Impact of Exercise to Improve Gait Efficiency on

Activity and Participation in Older Adults With

Mobility Limitations: A Randomized Controlled Trial
Jessie M. VanSwearingen, Subashan Perera, Jennifer S.
Brach, David Wert and Stephanie A. Studenski
PHYS THER. 2011; 91:1740-1751.
Originally published online October 14, 2011
doi: 10.2522/ptj.20100391

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Advances in
Disability Research
Impact of Exercise to Improve
Gait Efficiency on Activity and
Participation in Older Adults
With Mobility Limitations:
A Randomized Controlled Trial
Jessie M. VanSwearingen, Subashan Perera, Jennifer S. Brach, David Wert,
Stephanie A. Studenski
J.M. VanSwearingen, PT, PhD,
FAPTA, Department of Physical
Therapy, School of Health and
Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes
Tower, Pittsburgh, PA 15260
(USA). Address all correspondence to Dr VanSwearingen at:
jessievs@pitt.edu.
S. Perera, PhD, Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh.
J.S. Brach, PT, PhD, Department of
Physical Therapy, School of Health
and Rehabilitation Sciences, University of Pittsburgh.
D. Wert, PT, MPT, Department of
Physical Therapy, School of Health
and Rehabilitation Sciences, University of Pittsburgh.
S.A. Studenski, MD, MPH, Division
of Geriatric Medicine, Department of Medicine, University of
Pittsburgh.
[VanSwearingen JM, Perera S,
Brach JS, et al. Impact of exercise
to improve gait efficiency on activity and participation in older
adults with mobility limitations: a
randomized controlled trial. Phys
Ther. 2011;91:1740 1751.]
2011 American Physical Therapy
Association
Published Ahead of Print: October
14, 2011
Accepted: May 7, 2011
Submitted: November 15, 2010

Background. Definitive evidence that exercise interventions that improve gait also
reduce disability is lacking. A task-oriented, motor sequence learning exercise intervention has been shown to reduce the energy cost of walking and improve gait speed,
but whether the intervention also improves activity and participation has not been
demonstrated.

Objective. The objective of this study was to compare the impact of a task-oriented,
motor sequence learning exercise (TO) intervention and the impact of an impairmentoriented, multicomponent exercise (IO) intervention on activity and participation outcomes in older adults with mobility limitations. The mediating effects of a change in the
energy cost of walking on changes in activity and participation also were determined.

Design. This study was a single-blind, randomized controlled trial.

Setting. The study was conducted in an ambulatory clinical research training center.
Participants. The study participants were 47 older adults (mean age77.2 years,
SD5.5) with slow and variable gait.

Intervention. The intervention was a 12-week, physical therapistguided program of

TO or IO.

Measurements. Measures of activity (gait speed over an instrumented walkway;

daily physical activity measured with an accelerometer; confidence in walking determined
with the Gait Efficacy Scale; and physical function determined with the total, basic
lower-extremity, and advanced lower-extremity components of the Late-Life Function and
Disability Instrument [Late-Life FDI]) and participation (disability limitation dimension
and instrumental role [home and community task performance] domain components of
the Late-Life FDI) were recorded before and after the intervention. The energy cost of
walking was determined from the rate of oxygen consumption during self-paced treadmill
walking at the physiological steady state standardized by walking speed. An adjusted
comparison of activity and participation outcomes in the treatment arms was made by use
of an analysis of covariance model, with baseline and change in energy cost of walking
added to the model to test for mediation. Tests were used to determine the significance
of the mediating effects.

Results. Activity improved in TO but not in IO for confidence in walking (Gait Efficacy
Scale; mean adjusted difference9.8 [SD3.5]) and physical function (Late-Life FDI basic
lower-extremity component; mean adjusted difference3.5 [SD1.7]). Improvements in
TO were marginally greater than those in IO for gait speed, physical activity, and total
physical function. Participation improved marginally more in TO than in IO for disability
limitations and instrumental role.
Limitations. The older adults were randomized to the intervention group, but differences in baseline measures had to be accounted for in the analyses.

Post a Rapid Response to

this article at:
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Physical Therapy

Conclusions. A TO intervention that improved gait also led to improvements in some

activity and participation outcomes in older adults with mobility limitations.

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Improving Gait Efficiency in Older Adults With Mobility Limitations

ifficulty walking is associated

with reduced activity and participation, a path of decline
in physical and social function, and
a loss of independence.15 Walking underlies many activities of
daily living,6,7 and walking ability
(eg, gait speed) can be used to
predict future mobility and physical disability.6,8,9 Therapeutic exercise interventions for older adults
with mobility limitations have
focused on improving walking
(speed, endurance, and gait characteristics) as a means to reduce or
delay physical disability.10 12 Multicomponent exercise programs,
including strength, balance, walking,
and endurance, are intended to
reduce impairments and improve
physiological capacity for walking in
older adults. Such exercise programs
have resulted in modest gains in
walking ability (eg, an approximate
5% increase in speed, with a range of
0%16%),11,1323 with only one study
reporting disability outcomes (a
reduction in emotional disability).21

