Relationships between gait properties on soft surfaces, physical function, and fall risk for the eld

Vol.2, No.2, 57-64 (2013) Advances in Aging Research

http://dx.doi.org/10.4236/aar.2013.22008

Relationships between gait properties on soft

surfaces, physical function, and fall risk for the

elderly

Shinichi Demura1, Sohee Shin2, Shinji Takahashi3, Shunsuke Yamaji4*

1Graduate School of Natural Science and Technology, Kanazawa University, Kanazawa, Japan

2School of Medicine, Gifu University, Gifu, Japan

3Teikyo Heisei University, Chiba, Japan

4Faculty of Medical Sciences, Morphological and Physiological Sciences, Sports Medicine, University of Fukui, Fukui, Japan;

*Corresponding Author: yamaji@u-fukui.ac.jp

Received 5 December 2012; revised 20 January 2013; accepted 27 January 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

The plantar aspect change caused by contact

with soft surfaces creates and unstable gait and

increases the risk of falling, especially in the

elderly. This study aimed to analyze gait prop-

erty by three-dimensional motion analysis on

soft and normal surfaces and to clarify the rela-

tionship with physical function and fall risk.

Twenty-four older people aged 65 - 88 years old

and living independently without any assistive

device (7 men, 17 women) performed 5 m of

walking with own maximal speed on normal and

soft surface walkways. The soft surface walkway

used was a low rebound urethane foam mattress.

The three-dimensional kinematic gait analysis

by sixteen anatomic points was used to evaluate

gait property on both walkways. The gait prop-

erty on soft surfaces tended to be swinging up

and down in each joint and to largely lean left

and right as compared with the normal surface.

Moreover, it tended to decrease in a step length

and to increase in a step width. All gait parame-

ters on soft surfaces correlated significantly

with functional reach. On the other hand, that on

normal surface correlated significantly with leg

strength. Gait properties on soft surfaces which

changes in plantar aspect during foot contact

differs from those on normal surfaces. Walking

on soft surfaces may cause an unanticipated

inverted pendulum sway supporting a foot con-

tact point because of the disturbance by a sag-

ging walkway; in short, requiring more effort to

keep a body balanced. In conclusion, gait on the

soft surfaces requires balance ability (functional

reach) rather than leg strength.

Keywords: Three-Dimensional Kinematic Analysis;

Leg Strength; Balance

1. INTRODUCTION

Prolongation of independent life for the elderly and

control of the marked increased rate of medical expenses

are key tasks in Japan, which has become a super aging

society. Mobility is one of the most basic skills necessary

to keep an independent daily life. Their falls bring about

serious problems related to the decline of quality of life,

such as the bedridden state caused by bone fractures, and

the decline of activity range and volume due to the fear

of falling. It was reported that more than one third of the

elderly over 70 years of age living independently in com-

munities experience a fall at least once a year, and their

fall occur chiefly during walking or transfer movement

[1].

A fall is the result of exceeding the limit of one’s own

postural control from any cause. Age-related decline in

the physical functioning of visual, locomotion, and ner-

vous system makes stability during walking difficult.

However, a fall during walking rarely occurs without

some sort of trigger, except for those who fall due to

dizziness or syncopy. Most falls involve a trigger such as

a misstep or slip. The risk of falling increases when a

person lacks the ability to adapt to surface environment

changes (e.g. tilt, difference in floor height, slipperiness,

and hardness change) [2-4].

Many mobility tests that evaluate fall-related physical

fitness have been proposed in the previous studies: 10-m

S. Demura et al. / Advances in Aging Research 2 (2013) 57-64

Walking Test [5], Figure Eight Track Walking Test [6],

Timed Up and Go Test [7], and Tandem Gait Test [8].

These tests are useful to evaluate the independence of

daily living. However, mobility on stationary surfaces

may not reflect the ability to avoid a fall, because the fall

risk relates to the adaptability to variations in walking

environments, as previously stated.

On the other hand, an obstacle walk test has been

proposed as an irregular surface condition [9,10]. It is a

useful test to evaluate avoiding a stumble that induces a

fall. However, the participants can see the obstacles

placed in test walkways before they begin to walk, and

are therefore more likely to maintain stability.

There has been little research on the gait of elderly

people on varied surfaces. Therefore, a soft surface, such

as a mattress, is considered to be adequate for the gait

analysis of elderly individuals because the change of

plantar aspect when contacting the surface increases the

risk of falling. When an elderly person walks on soft

surfaces, the plantar aspect changes and they are required

to control the sway of their body by using somatosensory

input through plantar and postural reflexes. It is much

more difficult for an individual to maintain their balance

when walking on a softer surface compared to a normal

walkway.

