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Target individual in the transitional stage: experience onset of ill health (Model of care WA)

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Stroke study(Hill, Ellis, Bernhardt, Maggs, & Hull, 1997)

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Stroke study(Hill, Ellis, Bernhardt, Maggs, & Hull, 1997)

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1. 7% of patients after stroke are able to ambulate in dependently in the community.
2. Criteria were set by authors to  define community ambulation (FIM locomotion >5, FAC=6, Gait velocity >48m/min, endurance >500m)

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What will encourage older adults to walk outdoors?

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What will encourage older adults to walk outdoors?

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Presence of recreational facilities that are easy to access and located within walking distance (Eronen, von Bonsdorff, Rantakokko, & Rantanen, 2014)

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Can we use this approach for older adults to manage their concerns about walking in the community? (life space assessment, education, goal setting & f/up telephone support, healthcare provided comm & comm linkage delivered over 6 months)

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Fall prevention programme learning points(Barker et al., 2015)

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Fall prevention programme learning points(Barker et al., 2015)

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Patient centred education and behavior change strategies.
Guide patients make decisions about how they will manage their falls risk (Home based risk assessment, education, goal setting & F/up telephone support, healthcare provided comm & comm linkage delivered over 6 months)

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What are the advantages of outdoor walking? Why?

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What are the advantages of outdoor walking? Why?

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What are the facilitators/positive factors influencing the older adults to ambulate in the community? in simple terms=> what will get them out of the house?

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1. What can we do to reduce fear of moving outdoors? How can we track the mobility of the individual while they are outdoors?
2. What are the interventions that we can do to improve the life space of an individual who has FOF?
3. What are the consequences of not able to ambulate in the community?

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1. Can moderate home visit support using telephone contact improve participation in community ambulation?
2. What do they think about the above support?

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Positive health messages may improve participation.
Moderate home visit support and intervention via telephone contact improve participation in falls prevention strategies

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If we understand what are these influencing factors, we could treat/ modify these factors to influence the older adults mobility in community.
Think about how to map practice routes for clients to practice.

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If we add this as a addition to the Otago Exercise program, safety of training is a concern.

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Community ambulation is defined as “independent mobility outside the home, which includes the ability to confidently negotiate uneven terrain, private venues, shopping centres and other public venues,”(Lord, McPherson, McNaugton, Rochester, & Weatherall, 2004, p. 236). It requires the individual to have a higher motor control and adaptable cognition to respond to a range of environment stimuli or simultaneous task(Lord, Weatherall, & Rochester, 2010).

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Independent community ambulator means able to meet the demands of moving in the community.
"limited commun.ity arnbulator  is an individual who can safely perform some but not all tasks associated with moving through the environment; ·
"household ambulator," is an individual who can perform the tasks that define mobility within the home environment but is incapable of meeting the demands of mobility outside the home;  "nonfunctional ambulator" is an individual who cannot meet the requirements of ambulating within the home environment (Patla & Shumway-Cook, 1999, p. 9)
Consist of mobility (walking) and social component.

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Psychological factors:
1.Concern about falling influenced the older adults' walking patterns: shorter steps, decreased cadence & increased time in double support (Delbaere, Sturnieks, Crombez, & Lord, 2009).
2. Participants with lower gait efficacy (measured with gait efficacy scale) appear to approach obstacles of different heights with more caution, slower gait speeds & shorter step lengths (Rosengren, McAuley, & Mihalko, 1998).
3. Community dwelling older adults who perceive their health and balance to be good walked more blocks per week (higher physical activity) (Talkowski, Brach, Studenski, & Newman, 2008)
4. Individuals (19%) with fear of falling tend to avoid activities (Tinetti, De Leon, Doucette, & Baker, 1994) particularly reaching and walking(Delbaere, Crombez, Vanderstraeten, Willems, & Cambier, 2004)
5. Number of falls and affective-cognitive variable(concern about falls) influenced an individual's mobility. Catastrophic beliefs about adverse consequence of falls, creates concerns and lead to restriction in mobility  (Delbaere, Crombez, van Haastregt, & Vlaeyen, 2009)
Physiological factors:
1. Physiological falls risk (measured by PPA) was associated with slower waking speed(Delbaere, Sturnieks, Crombez, & Lord, 2009).
2. Older adults with normal walking speed walked more blocks/week(higher physical activity) (Talkowski, Brach, Studenski, & Newman, 2008)

