISE & TRAINING Physical Therapy (12 weeks) Improved confidence in walking, gait speed, and total physical function (VanSwearingen et al., 2011) Multi component exercise interventions are best strategy to improve gait ability (Cadore et al., 2013) Strength, endurance, balance, flexibility
CLINICAL IMPLICATIONS Importance of holistic examination History, medications, physical examination, physical performance testing, environmental assessment Understanding age related normative changes in posture and gait Approach to plan of care and intervention development Assist with various compensatory strategies Inter and intra individual differences ASSESSMENT TOOLS Gait & Functional Mobility International Classification of Functioning, Disability and Health
Functional Assessments Use of evidence based practice Guides further evaluation Use ICF model to assist Provides standardized baseline assessments Better justifies skilled need for reimbursement Allows objective tracking of progress More familiar to patient Usually easier to perform Which one should I use? Match assessment to desired outcome Level of patient Environmental considerations Responsiveness to change Minimal detectable change (MDC) Psychometric properties of assessment tool Validity Reliability Sensitivity and specificity Gait Speed Single best predictor of decline in health and function < 1.0 meter/second predicts functional limitations, hospitalization, and death (Cesari et al., 2005) Norms similar over 8 and 20 foot distance (Bohannon, 2008) Other parameters Rhythm Cadence Step Stride
Gait Speed Multiple assessments to measure gait speed, depends on availability of space 10 meter walk test 20 feet walk test 8 foot walk test Best to allow room for acceleration and deceleration if possible 10-Meter Walk Test Layout of 10 meter walk test: the bold line indicates timed portion of test, while dotted lines indicate areas of acceleration and deceleration that are not timed (Steffen et al., 2002). Category, Years GAIT SPEED Comfortable Gait Speed in m/s (SD) Maximum Gait Speed in m/s (SD) Men 20 29 1.39 (0.15) 2.53 (0.29) Women 20 29 1.41 (0.18) 2.47 (0.25) Men 30 39 1.46 (0.09) 2.46 (0.32) Women 30 39 1.42 (0.13) 2.34 (0.34) Men 40 49 1.46 (0.16) 2.12 (0.28) Women 40 49 1.39 (0.16) 2.12 (0.28) Men 50 59 1.39 (0.23) 2.07 (0.45) Women 50 59 1.40 (0.15) 2.01 (0.26) Men 60 69 1.36 (0.21) 1.93 (0.63) Women 60 69 1.30 (0.21) 1.77 (0.25) Men 70 79 1.33 (0.20) 2.08 (0.36) Women 70 79 1.27 (0.21) 1.75 (0.28) Bohannon, 1997
Comfortable Gait Speed Lusardi, 2003 Fast Gait Speed Lusardi, 2003 Gait Speed Function 1.2 1.4 m/s considered normal function <0.6 m/s: dependent in ADL/IADLs, more likely to be hospitalized <1.0 m/s: increased risk for falls <0.15 m/s: more likely to D/C to SNF Functional category <0.4 m/s: household walker 0.4 0.8 m/s: limited community ambulation 0.8 1.25 m/s: community ambulation >1.25 m/s: crossing streets, normal ambulation Fritz & Lusardi, 2009
MDC in Gait Speed Diverse population of older adults (Fritz & Lusardi, 2009) 0.5 m/s Stroke (Fulk & Echtemach, 2008) 0.30 m/s Alzheimer s disease (Ries et al., 2009) 0.094 m/s Parkinson s disease (Steffen & Seney, 2008) Comfortable speed: 0.18 m/s Fast speed: 0.25 m/s After hip fracture (Palombaro et al., 2006) Habitual speed: 0.08 m/s Fast speed: 0.10 m/s Functional Mobility Timed Up & Go (TUG) Quick, easy to perform Correlates with Berg Balance Scale, gait speed, and Barthel Index Tinetti Gait & Balance Scale Dynamic Gait Index Timed Up-and-Go Test Equipment Straight back chair, masking tape, stopwatch Set up Identify line on floor 10 feet away from chair Participant may use assistive device if needed Procedure On go, stand up from chair Walk to line on floor at normal pace then turn around Walk back to chair at normal pace and sit down Scoring Begin time on go and stop timing upon full sitting position
