INCE DISORDERS (0749-0690 /96 $0.00 + 20 EFFECTS OF AGE ON THE BIOMECHANICS AND PHYSIOLOGY OF GAIT James Oat Judge, MD, Sylvia Ounpuu, MSc, ‘and Roy B. Davis II, PhD Walking is an integral part of many activities of daily living, such as shepping, traveling, visiting friends, cleaning. The goal of this article is to discuss how study of the kinimatics (motion) and kinetics (joint power and joint moment) can help describe and understand the changes in gait with advancing age. Classic studies and recent data that provide insight into age-associated changes in relatively healthy older persons are re- viewed. Most of the biomechanical studies have described how healthy older people walk compared with young people. There is much less in- formation or agreement as to why gait changes with advancing age. Po- tenlial directions for future research are also discussed. This work was supported in part by a grant from the National Institue on Aging: NIA AKI GmnSS601 From the Travels Center on Aging, University of Connecticut Health Center Faemington (JO}}; and the Gat Laboratory, Connecticut Children’s Medical Center, Hartond (80, BD), Connecticut (CLINICS IN GERIATRIC MEDICINE VOLUME 12+ NUMBER + NOVEMBER 906 658660 juvctet st GAIT DEFINITIONS (Figs. 1 and 2) Gait cycle (GC)—The period from the initial contact of the foot (“heel strike”) through stance and swing until the same foot contacts the floor, For timing purposes, 0% of the GC (notated as 0% GC) is initial contact, and other events during gait are defined by the per- cent of the GC when the event occurs. Figure 1 defines the portions Of GC The GC is fist divided into stance and swing phases. Stance ‘occurs from OY%-60% GC in adults. Stance is further broken down {nto four phases, termed the loading response (10% GO), midstance (10%-30% GC), terminal stance (3%-5% GO), and preswing (0% {60% GC). Toe offs the term for the transition between stance and Swing, although for some older persons the term foot off would be more descriptive. During stance there are brief periods of double Support (when both feet are on the ground). The first double support time is from 0% to 10% GC during the loading response, and the second double support occurs from 50% to 6% GC during pre- swing, The swing phase is divided into three phases; initial swing, tnid-swing, and terminal swing. Sirute lengti—The distance along the plane of progression during a complete gait cycle (ue, the distance from the foot contact of one leg to the foot contact of the same leg) step length—The distance along, the plane of progression from the foot contact of one leg to the foot contact of the opposite leg. When gait s symmetric, step Tength is 50% of stride length; when gait is symmetric, the right and left step length will differ, but right and leftsride lengths will be identical ‘Stride width The distance in the plane perpendicular to the plane of progression between the foot contact of the left and right loot Concentric muscle contraction—When the muscle shortens during muscle activation (force production). One example is how calf mus- cles shorten (contract concentrically) when one stands on toes, Con- centric muscle contraction generates kinetic or potential energy (ac- celeration or hifting) or does work (moves the body forwand or upward). eventrie muscle contraction—When the muscle lengthens during muscle activation (ce, calf muscles lengthen when one leans forward [contract eccentrially]; when descending a flight of stairs, the quad- riceps muscle lengthens while the body descends). Focentrie muscle contraction allows energy absorption by the body. Teint moment—A jolnt moment Is produced when a force, whic produced by a muscle ora ligament acts at a distance from the joint enter. This results in a net internal (or muscle) moment that rep- resents the body's response to an external load. The external load during walking includes the ground reaction force and the segment ‘weight. Joint moments quantify the net moment of all muscles cross- ingajointand usually indicate which muscle group iscominant. Joint moments in the sagital plane are expressed as flexor or extensor.: EFFECTSOF AGE ON THE BIOMECHANICS AND PHYSIOLOGY OF GAtT 661 Joint power—Joint power represents the rateat which workis done by the joint moment in producing or controlling joint rotation. Itis the product of joint moment and joint angular velocity. Joint power can sometimes be related to the type of muscular contraction. That is, a positive joint power is sometimes referred to as power generation, and is related to the dominance of the concentrically contracting muscle group. Conversely, a negative power may be referred to as power absorption, and is related to the dominance of the eccentrically contracting muscle group. PHYSIOLOGIC CHANGES. Gait is dependent on the capacity of multiple organ systems, specif- ically neurologic (sensory, motor control), musculoskeletal (muscle force, joint range of motion [ROM], posture), and cardiovascular (cardiac out- Put, orthostatic blood pressure). In the absence of coronary artery disease, ‘congestive heart failure, or