Gait & Posture 30 (2009) 270–275

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Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Review

Obstacle crossing deficits in older adults: A systematic review

Brook Galna a,b,*, Alana Peters a,c, Anna T. Murphy b, Meg E. Morris a
a
School of Physiotherapy, Melbourne Physiotherapy School, Melbourne, 3010, Australia
b
Clinical Research Centre for Movement Disorders and Gait, Kingston Centre, 3192, Australia
c
Murdoch Children’s Research Institute, 3052, Australia

A R T I C L E I N F O A B S T R A C T

Article history: This systematic review and critical evaluation of the literature investigates whether advanced age
Received 15 September 2008 compromises obstacle crossing for unconstrained and time-constrained conditions. Eight electronic
Received in revised form 25 May 2009 databases were searched for articles with terms relating to obstacle crossing during walking in their title,
Accepted 30 May 2009
abstract or keywords. 15 articles were reviewed from an initial yield of 727 articles. The methodological
quality of each article was critiqued and data extracted by two reviewers. Young and older adults were
Keywords: shown to contact obstacles infrequently when adequate time was available to adapt foot placement in
Ageing
relation to the obstacle. When less time was available to adjust the foot trajectory, older adults contacted
Obstacle crossing
Accidental falls
obstacles more often than younger people. Older adults adopted a slower, more conservative obstacle
Gait crossing strategy. They demonstrated greater hip flexion during the swing phase of gait for the lead and
trail limbs as well as greater hip flexion, hip adduction and ankle dorsiflexion during the stance phase for
the lead and trail limbs. There was also evidence of reduced internal moments across the hip and ankle
during key events in the obstacle crossing gait cycle in older adults. Despite using a more conservative
obstacle crossing strategy, older adults are at greater risk of contacting obstacles for time-constrained
conditions.
ß 2009 Elsevier B.V. All rights reserved.

1. Introduction cognition contribute to age-related disorders in obstacle avoidance

A decline in obstacle crossing performance with advancing age
may be implicated in the higher incidence of trips and stumbles in
older adults [1]. Epidemiological evidence suggests that falls are
more common in older adults [2] and that trips frequently cause
accidental falls in older adults [1,3,4]. It is feasible that foot
contact with ground-based obstacles when walking can lead to
trip-related falls. Age-related changes in the way older adults
adapt their walking patterns to accommodate obstacles may also
put them at greater risk of contacting obstacles on the ground.
This systematic review and critical evaluation of the literature
investigates the extent to which advanced age compromises
obstacle crossing.
Two narrative reviews [5,6] and a book chapter [7] have
established that obstacle crossing can be compromised in older
adults. Kovacs found that age-related deficits in vision, proprio-
ception, visual-spatial cognition and attention can negatively
impact on postural stability and lower limb kinematics when
crossing obstacles [5]. Van Dieen et al. showed that vision and
[6]. Neither review provided conclusive evidence confirming that
healthy older adults were at greater risk of tripping on obstacles
when walking. The two reviews included studies that focussed on
participants walking over obstacles that were always visible [5,6],
however one study by Chen et al. argued slower reaction times in
older adults may impede their ability to avoid obstacles that
appear suddenly [8]. Confirmation of whether trips are more likely
in older adults under time-constrained conditions might assist
clinicians to better target trip prevention programs. A growing
literature provides evidence of age-related changes in the
spatiotemporal, kinematic and kinetic variables of obstacle cross-
ing. These findings help to explain age-related differences in
obstacle crossing performance.
The primary aim was to investigate whether older adults are
more likely to contact ground-based obstacles when walking
under time-constrained and unconstrained conditions. The second
aim examined whether older adults approach and step over
obstacles using different spatiotemporal, kinematic and kinetic
strategies than younger adults.

