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CHAPTER 17 Ambulation: Impact of Age-Related Changes on Functional Mobility patients tolerance for therapy or alter movement strategies. The reader is directed toward the in-depth discussion in Chapter 4, Geriatric Pharmacology. Physical therapy tests and measures for an older adult with mobility issues would include a thorough assessment of ROM, strength, motor control and coordination, somatosensation and proprioception, and functional mobility (bed mobility and transfers). Observational gait analysis (OGA) is a reasonable place to initiate a gait assessment, but cannot be considered the sole test of gait within an examination. Although the reliability of observational gait analysis is poor,85 it is very commonly used in the clinic. Its usefulness is to give the clinician a starting point to make some general observations about an individuals gait. It can be done without interrupting the ow of other parts of the examination, such as when the patient walks from the door back to the living room after letting the home care therapist into the house, or from the bed to the bathroom in the inpatient environment, or when the patient enters the outpatient clinic. The therapist can make general observations about speed, symmetry, stability, and efciency of gait. The observations made during OGA, including any specic gait deviations, will help direct the appropriate selection of more objective outcome measures. There are many gait-specic outcome measures from which to choose, and the clinician should have a reasonable rationale for selecting and combining specic measures. Commonly used gait outcome assessment tools include gait speed, timed up and go (TUG), 6-minute walk test (6MW), modied gait abnormality rating scale (GARS-M), performance oriented mobility assessment (POMA), functional ambulation categories (FAC), and dynamic gait index (DGI).

Stair Negotiation
Successful stair negotiation requires greater ROM (hip and knee exion, ankle dorsiexion) and muscle strength (extensors of the lower extremity working concentrically in ascent and eccentrically in descent) than level ground walking. Individuals may identify difculty with ascent or descent or both.78 Speed for ascending stairs in older adults correlates with strength and power of the lower extremity extensors.79-81 Self-efcacy on stairs relates to speed and safety precautions undertaken (e.g., use of rails).81,82 Because stairs are one of the most common environmental obstacles that are encountered both at home and in the community, it is important to consider the prerequisite actions and tasks needed for this activity and prioritize stair training within the plan of care.

EXAMINATION AND EVALUATION OF GAIT

A comprehensive examination of gait will include gathering a patient history, reviewing all pertinent systems, and carrying out appropriate tests and measures83 related to ambulation. A thorough gait assessment has signicant redundancy with balance assessment, and the reader is directed to Chapter 18, Balance and Falls for complementary content. A survey or interview of a patients perception of difculty with walking is a reasonable component of the physical therapy examination; however, it has been noted that patients frequently underreport gait difculties.84 Goals related to gait activities are pivotal in planning an intervention, as the intervention strategies will need to demonstrate specicity to goals. Prior level of function, and the duration of that level, is a key factor to appropriate intervention selection in a rehabilitation program. If an older adult was nonambulatory prior to admission to an inpatient setting, it is important to quantify the duration of this nonambulatory status (i.e., days, weeks, months, or years) as this information will signicantly affect the goal setting for the rehabilitation program. An individual who has only recently stopped walking due to acuity of illness or a progressive condition that is now being medically managed might return to prior level of functioning very quickly. A careful evaluation of patient potential and an individualized plan of care might even lead to an individual exceeding their previous level of function. Individuals whose ambulation disability is long-standing (e.g., months or even years) are also deserving of careful evaluation even if the preexisting nonambulatory status might not be completely reversible. Careful review of comorbidities and medications is another important component of the patient history. Some musculoskeletal and neurologic diagnoses affect gait in fairly predictable ways as previously noted. Many medications have systemic side effects that can affect a

Gait Speed
Using a timed walk of a specic distance is an easy, reliable, and efcient way to procure an objective measure of gait performance. The strong psychometric properties of walking speed, the clinical usefulness, and the potential modiability of this measure have led to its identication as a functional vital sign86 in the assessment of older adults. Self-selected or comfortable gait speed tends to be the most individually efcient gait speed.87 It is often useful to collect both self-selected and fast gait speed capabilities, as there are environmental challenges that sometimes demand increased gait speeds (e.g., crossing streets). Collection of gait speed data is feasible and useful even in the home care environment88 and can be collected using a 2.4-m (8-foot) versus 6-m (20-foot) walkway if necessary.14 Gait speed can be assessed with sophisticated equipment (e.g., portable computerized walkways, two- or three-dimensional motion analysis systems, triaxial accelerometer), but can be just as reliably assessed with a measured course and a stopwatch. The suggested method