severe deconditioning, cardiac output should not be a limiting factor in usual gait; however, in older men, usual and maximal gait velocity is strongly associated with fitness? The direct as- ion between normal gait velocity and fitness is consistent with the Fypothesis that a high level of physical activity can maintain fines and ‘usual gait velocity simultaneously. That is, a physically active lifestyle (which includes walking) will maintain gait by maintaining muscle strongth and by stimulating balance function. An alternative hypothesis, is that a primary impairment in balance reduces usual gait velocity, con- fidence, physical activity, and indirectly reduces fitness. Only long-term. cohort or intervention stuiclies will be able to determine the independent contribution of physical activity to the maintenance of balance and the independent contribution of balance to gat. ai oi eye Set Teor sae 09) Swing 40) anny woe |) Ty Vieng Bat | Tenia tcfs| sie |e st | ane | “rt Prep the at Figure 1. Gat eycl torminology (Adapted fom Pory J: Gait Analyia Normal and Patholog- ical Function. New York, Sack, 18982; wih permission)662 junc eta 100 a uo uc 8 uo ue Medal. baad Latent 604 Distance (em uo ue Lo uc | at 0 0 o 30 100 150 200 ise song te Line of Pogson cm) Figure 2. Plots ofthe deplacement of te total body center of mass (COM) of two oder {Subject similar step length, walking at normal page ovor one cide at eon rom above, ‘Shown with te corresponding Center of pressure (COP) tracings win the outines ofthe ‘Subjoets foot Tho uppor tracing in tik Ines raposents the priods of double suppest, ana the thin line represens periods of single suppor. Galt cycle evens are mnestod sequontally 485 right ital ontact (RIC), let oe of (LTO), leit inal contact (LO). ight oe off TO). “The top raping e of a eubjoct wou subjective moity cu; Pe botiom acing is from a subject wth moby complaints, Gat velocty inthe Upper tracing i 3 cm’, andthe bottom racing is 76 on. The side tang Is 95 cm in he upper tracing and 88 cm inthe bottom tracing, which i equvaent to 1-17 and 1.12 lg long, roepectvly. In the top tracing, he COM is never rec above the COP or within the outine ofthe stance fool, taorose in te Dotto tracing the COM fs within he ouling ofthe stance fot fr much of ‘single support Note aloo the prolenged third double eupport me onthe bottom racing NEUROLOGIC CHANGES ‘Sensory ‘There are striking age-associated changes in sensory function that may be important for gait. Although corrected visual acuity declines slightly with age, contrast sensitivity and edge detection also decreases markedly with age and are risk factors for falls and fractures.‘ Pressure sensitivity at the plantar surface also declines with age, and is associated with falls. Although the importance of sensory function is clear in pa- tionts with diabetic peripheral neuropathy who have marked gait im= pairments it is not clear how important age-associated sensory changes are in healthy older persons. MOTOR CONTROL AND BALANCE For this discussion, the term motor conto! will be used to represent the conto of joint moments and Joint power to move the bay. The motor control tasks used curing walking are to control the movement of the enter of mass (COM) a= progresses during the single support portion i sanee, alto control the movement ofthe swing leg and fot pace. ment, edeforward contol appears to be the dominant form of motorFFFICTSOF AGE ON THE BIOMECHANICS AND PHYSIOLOGY OF GAIT 663, control during gait. An example of feed forward control involves con- traction of muitiple leg muscles prior to foot contact (beginning at about 9% GC) Muscles must develop an adequate level of force before foot contact or the leg, will collapse on contact. ‘The major motor control task curing gait involves the control of the body during periods of single support. Although single support time is, lower in older subjects, it remains between 74% to 80% ofthe gait cycle. Figuie 2 describes the path of the calculated center of mass relative to the position of the feet in two older subjects, Periods of single and double support and the stance/swing transition are noted. The top tracing is of ar older subject without subjective difficulty with walking and walking at a velocity of 0.89 m/s with a stride length 95 em (1.17% leg length) and single suppor ime of 5% GC. The lower tracing sof suet with mobility problems and walking at a velocity of 0.76 m/s, with a stride length of 99 cm (112 X leg length) and a single support time of 35% GC. Although both subjects walk slower than usual, they spend 71% of the time walking in single stance. Note that for the subject without mobility complaints, the COM is never directly above the foot during petiods of single support. This means that the body is never stable during single stance. For example, in the top subject the body is initially “falling” fo-ward toward the stance foot and then falls away forward of the stance {foot until double support begins (initial contact of the opposite foot). Dur- ing the periods of double support, the COM is between the stance feet, which