On a bright Southern California spring afternoon as I sped across the pedestrian crossing to make it to the other side, I couldn't take my mind off the elderly man with grocery bag walking across to make it to the other side.
I slowed down to make sure he was not the only one left on the road when the crossing light turned red. I watched as he struggled to get on the pavement. I politely offered to help and he hesitantly accepted. I remembered a similar instance last year when a 82-year-old woman in Los Angeles was ticketed by police for taking too long to cross the street.
As we walked to the assisted living home down the road, we started talking and he was amused to learn that I was a physical therapist. As we said goodbye, he said the walk had become difficult after a fall few weeks ago because he got blinded by the sun and stepped off the pavement.
Meeting Environmental Demands
I thought about the environmental demands put on the elderly in the community and do we the therapy practitioners think about it enough while they are under our care. Shouldn't therapists pay as close attention to aspects of mobility and associated environmental demands as physicians do to vitals and blood chemistry?
Mobility is the ability to move independently from one location to another. Since mobility is such an integral component of most activities of daily living, any adverse impact on mobility can lead to disability.1 Reduced ability to ambulate is one of the primary reasons of institutionalization among the elderly, and improved ambulation is also positively correlated to socialization. One definition of impaired mobility is the inability to walk a specified distance, such as 0.8 KM (one-half mile), and climb stairs without assistance.2
There are other definitions based around gait velocity. Through a literature review, this article will examine the aspects of mobility that must be attained during the treatment and further examine how the current practice trends needs to evolve further to focus on the environmental demands.
In my early days as a clinician, I had routinely used common discharge criteria, which was the ability to walk between three and five hundred feet. I have learned to question whether the ability to walk few hundred feet in a therapy gym or a corridor is a predictor of successful community living.
The environmental demands on community dwellers who are elderly are the same as for those who are younger. An elderly person must cross the street at the same speed as other pedestrians negotiate the same curbs and walk through the same grocery store aisles and parking lots. The distances that must be walked during these grocery-shopping trips vary between 1,110 and 1,500 feet.1
An ability to carry a package of between 6.7 pounds and 10 pounds is also required during these trips. Similar distance has been reported for trips to physician's offices. In a study by a transportation research board, 90 percent of elderly people from a group of 70 and older were unable to reach the definition of normal walking velocity (4 feet per second) as defined by manual on uniform traffic control device, which is used to design traffic lights.
All of these tasks occur while the associated environmental demands (e.g., traffic, rain, sun, terrain) are processed. It has been argued that an individual's functional capability is an interaction between environmental demands and restrictions in individual's ability. It becomes more clinically thought-provoking in geriatrics as more elderly clients choose to live in the community and routinely go shopping or to physicians' appointments unaccompanied. With the graying of America, this will have larger implication on public health policies.
When the Going Gets Tough
With aging, decreasing physiological reserves and the associated environmental demands, mobility becomes a challenging task. Decreased mobility increases dependency in completing ADLs by three to five times.1 Therefore, it falls upon therapists to prepare clients for successful community mobility by recognizing and carefully addressing all aspects of mobility while considering the complex environment.
For most of the elderly, walking is the only form of exercise. Interestingly, in some studies higher mortality rates has been reported to be correlated with walking less than one mile a week or less. With aging, the most commonly identifiable traits of gait are slower velocity, decreased stride length, decreased initial swing height, decreased control terminal swing, longer double support time, toeing out and wider BOS.3 Gait assessment and training is a component of plans of care for most elderly patients, and gait impairment is one of the most commonly self-reported disabilities by the elderly.
In clinical settings, gait assessment and intervention happens in a controlled low-stimulus, evenly lighted environment and most times on an even terrain and steps with bilateral handrails. The components of gait most often assessed are distance, pattern, device, assistance, endurance and sometimes speed and reaction time.
The goals most often revolve around the ability to ambulate few hundred feet with or without devices on even and uneven surfaces. With the constant threat of Medicare denial and in a managed care environment, case mangers often state that if Mrs. Doe can walk 50 feet, she can walk in her home, and thus can be discharged.
In a study, Lerner-Frakiel identified the mobility requirements for safe community ambulation in the Los Angles area, and recommended a gait speed of 259.18 per minute, the ability to walk a distance of 1,089.23 feet continuously, the ability to step up onto and down from a curb of six inches in height, and the ability to climb three steps and a ramp without using a handrail.2,4
However, most of the mobility associated with day-to-day community living happens in a very different environment of uneven terrain, constantly changing weather conditions and distractions such as oncoming traffic, crowds, sounds and so on.
Shumway-Cook et al presented a conceptual model in which attributes of physical environments are grouped into eight categories that include distance, time, ambient conditions (e.g., lights, levels, weather), terrain characteristics, physical load, intentional demands, postural transitions and traffic levels.2
A successful community ambulator has to continuously process these and ambulate at the same time. Therefore, for any clinical gait assessment and intervention to be functional and reliable, it must consider environmental factors.
1. Patla, A. Mobility in complex environment: Implications for clinical assessment and rehabilitation.
2. Shumway-Cook, A., Patla, A., & Stewart, A. Environmental demands associated with community mobility in older adults with or without mobility disabilities.
3. Sullivan, P., & Maros, P. Ambulation: A framework of practice applied to a functional outcome. Geriatric Physical Therapy, Second Edition.
4. Lord, S., & Rochester, L. Measurement of Community Ambulation After Stroke Current Status and Future Developments.
Amit Mohan is a physical therapist and rehabilitation consultant. He can be reached at firstname.lastname@example.org