“What are some of your goals?”
This is one of the first questions I ask my patients in skilled nursing facilities (SNFs) and within their homes. Pretty much any rehabilitation therapist (RT) around the world can presume the most common answer to this question, and probably recite it alongside our patients in three-part harmony. Nevertheless, we ask it anyway and wait for the common refrain.
“To walk again” is the goal we hear most often, sometimes with the caveat of “I only want to work on walking!” Sometimes I even get a few patients who will boldly declaim, “I know what occupational therapy is, and I don’t need occupational therapy, I only need physical therapy, because all I want to do is walk!”
Often these same patients have been referred to skilled occupational therapy (OT) services following a fall. Sometimes the fall caused injury, and sometimes that injury is even in an upper extremity, which was used to break the fall. I have found that the best course of action is to assure them that their number one goal of walking is my number one goal for them too, and I have no reluctance in saying so.
According to the American Occupational Therapy Association (AOTA) [i], occupational therapists work with patients on functional mobility as a means of fall prevention and reducing fall risk. Thus they must be prepared to objectively assess for it as well as to pair walking interventions with specific occupational goals, such as activities of daily living (ADLs).
The AOTA specifies that OTs should refer patients with specific gait issues to physical therapy. However, fall risk assessments are common components of evaluations and are suitable to be used by both professions. The AOTA notes that occupational therapists must emphasize the significance of result findings as they pertain to patients’ balance and function in daily activities.
Variances in Walking and Mobility Assessments used by Occupational Therapists
A 2015 scholarly review article entitled “Walking Speed: The Functional Vital Sign” considered updated research regarding the way clinicians and researchers assess walking. Because there are different procedures for the various walking assessment tests, they can yield varying results. Among the various procedural differences are distance, static versus dynamic starts, straight path versus turns, self-selected speed versus maximal speed, and verbal instructions.
I like to utilize the Timed Up and Go (TUG) [ii] assessment test upon evaluation, at progress note intervals, and upon discharge for all of my ambulatory patients. I find that it requires minimal equipment: my stopwatch, an armchair, and a measuring tape that reaches ten feet. Furthermore, my patients usually respond well to it, subjectively stating, “That was fun!” or “This is exactly what I’d like to work on!” while it simultaneously affords me the opportunity to objectively measure their comfortable speed of walking. TUG assessment also allows me to screen their stride length and gait, their ability to transfer up and down from an armchair, their ability to turn 180 degrees, and their ability to utilize adaptive equipment such as a cane, a walker, or a rollator. I usually give them the opportunity to attempt a minimum of three trials, averaging the amount of time across all trials. Ultimately, this assessment takes less than a few minutes, yet its results yield valuable information to assist with my evidence-based reporting.
As indicated by the standardized TUG methods, my patients usually walk at a distance of ten feet; however, according to this review, a distance of five to ten meters (16.4 – 32.8 feet) is required in order to “maximize concurrent validity and maintain clinical psychometric soundness.” The article considered “timed distance” within a walking assessment and the difference between a static start versus a dynamic start. For example, I usually begin my stopwatch from the moment a patient lifts up from the armchair, as indicated by the standardized methodology of the TUG, and I stop the clock the moment a patient returns to sitting. In a sense, I am not only timing the distance walked, but also the transfer prior to and at the end of the walk, which may be considered a static start due to the nature of rising, adjusting, and then recovering from the sit to stand transfer. Some patients’ greatest challenge is transferring, and once they are standing it may take a second or two to adjust before they are able to “hit their stride” and walk at a nice pace. Thus, these patients are losing seconds on the clock due to inefficient transfers, not necessarily walking speed. However, if I were to time those very same patients for a distance of ten feet once they were already walking, thus a dynamic start, their results would understandably be very different.
Acceleration and deceleration are also variables that can change the results of a person’s overall walking speed, and this article considers whether a more accurate timed walking speed would be calculated when the phases of acceleration and deceleration are taken out of the equation. Similarly, a straight path versus assessments that require turning (like the TUG) can also result in widely ranging walking speeds. The act of turning requires greater motor control in order to adjust walking speed prior, during, and after the turn, thus increasing the complexity of the assessment test. I love that the TUG requires this because while it may seem as if it slows my patients down, it affords me the opportunity to observe their ability to weight shift, change direction, and perform a very functional movement that is prominent in standing ADLs.