isa stable position. Fallers and persons with fear of fang increase dcuble support time, and double support time is strongly predictive of gait velocity and step length For an older person to feel safe while walking, the periods of single support cant be perceived as dangerous, Stability during walking, dur- ing both single support and double support, will be enhanced by the ability to control the muscle moments at all lower extremity joints. Smooth progression and stability during walking is possible through power gen- eration and absorption at all lower extremity joints. Power is simulta- neously generated and absorbed at different joints at different portions of the gait cycle, For example, energy is transformed between kinetic and potential forms by elevating and lowering the COM during single sup- port. Winter et al! proposed that controf of the summed leg extensor ‘moments (developed at the ankle, knee, and hip) during stance is a useful ‘measure of motor control during walking. Poor motor control may also be reflected in problems with foot placement (i.., the foot is placed me- dially or laterally, touches down early, or scuffs the floor)” Maki found that fallers had greater variability in step length and wider stride width than nonfallers in a prospective study. There have been many stucles that have demonstrated age-associated dleslines in static and dynamic balance function.‘ It is not clear which ba.ance test is most relevant to gai function. Static or quasistatic balance tests can measure control ofthe body in the sagittal plane (functional base ‘of support), in the frontal plane (semitandem, tandem stance), and com- bined sagittal and frontal (single stance). Many older persons cannot ‘meintain single stance‘ The response to perturbations of stance may pre-664 pupae etal dict the response to a near-loss of balance while walking. The ability to adjust step length to the sudden appearance of an obstacle may be very useful to identily older persons at risk for falls during walking.' MUSCULOSKELETAL CHANGES Muscle mass, muscle strength, and muscle contractility decline with advancing age, but older athletes maintain contractility, and the loss of muscle mass and strength is lower. Cross-sectional and longitudinal Studies have found that muscle strength is directly associated with gait velocity2"* Muscle strength is also associated with measures of static Ind dynamic balance: Postural changes, which are associated with loss in intervertebral disc height, thoracic kyphosis, and! weakness in the ab- dominal wall muscles may displace the center of mass relative tothe pel vis; definitive data are lacking, however. Tn the absence of severe hip or knee arthritis, he ROM during usual {gait does not approach the limits of passive joint range of motion for most joints. The joint motions that may be limited by musculotendinous tight- hess or articular disease include peak ankle dorsiflexion, peak knee ex- tension, and hip extension, GAIT CHANGES WITH AGING: VELOCITY AND TIMED MEASURES: Usual and maximal gait velocity are maintained until the seventh decade, thereafter declining at arate of 12% to 16% per decade for usual gait, and about 20% for maximal gait®; cadence (steps /min) is usually Lnchanged in advanced age-*=" Two consistent findings have been re- ported in studies that have compared galt in young and healthy older Subjects. Older persons walk slower because they have shortened their Stride length,+°” and they spend more time in siance and less in swing. Stride length at usual pace is 1% to 18% shorter in healthy older persons compared to young, persons! “®; stride length is 20% shorter at maximal pace® More fime is spent with both feet on the ground (double support) find less in single support.® Stance time (the proportion of the gait cycle with the foot on the ground) increases in men from 59% in 20 year olds to 63% in 70 year olds, which results in substantial increases in double support time from 18% to 26%." ‘The reduction in swing phase may be due to reduced muscle power to accelerate the swing leg, reduced power to propel the body forward, impaired motor control of the body during single support, or a combi- nation of these factors ts important fo remember that reductions in joint power may be the cause of the short step or the strategy used to reduce the stance phase (which results ina short step). Determining the indepen- dent effects of power and motor control, and determining the interactions between these two factors is important, but has not been reported. DisEITTCTS OF AGE ON THE BIOMECHANICS AND PHYSIOLOGYOF GAT 665 guishing the independent contributions of muscle power and motor con- {rol to gait is important to the design of rehabilitation efforts and primary prevention. PHYSIOLOGY OF Gal KINEMATICS Study of joint kinematics and kinetics in the sagittal plane has pro: vided much of the information on gait changes with aging. More recent studies have provided three-dimensional kinematics and kinetics that have improved understanding of gait. For this review of gait kinematics and kinetics, the database from a