Do exercise interventions that

improve walking ability also reduce
disability? Keysor and Jette24 conducted a systematic review of the
effects of exercise interventions on
physical function and disability outcomes in older adults. Thirty-one
randomized controlled trials (RCTs)
of flexibility, strengthening, aerobic
conditioning, balance, and multicomponent exercise interventions
published between 1985 and 2000
were reviewed; 14 studies included
physical disability outcomes (even
fewer included social, emotional,
or overall disability outcomes), and
only 5 studies reported improvements in participation. The physical
disability findings varied. The effects
on physical disability were generally small to modest effect sizes and
mean differences; larger effects
were seen in older adults with substantial disabilities and in one study
of older adults with osteoarthritis.24
December 2011

We reviewed more recent RCTs of

exercise interventions for effects
on physical function and disability
outcomes in older adults.15,2528 Of
the 5 RCTs identified, 2 included
disability outcomes27,28; 1 study of
older adults with osteoarthritis
showed improvements in participation after interventions.27
Schrack et al29 and Ferrucci30 proposed an energetic model of frailty
in which the physical exertion of
walking with mobility limitations
may be a major factor in reduced
activity and participation (disability) in some older adults.2,31,32 In
older adults with mobility limitations, abnormalities in posture and
gait contributed to a greater energy
cost of walking (eg, inefficient gait),
with adjustments for age and gait
speed.33 Therapeutic exercise with
task-oriented motor sequence learning (motor skill)34 37 to improve the
efficiency of gait through training in
the timing and coordination of the
sequences of movements in walking
may be an alternative to traditional
multicomponent, impairment-based
exercise. For motor tasks, expert
movers, or those with greater motor
skill for a specific activity, tired less
easily than novices because of the
greater efficiency of skilled motor
performance.35,37,38 After a stroke,
task-oriented, gait-related exercise
treatment approaches enhanced the
efficiency of gait,39,40 the efficiency
of limb movement,41 and function in
daily activities.42 In people with multiple sclerosis, task-oriented, treadmill gait exercise reduced the effort
of walking.43 A task-oriented, motor
sequence learning, therapeutic exercise gait intervention reduced the
energy cost of walking and improved
gait speed more than an impairmentoriented, walking, endurance, balance, and strengthening exercise
gait intervention in older adults with
mobility limitations.44 Although the
task-oriented, motor sequence learning gait intervention appeared to

reduce energy cost and increase gait

speed, the impact of the intervention on activity and participation is
unknown.
Definitive evidence that exercise
that improves gait also reduces disability and, particularly, that exercise
that reduces energy expenditure
for walking positively influences
activity and participation is lacking. In an RCT of 2 gait interventions, we compared the impact
of task-oriented, motor sequence
learning exercise (TO) designed
to emphasize timing and coordination to make walking easierand
the impact of impairment-oriented,
multicomponent exercise (IO)
designed to emphasize strength,
balance, and endurance and correct
gait abnormalities to increase the
capacity to walk on activity and
participation outcomes in older
adults with mobility disabilities.
We also determined whether an
intervention-related change in gait
efficiency (energy cost of walking)
mediated changes in activity and
participation. We expected that an
exercise intervention that reduces
exertion and improves the ease of
walking also might improve activity
and participation in older adults with
mobility limitations.

Method
Overview
The study methods are described
in detail elsewhere.44 In brief,
we conducted a single-blind clini-

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Improving Gait Efficiency in Older Adults With Mobility Limitations

cal RCT to compare two 12-week,
protocol-driven, physical therapist
guided gait interventions based
on either TO or IO (to improve
the performance of body system
components) for older adults with
quantitative evidence of walking
difficulty. In the earlier report of
the RCT,44 the TO intervention
was referred to as timing and coordination (TC) exercise, and the
IO intervention was described as
walking, endurance, balance, and
strengthening (WEBS) exercise. All
participants gave informed consent
to participate.
Participants
The target population was older
adults with mild to moderate mobility difficulties. Potential participants
were recruited from the Pittsburgh
Pepper Center Registry of older
adults who were interested in participating in studies of balance and
mobility and who reported walking
difficulties. Eligibility was based on
the ability to walk independently
with or without a cane; medical
safety, including a personal physicians approval to participate in a
low- to moderate-intensity exercise
program; adequate cognitive function to provide informed consent
and participate in the exercise interventions (Mini-Mental State Examination [MMSE]45 score of 24); and
quantitative evidence of mobility
difficulties, defined as slow and variable gait (see below). Randomization
was based on a concealed block size
of 4. The study staff was unaware of
the randomization code, and participants were notified of their assignments at the first treatment visit,
after consent was given and baseline
data were collected. The flow diagram for the study is available in the
earlier report of the RCT.44
Measures
All measurements except demographic data were collected twice, at
baseline (before randomization) and
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after 12 weeks of exercise, by assessors who were unaware of treatment

arm assignments.
Descriptive Measures
Demographics and comorbid
conditions. Data on age, sex, level
of education, and coexisting medical
conditions were collected through
participant report. The Comorbidity Index46 was used to define medical history. Participants reported
whether a physician had ever told
them that they had any of 18 common conditions expected to influence physical function. Comorbidities were categorized into 8 domains
(cardiovascular, respiratory, musculoskeletal, neurologic, general, cancer, diabetes, and visual) and
summed to generate a summary
score from the report of the 18
conditions.46 Potential participants
also completed the MMSE measure
of general cognitive function.45
The MMSE was used to determine
whether potential participants had
adequate cognitive function to provide informed consent and as a
potential covariate in the analyses of
the findings.
Mobility performance measures.
Gait speed and variability were
recorded to determine eligibility to
participate. Potential participants
were instructed to walk at their
usual speed on a 4-m instrumented
walkway (GaitMatII, E.Q. Inc, Chalfont, Pennsylvania)47 with a 2-m noninstrumented section at each end
to allow for acceleration and deceleration. After 2 practice walks on
the mat, the potential participants performed 2 walks for data collection. Gait speed was defined as
the average from the 2 walks. Step
length variability and step width variability were derived from the standard deviations of all right and left
steps recorded during the 2 walks
and were reported as the coefficient
of variation, defined as (standard
deviation/mean step length or step