2. Methods

2.1. Search strategy

* Corresponding author at: School of Physiotherapy, The University of Melbourne,
3010, Australia. Tel.: +613 8344 4171; fax: +613 8344 4188. The search strategy was developed to identify all articles pertaining to obstacle
E-mail address: b.galna@pgrad.unimelb.edu.au (B. Galna). crossing in older adults. Eight online databases were searched in August, 2008. The

0966-6362/$ – see front matter ß 2009 Elsevier B.V. All rights reserved.
doi:10.1016/j.gaitpost.2009.05.022
 B. Galna et al. / Gait & Posture 30 (2009) 270–275
databases included CINAHL (from 1982), Cochrane library (from 1800), Embase
(from 1980), Inspec (from 1898), Medline – ISI (from 1950), PsycInfo (from 1806),
PubMed (from 1950) and Web of Science – ISI (from 1900). Targeted searching of
frequently cited journals, authors and article reference lists ensured that all
relevant articles were located.
To be deemed relevant for review, an article had to contain words referring to
walking, an obstacle and crossing in the title, abstract and keywords. As differences
in terminology and writing style exist between researchers, a list of synonyms was
used for each key term to identify all relevant articles. For example, the words ‘gait’,
‘locomotion’ and ‘ambulation’ were searched in conjunction with the word ‘walk’.
Key terms within the search strategy were also matched and exploded using
medical subject headings (MeSH) in databases such as Medline. Articles that are
related to animal studies, robotics, pulmonary obstruction, children, osteoarthritis
and amputees were excluded using another set of key terms. As an example, the
following search strategy was used with the Web of Science (‘‘*’’ indicates a
wildcard and ‘‘TS’’ indicates a search of titles, abstracts and keywords):
TS: (walk* or gait or locomot*or ambulat*)
AND TS: (obstacle* or obstruct*)
AND TS: (step* or cross* or negotiate* or adapt* or avoid*)
NOT TS: (child* or pulmonary* or obstructive* or osteoarthritis or amput* or cat or
animal or robot*)
The initial yield was obtained by combining all original articles from electronic
databases and targeted searches. Articles not relating to obstacle crossing were
excluded during an initial screening of titles and abstracts by the reviewer (BG). The
remaining abstracts were checked against the inclusion and exclusion criteria. The
full text of an article was examined if there was insufficient information contained
in the abstract to decide whether to include the article. There was one case where
there was insufficient detail in the full text article and the authors were contacted
for further details.
Agreement on article inclusion was reached by two reviewers (BG and MM).
Articles were included in the systematic review if they investigated a sample of
healthy older adults and younger adults walking over an obstacle. Only English
language articles were considered for analysis. It was beyond the scope of the
review to investigate other forms of adaptive gait such as turning, slips avoidance,
running or stair climbing. If a study investigated both obstacle crossing and another
form of locomotion, only details pertaining to obstacle crossing were considered.
Treadmill studies were excluded on the basis that gait adaptations for an obstacle
on a treadmill do not allow for natural spatiotemporal modifications to gait in
relation to the obstacle. Tripping studies were excluded because simulated trips in
previous studies were induced by the researchers rather than occurring naturally
[6].
2.2. Quality
The quality of each article was assessed independently by two researchers (BG
and AP) on the premise that ‘‘. . .it may limit bias, minimise errors and improve
reliability of findings. . .’’ [9,p. 93]. The quality of a study was defined as its capacity
to avoid potential bias and to generate results that were able to be generalised. This
definition encompasses both internal and external validity as dimensions of quality.
Internal validity refers to the accuracy of the measurements. External validity refers
to whether the results can be generalised to the population of interest [10,p 172].
It was predicted that many of the articles would have an ex-post facto design
[10,p 154]. This type of design compares different levels of an independent variable
that the researcher cannot actively manipulate, such as age. No valid and reliable
tools had been developed to assess the quality of such studies. A quality appraisal
tool was developed by the authors for this systematic review (Table 1). An accepted
generic tool for appraising the quality of a range of quantitative studies designed by
Law [11 p.305-308] was used in the development of the current tool. Additional
questions regarding whether potential confounding factors, such as strength and
