Mirjam Pijnappels

Gait stability and variability measures show effects of impaired cognition and dual tasking in frail people

BackgroundFalls in frail elderly are a common problem with a rising incidence. Gait and postural instability are major risk factors for falling, particularly in geriatric patients. As walking requires attention, cognitive impairments are likely to contribute to an increased fall risk. An objective quantification of gait and balance ability is required to identify persons with a high tendency to fall. Recent studies have shown that stride variability is increased in elderly and under dual task condition and might be more sensitive to detect fall risk than walking speed. In the present study we complemented stride related measures with measures that quantify trunk movement patterns as indicators of dynamic balance ability during walking. The aim of the study was to quantify the effect of impaired cognition and dual tasking on gait variability and stability in geriatric patients.MethodsThirteen elderly with dementia (mean age: 82.6 ± 4.3 years) and thirteen without dementia (79.4 ± 5.55) recruited from a geriatric day clinic, walked at self-selected speed with and without performing a verbal dual task. The Mini Mental State Examination and the Seven Minute Screen were administered. Trunk accelerations were measured with an accelerometer. In addition to walking speed, mean, and variability of stride times, gait stability was quantified using stochastic dynamical measures, namely regularity (sample entropy, long range correlations) and local stability exponents of trunk accelerations.ResultsDual tasking significantly (p < 0.05) decreased walking speed, while stride time variability increased, and stability and regularity of lateral trunk accelerations decreased. Cognitively impaired elderly showed significantly (p < 0.05) more changes in gait variability than cognitive intact elderly. Differences in dynamic parameters between groups were more discerned under dual task conditions.ConclusionsThe observed trunk adaptations were a consistent instability factor. These results support the concept that changes in cognitive functions contribute to changes in the variability and stability of the gait pattern. Walking under dual task conditions and quantifying gait using dynamical parameters can improve detecting walking disorders and might help to identify those elderly who are able to adapt walking ability and those who are not and thus are at greater risk for falling.

Changes in walking pattern caused by the possibility of a tripping reaction

This study investigated in 15 young adults whether their walking pattern was altered after forewarning for a possible trip. Such changes might affect tripping reactions and consequently the validity of experimental results. Kinematics and dynamics were measured during overground walking. No changes occurred in walking velocity, step frequency, duration of stride cycle, stance, swing and double support time, or step length. A small increase was found in step width and foot clearance due to ankle dorsiflexion, but these changes were not expected to alter the probability of tripping nor the recovery reactions after tripping in an experimental setup.

Ambulatory Fall-Risk Assessment: Amount and Quality of Daily-Life Gait Predict Falls in Older Adults

BACKGROUND Ambulatory measurements of trunk accelerations can provide valuable information on the amount and quality of daily-life activities and contribute to the identification of individuals at risk of falls. We compared associations between retrospective and prospective falls with potential risk factors as measured by daily-life accelerometry. In addition, we investigated predictive value of these parameters for 6-month prospective falls. METHODS One week of trunk accelerometry (DynaPort MoveMonitor) was obtained in 169 older adults (mean age 75). The amount of daily activity and quality of gait were determined and validated questionnaires on fall-risk factors, grip strength, and trail making test were obtained. Six-month fall incidence was obtained retrospectively by recall and prospectively by fall diaries and monthly telephone contact. RESULTS Among all participants, 35.5% had a history of ≥1 falls and 34.9% experienced ≥1 falls during 6-month follow-up. Logistic regressions showed that questionnaires, grip strength, and trail making test, as well as the amount and quality of gait, were significantly associated with falls. Significant associations differed between retrospective and prospective analyses although odds ratios indicated similar patterns. Predictive ability based on questionnaires, grip strength, and trail making test (area under the curve .68) improved substantially by accelerometry-derived parameters of the amount of gait (number of strides), gait quality (complexity, intensity, and smoothness), and their interactions (area under the curve .82). CONCLUSIONS Daily-life accelerometry contributes substantially to the identification of individuals at risk of falls, and can predict falls in 6 months with good accuracy.