width) 100.48,49 Potential participants who demonstrated mobility

limitations, defined as slow or variable gait, were eligible to participate.
Slow gait was a walking speed of less
than or equal to 1.0 m/s and greater
than or equal to 0.6 m/s (slow, but
not so slow as to limit the ability to
participate in walking-based interventions). Variable gait was either
step length variability (coefficient of
variation of 4.5%)5 or step width
variability (coefficient of variation of
7% or 30%).50
Activity Measures
Gait speed. Gait speed outcomes
were previously reported44 but are
included in the present report (as
activity-level outcomes) to provide
a comprehensive description of
the intervention effects. The exercise interventions were designed
to improve gait; thus, information
on the intermediate outcome of a
change in gait speed may be helpful
in understanding the more distal
activity and participation outcomes.
Physical activity. To capture daily
physical activity, participants wore
a CSA/MTI Actigraph accelerometer
(Actigraph LLC, Pensacola, Florida)51,52 at waist level for 7 consecutive days from rising until retiring
to bed at night. Activity was reported
in counts per minute, representing mean activity counts per day,
divided by the mean minutes worn
per day, averaged over days worn.
Data were available for 44 participants, and all but 1 participant provided 6 or more days of monitoring.
Gait Efficacy Scale (GES). The
GES53,54 is a self-report 10-item scale
of perceived confidence in walking
ability. Individual items in the GES
are rated from 1 (no confidence) to
10 (complete confidence). The items
represent a range of challenges from
level walking to walking on uneven
surfaces, curbs, or stairs. The GES
total score is the sum of the scores

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Improving Gait Efficiency in Older Adults With Mobility Limitations

for the items, with a range of 10 to
100.53,54
Late-Life Function and Disability Instrument (Late-Life FDI)
function component. We used
the Late-Life FDI function component7 (scores for overall functioning, basic lower-extremity functioning, and advanced lower-extremity
functioning) to assess the relationship between perceived changes in
physical function and walking ability. The Late-Life FDI total functioning scale includes 32 items
about the usual ability to perform
physical activities that are typically
part of an everyday routine. The
basic lower-extremity functioning
subscale includes 14 activities that
mainly involve standing and essential walking. The advanced lowerextremity functioning subscale (11
items) involves more physically challenging activities and endurance.
The Late-Life FDI function component scales have scores ranging
from 0 to 100, with higher scores
indicating better function, and excellent reproducibility (intraclass correlation coefficient of .91).7
Participation Measure: Late-Life
FDI Disability Component
We used the Late-Life FDI disability component55 (scores for disability limitation dimension and
instrumental role domain) to reflect
changes in the ability to perform
socially defined life tasks. The disability limitation dimension includes
16 items about participation in
social, work, leisure, and travel activities and taking care of finances
and health. The instrumental role
domain reflects perceived limitations
in home and community tasks.55
The Late-Life FDI disability component scales have scores ranging
from 0 to 100, with higher scores
indicating less disability, and excellent reproducibility (intraclass correlation coefficient of .81).55

December 2011

Measure of Potential Mediation:

Energy Cost of Walking
The energy cost of walking reflects
gait efficiency and is defined as
the mean rate of oxygen consumption divided by walking speed.
Lower energy cost reflects higher
gait efficiency.38,56 Standardized
methods for determining the energy
cost of walking from the rate of
oxygen consumption during walking were established in previous
studies.39,57 61 The energy cost of
walking (mL/kgm)56,62 is a timeindependent, repeatable measure
of the physiological cost of gait63 65
and is influenced little by changes in
oxygen consumption related to aerobic exercise64,65; the energy costs
of walking can be compared across
individuals and over time, regardless
of changes in gait speed.60,64,65 Participants walked on a treadmill at a
self-selected pace while oxygen
consumption data were collected
with open-circuit spirometry and
expired gases were analyzed with a
Medgraphics VO2000 portable metabolic measurement system (Medical
Graphics Corp, St Paul, Minnesota).
The energy cost of walking was
calculated from the mean rate of
oxygen consumption during 3 minutes of treadmill walking after
the physiological steady state was
reached.38,62,63,65 We used the total
rather than the net energy cost of
walking as the measure of gait efficiency. Net energy cost requires a
correction for energy expenditure
at rest, different methods, and
more testing.66 Because we were
interested in changes in the energy
cost of walking over time and
because we expected resting energy
expenditure to be unchanged, we
used total energy cost to reduce the
burden of testing on participants.
The mean between-group difference in the energy cost of walking
after the intervention was previously reported.44 In the present
study, we used the energy cost of

