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How To Identify The Risk Of A Fall Using 2 Gait Assessments

Written by: Nick Jack
Category: 2014
on 07 November 2019
Hits: 6120

Without a doubt the most difficult movement to help someone improve is WALKING. There is so many moving parts within the gait cycle that the use of simple isolated exercises do very little to improve the motor program. But due to this complexity it makes it very difficult to find exercises that are both useful and safe to do. The two main problems associated with loss of stability in the gait cycle are smaller stride lengths and a loss of speed. A slowing of neural firing speed, (the brains message to the nerves within muscles for movement) from lack of exercise produces a slower response time for the initiation of movement. To make up for the body’s lost reaction it compensates by slowing everything down and shortening our stride to overcome our lost reflexes and reaction times. In theory this sounds like a good thing, but in reality this sets people up for disastrous accidents. In this article we show you some simple tests to use for identifying exactly where your loss of stability is that is affecting how you walk, and how these tests can then become a great exercise for significantly improving your walking ability.

The Danger of Falling from a Dysfunctional Gait Cycle

The first people we think of when we talk about dysfunctional gait cycles are older adults. And while it is true many older adults have problems with walking it is not limited to getting old. Sometimes this can be a real problem for much younger people too who may be recovering from a serious injury or perhaps disease like MS or a Stroke has greatly affected their ability to walk.

In all these cases finding ways to restore their ability to walk back to normal is vital for leading a quality life. Until it affects you or someone you know many of us do not realize how much our entire life will change if we lose the ability to walk.

We have covered specific exercises to enhance walking so make sure you check out our article – 6 Ways to improve Walking for the details of this. Included in the article is several examples of clients who we helped improve their walking ability after developing a walking impairment due to MS, spinal cord injury, car accident, and a stroke.

When you are in your 30's or 40's and you slip or trip your reactions are extremely fast. Your brain sends a very rapid response to adjust your centre of gravity, step forward, grab something and prepare your body into a safer position for impact with the ground. This all happens in the blink of an eye and is not a conscious thought. We do not need to train this skill when we are younger as we very active and constantly exposing our bodies to this ability in daily life.

However an older adult that has gradually become less active and is losing muscle mass, or someone who may have suffered an extreme lower limb injury and has lost their walking ability will have a much slower firing speed. As their brain recognizes this weaker signal it compensates by making several changes to how we move and adopts a stiffening approach to stabilizing.

People with poor balance often apply a rigid and stiffening strategy of locking the knees and straightening their legs and stiffening all their muscles to prepare for impact. This strategy makes falling inevitable and the consequences of one much more severe.

It is important to understand that this is not just due to getting old for the rate of decline varies greatly between people of the same age as we do not all age the same. A person in their 80’s who regularly exercises will be able to retain this skill much more effectively than the person who never exercises. It is not good luck they were able to retain their balance in their older years.

We have covered articles about falls prevention and balance training before and I suggest checking out the articles below for more detail about this.

You Must Use an Assessment to Know Where to Start

There is many things you would need to check to rule out problems affecting your walking ability so it is important to find someone experienced with movement assessments. You will find a great example of this full process in our article – How to complete a mobility assessment

You can also check out the video below that takes you through several gait specific exercises that we will discuss in more detail shortly.

My usual starting place is to use simple tests for mobility. The main areas to look at are joints like the ankle, knee, hip, thoracic, and even the shoulder. Lack of ankle mobility is a very common problem we see with walking impairments. When we walk we need at least 10 degrees of ankle dorsiflexion with maximum ankle dorsiflexion occurring during late mid-stance. Limited ankle mobility can lead to a chain reaction of compensations including midfoot pronation, knee hyper-extension and an early heel rise during gait.

If you have suffered an extreme loss of mobility at any of these joints you will have to compensate with ALL movements you make so it makes good sense to start here, as improving mobility is one of the easier things to begin implementing. Your first point of call will be to assess mobility at your joints.  

Secondly it is wise to evaluate stability and basic strength of muscles like the feet and the glutes as these will have a huge role to play in providing efficient walking movement. The big toe in particular has a massive role and many are not aware of the damage poor stability at the feet can cause to your walking.

See article – How the big toe influences your stability and movement

Limited hip extension can lead to abduction compensation and produce the classic over pronated foot type and abducted stance position. The stride length shortens and reduces hip extension and glute activation. You can see examples of this in the videos below.

 

Now what if you have do not have any problems with mobility or your basic strength and stability is pretty good, but you still have a walking impairment? Unfortunately this is very common and the reason is like we stated at the beginning that the problem is with the MOTOR PROGRAM. You have to change the program by working on things within the pattern itself.