CHAPTER 17 Ambulation: Impact of Age-Related Changes on Functional Mobility

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of data collection is a 20-m pathway, where the central 10 m are marked for timed testing.86 This allows for appropriate acceleration and deceleration outside of the timed walking course, such that the measured distance represents a steady state of speed. In a typical clinical environment, a 20-m uninterrupted walkway may be unrealistic. Published protocols for gait speed calculation span distances from 2.4 m to total 6-minute walk distances, and many values in between.89 Reliability of comfortable gait speed as assessed with a stopwatch and measured path has been consistently determined to be excellent, with repeated measure reliability intraclass correlations (ICCs) reported as 0.903 and 0.9790,91 in representative studies. Table 17-3 represents comfortable or self-selected gait speed norms of community-dwelling older adults by decade as presented by Bohannon,14 Lusardi et al,77 and Steffen et al.91 Bohannon presented the retrospective data of 1923 subjects performance on a 6-m measured walk, timed with a stopwatch. Lusardi et al presented the data of 76 subjects using a 3.7-m GaitRite walkway.77 Steffen et al studied 96 subjects using a stopwatch to measure the time to traverse the central 6 m of a 10-m walkway.91 These subjects were all healthy, independently living, self-reliant older adults. The differences in norms in Table 17-3 may be explained to some extent by methodological differences in the studies cited. Steffen et al, who reported the fastest self-selected gait speeds, had the most stringent inclusion

criteria, required that subjects were able to stand or walk for 6 minutes without complaints, and eliminated anyone using an assistive device.91 Lusardi et al included individuals with assistive devices, as it was felt that this inclusion was representative of the population of study.77 Bohannon presented times for walks that were initiated from a standing position, including acceleration within the recorded time, thereby accounting for why these scores may appear slower than the others.14 Access to these norms and the idiosyncratic differences among these studies provides the clinician with reference values for particular clients and can give more meaning and perspective to data collected in the clinic environment. Gait speed is often considered the most critical of the gait parameters, but there are ways in which other parameters of interest can be assessed in the clinic. The GaitRite walkway is a valid and reliable quantitative gait analysis system that uses imbedded sensors in a portable mat that are triggered when mechanical pressures (footfalls) are applied.92,93 The software program provides a diagrammatic representation and mathematical prole of the subjects temporal and spatial gait parameters. This type of equipment is not often found in a typical clinic because of its expense. An inexpensive, but reliable, alternative for measuring step length, stride length, step width, and cadence is to ask the individual to perform a timed walk down a measured paper walkway (brown roll paper works well) with ink footprints, measure the appropriate distances between landmarks, and

TA B L E 1 7 - 3

Comfortable Gait Speed Reference Values for Community-Dwelling Older Adults as Reported in Three Different Studies Bohannon14 Gait speed over 6 m using stopwatch mean (SD) (m/sec) Subjects were patients receiving home care PT for varied diagnoses Lusardi et al77 Gait speed over 3.7-m GaitRite walkway mean (SD) (m/sec) Included subjects both with and without assistive devices Steffen et al91 Gait speed over central 6 m of 10-m walkway using stopwatch (m/sec) Able to walk 6 minutes without complaints or assistive device

Key subject characteristics Reference norms by gender and age in decades (years) Female 50-59 60-69 70-79 80 (Bohannon) 80-89 90-101 Male 50-59 60-69 70-79 80 (Bohannon) 80-89 90-101 ***, not measured in these studies.