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Transitions could occur in both directions between the no-disability,

intermittent-disability, and continuous-disability states

and in one direction from each of these three states to death.
(Gill, Allore, Hardy, & Guo, 2006).
Defined as the need for personal assistance (or inability) to walk one quarter of a mile and to climb a flight of stairs, respectively

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Outcome measures:
Importance of including temporal-spatial measurements of gait, e.g. walking at various speeds, different task conditions

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Gait differences of fallers vs. non fallers

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Gait differences of fallers vs. non fallers

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1. Fallers demonstrate reduced walking velocity, cadence, shorter stride and step lengths, reduced single support time during obstacle clearance (Newstead, Walden, & Gitter, 2007)
2. Fallers were unable to increase speed on demand. Study of treadmill walking at progressively faster speeds. Non-fallers completed all trials (highest speed of 1.52m/s), 57% of fallers found this speed incompatible.
3. Further decrease in hip extension (Kerrigan, Lee, Collins, Riley, & Lipsitz, 2001) and ankle plantarflexion movement (Barak, Wagenaar, & Holt, 2006)
4. Increase gait variability (stride to stride variations)  (Barak, Wagenaar, & Holt, 2006) (Hausdorff, Rios, & Edelberg, 2001)

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Improve an older adults' ability to ambulate in the community if they have fallen/impaired balance

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1. How does these age related changes impact on an older adults ability to ambulate outdoors?
2. Are there any gait differences between someone who have fallen versus someone who have not fallen?
3. What are the strategies that they utilize when they encounter environmental demands? Is there a difference between fallers versus non fallers?

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Does the inclusion of variation of patterns of gait training reduces the
1. probability indoor and outdoor falls?
2. increases the frequency of outdoor ambulation?
3. Improves the quality of life of older adults?
4. Improves the ability of the older adult to ambulate in the community? (distance, speed, multi-tasking, carrying a load, climb stairs etc)

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What I do not know /What I want to know? Ideas for research

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What I do not know /What I want to know? Ideas for research

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Support for rehabilitation/ different patterns of gait training

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Support for rehabilitation/ different patterns of gait training

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1. Research:

Individuals utilise specific strategies to maintain postural control changes when there are any challenges to balance(Adkin, 2000), (Horak, 2006).

Walking patterns is adjusted to meet the type of balance demands encountered to maximize stability(Shkuratova, Morris, & Huxham, 2004).

Response time appears to be important factor of recovery from tripping if a lowering strategy is used(van den Bogert, Pavol, & Grabiner, 2002)

This implied that postural adjustments and walking patterns are task specific. Therefore, this reiterates the importance that rehabilitation should focus on training using a task-oriented approach.

2. Theory:

Walking skill training allows the brain to relearn and to integrate the sequence and timing of movements during gait through motor learning. Motor learning is associated with plastic changes in the brain. With practice, it allow a series of movements to be sequenced together efficiently and automacity (VanSwearingen & Studenski, 2014).

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Changes in sensory, motor & CNS integration of systems that work together to bring about movement during gait.

Sensory changes are decreased visual acuity, somatosensory and proprioception.

Adults used speed appropriate responses immediately following perturbation, but took longer to recover steady-state walking at all speeds and variable inter-limb coordination (Krasovsky, Lamontagne, Feldman, & Levin, 2014)

Changes in biomechanical and neuromuscular factors contribute to a loss of motor skill and increased energy cost of walking (VanSwearingen & Studenski, 2014)

Comfortable gait speed may decline at a rate of 0.2% per year up to age 63, accelerates at 1.6% after age 63 (Alexander, 1996)

Decrease in step and stride length(Krasovsky, Lamontagne, Feldman, & Levin, 2014)

Decrease knee extension (Ostrosky, VanSwearingen, Burdett, & Gee, 1994),  hip extension (exaggerated
in fallers) (Kerrigan, Lee, Collins, Riley, & Lipsitz, 2001) and ankle ROM (Krasovsky, Lamontagne, Feldman, & Levin, 2014)

Changes in gait have been related to age, psychological factors, mobility, function and risk of falls

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Walking is a highly skilled motor task. It is gained through motor learning (VanSwearingen & Studenski, 2014)
Why?
1. Body mass are balanced over the moving lower limbs,
2. Body’s center of mass travels outside of the base of support for 80% of each stride,
3. Acceleration and brake forces of each step continually challenge trunk stability,
4. toe clears the ground less than 2.5 cm as the swing limb begins to move forward and drops to 1 cm during mid-swing (Frank & Patla, 2003).