Considering a fall process, it will be important to ex-

amine the body’s stability during walking in the above

walkway condition. It was hypothesized that gait pro-

perty on soft surfaces differs from that under normal con-

ditions, and is related to different physical functions,

adding that walking on soft surfaces reflects more the

degree of fall risk and independence of daily living. If

physical functions related to gait properties on both

walkway conditions differ, it is necessary to review the

exercise and physical functions to prevent falls.

This study aimed to analyze gait property by three-

dimensional motion analysis on soft and normal surfaces

and to clarify the relationship between physical function

and fall risk.

2. METHODS

2.1. Participants

Seven older men (Age: 72.4 ± 5.2 years, Height: 162.6

± 6.2 cm, Body mass: 65.7 ± 13.0 kg) and seventeen

women (Age: 74.6 ± 7.5 years, Height: 148.9 ± 7.3 cm,

Body mass: 52.2 ± 9.8 kg) living independently without

any assistive devices in the community dwelling partici-

pated in this study. There was no significant difference in

the mean ages of the sexes (t(22) = 0.670, p = 0.510).

Informed consent was obtained from each participant

after a full explanation of the experimental project and its

procedure. This study was approved by the Ethics Com-

mittee on Human Experimentation of Faculty of Educa-

tion, Kanazawa University.

2.2. Experimental Device

For the three-dimensional kinematic gait analysis, si-

xteen passive markers (15-mm diameter reflective, adhe-

sive styrofoam) were attached bilaterally to the following

anatomic landmarkers; acromion, olecranon, ulnar head,

anterior iliac crest, greater trochanter, knee, ankle and

fifth metatarsal. Marker trajectories were recorded two

strides after one stride from onset of walking at 60 Hz by

six digital camcorders (MA-2000, Anima, Japan). Tridi-

mensional reconstruction of the marker trajectories was

performed by means of a reference system (leveling

wires with equally spaced markers, forming a cube 3.0 m

in length, 1.70 m in height, and 1.30 m in width) in order

to calibrate the experimental set.

Gait parameters were selected as follows: mean walk

velocity, standard deviations of the movement distance

of joint points (acromion, knee, and ankle) in the frontal

and sagittal directions [11]. Further analysis was per-

formed on only the right joint points because the move-

ment distance between the right and left joints had a 0.95

correlation.

2.3. Procedure

Using within-subjects design, the participants perfor-

med a 5-m walk at their own maximal speed on normal

and soft surface walkways. The trial order on both

walkway conditions was allocated randomly, and the rest

among the trials was set 10 minutes. The participants

walked on a low rebound urethane foam mattress (Blan-

ce mattress, Achiless, Japan; width: 970 mm, depth: 603

mm, thickness: 80 mm) spread on the soft surface walk-

way. The toughness of mattress was 75 N and the ratio of

renaturation was 92%.

2.4. Falls Risk Assessment Score and

Independent of Daily Living Score

Fall risk was estimated using a fall risk assessment

questionnaire [4-12]. This consisted of eight risk factors

(gait deficit, balance deficit, muscle weakness, disease,

medication use, environment, visual and hearing deficit,

and fall fears: 15 items). Participants answered all ques-

tions with a dichotomous scale (yes or no). The response

with a high risk category for each question was consid-

ered to be a “high-risk response”, and persons scoring

over five points were judged to have a high fall risk.

Independence of daily living was estimated from the

view point of physical function level by falls efficacy

scale [13] and activity of daily living (ADL) test [14].

The former consists of 13 items common to daily living,

and participants were evaluated regarding their confi-

dence with these items on a scale of one to ten. The ADL

S. Demura et al. / Advances in Aging Research 2 (2013) 57-64 59

test consisted of 12 items representing ADL domains of

walking ability, changing and holding posture, balance,

and muscular strength and dexterity (manual activity).

2.5. Tests of Leg Function

Tests of leg function were selected from leg strength

and dynamic balance ability which related to mobility/

transfer movement and posture control ability: isometric

muscle strength tests of toe flexion, knee extension, and

hip flexion joints in the former, and a functional reach

test in the latter. Isometric muscle strength tests were

performed twice for both legs using a hand held dyna-

mometer (μTAS F-1, ANIMA, JAPAN). A mean of a

higher value in both legs was used as maximal strength

in each joint. Plantar flexion was measured in long sit-

ting position, and the others were measured in sitting

position. Functional reach was measured by using an

elastic stick [15]. Each participant maximally extended

the dominant hand from an upright posture while touch-

ing the top of an elastic stick fixed at dominant acromion

height on the wall. They pushed and shortened the elastic

stick by extending the dominant hand and the shortened

distance of the elastic stick was measured.

2.6. Data Analysis

An unpaired t-test was used to reveal sex differences

in the fall risk assessment score and independence of

daily living score. Two-way ANOVA (sex × walkway

condition) was use to reveal the difference of gait para-

meters between both surface conditions. Pearson’s cor-

relation coefficient was calculated to clarify the rela-

tionships between gait parameters under both walkway

conditions, fall risk score, independence of daily living

score, and leg function. A probability level of 0.05 was

indicative of statistical significance.