It is these very reasons that clinicians must consider the methodology and outcome delineations between walking assessments. The TUG is an assessment for mobility, perfectly suitable for within the scope of OT, and while it correlates well with walking speed, it is not a walking speed test.
This article discusses how assessments that allow for self-selected speed indicate current functional status and health outcomes, whereas those that test maximal walking speed provide information regarding the ability to function within the community. The example was one that I often use with my homecare clients who wish to walk within their neighborhoods and is that of crossing a street in time before the traffic lights change. A thorough evaluation of a patient living within the community will involve assessing for general mobility as well as their ability to adjust walking speed according to environmental demands.
Lastly, the article stressed the importance of being consistent with verbal cueing or method of instruction throughout the assessment. Variances in simple instructions such as “Walk as fast and as safely as you can” versus the more exacting “Try to get to the corner before the walk sign flashes” can also yield differing results.
Walking, Talking and Falls
Ultimately, when we are assessing walking within a geriatric population we are striving to assess the risk of falls. The TUG assessment gives me a wealth of insight as to my patient’s mobility; however, it is usually performed in relative silence with a concerted effort on my patient’s part. In other words, it isn’t an accurate portrayal of walking in “the real world,” because very seldom do we go about our day walking in silence with a fixed concentration on simply walking. Would increased cognitive demands, such as walking while talking, make an objective and significant difference in functional mobility? A 2014 study reported in Gerontology [iii] on “walking while talking” (WWT) as a predictor of falls in older adults.
The study involved participants dividing their attention on both a cognitive task (such as reciting every other letter in the alphabet) along with walking, and they were instructed to pay equal attention to both. Meanwhile, the researchers objectively measured for various gait variables including velocity (centimeters per second), cadence (steps per minute), step length (centimeters), swing, and stance. After a period of 638.3 days, the participants were interviewed by phone, and 52 percent of the 337 participants reported a fall.
After analyzing the data, the study results showed that the only predictor of falls was the WWT parameter of step length. Those that reported falls had demonstrated significantly shorter step length than those that did not experience a fall. When combined with velocity, or “pace”, the association between step length and falls strengthened; however, “pace” during WWT was not identified as a significant predictor of falls when factored alone. The number of letters recited during the WWT task as well as the number of cognitive errors was also not a factor in fall prediction.
While the cognitive aspects of the WWT study were not a significant factor in fall prediction, the study discussed how attention, executive function, and memory are cortical functions in both cognitive activities as well as gait. It suggested that gait dysfunction, as measured within a WWT protocol, might also be an indicator of cognitive decline. Thus, we return to within the scope of OT practice and patient functional performance, as possibly indicative of the association of their walking ability and their cognitive function.
Ultimately, I love trying to simulate “real life” as much as possible in my treatments. Once I know that a patient is comfortable with the motor control of walking and the use of their adaptive equipment for balance, I often try to engage them in walking and talking, just as they would do as part of an activity or as the sole occupation of socialization within their homes and community with their family, aides, friends or neighbors. [iv]
References
[i] “Q&A: Gait Assessment for Falls Risk.” Aota.org, The American Occupational Therapy Association, 2017, www.aota.org/Practice/Manage/Scope-of-Practice-QA/gait.aspx.
[ii] Podsiadlo, D. and Richardson, S. (1991). “The Timed “Up & Go”: A Test Of Basic Functional Mobility For Frail Elderly Persons.” J Am Geriatr Soc 39(2): 142-148.
[iii] Ayers E, I, Tow A, C, Holtzer R, Verghese J, Walking while Talking and Falls in Aging. Gerontology 2014;60:108-113.
[iv] Middleton, Addie, et al. “Walking Speed: The Functional Vital Sign.” Journal of Aging & Physical Activity, vol. 23, no. 2, Apr. 2015, pp. 314-322. EBSCOhost, doi:10.1123/japa.2013-0236.