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For any intervention programmes, it should be catered to the different demographics of the individuals.
If we could find out/understand what are the factors that is preventing outdoor mobility, this could prevent future disability.

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Indoor falls: participants were older, female and poorer health

Outdoor falls: participants were younger, male and physically active. (Kelsey et al., 2010)

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1. Distance & speed requirements (Sys Review)
Distances for community sites frequented are 16 to 672m on average, cross the street .44 to 1.32m/s.
Sites essential for older adults, drs' offices, banks, drugstores, department stores & supermarkets.
Speed & distance influenced by type of site & pop size
(Salbach et al., 2014)
2. Navigation of different terrains
Ability to increase and decrease speed, make anticipatory and reactive postural adjustments, ability to navigate a combination of task  and environmental demands (Oh, 2013) (Patla and Frank 2003)

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Because of the variability in comm ambulation, importance of discussion with pt to identify needs

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Training should encompass endurance, varying surfaces, challenges to postural balance,
ability to adjust/ utilise appropriate  postural strategies when encountering challenges
Consider methods of monitoring physical activity of the older adults

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1. Locomotion often occurs in a complex environment.
When individual encounter challenges, we either avoid or adjust travel path. Challenges: Distance to destination (endurance), stairs & slopes & transition between surfaces (uneven surfaces), varying levels of lighting (vision is important for adaptive locomotion: plans gait modifications & guide locomotion), steering control (turns) (Patla, 2001)
2. Rehabilitation should prepare individuals with limitations to engage in meaningful activities, be physically active to reduce risk of non-communicable diseases
3. May address the older individuals' concern about ambulating in the community and protect against loss of functional capacity.
4.Most falls occur when an individual is walking. Walking accounted for 47.3% of all falls outdoors (Li, 2006)
5. Both groups of older women (walkers and non-walkers) experience loss of reserve capacity. Small amounts of outdoor walking offers  protection against loss of mobility in the short term and helps to retain reserve capacity in the long term (Barak, Wagenaar, & Holt, 2006)
6. All physiotherapist knows that it is crucial to prepare an individual to transit back into the community seamlessly. However, there is no guideline/protocol to guide newly graduated physiotherapist of what is important to prepare patient for community ambulation
6. To help older adults remain functionally independent in their homes and communities and out of long term nursing care facilities.

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1.What are the primary factors that prevent older adults having difficulty with accessing the community?
If we understand what are these influencing factors, we could treat/ modify these factors to influence the older adults mobility in community. Can these factors be grouped into physical, emotional and behavioral practices?
2. Can we help older adults to ambulate in the community if we teach them how to walk if we use environmental mapping?
3. Can we map training programmes using life space?
4. What are the recommended outcome measures to determine community ambulation?
5. Based on research by Chippendale and Chang (2017),Chippendale and Raveis (2017) older adults with concern of fall use strategies like visual scanning, avoiding distractions, use of rails on stairs and choice of footwear to prevent falls. Can we use these strategies as part of the intervention programme to empower the older adults to encourage community ambulation?
6. What are the strategies that older adults utilize to ambulate in the community safely

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Need to explore theory that will look at helping older adults embrace their fear/ concerns.

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Reasons for reduce frequency/not going outdoors: 

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Reasons for reduce frequency/not going outdoors: 

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1. Poor socioeconomic status, MS conditions, slow walking speed, Environment (presence of poor street conditions, hills, noisy traffic)

2. Fear of moving outdoors increased risk of developing walking difficulties in long term (Rantakokko et al., 2009).
3. Fear of falling appears to reduce the spatial area that an individual moves through in daily life (called life-space) (Auais et al., 2017)

3. Older adults who report that they are concerned about their balance complained of difficulty accessing the community (Yang & al, 2011) and will adjust their behaviour by reducing outdoor activities (Wijlhuizen, de Jong, & Hopman-Rock, 2007) which may have profound effects on their participation in society and quality of life (Pound, Gompertz, & Ebrahim, 1998) (Hirvensalo, Rantanen, & Heikkinen, 2000) .

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Requirements of going outdoors/community ambulation: 

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Requirements of going outdoors/community ambulation: 

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Adequate  physical and cognitive abilities. it acts as a motivation stimulation to their daily life.

Successful mobility depends on skills of the individual, requirements of the task, & challenges of the environment.

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When people age, and become more frail, they decrease their frequency of going outdoors. (Kono, Kai, Sakato, & Rubenstein, 2007)
if the frequency of going outdoors increase, they remain more highly functional, socially active and less depressed.