3. RESULTS

Table 1 shows sex differences of fall risk scores, in-

dependence of daily living scores, and leg function.

There were no significant sex differences in all parame-

ters. All effect sizes by Cohen’s d were less than mode-

rate values (d < 0.68).

Figure 1 shows exemplification of the gait pattern

analyzed by joint point trajectories in the frontal and sa-

gittal directions. The gait properties on a soft surface

tended to swing up and down in each joint and to lean to

the right and left directions significantly as compared

with the normal surface. Moreover, it tended to decrease

with a step length and to increase with step width.

Table 2 shows the result of two-way ANOVA (sex ×

walkway condition) regarding gait parameters. There

were significant walkway condition effects in all para-

meters. Walk velocity on soft surface significantly de-

creased, and body sway in the right-left and up-down

directions significantly increased. Effect sizes between

walkway conditions by sexes were over 0.5 in all pa-

rameters. In particular, the effect of the magnitude of the

standard deviation of movement distance in the sagittal

direction was relatively high (1.2 - 5.2).

Table 3 shows the correlation coefficients among gait

parameters, fall risk score, and independence of daily

living score by sexes. Walk velocity on the soft surface

correlated significantly with fall efficacy scale and ADL

score in both sexes.

Table 4 shows the correlation coefficients between

gait parameters and leg functions by sexes. All gait pa-

rameters, except for standard deviation of movement

distance in frontal direction at acromion and knee in

males, on soft surface correlated significantly with func-

tional reach in both sexes. On the other hand, those on

normal surfaces tended to correlate significantly with leg

strength.

4. DISCUSSION

This study examined whether the gait properties and

their relationship with the fall risk score and leg func-

tions differ between those on the soft surface which

changes the plantar aspect during foot contact and on the

normal surface.

Takenaka and Uechi [16] reported that sex differences

were not found in walking velocity and fall self-efficacy

scale for people 61 - 91 years of age. In previous studies,

the findings of sex difference on fall incidence were not

always agreement. Some researchers reported that they

were higher in women than in men [4,17,18], but others

reported that there was no significant difference [19,20].

Physical fitness level varies among individuals because it

does not only relate to sex and aging, but also relates to

various factors such as chronic disease, physical activity

and cognition function. There were no significant sex

differences in age, fall risk score, independence of daily

living score, and leg strength in this study. The effect

sizes by Cohen’s d in fall risk and ADL score, and leg

strengths were moderate (0.40 - 0.68), and the sex dif-

ference in these parameters will be found in studies with

a larger sample size.

The standard deviations of movement distance in

frontal and sagittal directions in this study evaluate the

degree of a joint sway. Walking velocity and body stabi-

lity on soft surface decrease because the walkway sinks

down during foot contact. Body sway of acromion in the

frontal direction on soft surface was larger than that of

knee and ankle joints. It is inferred that walking on a soft

surface causes an unanticipated inverted pendulum sway

supporting a foot contact point because of the distur-

bance by the sagging walkway. That is, walking on the

soft surface required to keep the body in balance. On the

other hand, body sway in the sagittal direction was larger

S. Demura et al. / Advances in Aging Research 2 (2013) 57-64

Table 1. Sex differences of fall risk score, independence of daily living score, and leg muscle functions.

Male (n = 7) Female (n = 17)

M SD M SD

t ES

Fall risk score point 3.9 2.6 2.9 2.2 0.9 0.40

Fall efficacy scale point 122.1 12.3 122.5 10.4 0.1 0.04

ADL score point 29.7 4.6 26.6 6.0 1.2 0.55

Toe flexion strength kg 5.6 3.0 4.1 2.0 1.5 0.68

Knee extension strength kg 17.0 7.3 14.1 3.7 1.3 0.57

Hip Flexion strength kg 23.1 11.3 19.1 6.4 1.1 0.50

Functional reach cm 32.3 6.6 32.2 5.6 0.0 0.00

There were no significant sex differences in any parameters.

100

120

140

0.00.81.21.62.02.42.9

movement distance in sagittaldirection(cm)

(sec)

‐60

‐55

‐50

‐45

‐40

‐35

‐30

‐25

‐20

0.00.81.21.62.02.42.9

movement distance in frontal direction (cm)

(sec)

‐60

‐55

‐50

‐45

‐40

‐35

‐30

‐25

‐20

0.00.61.01.41.92.32.73.13.5

movement distance in frontal direction (cm)

(sec)

100

120

140

0.00.61.0 1.41.92.32.73.13.5

acromion

knee

ankle

movement distance in sagittaldirection(cm)

(sec)

Gaitonnormalsurfacewalkway

Gaitonsoftsurfacewalkway

Figure 1. Exemplification of gait pattern analyzed by movement distance of 8 joint points (only right side) on the both surface

conditions. Upper panel: normal surface walkway, Lower panel: soft surface walkway.

to be small as compared with that at knee and ankle

joints. It is inferred that walking on soft surface required

igher elevation of the foot during the swing phase.

in the knee and ankle joints than in acromion. A sagging

walkway by a foot contact makes the whole body sway

to downward. However, body sway at acromion tended h

OPEN ACCESS

S. Demura et al. / Advances in Aging Research 2 (2013) 57-64 61

Table 2. Two-way ANOVA of gait parameters between the both walkway conditions by sexes.

