Continuum (Minneapolis, Minn.)
10/2013; 19(5, Movement Disorders):1344-1382. DOI: 10.1212/01.CON.0000436159.33447.69
This article provides insight and reviews useful tools for the clinical assessment, understanding, and management of neurologic gait disorders.
In recent years, our understanding of the physiology of human walking has steadily increased. The recognition of gait as a complex, "higher-order" form of motor behavior with prominent influence of mental processes has been an important new insight, and the clinical implications of gait disorders are increasingly being recognized. Better classification schemes, the redefinition of established entities (eg, senile gait), and new insights from research on degenerative disorders primarily affecting gait (eg, primary progressive freezing of gait) have become available.
Gait disorders are directly correlated with poor quality of life and increased mortality. Because gait is very sensitive to any insult to the nervous system, its assessment should be carried out carefully in routine clinical practice.Disorders of locomotion are easily discernible to the naked eye. However, when examining gait, clinicians should bear in mind that the clinical phenotype is the net result of changes induced by the disease itself plus any compensations adopted by the patient to improve stability. This review presents a clinically oriented approach to gait disorders based on the dominant phenomenology and underlying pathophysiology, which are tightly connected. The authors conclude by proposing a practical management approach.
Available from: Eling D de Bruin
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Exercise interventions often do not combine physical and cognitive training. However, this combination is assumed to be more beneficial in improving walking and cognitive functioning compared to isolated cognitive or physical training.
A multicenter parallel randomized controlled trial was conducted to compare a motor to a cognitive-motor exercise program. A total of 182 eligible residents of homes-for-the-aged (n = 159) or elderly living in the vicinity of the homes (n = 23) were randomly assigned to either strength-balance (SB) or strength-balance-cognitive (SBC) training. Both groups conducted similar strength-balance training during 12 weeks. SBC additionally absolved computerized cognitive training of alertness and divided & selective attention. Outcomes were change in dual task costs of walking, physical performance, simple reaction time, executive functions, divided attention, fear of falling and fall rate. All randomized participants were analysed with an intention to treat approach.
All 182 participants were randomized (mean age +/- SD: 81.5 +/- 7.3 years) and allocated to either SB (n = 98) or SBC (n = 84). The attrition rate was 14.3%, thus, 156 participants completed the intervention (SB n = 82; SBC n = 74). Interaction effects were observed for dual task costs of step length (preferred walking speed: F(1,174) = 4.94, p = 0.028, eta2 = 0.027, fast walking speed: F(1,166) = 6.14, p = 0.009, eta2 = 0.040) and dual task costs of the standard deviation of step length (F(1,166) = 6.14, p = 0.014, eta2 = 0.036), in favor of SBC. Significant interactions in favor of SBC were also seen in gait initiation (F(1,166) = 9.16, p = 0.003, eta2 = 0.052), 'reaction time' (F(1,180) = 5.243, p = 0.023, eta2 = 0.028) & 'missed answers' (F(1,180) = 11.839, p = 0.001, eta2 = 0.062) as part of the test for divided attention. Within-group comparison revealed significant improvements in dual task costs of walking (preferred speed; velocity (p = 0.002), step time (p = 0.018), step length (p = 0.028), fast speed; velocity (p < 0.001), step time (p = 0.035), step length (p = 0.001)), simple reaction time (p < 0.001), executive functioning (Trail making test B; p < 0.001), divided attention (p < 0.001), fear of falling (p < 0.001), and fall rate (p < 0.001).
Combining strength-balance training with specific cognitive training has a positive additional effect on dual task costs of walking, gait initiation, and divided attention. The findings further confirm previous research showing that strength-balance training improves executive functions and reduces falls.
Trial registration: This trial has been registered under ISRCTN75134517
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