walking speed, were controlled for when comparing age groups were included.
Questions focussed on internal validity, external validity and the ability for the
methods to be replicated. A scoring system was developed to quantify the quality of
each study and to assess the methodological strengths and weaknesses of the
reviewed articles. A similar quality appraisal scoring system has previously been
published [12]. Each question on the quality appraisal tool was scored out of one. A
score of one indicated high quality research and zero indicated lower quality.
2.3. Data extraction
Data concerning the sample and key results of each article were obtained
independently by two reviewers (BG and AP) using a data extraction form. Data
extracted from each article included the description of the sample and the key
results concerning obstacle crossing success, foot clearance, spatiotemporal, and
kinematic and kinetic measures of obstacle crossing in older adults. Obstacle
crossing success is reported as the ability of a participant to avoid any part of their
foot contacting an obstacle when attempting to walk over it, including stepping on
an obstacle.
271
2.4. Reliability of the reviewing process
To ensure the reliability of the quality assessment and data extraction tools, each
tool was piloted with a test article by two reviewers (BG and AP). A set of guidelines
and examples for completing article reviews were also provided to both reviewers
to improve inter-reviewer reliability. A third reviewer (MM) independently
identified discrepancies between the completed quality appraisal and data
extraction forms of the two reviewers (BG and AP). The consensus method
suggested in the Cochrane Systematic Review Handbook [9,p. 103] was used by the
two reviewers (BG and AP) to resolve discrepancies.
3. Results
3.1. Yield
The electronic database search resulted in an initial yield of 727
articles (Fig. 1), including 232 articles relating to obstacle crossing
in humans. Two original articles were sourced by hand searching
relevant journal titles, reference lists and frequently cited authors.
The final yield included 15 articles related to obstacle crossing in
older adults and young adults.
3.2. Quality assessment
Table 1 summarises the quality assessment for each article. The
articles stated the aims sufficiently, gave an appropriate descrip-
tion of the participants, stated the inclusion and exclusion criteria,
detailed the key outcomes clearly, employed a suitable methodol-
ogy for answering their research questions and discussed the
results of their study appropriately. Details provided were
adequate to replicate the research although methods for partici-
pant recruitment and sampling were not reported often. The
reliability of key outcome measures was only addressed in two of
the 15 studies and the internal validity of the key outcome
measures was only reported once. The clinical implications of the
research was also lacking in detail or clarity in seven studies and
not addressed in seven studies. Most investigations controlled for
height, age and gender but typically did not control for limb
asymmetries and strength differences between groups. No article
had particularly poor scientific quality so data concerning the
results were extracted from all articles.
3.3. Sample characteristics
The mean age for healthy older adults in each of the studies
ranged from 68 to 76 years in all except one study which recruited
participants between the ages of 84 and 93 years [13]. The mean
age of the control groups of young adults ranged from 22 to 28
years. Both male and female participants were recruited into each
investigation, except for one study that included only males [14]
and two that did not report the sex of participants [15,16].
3.4. Obstacle contacts and foot clearance
The number of obstacle contacts, time constraint and foot
clearance results are summarised in Table 2. 10 studies reported
whether participants contacted the obstacle. Of these, four
included time constrained conditions, where participants had to
avoid an obstacle that appeared suddenly during the walking trial
[8,17–19]. Obstacle contacts were more frequent in older adults
compared to younger adults under time-constrained conditions in
each of these studies. Obstacle contacts were reported in six
studies that did not constrain the amount of time participants had
to adapt to an obstacle. No obstacle contacts occurred for either age
group in four of these studies. In the two investigations that
obstacle contacts occurred, Chen et al. [20] reported four older
adults hit the obstacle and both an older and young adult contacted
the second of two obstacles in a study by Lowrey et al. [21].
 272
Table 1
Summary of quality appraisal for individual studies.