This brings us to the more specific GAIT ASSESSMENT.

And this is where I would often begin my assessment process before doing anything. I know I just contradicted what I said in the previous section by saying it is best to start with mobility but I like to test the person with these tests first, before implementing the mobility and stability tests and then re-testing to see any improvement.

There are two tests I like to use and here is how they work.

Gait Assessment – 8 Levels

 

Make sure you watch the video above as I go through each of the 8 levels with one of our clients from our Stronger for Longer Older Adults Strength Training Program. You will need a partner to assist you and few pieces of equipment to do this test. A clear are to walk of approximately 10 metres, two cones, and 4 mini hurdles (you can use a small box or an object of similar size if you do not have any mini hurdles).

The scoring system works as follows.

The higher the score the better with the maximum score for each test being a three and the lowest score being zero. Your partner will need to evaluate you by reading the definitions of each score.

When you total your score anything above 22 is normal and minimal risk of falling. A score of 21 or less indicates there is a loss of stability and some degree of walking impairment that will expose you to falling.

I did not invent this test and found it many years ago in a course for older adults.

(References: Herdman SJ. Vestibular Rehabilitation. 2nd ed. Philadelphia, PA: F.A.Davis Co; 2000, and Shumway-Cook A, Woollacott M. Motor Control Theory and Applications, Williams and Wilkins Baltimore, 1995: 323-324).

The only problem I had with the test is the exercises to improve it were very ordinary at best, so to overcome this I have given you some suggestions for each test of what you could do.

Level 1 – Walking Normally on a Flat Surface

This is quite a simple test and is a good warm up for the client. It also gives the tester a chance to identify some gait abnormalities that they may want to keep an eye on in the later tests.

Instructions: Walk at your normal speed from cone to cone. Approximately 10 metres.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Walks 10 metres, no assistive devices, good sped, no evidence for imbalance, normal gait pattern
  • 2 Points - Mild Impairment: Walks 10 metres, uses assistive devices, slower speed, mild gait deviations.
  • 1 Point - Moderate Impairment: Walks 10 metres, slow speed, abnormal gait pattern, evidence for imbalance.
  • 0 Point - Severe Impairment: Cannot walk 10 metres without assistance, severe gait deviations or imbalance.

The first exercise you can try is standing on one leg for as long as you can. If you can do this easily try to do it with your eyes shut.

Level 2 – Walking with Changes in Gait Speed

This test is very important as it determines if the person can enhance either their STRIDE LENGTH or the STRIDE FREQUENCY to move faster. These are the two things people lose with walking impairments in order to provide more stability to the body. If they have adopted a dysfunctional gait for some period of time this will prove to be very difficult to get back. This test exposes deficiencies in both of these abilities significantly.

Instructions: Begin walking at your normal pace for a few metres, when I tell you “go,” walk as fast as you can a few metres. When I tell you “slow,” walk as slowly as you can a few metres.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast and slow speeds.
  • 2 Points - Mild Impairment: Is able to change speed but demonstrates mild gait deviations, or not gait deviations but unable to achieve a significant change in velocity, or uses an assistive device.
  • 1 Point - Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, or changes speed but has significant gait deviations, or changes speed but loses balance but is able to recover and continue walking.
  • 0 Point - Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught.

Once the test is completed I might come back to this and coach them through it by showing an increased stride length with arm swing or faster leg action to see if they can change their result from instruction.  If they cannot change the result I know I need to implement some specific exercises to enhance their strength and timing.

A simple example might be include an exercise like the toe touch drill to improve the balance of the stance leg. And to improve speed I might try a medicine ball throw.

 

It all depends on the person what type of exercise I choose but I know I need to expose them to challenges of balance for the stance leg and also speed.

Level 3 – Walking with Horizontal Head Turns

This test can be very confronting at first for the person who is very wary of their impairment. Taking your eyes away from the horizon while continuing to walk forces your proprioceptive system to engage and maintain balance and also your correct path.

A problem in this test and also the next one indicates a series of proprioceptive exercises will be very beneficial to this client. Things like standing on one leg with eyes shut will be perfect for a person with this deficit.

Instructions:  Begin walking at your normal pace. When I tell you to “look right,” keep walking straight, but turn your head to the right. Keep looking to the right until I tell you, “look left,” then keep walking straight and turn your head to the left. Keep your head to the left until I tell you “look straight,“ then keep walking straight, but return your head to the centre.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Performs head turns smoothly with no change in gait.
  • 2 Points - Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid.
  • 1 Point - Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.
  • 0 Points - Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside of path, loses balance, stops, reaches for something to grab onto.