Timed Up-and-Go Test Timed Up-and-Go Test Age related norms for TUG performance (Bohannon, 2008) 60 99 years: 9.4 seconds 60 69 years: 8.1 seconds 70 79 years: 9.2 seconds 80 99 years: 11.3 seconds Relative reliability between 3 test sessions (Nordin et al., 2006) Inter rater: 0.91; Intra rater: 0.92 Results should exceed boundaries of expected variability to be interpreted as true change TUG Expected Variability Nordin et al., 2006 Observed value, seconds Lower bound, seconds Single Measure Upper bound, seconds Lower bound, seconds Repeated Measure Upper bound, seconds 10 7.4 13.5 6.6 15.2 20 14.8 27.0 13.2 30.3 30 22.2 40.5 19.8 45.5 40 29.6 54.0 26.4 60.6 50 37.0 67.5 33.0 75.8 60 44.4 81.0 39.6 91.0 70 51.8 94.5 46.2 106.1 80 59.2 108.1 52.7 121.3 90 66.6 121.6 59.4 136.5 100 74.0 135.1 65.9 151.6
TUG scoring Mobility (Podsiadlo & Richardson, 1991) <10 seconds: freely mobile <20 seconds: mostly independent 20 29 seconds: variable mobility >30 seconds: impaired mobility Cut off score of 14 seconds identifies fall risk (Shumway Cook et al., 2000) 87% sensitivity 87% specificity Tinetti Gait & Balance Scale Had lower rates of refusal and inability to complete than the One leg Stance Test and Functional Reach (Lin et al., 2008) Higher risk for ceiling effects than floor effects (Faber et al., 2006) Good reliability and validity noted (Faber et al., 2006; Lin et al., 2008) Retest reliability ranged from 0.72 to 0.86 Inter rater reliability range from 0.80 to 0.93 Moderately correlated with TUG test (r= 0.55) and ADL scale (r=0.60) Significantly predicted the occurrence of falls and changes in ADL function (Faber et al., 2006; Lin et al., 2008) Tinetti Gait & Balance Scale Consists of 16 items with 2 or 3 point scale 8 balance & 8 gaits Score ranges from 0 to 28 with higher score better Maximum score of 12 on balance items Maximum score of 16 on gait items MDC value of 4.0 to 4.2 (Faber et al., 2006)
Tinetti Gait & Balance Scale Balance Section Gait Section Sitting balance Rises from chair Attempts to rise Immediate standing balance Standing balance Nudged Eyes closed Turning 360 degrees Sitting down Initiation of gait Step length and height Foot clearance Step symmetry Step continuity Path Trunk Walking time Tinetti Gait & Balance Scale Total Balance Gait Mean (SD: non fallers) 20.8 (5.5) 11.1 (3.8) 9.7 (2.4) Mean (SD: fallers) 17.4 (5.5) 9.2 (3.6) 8.3 (2.7) Suggested cut off 19 10 9 Sensitivity 64% 64% 64% Specificity 66.1% 66.1% 62.5% Faber et al., 2006
Dynamic Gait Index 8 common gait tasks to measure balance and functional mobility (Shumway Cook, 1995) Equipment: shoebox, 2 cones, stairs with rails Score range 0 24 with high scores indicating more independence Cut off score 19 to predict fall risk (sensitivity 59%, specificity 64%: Shumway Cook et al., 1997) Reliability scores have varied in studies from 0.63 to 1.00 (Hayes & Johnson, 2003) Moderately correlated with Berg Balance (r=0.53) & TUG (r= 0.42: Herman et al., 2009) Dynamic Gait Index Gait level surface Change in gait speed Gait with horizontal head turns Gait with vertical head turns Gait and pivot turn Step over obstacles Step around obstacles Steps Dynamic Gait Index Age in years Mean (SD) 20 29 24 (0.2) 30 39 24 (0.2) 40 49 23.9 (0.4) 50 59 23.9 (0.4) 60 69 23.2 (0.9) 70 79 22.0 (2.0) Vereeck et al.,2008
GAITRite System Evaluation & Documentation Make objective Use actual scores with interpretation of scores in evaluation Connect objective scores with functional or activity limitations Body functions and structures Strength Balance ROM & Flexibility Identify need for skilled therapy based on findings Connect functional or activity limitations with participation restrictions Role level (e.g., work, leisure, social) Goal Writing Specific Measurable Attainable Realistic Timely
THANK YOU! QUESTIONS? email: nicole.dawson@ucf.edu