recent study of 26 healthy older subjects (mean age ~ 79 years) and 32 young adults (mean age = 26 years) are [presented to illustrate the points made in the text.” The kinematics results inthis database are similar to the results reported earlier by other inves- tigators.5**" Key variables are listed in Table 1 Figures 3, 4, and 5 present the kinematics ofthe joints and body sep- ‘ments inthe sagittal, frontal, and transverse planes during a complete GC ‘ofa normal adult, from initial contact (0% GC) until the following initial contact (100% GC). Reviewing these figures will help orient the reader to Figure 6, Figure 6 and Table 1 present the average kinematics from the database of young and older subjects. In this database, step length was 12% shorter in the older subjects after correcting for leg length differences (O74 + 0104 leg length in young patients compared with 0.65 + 0.07 in older patients), Te wo tracings in Figure 6 represent the grand mean of the young adult group and the older adult group (the gray area represents one standard deviation above and below the mean of the young adult group). On initial examination, the kinematics are notable for the similar- ity between young and older subjects. On closer inspection, there are sub- tle differences between the two groups at multiple joints in multiple planes. The stance phase takes up 61% GC of the older adults and 59% of Ein the young adults: The left column of Figure 6 represents the frontal plane (view from the front), the middle column represents the sagittal plane (view from the side), and the right column the transverse plane (view from the ceiling). ‘The older subjects walked with an upright torso, ic., without a for- ward lean [see Fig. 6 top row] but had greater thoracic curvature (data not presented). The torso motion in the frontal and transverse planes was similar in young and older subjects, Older subjects had greater forward tik of the pelvis (14 degrees + 6 degrees in older, 10 degrees + 5 degrees in young, P < 0,001), and a reduced range of pelvis motion in the frontal plane (6 2 degrees, 9 + 3 degrees P < 0.001) and transverse plane (7 2 degrees, 9 + 3 degrees [? = 0.002)]. Hip motion in the sagittal plane was shifted 3 degrees to greater flexion in the older subjects compared wth the young subjects, but flexion /extension and overall ROM was sim- iler. The combination of a 4-degree anterior pelvic tilt and 3degree hip flexion bias in older persons means that the orientation of the thigh rela- tive to the vertical axis was similar in young, and older subjects; the in-Sailapo seaitop s soutop 22 ‘oo Samar} sone OL Soups ——«sopo>—seashope’ "9 seabopg ve Swope, dono” Seamap =e seoibepy sb sooitepze —-—«sop0>—seatepe +2 or seolbons Fc tro scoops so ito Senin + ee soaibop 62 jov0> —seaiBapg = cs senitep S70 seaape = 6 So ceebapy a (sombop z¥"s0aop 3) soaepez —za00—seaiens + 61 oo ‘seaiboop =f (conten ¢'¢2)sondop ey 1050 SaaS BL 990) se wo eso oz wert sco o0d> so =990 sos opos Breet fe sin vo eo oat ao ree se we ape ia = w croiB by WAONY ‘sinpy eraro sby “no ‘SSUNSVINOLWNGNDIGNVSOUSHELOVEMND lOmENS TOREPntadorataon Figure 3 Kinamatics inthe sagital plane. The ordinate for his an alt eudsoquent raphe ‘a comploto galt yale (GC), or tide, whore 0% represents ina fot contact and 100% rial foot contact ofthe next sie. A. Pelvis the pelvis rotates pester (countr-cockwis om "he ight) during the loading response (2-0), and then rotates antenor (B-c) dug singlo ‘vapor. B, Hip the hip extends from inal contact unl terminal stance, but begin to ex ‘ring teminal stance. G,Kree: the kee llxes ding an ater loading response (a by extende during Siglo support (bc), and taxes dug torminal stan (oc, (Fem Our ' 8: Cinical gat analysis. n Spivack BS (od): Evaluation and Managemen ol Gat Dsor- ‘e's Naw York, Marcel Dekter, 1995; wih perrisson )O, Ane: he fet plata exes (2-0) ‘for inal contac, and thon doriloxos during stance (band rapidly plantar foxes during {eminal stance (cc. (From Ounpuu S: Creal gait analysis. fn Spvack BS (0): Evaluation {and Management of Gall Dsordars Now York, Marcel Doxko, 1085, pp 1=51; wh perm fen) ae668 JUDGE A etic sly Reef Figure 4. Kinematics inthe frontal plane. A, Pelvic obluly: the pelvis olates “up” relative fo the eving log (2-0) during the loading response and eary stance. The net eflect is 10 ‘educe the upward verical maton of the center of mass (CON). During mid and torminal ‘Stance, the pelvis flats “down which reduces the downward motion ofthe COM. B, Hip ‘Tho hp adducts during tho loading response ane early stance (2), and tnen abducts, par- ‘culty diring terminal stance (2) asthe COM is maving tothe opposite foot. (From Ounpwu 5: Clnea galt analysis: In Spwvack BS (ed): Evaluation and Management of Gat Disorders. Now York Marcel Dekkor, 1095, pp 1-81; wth pormision.) B Hab eduction ear creased hip flexion is due to the anterior pelvic tilt. In the frontal plane, the older subjects had greater hip abduction throughout stance phase andl early swing phase. Hip rotation was similar in both groups. Knee flexion during, 0% to 15% GC was similar in