One of my favourite drills to use for to improve this test and also the next one is the Inline Lunge drill which is performed on the floor in a kneeling position. Don’t be fooled by this as it can be quite a difficult drill for a person with walking impairment to complete. Even though they are already on the floor there is a real feeling of falling face first if you do not stabilize effectively. The key to the success of this drill is trusting the stability of the stance leg without being able to look at it.

The second component is the need for good hip mobility to achieve full flexion. Without either of these two things the person will find this almost impossible to complete. The best news is the risk of falling is negated as they are on the floor already.

 

Level 4 – Walking with Vertical Head Turns

Very similar to the last test although this one is a little bit more difficult. Once again if you spot any issues in this test you will know that a stack of proprioceptive work will benefit this client immensely.

Instructions: Begin walking at your normal pace. When I tell you to “look up,” keep walking straight, but tip your head up. Keep looking up until I tell you, “look down,” then keep walking straight and tip your head down. Keep your head down until I tell you “look straight”, then keep walking straight, but return your head to the centre.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Performs head turns smoothly with no change in gait.
  • 2 Points - Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid.
  • 1 Point - Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.
  • 0 Points - Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside path, loses balance, stops, and reaches for a wall.

Refer to the previous exercise drill for help with this one. If you have mastered this then try a static lunge. The picture below gives you some ideas of how to improve this and gradually progress.

Read the article - Why lunges are critical to fitness success to see more examples and videos of the lunge.

Level 5 - Walking with Fast Pivot and Turn

This test is the first to introduce AGILITY and more specifically the ability to slam on the brakes. The client must be able to react instantly to the command and have no fear in turning around as fast as they can. This is something we take for granted that we can always do, but a person with reduced balance and slow reaction times almost turns in a slow circle instead of a sharp brake and pivot. It is very important you take note of how fast they turn as anything slower than 3 seconds indicates an impairment.

Instructions: Begin walking at your normal pace. When I tell you, “turn and stop,” turn as quickly as you can to face the opposite direction and stop.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance.
  • 2 Points - Mild Impairment: Pivot turns safely in > 3 seconds and stops with no loss of balance.
  • 1 Point - Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop.
  • 0 Points - Severe Impairment: Cannot turn safely, requires assistance to turn and stop.

Exercises to improve this are ones that require you to BRAKE. One of the best ways to learn this is with a forward lunge.

Level 6 – Walking Over Obstacles

A continuation of the agility component and this one is the first time we see a much higher degree of HIP FLEXION required. Reduced hip flexion is a massive contributing factor with older adults who fall, so it is not surprising that this test may reveal the biggest weakness. If they do stumble pay very close attention to what they do to correct the fall.

Younger people with great balance will lower their centre of gravity by bending their knees to make big, fast movements that counteract the momentum of the fall. As we explained earlier older people with balance problems tend to do the exact opposite, and apply a rigid stiffening strategy of locking the knees and straightening their legs to brace for the fall.

This second strategy makes falling inevitable and the consequences of one much more severe. Loss of hip flexion will reveal this weakness that up to this point may not have been a problem. Apart from the last test I would rate this the most difficult and confronting for the person with stability problems.

Instructions: Begin walking at your normal speed. When you come to the hurdles, step over it, not around it, and keep walking.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Is able to step over the box without changing gait speed, no evidence of imbalance.
  • 2 Points - Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box safely.
  • 1 Point - Moderate Impairment: Is able to step over box but must stop, then step over. May require verbal cueing.
  • 0 Points - Severe Impairment: Cannot perform without assistance.

To improve at this test you need to be exposed to agility training. Use of speed ladders and hurdles are fantastic as they give instant feedback as to whether you lift your leg enough without any risk of injury. They are used in sports to make athletes faster but these same attributes can help prevent a fall by enhancing the positioning reflex skills needed to maintain balance.

The progressions and exercise choices for this are endless and you can see below how we might take this to a whole new level. The guy in the video below is 80 years of age and he demonstrates great skill in completing many exercises to enhance his stability.

 

He made many mistakes before he could get through the whole course without a stumble. The mistakes are a necessary part of the training to force the brain to make changes and adapt to the stimulus accordingly. If he was to slip in real life his brain would instantly call upon this training program in a millisecond to save him from falling.

