University of Groningen Effects of lower extremity power training on gait biomechanics in old adults Beijersbergen, Chantal

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Effects of lower extremity power training on gait biomechanics in old adults

Beijersbergen, Chantal

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Beijersbergen, C. (2017). Effects of lower extremity power training on gait biomechanics in old adults: The Potsdam Gait Study (POGS). Rijksuniversiteit Groningen.

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Chapter 1

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Chapter 1

General introduction

1. GENERAL INTRODUCTION

Level walking gait is the most common form of human locomotion and is an integral

component of many daily tasks. Habitual gait velocity, i.e., the speed at which a person

chooses to walk given no specific instructions or environmental limitations, is an accurate

measure of health and function and is easy to administer. Indeed, slow gait is a predictor of

adverse clinical events, such as falls, declines in mental health, cognitive functioning, and

even all-cause mortality [1–8]. Additionally, slow walkers have greater risks for mobility

disabilities, dependency, institutionalization, and hospitalization, which all cause a decline

in quality of life [1,5,9,10]. Habitual gait velocity is relatively stable throughout adult life

until the seventh decade; thereafter, gait velocity decreases by 7-20% per decade [11].

Specifically, a healthy 25-year old generally walks at 1.38m/s compared to 1.29m/s at

age 65 and 0.96m/s at age 85 [11]. In view of the increasing portion of elderly people in

the population due to an increase in life expectancy, maintaining adequate levels of gait

velocity and delaying the onset of mobility impairments have become universal health

care priorities.

It is well established that exercise training is an effective tool for increasing

walking speed in old adults [12]. However, the biomechanical mechanisms responsible

for improvements in old adults’ gait velocity after exercise training are not understood.

More insights into the involved mechanisms can increase the effectiveness of exercise

interventions that aim to attenuate the age-related reductions in mobility function.

1.1. HISTORICAL BACKGROUND

The present-day knowledge of the effects of age on the mechanics of human locomotion

is due to the contributions by many scientists. Until the mid-nineteenth century, a lack

of technology limited the objective recording of human gait and locomotor studies

were based on primarily anatomical knowledge and empirical evidence [13–15]. In

the mid-nineteenth century, the Weber brothers [16,17] studied human gait using a

telescope with a calibrated graticule and provided the first objective experiments. By

the end of the nineteenth century, Muybridge [18] developed photographic methods

to record instantaneous pictures of locomotion displacements. Marey and his group

[19–22] improved these methods and developed the first version of the modern force

plate using a pneumatic mechanism. Shortly after, Braune and Fischer [23–27] employed

fundamental mechanical principles and performed a variety of kinematic and kinetic

studies on military personnel carrying backpacks and their methods of study are still

recognized as valid today. In the mid-twentieth century, Inman and Eberhart [28,29]

used kinesiologal electromyography (EMG) to relate muscle function to joint motion

and phases of gait in disabled populations. From that point on, gait analysis became a

useful clinical tool through the efforts of Perry [30–32] and others [33–36]. Around

1980, David Winter’s pioneering work [37–40] profoundly influenced the course of

clinical gait analysis as he popularized the routine use of inverse dynamics to compute

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laboratories operating around the world today and gait analysis has been increasingly

used for both clinical and research purposes.

1.2. THE ELDERLY GAIT

The gait pattern of an elderly person is different from that of a young adult. It is

characterized by a stooped posture, increased knee and hip flexion, reduced ankle joint

ranges of motion, diminished arm swing, increased time with both feet on the ground,

and wide and short steps [41–47]. The kinetic changes associated with these age-related

changes in kinematic pattern include reduced torques and powers at all three lower

extremity joints, and especially so at the ankle [43,45,46,46,47]. Because kinematic

and kinetic patterns are a function of stride length and velocity [43,48], later studies

compared gait biomechanics of young and old adults walking at identical speeds. These

studies revealed that shorter steps, higher cadence, larger hip joint range of motion,

and reduced ankle joint range of motion in the elderly were still present when walking

speeds were matched [49–52]. The kinetic pattern also differed at matched speeds and

old compared with young adults generate less work around the ankle joint and generate

more work around the hip joint, with little to no change in work around the knee joint

[49–52]. Aging thus affects the biomechanics of gait, leading to a redistribution of lower

extremity mechanical output and altered control of the lower extremity muscles during

walking. The distal-to-proximal shift in muscle function or, “biomechanical plasticity”, is

robust and is present even in fit and trained old adults [53–55].