the two groups; however, older persons tended to have greater hyperextension during, midstance (~3 + 5 degrees) than young subjects (~ 1 ++ 5 degrees [P 0.06), andl overall ROM was lower in older subjects (55 + 5 degrees com- pared with 59 + 5 degrees [P < 0.001)) due to a reduction in peak knee flexion during swing phase (52 degrees in older, 58 degrees in young). ‘Ankle motion was similar during the loading response and midstance in the young and older subjects; however, there were significant differ ences in plantar flexion during terminal stance (50%-60% GC). The older subjects had 13 2 5 degrees peak plantar flexion compared with 17 + 5 degrees in the young subjects (P ~ 0.002). In the frontal plane, older sub- jects had greater external rotation of the foot, which is also termed foe out, throughout stance (16 + 5 degrees, 11 = 4 degrees [P < 0.001), To summarize, older persons take shorter steps, spend less time in single support, walk with their pelvis rotated anteriorly, hips slightly flexed, and feet toed out. Thoracic kyphosis is common, but healthy older people do not lean forward. There is reduced rotation at the pelvis, asEFFECTS OF AGE ON THE BOMECHANICS AND PHYSIOLOGY OF GATT 669 A Pv lation B Ho ett c Foot eatin € Figure 5. Tranevere plano. A, Pave relation: the mation ofthe polis rom abovo, demon sting sideroside ration, olaton, and forward movement. 8, Hip lan: theresa smal progression of tama rotaiton during stancs, and extemal rotation ung late stance and Sing. C, Foot rolaton the longtudnal exe ofthe fot is sight extrmalyroatod during Sanee (a, and oles internally during terminal stance. (From Ounput 5: Ciical gai anal Yyss: In Spivack BS (od) Evaluation and Management of Gal Disorders, New York, Marcel Dekker, 1005, pp 1-51; with pormicsion,) seen from the ceiling and from the front, and reduced plantar flexion during terminal stance. Ifa healthy adult assumes this posture (with some ‘@aggeration) and starts walking, he orshe may have a better understand- ing of how an older person walks. It will also help the reader understand the kinetics section that follows.670 juoceotat vs0 Obtaaty Taso Taso Raton Powe Obigay Peet Powe Rotten & J J Hip Paden Aéoten "Hp sn xa to a= cE _—_—— 4 | “| i | acdoa "Kowa Roxen tonton ‘ee rar Dereon Foot Popreecon | |] ] Figure 6. Gat kinematics of young and alder subjects. The stance phaso is fom 0% 0 60% gal cjels (60) Inthe young subjects and Oo 63% inthe det subjects. The lft pana Fopresont kinomatis into feral (corena) plan, the mide panel th eagitl plane, and the right panel the transverse plane (view from the cling). For both age groups. the mean land one standard deviation above and Dalow the maan are grapied. For young subjects, ne ‘mean value is the thick coi line, and the shaded area is = 1 SD. For older subjects, ean Valve the tick dashedtino, and ve thin sold tines are * 1 SD. (From Judged, Davis Re, Ounpuu S: Step length reductions in advances age The ole of ankle and ip sinetes Gerona in press.)| | EFFECTS OF AGE ON THE BIOMECHANICS AND PHYSIOLOGY OPGamT 671 Improving posture and strengthening abdominal muscles to reduce anterior pelvic tilt may play a role in maintaining step length and quality of gait in advanced age GAIT KINETICS Winter and others have proposed that kinetic analysis can help de- termine the cause of a short step length and increased double support in acvanced age.*** It is possible to estimate joint moment, power, and work atthe ankle, knee, and hip during walking, Theoretically, it may be pos- sible to identify why step length is reduced and double support is in- creased. In practice, itis very difficult to determine if reductions in joint power are the limiting factor or the motor strategy used to increase double support time (stability) that results in reduced swing time, slow velocity, ard step length. Figure 7 is the joint moment and joint power of the hip, knee, and anicle in the sagittal plane. Before exploring the specifics of the kinetics shown in Figure 5, it is worthwhile taking an overview of the power curves in the bottom row. The power curves of the hip, knee and arkle have portions where the instantaneous power is greater than zero, waich represent power generation at the joint, and areas below zero, ‘waich represent power absorption at the joint. joint power is the result (acithmetic product) of joint moment (torque) times joint angular velocity. For example, during mid-stance, the ankle plantar flexor moment is in- creasing, during which time the ankle is dorsiflexing (Fig. 7). Therefore, there is power absorption (eccentric contraction) at the joint. In terminal stance, there isa continueel ankle plantar flexor moment, but the ankle is antar flexing, resulting, in power generation (concentric contraction), Fech joint generates and absorbs poster at specific tines in the GC. The GC. is notable for the phasic characteristics of power generation and ab- sorption (Fig, 7). Power generation is greater at the hip and ankle com- pared with the knee despite the fact that the quadriceps (knee extensors) make up the largest muscle group. ‘The