Consequences of lower extremity and trunk muscle fatigue on balance and functional tasks in older people: A systematic literature review

BackgroundMuscle fatigue reduces muscle strength and balance control in young people. It is not clear whether fatigue resistance seen in older persons leads to different effects. In order to understand whether muscle fatigue may increase fall risk in older persons, a systematic literature review aimed to summarize knowledge on the effects of lower extremity and trunk muscle fatigue on balance and functional tasks in older people was performed.MethodsStudies were identified with searches of the PUBMED and SCOPUS data bases.Papers describing effects of lower extremity or trunk muscle fatigue protocols on balance or functional tasks in older people were included. Studies were compared with regards to study population characteristics, fatigue protocol, and balance and functional task outcomes.ResultsSeven out of 266 studies met the inclusion criteria. Primary findings were: fatigue via resistance exercises to lower limb and trunk muscles induces postural instability during quiet standing; induced hip, knee and ankle muscle fatigue impairs functional reach, reduces the speed and power of sit-to-stand repetitions, and produces less stable and more variable walking patterns; effects of age on degree of fatigue and rate of recovery from fatigue are inconsistent across studies, with these disparities likely due to differences in the fatigue protocols, study populations and outcome measures.ConclusionTaken together, the findings suggest that balance and functional task performance are impaired with fatigue. Future studies should assess whether fatigue is related to increased risk of falling and whether exercise interventions may decrease fatigue effects.

Estimating fall risk with inertial sensors using gait stability measures that do not require step detection

Falls have major consequences both at societal (health-care and economy) and individual (physical and psychological) levels. Questionnaires to assess fall risk are commonly used in the clinic, but their predictive value is limited. Objective methods, suitable for clinical application, are hence needed to obtain a quantitative assessment of individual fall risk. Falls in older adults often occur during walking and trunk position is known to play a critical role in balance control. Therefore, analysis of trunk kinematics during gait could present a viable approach to the development of such methods. In this study, nonlinear measures such as harmonic ratio (HR), index of harmonicity (IH), multiscale entropy (MSE) and recurrence quantification analysis (RQA) of trunk accelerations were calculated. These measures are not dependent on step detection, a potentially critical source of error. The aim of the present study was to investigate the association between the aforementioned measures and fall history in a large sample of subjects (42 fallers and 89 non - fallers) aged 50 or older. Univariate associations with fall history were found for MSE and RQA parameters in the AP direction; the best classification results were obtained for MSE with scale factor τ = 2 and for maximum length of diagonals in RQA (72.5% and 71% correct classifications, respectively). MSE and RQA were found to be positively associated with fall history and could hence represent useful tools in the identification of subjects for fall prevention programs.

Assessing gait stability: the influence of state space reconstruction on inter- and intra-day reliability of local dynamic stability during over-ground walking.

Estimating local dynamic stability is considered a powerful approach to identify persons with balance impairments. Its validity has been studied extensively, and provides evidence that short-term local dynamic stability is related to balance impairments and the risk of falling. Thus far, however, this relation has only been proven on group level. For clinical use, differences on the individual level should also be detectable, requiring reliability to be high. In the current study, reliability of short-term local dynamic stability was investigated within and between days. Participants walked 500 m back and forth on a straight outdoor footpath, on 2 non-consecutive days, and 3D linear accelerations were measured using an accelerometer (DynaPort MiniMod). The state space was reconstructed using 4 common approaches, all based on delay embedding. Within-session intra-class correlation coefficients were good (≥0.70), however between-session intra-class correlation coefficients were poor to moderate (≤0.63) and influenced by the reconstruction method. The same holds for the smallest detectable difference, which ranged from 17% to 46% depending on the state space reconstruction method. The best within- and between-session intra-class correlation coefficients and smallest detectable differences were achieved with a state space reconstruction with a fixed time delay and number of embedding dimensions. Overall, due to the influence of biological variation and measurement error, the short-term local dynamic stability can only be used to detect substantial differences on the individual level.