Question Scoring criteria Brown Brown Chapman and Chen Chen Chen Chen Di Fabio Draganich Hahn and Hahn Lowrey Lu McFayden McKenzie Average
et al. et al. Hollands et al. et al. et al. et al. et al. and Kuo Chou et al. et al. et al. and Prince and Brown
[23] [17] [15] [20] [18] [8] [19] [13] [22] [24] [25] [21] [16] [14] [26]

1. Research aims or 1 – Yes; 0.5 – yes, lacking 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

questions stated detail or clarity; 0 – no
clearly

2. Participants detailed Number 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Age 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 0.93
Sex 1 1 0 1 1 1 1 1 1 1 1 1 0 1 1 0.87
Height 1 0 1 1 1 1 1 0 1 1 1 1 1 1 0 0.80
Sub Total 1 0.75 0.5 1 1 1 1 0.75 1 1 1 1 0.75 1 75 0.90

3. Recruitment and 1 – Yes; 0.5 – yes, lacking 0 0 0.5 0.5 0.5 0.5 0.5 0.5 0 0.5 0.5 1 0 0.5 0 0.37
sampling methods detail or clarity; 0 – No
described

4. Inclusion and 1 – Yes; 0.5 – yes, lacking 1 1 1 1 1 1 1 0.5 1 1 1 1 0.5 1 1 0.93

exclusion criteria detailed detail or clarity; 0 – no

5. Controlled co-variates Height 0 1 0 0 1 1 1 0 1 1 1 1 1 0 0 .60

B. Galna et al. / Gait & Posture 30 (2009) 270–275

Walking Speed 1 0 0 1 1 1 0 1 1 1 1 0 0 0 0 0.53
Age 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Gender 1 0 0 1 1 1 1 1 0 1 1 1 0 1 1 0.73
Limb Asymmetries 0 0 1 1 1 1 0 0 1 0 0 0 1 0 0 0.40
Strength 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0.13
Sub Total 0.5 033 0.33 0.67 0.83 0.83 0.67 0.5 .67 0.7 0.83 0.5 0.5 0.33 0.33 0.57

6. Key outcome variables 1 – Yes; 0.5 – only some defined; 1 1 1 1 1 0.5 1 0.5 0.5 1 0.5 1 1 1 1 0.87
clearly described 0.5 – yes, lacking detail or clarity;
0 – no

7. Adequate methodology Participant sampling 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0.07

able to repeat study Equipment 1 1 1 1 1 0 1 1 0 1 0 1 1 1 1 0.80
Procedure 1 1 1 0 1 1 1 0 1 1 0 1 1 1 0 0.73
Data processing 0 0 1 0 1 1 1 1 1 1 1 1 1 1 0 0.73
Statistical analysis 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Sub total 0.6 0.6 0.8 0.4 0.8 0.6 0.8 0.6 0.6 0.8 0.4 1 0.8 0.8 0.4 0.67

8. Methodology able to Participant sampling 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

answer research question Equipment 1 1 1 1 1 0 1 1 0 1 1 1 1 1 1 0.87
Procedure 0 1 1 0 1 1 1 0 1 1 0 1 1 1 1 0.73
Data processing 0 1 1 1 0 1 1 1 1 1 0 1 1 1 1 0.80
Statistical analysis 0 1 1 0 0 1 1 1 0 1 1 1 0 1 1 0.67
Sub total 0.4 1 1 0.6 0.6 0.8 1 0.8 0.6 1 0.6 1 0.8 1 1 0.81

9. Reliability of the 1 – Yes; 0 – no 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0.13

methodology stated

10. Internal validity of 1 – Yes; 0 – no 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0.07

the methodology stated

11 Research questions 1 – Yes; 0 – no 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

answered adequately
in the discussion

12. Key findings 1 – Yes; 0 – no 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

supported by the results

13. Key findings interpreted 1 – Yes; 0 – no 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

in a logical manner which
is supported by references

14. Clinical implications 1 – Yes; 0.5 – yes, lacking 0.5 0 0.5 0.5 0 0 0 0.5 0 0.5 1 0.5 0.5 0 0 0.30
stated detail or clarity; 0 - No
 B. Galna et al. / Gait & Posture 30 (2009) 270–275 273

Fig. 1. Flowchart of articles included for review. The number under the text indicates the number of original articles (i.e. not duplicates) at each stage of the search.

Several obstacle crossing studies that were reviewed did not future obstacle crossing studies report the frequency and nature of
state whether any obstacle contact events occurred during testing. any obstacle contacts that occur.
Given the infrequent nature of obstacle contact events that occur There were conflicting results for the effects of age on foot
when conducting obstacle crossing studies, it is recommended that clearance. Both Chen et al. [20] and Lowrey et al. [21] reported that

Table 2
Summary of obstacle crossing success, time constraint and foot clearance.