walking as a measure of gait efficiency and explored the role of

changes in gait efficiency in changes
in activity and participation.
Interventions
General. Both interventions were
12-week, twice weekly, protocoldriven, physical therapistled programs for small groups of participants (n2 or 3). The interventions
were previously described.44 The
interventions were conducted at different times or on separate days to
avoid cross-contamination. Therapists received initial training in all
aspects of the protocols and were
assessed for adherence before intervention implementation and periodically throughout the study. The protocols provided operational criteria
for the exercise activities and standards for progression and allowed
for various individual levels of initial
performance and rates of change.
Progression was mandated after a
set of exercises were completed
with 80% accuracy and self-reported
ease of performance. The time spent
on walking itself was monitored to
equalize walking practice between
the treatment arms at 20 to 30 minutes per session. Detailed logs of
treatment sessions were maintained,
with biweekly reviews of a sample
of treatment logs for evidence of
consistency with the protocols and
progression.
TO program. The TO program
was based on principles of motor
sequence learning34,37,67 69 that
enhance skill or smooth, subconscious, and automatic control of
movement.35 The motor sequence
learning exercise involved taskoriented stepping and walking patterns to promote the timing and
coordination of locomotor stepping patterns, integrated with the
phases of the gait cycle to enhance
smooth movements in walking.67,70 72 Progression involved separately increasing the speed, ampli-

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Improving Gait Efficiency in Older Adults With Mobility Limitations

tude, or accuracy of performance
before advancing to a more complex
movement task.68,71 For example,
the progression of diagonal stepping
patterns was as follows: step forward across the midline of the
body at a self-selected pace in one
direction and then in the other
direction, increase stepping speed,
alternate the side of stepping, and
alternate forward and backward
stepping. Oval and spiral walking
patterns were used to incorporate
the motor sequence and interlimb
timing of the stepping patterns into
walking tasks. Walking patterns
were advanced by altering the
speed, amplitude (eg, narrowing the
width of the oval), or accuracy of
performance (eg, not straying from
the desired path). The complexity of
the gait exercise was increased by
instructing the participants to perform the gait activities while walking
past others and in combination with
upper-extremity tasks, such as carrying, rolling, bouncing, or tossing a
ball.67,68 To promote regular timing
of the stepping patterns, treadmillpaced walking practice was performed for 10 to 15 minutes. This
walking exercise was not targeted at
endurance training and did not
increase the rate of perceived exertion. The treadmill-paced walking
occurred primarily at the preferred
walking speed, with brief (30 60
seconds) repeated (35 times) intervals of increased speed followed by
a return to a comfortable walking
speed to reinforce the consistency of
the timing of stepping and speed.73
IO program. The IO program was
based on current standards of physical therapy for gait and balance
retraining. The impairment-based
exercise began with a brief warm-up
of gentle stretching exercises for the
leg (ankle, knee, and hip) and trunk
muscles. Strength training consisted
of lower-extremity progressive resistive exercises in sitting and standing
positions for lower-extremity muscle
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groups. Progression of the strength

training exercises involved increasing the repetitions to a maximum of
20 and then increasing the resistance. The resistance was provided
by cuff weights.
The balance exercises were performed by redistributing the center
of mass of the body over the base of
support.74 The balance exercises
started with the feet positioned at
the participants self-selected comfortable distance apart for upright
balance. With practice, the balance
exercises progressed to a narrower
base of support and less upperextremity support. The endurance
exercises were performed on a
NuStep (NuStep Inc, Ann Arbor,
Michigan) (which provides a seated,
stair-climbinglike activity) or on a
stationary bicycle.
The endurance exercise training
was conducted at a submaximal
workload, defined as a self-reported
rate of perceived exertion of 10
to 13, or a somewhat hard level
of effort.75 Heart rate and blood
pressure were monitored in accordance with recommended guidelines for safe exercise.76,77 Progression involved increasing the
duration of exercise (the ability to
sustain a somewhat hard level of
effort for up to 15 minutes) and
then on increasing the intensity of
exercise.
Specific gait training involved the
therapist giving verbal instructions
aimed at correcting abnormalities of
spatial or temporal characteristics of
gait or posture during walking (eg,
verbal cues to facilitate heel-strike or
push-off from the trailing limb and to
encourage participants to look in the
direction in which they were
walking).
Sample Size
The original RCT was designed as
a pilot study of 2 interventions and

the impact on measures of gait

chosen to represent the complexity
of walking, gait variability, and the
energy cost of walking. The sample
size for the original RCT was based
on having adequate power to test
for differences in measures of gait
variability. On the basis of data
from a preclinical trial of similar
interventions and mean changes in
the step length variability coefficient
of variation of 3.05 (SD1.45)
for the task-oriented exercise group
and 0.80 (SD2.80) for the
impairment-oriented exercise group,
a sample size of 2 groups of 16 participants would enable testing with
80% power. We included 25 participants in each intervention group
(for a total of 50 participants) to
account for a potential 20% dropout
rate for older adults with disabilities
and a mean expected age of greater
than 80 years and to account for
the potential wide variations in performance and inability to complete
some measures for older adults with
mobility disabilities. Given the pilot
nature of the original RCT and the
cost and burden of conducting an
RCT, we also measured activity and
participation outcomes. We report
the activity and participation outcomes of the original RCT here and
acknowledge that the original RCT
was not powered to study the secondary outcomes described.
Data Analysis
All statistical analyses were performed with SAS version 9.2 (SAS
Institute Inc, Cary, North Carolina).
Participant characteristics and baseline measurements in the treatment
arms were compared by use of t tests
for continuous variables and chisquare tests for categorical variables.
To make an adjusted comparison of
activity and participation outcomes
in the treatment arms, we fitted an
analysis of covariance model with
the change in each outcome from
baseline to follow-up as the response
variable; with treatment arm as the