kinetics review begins atthe ankle and proceeds proximally. The ankle plantar flexes on initial contact (see Figs. 4 and 6) and then slowly drsiflexes during single support. During stance there is a progressive increase in plantar flexor moment, and the power curve demonstrates small amount of power absorption. The finding of power absorption with inereasing ankle plantar flexor moment while the ankle is dorsiflexing, ‘means that the plantar flexors are contracting eccentrically. The increasing, plantar flexor moment (from 10%-40% GC) is due primarily to the pro gression of the resultant ground reaction force acting atthe center of pres sure (COP) from the heel to the midfoot (Fig. 2 also illustrates the pro- gression of the COP under the stance foot). During single support, the COM moves toward the stance foot (ee Fig. 2) and then moves in front of the stance leg. The foot and the stance leg must provide stability to permit the COM to move in front of the foot. In terminal slance, ankle power is generated when the plantar flexors contract concentrically and72 junceetat Figure 7, Sagital plane Kinetics. The top row presents joint moment corrected for body ‘abe. The bottom row represents jon power. For the power graphs, the novizontal ine (0) siiferenites power absorption (negate values) and power generation (postive values). For Young subject, the mean vale fete hick so ne. ad the shaded area is = 1/80. For ‘Sider oubjete tha moan valuo i he thick dashed ne, and th hn sod ines are 1 SD. {Fem Judge J, Davis RB, Ounpuu S: Step length reductions in advanced age: The role of fnkle and np Kinetics. Gerona, a press) the heel lifts off the floor. Stability of the stance leg during single support requires sufficient eccentric and isometric ankle plantar-flexor strength (greater than 1.0 Nmv/kg in Figure 5). In diabetic patients with peripheral neuropathy (sensory loss on the plantar surface and plantar flexor weak- ness), advancement of the COP under the stance foot was reduced and peak plantar flexor power in terminal stance™*” was reduced 45%. When plantar anesthesia and plantar flexor weakness was induced experimen- tally by blockade of the posterior tibial nerve, the effects on gait kinetics ‘were comparable to diabetic patients with peripheral neuropathy.” Single stance time on the anesthetized leg was reduced, and the advancement of the COP under the foot, the plantar flexor moment, and the opposite leg step length was markedly reduced. There was sustained knee flexion and quadriceps electromyogram (EMG) activity during the stance phase, ‘Which is consistent with an attempt to stabilize the body at the knee. In late stance, ankle plantar flexors contract concentrically and prob- ably act both to accelerate the body forward and to accelerate the stance leg upward into swing. Toe flexors are estimated to contribute 30% of the power developed at the ankle.” Some texts have proposed that ankle plan- tar flexors are the primary muscle group to propel the body forward.**" Convincing data on the role of the plantar flexors in late stance have not bbeen presented, however. Ankle power generated prior to 5% of the GC (the time of initial contact ofthe opposite leg and the end of single stance) will probably contribute to the forward progression of the body, but after 50% GC, the contribution of the ankle plantar power may be primarily to accelerate the stance eg into swing, Note that the rapid rate of knee flexionEFFECTS OF AGE ON THE BIOMECHANICS AND PHYSIOLOGY OF GAIT 673 and power absorption atthe knee (K3) beginning at 50% of GC in Figure 2 will limit the propulsion of the body by the power generated at the ankle, ‘THE KNEE ‘The knee generates and absorbs low levels of power during gait, and the knee joint appears to flex primarily to improve the efficiency of gait but not to propel the body forward, After initial contact, knee extensor moment is greatest during the loading response as the knee extensors contract eccentrically and power is absorbed (K1), There is contraction of the hamstrings and knee extensors prior to initial contact to stabilize the knee? This is evidence of feed forward control, The muscles must be ac tivated before initial contact so that sufficient force is present to be able to respond to weight acceptance. During the loading response (0%~10% Gt), ke flexion and associated power absorption can be considered a shock absorber."