Sensitivity of trunk variability and stability measures to balance impairments induced by galvanic vestibular stimulation during gait

For targeted prevention of falls, it is necessary to identify individuals with balance impairments. To test the sensitivity of measures of variability, local stability and orbital stability of trunk kinematics to balance impairments during gait, we used galvanic vestibular stimulation (GVS) to impair balance in 12 young adults while walking on a treadmill at different speeds. Inertial sensors were used to measure trunk accelerations, from which variability in the medio-lateral direction and local and orbital stability were calculated. The short-term Lyapunov exponent and variability reflected the destabilizing effect of GVS, while the long-term Lyapunov exponent and Floquet multipliers suggested increased stability. Therefore, we concluded that only short-term Lyapunov exponents and variability can be used to asses stability of gait. In addition, to investigate the feasibility of using these measures in screening for fall risk, the presence or absence of GVS was predicted with variability and the short-term Lyapunov exponent. Predictions were good at all walking speeds, but best at preferred walking speed, with a correct classification in 83.3% of the cases.

Cortical facilitation of cutaneous reflexes in leg muscles during human gait

During human gait, cortical convergence on sural nerve reflex pathways was investigated by means of transcranial magnetic stimulation (TMS) of the cortex in five phases of the step cycle during human walking on a treadmill. Muscular responses to paired electrical and magnetic stimulation were compared with the linear summation of the individual stimuli. For both the tibialis anterior (TA) and biceps femoris (BF) muscles, the averaged data of four subjects showed a significant facilitation mainly in the swing phase of the step cycle. It is suggested that facilitation of corticospinal input onto cutaneous reflex pathways is enhanced specifically in these periods of the step cycle.

The association between choice stepping reaction time and falls in older adults—a path analysis model

BACKGROUND choice stepping reaction time (CSRT) is a functional measure that has been shown to significantly discriminate older fallers from non-fallers. OBJECTIVE to investigate how physiological and cognitive factors mediate the association between CSRT performance and multiple falls by use of path analysis. METHODS 294 retirement-village residents, aged 62-95 years, undertook CSRT tests, requiring them to step onto one of four randomly illuminated panels, in addition to physiological and cognitive tests. Number of falls was collected during 1-year follow-up. RESULTS 79 participants (27%) reported two or more falls during the follow-up period. Regression analyses indicated CSRT was able to predict multiple falls by a factor of 1.76 for each SD change. The path analysis model revealed that the association between CSRT and multiple falls was mediated entirely by the physiological parameters reaction time and balance (postural sway) performance. These two parameters were in turn mediated over a physiological path (by quadriceps strength and visual contrast sensitivity) and a cognitive path (cognitive processing). CONCLUSIONS this study provides an example of how path analysis can reveal mediators for the association between a functional measure and falls. Our model identified inter-relationships (with relative weights) between physiological and cognitive factors, CSRT and multiple falls.

Identification of fall risk predictors in daily life measurements: gait characteristics' reliability and association with self-reported fall history

Background. Gait characteristics extracted from trunk accelerations during daily life locomotion are complementary to questionnaire- or laboratory-based gait and balance assessments and may help to improve fall risk prediction. Objective. The aim of this study was to identify gait characteristics that are associated with self-reported fall history and that can be reliably assessed based on ambulatory data collected during a single week. Methods. We analyzed 2 weeks of trunk acceleration data (DynaPort MoveMonitor, McRoberts) collected among 113 older adults (age range, 65-97 years). During episodes of locomotion, various gait characteristics were determined, including local dynamic stability, interstride variability, and several spectral features. For each characteristic, we performed a negative binomial regression analysis with the participants’ self-reported number of falls in the preceding year as outcome. Reliability of gait characteristics was assessed in terms of intraclass correlations between both measurement weeks. Results. The percentages of spectral power below 0.7 Hz along the vertical and anteroposterior axes and below 10 Hz along the mediolateral axis, as well as local dynamic stability, local dynamic stability per stride, gait smoothness, and the amplitude and slope of the dominant frequency along the vertical axis, were associated with the number of falls in the preceding year and could be reliably assessed (all P < .05, intraclass correlation > 0.75). Conclusions. Daily life gait characteristics are associated with fall history in older adults and can be reliably estimated from a week of ambulatory trunk acceleration measurements.