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main factor of interest; and with
age, sex, and baseline value for the
outcome variable as covariates. To
obtain estimates of the mediating
effects of changes in gait efficiency
on changes in activity and participation outcomes, we fitted an analysis
of covariance model with the change
in each outcome from baseline to
follow-up as the response variable;
treatment arm as the main factor
of interest; and age, sex, baseline
value for the outcome variable, baseline value for the energy cost of
walking, and change in the energy
cost of walking as covariates. A
change in gait efficiency was considered to be a partial mediator of the
activity or participation outcome if
the betweenintervention group difference estimate was reduced with
the addition of the variable change
in energy cost to the analysis of
covariance. We used methods proposed to test the significance of a
mediating or indirect effect,78,79
including a bootstrap approach to
obtain confidence intervals for a
mediating effect.
In brief, the standard approach for
testing the statistical significance of a
change in an effect (ie, the between
intervention arm difference) is the
Sobel test, but it is based on certain
assumptions about the stochastic
independence of underlying random
variables. Although this assumption
facilitates mathematical derivations
required to obtain the necessary
formulas in an otherwise intractable
problem, it also makes the Sobel
test vulnerable to any violation of
the said assumptions. Statistical
bootstrapping is a relatively new
computation-intensive method based
on repeated Monte Carlo simulations
to obtain confidence intervals without
relying on restrictive assumptions.
Role of the Funding Source
This work was supported by the
Pittsburgh Older Americans Independence Center (NIA P30 AG024827)
December 2011

and a Beeson Career Development

Award (NIA K23 AG026766).

pated in at least 22 of the 24 treatment sessions.

Results

Activity Outcomes
After treatment, gait speed improved
with both forms of exercise (Tab. 1);
the improvement was marginally
greater in the TO group than in the
IO group. Physical activity increased
marginally more in the TO group
than in the IO group because of a
slight increase in activity in the TO
group and a slight decrease in activity in the IO group. Confidence in
walking, as determined with the
GES, improved 10.8 points in the
TO group but did not change in the
IO group. Physical function (usual
daily activities) improved in the TO
group but not in the IO group. Participants in the TO group demonstrated greater gains in basic lowerextremity functioning than those in
the IO group (Tab. 1).

Fifty participants were randomized,

and 47 completed the study23 in
the TO group and 24 in the IO
group. The 3 participants who did
not complete the study withdrew
because of medical conditions unrelated to study participation. The participants who withdrew did not differ at baseline from the participants
who completed the interventions.
The mean age of the older adults
completing the study was 77.2
(SD5.5) years (in the TO group, the
mean age was 76.5 [SD5.5] years;
in the IO group, the mean age was
78.4 [SD5.5] years), 65% were
women, 12% were black, 67% had
more than a high school education,
and all had generally good cognitive
function (mean Mini-Mental State
Examination score of 28.7 [SD
1.4]). On average, the participants
had few of the 18 comorbidities
surveyed (mean Comorbidity Index
of 2.6 [SD1.1]), and the comorbidities were predominantly in the
domains of arthritis (72%), vision
(66%), osteoporosis (38%), and hearing (32%). Most (72.3%) of the participants reported some difficulty
walking 2 or 3 blocks. All participants demonstrated slow gait (mean
gait speed of 0.85 [SD0.13] m/s)
and variable gait (step length variability of 78%; step width variability
of 78%).
Despite random assignment, baseline differences between the treatment arms were observed. Compared with participants in the IO
group, participants in the TO group
had a lower energy cost of walking,
fewer gait abnormalities, and nonsignificant but potentially meaningful
between-group differences in sex,
gait speed, and self-reported functional limitations. All 47 participants
who completed the study partici-

The between-group difference for

TO versus IO was large for confidence in walking, but for physical
function, the difference was small;
for gait speed, activity, and total and
advanced lower-extremity functioning, the differences were marginal.
Although clinically meaningful difference values for gait speed are
known,80 such values have not been
defined for activity, the GES, or LateLife FDI measures. Therefore, we
estimated meaningful differences
from the baseline sample data for
these variables by using Cohen effect
size criteria (eg, small effect0.2
baseline standard deviation; moderate effect0.5 baseline standard
deviation)81,82 and applied them to
the interpretation of the results. The
adjusted mean difference for confidence in walking was greater than an
estimated moderate effect size, and
the adjusted mean differences for the
remaining activity outcomes were
between small and moderate effect
sizes (Fig. 1).

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.6647
0.01 (0.10)
0.35 (0.10)
0.34 (0.09)
.0266
0.04 (0.10)
0.21 (0.06)
0.26 (0.10)
Energy cost of walking, mL/kgm

Gait efficiency (mediator)

cpmcounts per minute, GESGait Efficacy Scale, Late-Life FDILate-Life Function and Disability Instrument, Totaloverall functioning, Basic LEbasic lower-extremity functioning, Advanced
LEadvanced lower-extremity functioning.
b
Between-group mean difference at baseline.