Level 7- Walking Around Obstacles

Instructions: Begin walking at normal speed. When you come to the first cone (about 6’ away), walk around the right side of it. When you come to the second cone (6’ past first cone), walk around it to the left.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Is able to walk around cones safely without changing gait speed; no evidence of imbalance.
  • 2 Points - Mild Impairment: Is able to step around both cones, but must slow down and adjust steps to clear cones.
  • 1 Point - Moderate Impairment: Is able to clear cones but must significantly slow, speed to accomplish task, or requires verbal cueing.
  • 0 Points - Severe Impairment: Unable to clear cones, walks into one or both cones, or requires physical assistance.

Exercises to enhance this test include lateral lunges and wood-chop exercises. I like to use an exercise that mimics the activity of sweeping leaves to help the older client get used to moving laterally. A harder version is the mirror drill as seen in the video below.

 

Level 8 – Walking Up and Down Stairs

There is nothing very fancy or technical about this test as you are just observing how efficient they are at walking up stairs. For some walking down may be more of a problem, especially those with eyesight problems. Just like test number 6 this test may reveal a weakness that had not been seen for it does offer a significantly greater challenge.

The biggest difference here is the need for POWER! From age 65 to age 89, explosive lower limb power declines 3.5% every year which is much faster than our rate of decline with strength, which is 1-2% per year.

Read our article – Why Power Training is so important for more detail on this.

Instructions: Walk up these stairs as you would at home, i.e., using the railing if necessary. At the top, turn around and walk down.

Grading: Mark the lowest category that applies.

  • 3 Points - Normal: Alternating feet, no rail.
  • 2 Points - Mild Impairment: Alternating feet, must use rail.
  • 1 Point - Moderate Impairment: Two feet to a stair, must use rail.
  • 0 Point - Severe Impairment: Cannot do safely

Great exercises to enhance stairs are step up exercises. See the video below for an example of this.

 

This completes the gait assessment.

Add up your scores and see if you fall in the 22 – 24 point mark. Wherever you have lost a point is where you will use the test itself as an exercise to try and improve your score. Your goal is to eventually gain a perfect score of 24!

The second great assessment tool for improving the gait cycle that introduces different stability challenges is the LINE DRILL.

The Line Drill – 5 Levels

 

I love this drill as it is so easy to implement but provides such a great challenge to someone with walking impairment. The best part is the improvement is very rapid without a need for massive strength and the risk of falling is minimal.

This test has 5 levels of difficulty to achieve in order to pass the test.

Each level narrows the base of support and increases the coordination from the brain, the balance time on the stance leg, and flexibility for the leg swing. Speed and precise timing are needed to make the test efficient in the level 4 and 5 part of the test.

Exercises I would use to improve this include all the ones provided throughout the article. The toe touch drill and the lunge would be my favourite for this as a person who can demonstrate great strength and balance with these two movements will find this test fairly easy to do.

Do You Need More Help?

There is obviously a lot of information and great exercises I have not included in this article and I do suggest to grab a copy of our latest report that covers everything you need to know about older adults health. This report provides you with detailed pictures, instructions of over 50 exercises and some excellent workouts and tests to use for measuring your improvement. Many of the exercise pictures shown in this report are of clients who in their 70’s and 80’s who currently train with us at No Regrets. We also feature several of their stories for you to see how they changed their life by adopting the methods explained in this report. I hope you enjoy reading this and it helps you to enjoy your golden years.

 

 

Summary

The two gait assessments are both excellent exercise prescriptions for anyone with a walking impairment. It is important to know that many mistakes will be made in the learning process and this is perfectly fine. In fact the mistakes are great for they are providing the brain with the necessary information it needs to make adjustments to prevent falls out in the real world.

Try not to get frustrated and use the various exercise regressions shown throughout the article to improve your test result. Once you have restored your walking ability ensure you keep doing this test all the time so you do not lose the ability again.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

If you enjoyed this article, live in Melbourne and would like to organize a Free Consultation to discuss how we can help you improve your strength and movement fill in the form below and I will be in touch within 24 hours to schedule a time.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 14 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

  • Bending the Aging Curve -  Joseph Signorile
  • Movement - By Gray Cook
  • Functional Training for Sports - By Mike Boyle
  • Corrective Exercise Solutions - by Evan Osar
  • Athletic Body Balance by Gray Cook
  • Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
  • Low Back Disorders - by Stuart McGill
  • Back Pain Mechanic - by Stuart McGill
  • Anatomy Trains - by Thomas Meyers
  • Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
  • Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
  • How To Eat, Move & Be Healthy by Paul Chek
  • Scientific Core Conditioning Correspondence Course - By Paul Chek
  • Advanced Program Design - By Paul Chek