Aging also alters the neural activation patterns of the lower extremity muscles

during gait. Old compared with young adults generally walk with increased coactivity

around the knee and ankle joints [56–59]. Coactivity is the concurrent activity of agonist

and antagonist muscles surrounding a joint and increased coactivity is associated with

increased joint stiffness and thereby enhanced joint stability [60,61]. Old adults probably

use the coactivity-mediated increase in lower-extremity stiffness in order to prepare the

limb for impact and compensate for age-related reduction in muscle strength and power

[60]. The age-related increase in coactivity is one of the factors that is associated with a

~20% higher metabolic cost of walking in the old compared with young adults [56,61].

1.3. POWER TRAINING TO IMPROVE GAIT IN THE ELDERLY

Preventing mobility disability is necessary for maintaining independent function in old age

[1]. Impaired mobility is strongly associated with low levels of lower extremity extensor

strength and power [55,62]. Muscle strength is the ability to produce voluntary muscle

force and muscle power is the product of muscle force and the velocity of shortening

and it is the rate of muscle work done to the skeletal system [63]. Although muscle

strength and power are two inter-related mechanical properties of muscle, muscle

power declines earlier and more rapidly with age [64–67], and is a stronger predictor of

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Chapter 1

General introduction

functional performance, including gait velocity [62,68–73]. Lower extremity extensor

power is a key determinant of locomotor performance and logically recognized as an

efficient target for interventions that aim to improve gait velocity. Progressive resistance

training is an effective way to maximize muscle force and to improve muscle power in

the elderly. While traditional strength training is typically performed with heavy weights

(i.e., at 80% of maximal muscle force) and slow movement speeds, muscle power can

best be improved by training protocols that incorporate exercises with moderately heavy

weights (i.e., at 60% of maximal muscle force) moved at high movement velocity during

the concentric phase [73–76]. In addition to improvements in muscle performance,

power training also leads to increases in neuromuscular activation of the trained muscles

[77] and improve gait velocity [78]. Despite these beneficial results, it is unclear how

the improved physiological capacities (i.e., improved muscle strength and power, as

well as increased neuromuscular activation) evoke kinematic, kinetic, or neuromuscular

changes during gait that ultimately lead to faster walking in old adults. Overall, the

biomechanical mechanisms of power training-induced adaptations in old adults´ gait

velocity have not yet been identified or even studied comprehensively.

1.4. OUTLINE OF THIS THESIS

The main objective of the present thesis is to increase our understanding about the

biomechanical mechanisms of how lower extremity power training increases walking

speed in old age. Chapter 2 provides a review of the existing literature on the effects

of interventions on gait biomechanical in general and, in particular, how strength and

power training improve walking speed in old age. Based on the limited available evidence,

chapter 2 discusses candidate mechanisms of how strength and power interventions can

evoke adaptations in gait biomechanics that potentially underlie improvements in old

adults’ gait velocity. By using the knowledge gained from chapter 2, chapter 3 provides a

detailed description of the design and methodology of the Potsdam Gait Study (POGS),

which aims to determine the biomechanical mechanisms of how lower-extremity power

training evokes adaptations in walking speed in old age. Next, chapters 4-6 describe the

effects of the in chapter 3 described power training study on a series of biomechanical

and neuromuscular outcome measures. Specifically, chapter 4 is an evaluation of

training-induced changes in lower-extremity power on stride characteristics and joint kinematics

during gait. Chapter 5 focusses on the effects of power training on joint kinetics during

gait. Moreover, chapter 6 shows the effects of power training on lower extremity muscle

activity and coactivity during gait. Last, chapter 7 provides a general discussion of the

finding reported in this thesis.

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