.0002
0.10 (0.03)

.0844
6.5 (3.7)
.5474
1.1 (8.4)
66.7 (9.7)
66.1 (9.3)
.0955
5.1 (13.6)
72.3 (10.9)
Late-Life FDI instrumental role,
0100

77.4 (13.8)

.0984
5.3 (3.1)
.7107
0.63 (7.7)
67.2 (8.1)
67.1 (9.2)
.1303
4.1 (11.56)
76.7 (15.5)
72.7 (11.0)
Late-Life FDI limitations, 0100b

Participation

.0379

.1230
2.6 (1.7)
.4068

3.5 (1.7)
.6763
0.5 (5.6)

0.9 (5.4)

63.6 (7.4)

43.2 (6.2)
44.1 (6.0)

63.1 (7.6)
.0032

.2090
2.0 (7.3)

4.05 (5.9)

Late-Life FDI advanced LE, 0100

67.3 (10.02)
63.3 (10.8)

44.5 (12.3)

Late-Life FDI basic LE, 0100

46.4 (9.4)

.0081

.1154
1.8 (1.1)

9.8 (3.5)
.6504

.7106

.0970

1.3 (13.8)

0.3 (3.3)
54.8 (4.7)

71.3 (11.2)
72.6 (13.5)

54.5 (4.6)
.0508

.0065
10.8 (17.2)

2.1 (4.9)
57.0 (6.3)
54.9 (7.6)
Late-Life FDI total, 0100

80.3 (13.9)
69.5 (20.2)
GES score, 10100

0.07 (0.04)

15.5 (9.1)
.1304

.0002

10.9 (31.6)

0.14 (0.15)
0.96 (0.19)

110.8 (62.1)
120.6 (69.2)

0.82 (0.13)
.0001

.5915
3.5 (30.4)

0.21 (0.14)
1.09 (0.13)
0.88 (0.13)
Gait speed, m/sb

Activity

152.8 (53.5)

P
Change
After
Intervention
Before
Intervention
P
Change
After
Intervention
Before
Intervention
Measure

Task Oriented,
Motor Sequence Learning Exercise,
X (SD), n23

147.9 (56.3)

Adjusted
Group
Difference
(SE)
Treatment Group

Baseline Status and Postintervention Activity and Participation Outcomes by Treatment Groupa

Table 1.

We assessed the results for a mediating effect of the change in gait efficiency by examining the change in
the between-intervention difference
estimate due to additionally including the change in the energy cost of
walking as a predictor. The change
in gait efficiency partially explained
the intervention-related changes in
some activity and participation outcomes, based on the reduction in the
between-intervention difference estimate (Tab. 2, Fig. 2). The reduction
in the difference estimate due to
the change in gait efficiency represented a small meaningful change80
for the activity outcome of gait
speed. The adjusted mean difference
estimate increased for the Late-Life
FDI disability limitation and instrumental role outcomes, an indication
of no mediating effect of the change
in gait efficiency on the participation outcomes. The impact of the
change in the energy cost of walking on the between-group difference
in mean changes in activity and participation outcomes did not persist
when additional methods (Sobel test
and bootstrap confidence intervals)
were used to test the significance of
the mediating or indirect effects78,79
(Tab. 2).

Impairment Oriented,
Multicomponent Exercise,
X (SD), n24

Mediating Effects of Changes in

Gait Efficiency on Activity and
Participation Outcomes
Gait efficiency improved in the TO
group but did not change in the IO
group (Tab. 1, mediator; change in
the energy cost of walking).44

Activity, cpm

Participation Outcomes
The improvement in participation
was marginally greater in the TO
group than in the IO group (Tab. 1).
Values for both disability limitations
and instrumental role increased marginally more in the TO group than in
the IO group. Although the adjusted
mean differences for the participation outcomes were marginally significant, both exceeded a moderate
effect size for the measures (Fig. 1).

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Improving Gait Efficiency in Older Adults With Mobility Limitations

December 2011

Improving Gait Efficiency in Older Adults With Mobility Limitations

Discussion
The TO program led to greater gains
in some activity and participation
outcomes than the IO program.
These greater gains appeared to be
partially mediated by the improvement in gait efficiency; however,
these indirect effects could not be
substantiated by the formal statistical
tests of mediation.
Both task-oriented and impairmentoriented interventions improved gait
speed. The gait speed improvement
was equal to or greater than that
observed in previous exercise intervention trials for older adults with
walking problems.11,13,16,17,19 21,23
Only the task-oriented intervention
improved gait and improved some
activity and participation outcomes
for the older adults studied.
After the TO program, activity
improved in terms of daily physical
function, specifically, basic activities
of daily living involving the lower
extremities, and total physical function and participation improved marginally. The impact of the motor
sequence learning exercise on basic
lower-extremity functioning, with a
marginal impact on total physical
function and disability, may be secondary to the focus of the intervention on fixing gait. The motor
sequence learning intervention was
targeted at correcting deficits in the
muscle patterns of stepping and
integrating posture with the phases
of gait through task-oriented, progressive stepping and walking tasks
and treadmill-paced practice. Many
of the items on the Late-Life FDI
basic lower-extremity functioning
subscale represent stepping activities or short-distance, indoor walking,7 which most likely require path
adjustments to walk around objects
such as chairs and tables and turning
to enter or exit a room. Similarly,
the specificity of the exercise may
explain the better activity and participation outcomes after the TO
December 2011