Author Obstacle contacts Time-constraint Lead limb clearance Trial limb clearance

Brown et al. [23] No obstacle contacts occurred No – –

Brown et al. [17] Older adults contacted the obstacle more Yes – –
frequently than older adults, especially
when less time was given to adapt to the
obstacle Older adults contacted the obstacle
less often when walking on an elevated
surface than walking on the floor
Chapman and - No – –
Hollands [15]
Chen et al. [20] 3 older females and 1 older male stepped No No effects of age –
on an obstacle
Chen et al. [18] 4 trips were reported. 2 older females, Yes - –
an older male and a younger male fell
once each under time-constrained conditions.
Chen et al. [8] Older adults were more likely to contact Yes – –
the obstacle
Obstacle contacts were more frequent
when less time was given to adapt to
the obstacle
Chen et al. [19] Older adults contacted the obstacle Yes – –
more often than YA. Obstacle contacts
were more frequent when performing
a verbal RT task
Di Fabio et al. [13] - No - –
Draganich and – No – No effects of age
Kuo [22]
Hahn and Chou [24] No obstacle contacts occurred No – –
Hahn et al. [25] No obstacle contacts occurred No – –
Lowrey et al. [21] One older adult and one YA contacted No No effects of age No effects of age
the second obstacle in the two-obstacle
condition
Lu et al. [16] – No Toe clearance increased with obstacle height No effects of age
for older adults but remained constant for YA.
Older adults had higher toe clearance than YA
at obstacle heights of 20% and 30% of leg length
McFayden and Prince [14] No obstacle contacts occurred No Toe clearance was lower in older adults No effects of age
compared to YA.
McKenzie and Brown [26] – No – –

YA = Young adults, A dash indicates no results were presented.