1.11 (0.22) 1.01 (0.23) 0.93 (0.23) 0.78 (0.22) *** 1.12 (0.21) 1.03 (0.21) 0.96 (0.23) 0.83 (0.22) ***

*** 1.24 (0.12) 1.25 (0.18) 0.80 (0.20) 0.71 (0.23) *** *** 1.25 (0.23) 0.88 (0.24) 0.72 (0.14)

*** 1.44 (0.25) 1.33 (0.22) 1.15 (0.21) *** *** 1.59 (0.24) 1.38 (0.23) 1.21 (0.18) ***

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CHAPTER 17 Ambulation: Impact of Age-Related Changes on Functional Mobility

calculate mean values for the walk.94 The patient can also walk with water footprints and the therapist can simply mark the point of heel strike on each footprint with a marker before the water dries to be measured later. Identifying change scores that represent a clinically important difference in performance is a relatively new area of study in physical therapy.95 Studies across a variety of older adults (community dwelling, sedentary, chronic stroke) have suggested that a change in gait speed of approximately 0.05 m/sec represents a small but clinically meaningful change, and a change greater than approximately 0.10 m/sec represents a substantial meaningful change in gait performance.96,97 Gait speed norms should also take into account the use of an assistive device, as assistive device use does correlate with slower self-selected and fast gait speeds.77 Both age and use of assistive device are predictors of performance on functionally based tests such as gait speed, TUG, and 6-minute walk.77

Six-Minute Walk
The 6MW was initially introduced as a measure of endurance in patients with cardiac and pulmonary problems, but it has come to be considered a broader measure of mobility and function in older people rather than an assessment of cardiovascular tness.91,102 The subject walks as far as possible, at a safe speed, in 6 minutes, and the test score is the distance covered in meters. Several studies have demonstrated the degradation of performance on the 6MW with increasing age.77,91,102-104 The 6MW has excellent testretest reliability (ICCs 5 0.95 to 0.97)91,105 and correlates well with other measures of functional performance.77,91,102,105 Six-minute walk reference values are identied in Table 17-5. The difference in values in the two studies cited may be a function of the study subjects. While Lusardi et al included participants with and without assistive devices,77 Steffen et al included only individuals who were ambulatory without the use of an assistive device.91 A change of 20 m in the 6MW represents a minimal clinically important change, and a change of 50 m represents a substantial change.97

Timed Up and Go
The TUG, developed by Podsiadlo and Richardson,98 is a tool that has been extensively used with healthy and frail older adults as well as older adult fallers. The TUG correlates well with balance, gait speed, and functional capacity.77,98,99 The test requires the subject to stand from a standard-height arm chair, walk forward 3 m to a target mark (or around a cone) and walk back to the chair and sit. The score is the time required for the task. The TUG has demonstrated excellent intra- and interrater reliability, with ICCs of 0.97 to 0.99.91,98 Reference values for community-dwelling older individuals have been documented77,91,99 and the results of a recent metaanalysis are presented in Table 17-4. Because of the large number of subjects represented through this metaanalysis (N 5 4395), it is suggested that the upper level of the condence interval can be used to identify poorer than average performance for the given age group on this test.99 Recent publications have conrmed the general nding that age and gender affect TUG performance, with females consistently taking longer than males.100,101

Modied Gait Abnormality Rating Scale

The GARS-M106 (a seven-item modication to the original GARS107) has been found to be a valid108 and reliable gait assessment tool for use with older adults, with intraand interrater ICCs ranging between 0.932 and 0.984.106 It requires the videotaping of an individual walking roughly 8 m, turning and walking back. The videos are evaluated for gait variability, guardedness, staggering, foot contact, hip range of motion, shoulder extension, and armheel strike synchrony. Scoring criteria are operationally dened for each item. Video playback with slow motion and stop-action capabilities are used to score each item. A unique element of the GARS-M is that it does document variability of gait,108 a gait

TABLE 17-5

Reference Values for Six-Minute Walk Test for Community-Dwelling Older Adults as Reported in Two Different Studies 6MW91 Mean (SD) (m) 538 (92) 471 (75) 392 (85) N/A 572 (92) 527 (85) 417 (73) N/A 6MW77 Mean (SD) (m) 405.0 (110.0) 406.4 (94.8) 281.8 (122.7) 261.4 (81.1) 497.7 (0) 475.3 (93.0) 319.6 (79.7) 295.7 (14.6)

TA B L E 1 7 - 4

Timed Up & Go (TUG) Reference Values for Community-Dwelling Older Adults99 Mean TUG (sec) 8.1 9.2 11.3 95% condence interval* 7.1 9.0 8.2 10.2 10.0 12.7

Gender Female

Decade (years) 60-69 70-79 80-89 90-101 60-69 70-79 80-89 90-101

Decade (years) 60-69 70-79 80-99

*

Male

Upper limit of the condence interval is the cutoff point for a normal TUG score.