Figure 1.
Between-group adjusted mean differences in activity and participation outcomes relative to small and moderate effect sizes for the variables. The radar graph provides an
overall view of the between-group differences in the activity and participation variables.
The adjusted between-group differences for each variable are plotted on separate spikes
of the radar. The thick solid line connects the adjusted between-group differences for
the variables. The estimated meaningful differences for each variable are represented as
small meaningful changes (area enclosed by the dashed line) and moderate meaningful
changes (area enclosed by the dotted line). The meaningful differences for each variable
were estimated by calculating a small effect as 0.2 baseline standard deviation of the
sample mean of the variable and a moderate effect as 0.5 baseline standard deviation
of the sample mean of the variable. The values for gait speed and activity were adjusted
by a multiple of 10 so that the same scale could be used in the axes for all of the
variables. For gait speed, the actual value was the value shown times 102; for activity,
the actual value was the value shown times 10. Asterisks indicate participation variables.
cpmcounts per minute, GESGait Efficacy Scale, Instrumentalinstrumental role,
Late-Life FDILate-Life Function and Disability Instrument, LElower extremity,
Limitationsdisability limitations.

program than after the IO program.

The diagonal stepping and curvedpath walking tasks emphasized in
the TO program are similar to
the steps, curbs, and indoor walking paths represented by the LateLife FDI basic lower-extremity
functioning items. Although the IO
intervention involved standing balance activities and lower-extremity
muscle strengthening and flexibility exercises specific for muscle
groups necessary for stepping up
onto curbs, rising from chairs, balancing while reaching, and providing stability while turning or

changing directions, this intervention was not goal oriented for walking and did not change basic lowerextremity functioning.
The motor sequence learning exercise also differed from the impairmentbased exercise in that the stepping
and walking patterns in the TO program were designed to facilitate the
implicit motor learning of movement patterns.37,83,84 The exercise
activities in the TO program were
all task oriented (eg, step across
and walk around cones [to form
an oval]), but there was no mention

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Improving Gait Efficiency in Older Adults With Mobility Limitations

Table 2.
Estimates of Adjusted Mean Between-Group Differences and Mediating Effects of a Change in Gait Efficiency on Difference
Estimates for Activity and Participationa
Estimate
(SE)b

P for
Estimate

Change in
Estimatec

Sobel Method Change

in Estimate (95% CI)

Sobel Method
P for Change

Bootstrap Method
Change in Estimate
(95% CI)

Gait speed, m/s

0.06 (0.04)

.16

0.055

0.030 (0.069 to 0.008)

.1255

0.031 (0.078 to 0.000)

Activity, cpm

16.9 (9.5)

.08

2.6

0.78 (6.27 to 4.70)

.7794

0.74 (6.91 to 4.71)

GES score, 10100

9.2 (3.7)

.02

1.3

0.81 (3.18 to 1.55)

.5001

0.82 (3.47 to 1.05)

Measure
Activity

Late-Life FDI total, 0100

2.6 (1.2)

.03

0.70

0.27 (1.04 to 0.50)

.4904

0.31 (1.46 to 0.42)

Late-Life FDI basic LE, 0100

4.6 (1.7)

.01

0.56

0.44 (1.58 to 0.70)

.4475

0.49 (2.14 to 0.59)

Late-Life advanced LE, 0100

3.9 (1.7)

.03

0.11

0.22 (1.30 to 0.85)

.6826

0.25 (1.62 to 0.80)

Late-Life FDI limitations, 0100

5.6 (3.2)

.09

1.5

0.15 (1.84 to 2.15)

.8804

0.13 (1.32 to 1.77)

Late-Life FDI instrumental role,

0100

6.4 (3.8)

.10

2.5

0.42 (1.94 to 2.77)

.7281

0.36 (1.38 to 2.32)

Participation

a
CIconfidence interval, cpmcounts per minute, GESGait Efficacy Scale, Late-Life FDILate-Life Function and Disability Instrument, Totaloverall
functioning, Basic LEbasic lower-extremity functioning, Advanced LEadvanced lower-extremity functioning.
b
Mean difference estimate for task-oriented, motor sequence learning exercise versus impairment-oriented, multicomponent exercise, adjusted for age, sex,
baseline value for the outcome variable, and baseline value of the energy cost of walking.
c
Change in the mean difference estimate, adjusted for age, sex, baseline value for the outcome variable, baseline value of the energy cost of walking, and
mean change in the energy cost of walking.

Figure 2.
Change in the estimates of the between-group adjusted mean differences explained by a change in gait efficiency. The black bars
represent the between-group mean differences in the change in each variable from baseline to follow-up, adjusted for the covariates
age, sex, and baseline value for the outcome variable. The gray bars represent the between-group mean differences in each variable
from baseline to follow-up, adjusted for the covariates age, sex, baseline value for the outcome variable, baseline value of the energy
cost of walking, and change in the energy cost of walking. A comparison of the gray bars with the black bars illustrates the mediating
effects of the change in the energy cost of walking on changes in activity and participation outcomes. The values for gait speed and
activity were adjusted by a multiple of 10 so that the same scale could be used in the axes for all of the variables. For gait speed, the
actual value was the value shown 102; for activity, the actual value was the value shown 10. Asterisks indicate participation
variables. cpmcounts per minute, GESGait Efficacy Scale, Late-Life FDILate-Life Function and Disability Instrument, LElower
extremity.