**' Knee flexion during the loading response is potentially destabilizing, however. Knee flexion and knee extensor moment is great- est at about the beginning of single support (at about 10% GC). Persons with quadriceps weakness may be unstable standing on one leg with the knee flexed. For example, because patients with severe quadriceps weak- ness due to polio have no loading response, they keep the knee in full exlension or hyperextension during stance.” It is not clear whether the age-associated weakness in quadriceps strength will causes limitations in the loading response; however, in the authors’ database there was no difference in the kinematics of the loading response or in power absorp- tion between the two age groups (see Table 1). ‘There is little energy absorption or generation at the knee during single support. Power is absorbed during knee flexion in late stance/early siting phase (K3 in Fig. 3) and just prior to foot strike when the hamstrings decelerate knee extension." Knee flexion during swing phase is neces- sary for swing foot clearance and reduces the required pelvis elevation in the frontal plane, which may improve gait efficiency. THE HIP Hip extensors generate extensor power soon after initial contact (0%— 20% GC). This short burst of power propels the body forward and up- ward, During single support the hip i extending inital under concer trie control of the hip extensors. Alter about 25% GC there is a net hip flexor moment and power absorption (i. the hip is extending while the hip flexors are contracting eecentrcally and absorbing energy [see Fig. 6), The hip flexors then contract concentrically after about 55% GC, gener ating energy to accelerate the thigh and leg into swing674 juvceetat Kinetics of Late Stance Piece ocnnge vie are COMPARISON OF GAIT DATA BETWEEN YOUNG AND OLDER PERSONS: ‘A consistent finding, from kinetic studies has been that older subjects develop lower peak plantar flexor moment and plantar flexor power in terminal stance. Figure 7, which includes joint moment and joint power tracings in young and older subjects, illustrates this point. Peak ankle plantar flexor moment is reduced, as is peak plantar flexor power (2.9 0.9 W/kg in older subjects, 35 + 0.9 W/kg~’ in young subjects [? = 0.007). Peak joint power developed at the knee and hip extension were slightly lower in the older subjects, but the differences were small and nonsignificant. In contrast, peak hip flexor power (at 60% GC) wasslightly higher in older subjects compared with young, subjects (0.92 + 0.27 W/kg, 0.87 + 0.29 W/kg, respectively). After correcting for differences in step length, peak hip flexor power was 16% higher in older subjects (age effect 0.15 W/kg [P = 0.002)} than young subjects. This suggests that the older subjects may be compensating for reduced peak ankle plantar flexor power by increasing hip flexor power. Stated differently, older subjects developed significantly greater hip flexor power than young subjects after adjusting for the short step length in older subjects. ‘The relationship between joint power and Step length was examined ina multivariate linear regression where peak power ofall eg joints were included in the model. Older subjects took significantly shorter steps G cm, partial ® for age group = 0.15 [P < 0.001)) than young subjects after correcting for differences in joint power. These data suggest that joint power is not the only reason older subjects take shorter steps. The 15% of the variance in step length explained by age group probably represents the effect of balance, seléconfidence, and possibly, lower gait efficiency. ‘Maximal Gait Winter found that when young adults walk at their maximal pace, ppeak joint moments and peak power increase substantially inal joints, For example, peak ankle plantar flexor power increased 38% (from 3.4 W//kg- 47 W/kg) at maximum pace. In contrast, five older subjects in the data- base presented here did not increase peak ankle plantar flexor moment (14 = 3Nm/kgor peak ankle plantar flexor power at maximal pace (3.1 +EFFECTS OF AGE ON THE BIOMECHANICS AND PHYSIOLOGY OF GAIT 675 12 W/kg at usual, 32 -t 1.5 W/kg at maximal). The older subjects in- creased hip flexion power by 72% at maximal pace (1.1 + 3 W/kg at usual, 1.9 + 1.0 W/kg at maximal [P < 0.05]). Therefore, itis possible that the reductions in ankle power found in several cross-sectional stuclies are responsible for at least part of the reduction in step length associated with advanced age. Older subjects appear capable of increasing hip power to walk faster. Gait Efficiency/Energy Transfers During gait there isa cyclical transfer between potential and kineticen- cergy.*In early stance (10%-20% GC) the COM moves upward as the hip &x- tends, The vertical elevation of the COM increases the potential energy of the body. During late stance the COM descends and the potential energy is converted into kinetic energy: ‘Murray et al found that older subjects had reduced vertical move- ment of the head during gait, suggestive of lower potential energy de- velopment during carly stance. Healthy older subjects had lower effi cieney during treadmill walking (older subjects consumed 25% more ‘oxygen [mL O, kg? m-*] during treadmill walking at a variety of tread ml speeds compared with young subjects). The older subjects” preferred {it speed was in the range of the most efficient gat speed. Stride length Was 6s to 10% shorter in older subjects at various Velocities: Itis possible that the shorter stride is less efficient. In the database presented here, multivariate analysis determined that the older subjects had a step length that was about 5 em shorter than expected based on peak joint power measured at al joints ‘There are several models of gait that have tested whether efficiency isa goal and determines