274 B. Galna et al. / Gait & Posture 30 (2009) 270–275
lead limb toe clearance was unaffected by age. Lu et al. [16]
however, reported an interaction of lead limb toe clearance with
age and obstacle height, whereby older adults increased their toe
clearance with increasing obstacle height and younger adults did
not. Older adults had a higher lead limb toe clearance than younger
adults for higher obstacles. In contrast, another study demon-
strated that lead limb toe clearance was lower in older adults [14].
There was consistently no effect of age on trail limb toe clearance in
three studies [14,16,22]. Given the disparate characteristics of
experimental methodology and measurement of obstacle contacts
and foot clearance, a meta-analysis was not performed.
3.5. Spatiotemporal adaptations during obstacle crossing
The effect of ageing on spatiotemporal variables of obstacle
crossing was not consistent. Of the 13 studies that reported
spatiotemporal data, five reported no difference in spatiotemporal
variables between young and older adults [17,22–25]. In the eight
that reported differences, older adults walked slower during
obstacle crossing [13,14,15,20,21,26], with smaller steps
[13,14,18,21]. Older adults landed closer to the obstacle with
their lead limb after crossing in three studies [14,21] however, only
a significant difference between older and younger females was
reported in the study by Chen et al. [20]. In contrast, Lu et al. [16]
reported that older adults placed their foot closer to the obstacle
prior to crossing and landed further from the obstacle after
crossing. Older adults were more likely to take more steps to reach
an obstacle [13] and use a short step strategy compared to younger
adults [18]. A short step strategy was defined as the reduction of
step length in the step prior to crossing the obstacle [18].
3.6. Kinematics and kinetics
Six studies reported the kinematics of obstacle crossing. Brown
et al. [17] did not find any effects of ageing on kinematics. Chen
et al. [20] tested hip, knee and ankle range of motion during
obstacle crossing and when standing, holding onto a rail. The
standing condition was used to measure maximum range of
motion (RoM). The authors found lower limb RoM during obstacle
crossing was less than the RoM when standing and holding onto a
rail. They concluded that although older adults had a reduced step
length during obstacle crossing, it was unlikely that it was due to
their reduced lower limb RoM, because they did not use the same
lower limb RoM during obstacle crossing as they did during the
standing condition. Lowrey et al. [21] found that sagittal plane
trunk RoM was greater in older adults in the step prior to crossing
than younger adults.
Three articles reported age-related kinematic differences
during lead or trail limb clearance. When the lead limb toe was
over the obstacle, older adults had greater lead hip flexion and less
ankle eversion, whilst their trail hip was more flexed and adducted,
and the ankle in greater dorsiflexion [14,16]. When the trail toe
was above the obstacle, older adults had slower trail limb hip
angular velocities [22], greater lead limb hip flexion and adduction,
and greater lead ankle dorsiflexion [16]. Older adults also
demonstrated greater pelvic drop of the trail limb at trail limb
toe off and when the trail foot was over the obstacle, whereby the
pelvis was closer to the ground on the side of the trail limb [14].
Only two articles documented the kinetics of obstacle crossing.
Draganich and Kuo [22] reported that when older adults walked at
similar speeds to their younger counterparts, they had greater peak
trail limb hip abduction internal moments in early trail limb
stance. Peak trail limb hip abduction, knee abduction and ankle
abduction moments were also greater in older adults in late trail
limb stance. When walking speed was not constrained, McFayden
and Prince [14] showed that older adults tended to have reduced
internal hip extensor, hip abductor and knee extensor moments
during the stance phase of both lead limb crossing as well as
reduced ankle evertor moments for the mid stance phase of the
trail limb. Older adults also had reduced peak ankle power during
late stance and reduced eccentric hip abductor activity. The power
generated to raise the stance hip vertically at the end of stance
phase for the trail limb was reduced in older adults [14].
4. Discussion
Obstacle contacts were more frequent in healthy older adults
than young adults when there was limited time to avoid the
obstacle [8,17–19]. Treadmill studies have also shown that older
adults are more likely to contact obstacles when walking under
time-constrained conditions [27]. Older adults adopted a short
step strategy to avoid obstacles under time-constrained condi-
tions, which could increase the risk of stepping on an obstacle.
Using a short step strategy might also indicate an inability or
reluctance of older adults to walk with long steps [18].
There was little evidence to show that older adults contact
ground-based obstacles more often than younger adults when
ample time is given to adjust foot placement. In most of the
reviewed articles, older adults adopted a slower, more con-
servative strategy than young people when stepping over
obstacles when time was not constrained [13,14,15,20,21,26].
Adopting a conservative strategy with advancing age helps to
explain why so few obstacle contacts occurred during uncon-
strained locomotion. Walking slower could also provide older
adults with more time to adjust their foot placement in relation
to the obstacle in order to reduce the risk of tripping
[13,14,15,20,21,26].
In previous studies that reported the kinematics of obstacle
crossing, older adults were shown to be more flexed and adducted
at the hip during stance [14,16]. An analysis of joint powers
indicated that older adults demonstrated reduced eccentric
contraction of the stance limb hip abductors and vertical hip
power (defined as the power used to raise the stance hip) at toe-off
were both reduced in older adults [14]. Reduced hip abductor
strength may lead to pelvic drop during stance, effectively
lowering the height of the crossing limb. Age-related changes in
proprioception, vision and cognitive function are also potential
factors explaining deficits in obstacle avoidance [5,6,25], yet
further investigation of obstacle crossing under time-constrained
conditions is required.
Despite including only articles that tested healthy older adults,
it is unlikely that all of the participants were all free from age-
related conditions that influence the ability to cross obstacles. It is
possible that underlying deterioration in visual, orthopaedic and
cognitive systems associated with ageing might contribute to a
decline in obstacle crossing performance.
5. Conclusion
Healthy older adults contact obstacles more often than younger
adults when limited time is available to respond. It is possible that
more frequent contacts with ground-based obstacles during
walking may contribute to an increased risk of injurious falls in
older adults, although this requires empirical confirmation.
Conflicts of Interest
There are no conflicts of interest to disclose for any of the
authors.
 B. Galna et al. / Gait & Posture 30 (2009) 270–275
Funding
National Health and Medical Research Council of Australia
#466630.
Clinical Centre for Research Excellence in Gait, Australia.
Melbourne Physiotherapy School, Australia.
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