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Improving Gait Efficiency in Older Adults With Mobility Limitations

of which muscles to contract or
where to place steps or shift body
weight. The impairment-oriented
exercise facilitated improvements
in body systems that contribute to
the ability to walk, but the IO program was not task oriented and
was not designed to facilitate the
implicit learning of how to integrate
increased physiological capacities
with walking. Van Peppen et al42
reported a similar impact of taskoriented but not impairmenttargeted physical therapy exercise
interventions on functional outcomes after stroke. Although
impairment-targeted exercise interventions improved range of motion,
strength, and exercise tolerance,
only task-oriented exercise interventions improved function in tasks representing activities of daily living.42
Task-oriented, gait-related exercise
was described as being effective and
efficient in improving functional outcomes after stroke in a summary of
several systematic reviews of interventions to improve mobility-related
activities.72
The change in gait efficiency after
the intervention did not mediate the
changes in activity and participation
outcomes. The lack of mediation of
the outcomes by the change in gait
efficiency may be related in part to
how gait efficiency was measured.
Gait efficiency was derived from
the energy expenditure for walking
measured during treadmill walking.
Treadmill walking may not be representative of walking-based activities
and physical function in daily life.
The treadmill path is straight, and
the continuously moving belt drives
the stepping pattern of walking.
Physical activities typical of daily living (eg, cleaning house, taking care
of oneself, shopping, and visiting
others) in the home or community
can involve irregular paths, repeated
changes in acceleration, starts and
stops, and elevation. If the energy
cost of walking were measured durDecember 2011

ing the performance of physical

activities typical of daily living, an
improvement in gait efficiency might
be found to be a better mediator of
activity and participation outcomes.
Unfortunately, measuring the energy
cost of walking during the performance of physical activities typical
of daily living is difficult. The rate
of oxygen consumption must be
recorded at the physiological steady
state to be an accurate indicator
of the energy expenditure for the
activity. Achieving the physiological
steady state usually requires 1 to 3
minutes of continuous activity.38,63,65
The performance of many physical
activities typical of daily living does
not occur continuously for 1 to 3
minutes. Rather, the performance of
the activities usually is intermittent
or varies in level of intensity over
time.
The present study had several limitations. The study was powered to
detect differences in physiological
and performance measures of gait
but was not powered to detect differences in self-reported, more distal outcomes or to test mediating
effects.
The differences in the estimated
mediating effects across the methods
also warrant comment. The similarity of the results obtained with the
2 formal mediation methods (Sobel
method and bootstrap method) is
reassuring for the validity of the
Sobel method because it relies on
certain assumptions, whereas the
bootstrap method does not. The difference between mediating effect
results obtained with formal methods and a simple change in the effect
of an intervention is likely due to the
different estimation algorithms (optimizing different objective functions)
used to obtain the estimates, with
formal mediation analyses resulting
in more conservative estimates. Consistent results across all 3 methods
would have strengthened our results

and allowed us to make a more forceful conclusion regarding mediating

effects.
The older adults were randomized to
the intervention group, but differences in baseline measures44 had to
be accounted for in the analyses.
Although the Late-Life FDI functioning and disability component scales
were developed to measure changes
in activity and participation, some
of the items from each scale have
been found to be more representative of a different domain of activity
and participation than the original
domain to which the item scores
contribute.85

Conclusion
An exercise intervention that
improved gait also improved some
activity and participation outcomes.
A task-oriented, motor sequence
learning intervention targeted to
fix gait may have a greater potential to affect activity and participation. The mechanism of the effect of
such an intervention on disability in
older adults with mobility limitations
is not clear.
Dr VanSwearingen, Dr Brach, and Dr
Studenski provided concept/idea/research
design. Dr VanSwearingen, Dr Perera, Dr
Brach, and Mr Wert provided writing. Dr
VanSwearingen, Mr Wert, and Dr Studenski
provided data collection. Dr VanSwearingen
and Dr Perera provided data analysis. Dr
VanSwearingen provided project management and institutional liaisons. Dr VanSwearingen, Dr Brach, and Dr Studenski provided
fund procurement. All authors provided consultation (including review of manuscript
before submission).
This study was approved by the University of
Pittsburgh Institutional Review Board.
The data from this study were presented at
the Annual Conference of the American
Physical Therapy Association; June 8 11,
2011; Baltimore, Maryland.
This work was supported by the Pittsburgh
Older Americans Independence Center (NIA
P30 AG024827) and a Beeson Career Development Award (NIA K23 AG026766).

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Improving Gait Efficiency in Older Adults With Mobility Limitations

Trial registration: ClinicalTrials.gov Identifier:
NCT00177359.
DOI: 10.2522/ptj.20100391

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Volume 91 Number 12
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Physical Therapy f

1751

Impact of Exercise to Improve Gait Efficiency on

Activity and Participation in Older Adults With
Mobility Limitations: A Randomized Controlled Trial
Jessie M. VanSwearingen, Subashan Perera, Jennifer S.
Brach, David Wert and Stephanie A. Studenski
PHYS THER. 2011; 91:1740-1751.
Originally published online October 14, 2011
doi: 10.2522/ptj.20100391

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