the pattern of muscle contraction and body move- ment. These models are termed optimization modes. Collins’ tested mult ple optimization models in healthy adults and found that instantaneous muscle power, muscle force, muscle force squared, and intra-articular con- tact force were all “minimized” during walking. Knee ligament strain was the only outcome that dic not appear to be minimized, Collins also found that there was redundancy. There were at least six solutions oF patterns ‘ofmusele activation that could minimize muscle force, power, or articular contact force during every part of the Gd. The redundancy of solutions Suggests that older persons may have many solutions to substitute muscle force or muscle power to accommodate weakness in a particular muscle group of to reduce intra-articular contact force to minimize pain from arihnits, There are no studies that have described what older persons optimize during walking. Older persons may try to maximize efficiency, stability, or safety" Some older persons may try to maximize velocity whereas ‘others may try to maximize time or distance walked before fatigue. Max- inizing stability or velocity may result in very “inefficient” gat676 juvcretal CONCLUSIONS Gait kinematics and kinetics studies of healthy older persons have provided useful data on changes in gait associated with advanced age. Older people walk with short steps, spend less time in single support, have less motion at the pelvis and ankle, and generate less power at the ankle. Older persons appear to attempt to compensate for ankle plantar flexor power weakness by generating greater power using their hip flexor muscles. Interventions that improve ankle power and. correct postural changes (noted in the kinematics section) have promise to improve or ‘maintain step length and gait velocity in advanced age. FUTURE WORK Studies to date have been too small to explore performance within older subjects or to explore the impact of specific diseases, with the ex- ception of arthritis. There are very limited data on gait in frail older per- sons, who are at highest risk for falls and loss of independence." Research has also been hampered by a lack of definition ofthe relevant motor con- trol tasks during walking and how to measure motor control. Several measures of gait motion or gait Kinetics have been proposed to serve as indicators of motor control. Winter etal have proposed that an index of dynamic stability (derived from the assumption that overall Stance leg extension moment should be constant during stance) will be useful. Investigators are determining if variability (using timing, stride ‘width, and stride length) will provide clues to impairment in motor con- trol during gait* For example, one prospective study found that stride length varlability (not stride length) was a risk factor for falls Others are using accelerometers to determine if frequency components of body motion (harmonics ofthe step and slride cycle) wil provide insight into motor control" Alexander’ has explored obstacle avoidance patterns dur- ing goit. Although all of these methods are promising, there is not suffi cient experience to decide which measures will add useful information. “The gait lab may prove to be most useful in future intervention stud- ies where targeted interventions (balance, strength, endurance) can be as- sessed for effects on gait kinetics, particularly on ankle plantar flexor power and hip flexor power References 1. Alexandee Nile diagnosis of gait isondrs in older ads, Cin Get Med te 1990 1. Anlanceon A, Rundgren A, Sperling L: Evaluation of functional capacity in atti of dduiyUving in POyeucakd nen ant women, Scand | Rehab Med IE 15°15, 190 3. eral Mf Pern Me Muscle eng nthe tripe sae aa objec memsured fKstomary walking activity in men ad women ove 6 years Of age hin (Caen) Feas9, 1988 4. Bohannon Ry Larkin PA, Cook AC; tal: Decree in timed Balance test cores with ein Phy ther 1067-107, 1988FFFICTS OF AGE ON THE BIOMECHANICS AND PHYSIOLOGYO# GAIT 677 5 Campbell A], Bone IM, Spee GF. 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Kory RC, Cason BH: Walking pater n ety ld men. } Garon Dees 29 Nevit MC Cummings SR, Kid eta Risk factors for recuret rons ncopl alls A prospective study) Am Caria Soc 21266-20009 ax. Bartwaly KM, Sncwearingen IM, Busdelt RG, a A comparison of gait charac ites in yong ae old sje Phys Ther 79a, Yoo 21, Ouran’ The baomectants of walking and running Clin Sports Med 1343-86, 194 52. Penry Gat Analysis Nonal and Pathgkal Function. New York Slack, 1992 38. Pet) Mulroy 3) Renwick: SE: Te elton olor exert eng and gait ‘armiter in patents with post pai syndrom Ach Phy Med Rehab 74.165-18) i 20 2678 junce eat Ne aa ra alee a eS a Ee en A Caen ee ea veces acu ph Hc fice ee eo ee ee i piieriaciniypltj eet Set aE oe eng ely pena ig oO REE Laas cic acd pa i Des Deere ets eee eee ea Pg peepee heer hha ie er ae eee oa acess ere Mesh at oS ee eae eae geo Address reprint requests to James Oat Judge, MD. “Travelers Center on Aging University of Cannacicwt Health Centr 263 Farmington Ave Farmington, CT 06690-5215,