Soft surface Normal surface Two-way ANOVA

Effect size

between both

walkway

conditions

Male Female Male Female sex

walkway

condition inter-action

M SD M SD M SD M SD

ＦＦＦ Male Female

Walk

velocity

(cm/s)

67.3 18.1 72.0 19.6 93.517.890.4 38.5 0.0 11.0* 0.3 1.6 0.6

Standard deviation of movement distance in frontal

direction (cm)

acromion 4.1 1.9 3.4 1.7 2.6 0.7 2.1 0.8 2.3 14.8* 1.3 1.1 1.0

knee 2.9 1.0 2.6 1.8 1.7 0.7 1.8 0.9 0.2 5.8* 0.2 1.5 0.6

ankle 3.9 1.3 2.9 2.0 2.1 0.7 2.1 1.0 1.1 7.8* 1.2 1.8 0.5

Standard deviation of movement distance in sagittal

direction (cm)

acromion 1.9 0.5 1.7 0.7 1.3 0.4 1.0 0.2 1.7 14.7* 0.0 1.5 1.2

knee 3.3 0.5 3.4 0.7 1.4 0.2 1.3 0.3 1.0 337.1* 2.2 5.2 4.2

ankle 6.5 1.1 6.3 0.9 4.9 0.9 4.1 0.7 2.1 105.0* 1.8 1.8 2.8

*p < 0.05.

Table 3. Correlation coefficients among gait parameters, fall risk score, and independence of daily living score.

Male Female

Soft surface Normal surface Soft surface Normal surface

Fall risk

score

Fall efficacy

scale ADL Fall risk

score

Fall

efficacy

scale

ADL Fall risk

score

Fall

efficacy

scale

ADL Fall risk

score

Fall efficacy

scale ADL

Walk

velocity

(cm/s)

−0.43 0.78* 0.76* −0.13 −0.09 0.24 −0.33 −0.65* 0.58* 0.08 0.14 0.33

Standard deviation of movement distance in frontal

direction (cm)

acromion −0.16 0.13 0.51 0.40 −0.45 −0.43 0.19 0.16 −0.16 0.07 −0.34 −0.35

knee −0.27 0.16 0.49 0.22 0.02 0.12 −0.26 0.21 0.02 0.01 0.03 0.02

ankle −0.10 0.64 0.22 −0.32 −0.38 0.22 0.06 0.23 0.10 −0.04 0.07 −0.03

Standard deviation of movement distance in sagittal

direction (cm)

acromion 0.72 −0.17 −0.42 0.52 0.03 0.14 −0.01 0.26 −0.01 0.04 0.19 0.51*

knee 0.74 0.14 −0.39 0.19 0.34 −0.11 −0.21 0.19 0.08 −0.35 0.40 0.13

ankle 0.35 −0.13 0.18 0.30 0.45 0.11 −0.23 0.49* 0.41 −0.43 0.65* 0.74*

*p < 0.05.

Moreover, all correlations of gait parameters between

both walkways were not high. Thus, walking properties

on both walkways may be affected by different physical

functions.

Significant correlations were not found between gait

parameters and fall risk score. However, the indepen-

dence score of daily living correlated significantly with

walking velocity on a soft surface in both sexes and the

sagittal direction sway of the ankle joint on a normal

surface in females. Nine participants in this study were

identified to have a high fall risk by cut-off score (5

points) (37.5%), and the others were lower than 3 points.

Fall risk scores involve not only physical function such

as walking ability, leg strength, and balance ability, but

also the other factors such as medicine, environment,

personality, visual and hearing problems, and fear of

falling [4,12]. From the present results, gait parameters

may reflect mainly physical function factors. Meanwhile,

S. Demura et al. / Advances in Aging Research 2 (2013) 57-64

Table 4. Correlation coefficients between gait parameters and leg muscle functions.

Male Female

Soft surface Normal surface Soft surface Normal surface

Toe

flexion

Hip

flexion

Knee

extension FR Toe

flexion

Hip

flexion

Knee

extension FR Toe

flexion

Hip

flexion

Knee

extension FR Toe

flexion

Hip

flexion

Knee

extension FR

Walk velocity (cm/s) 0.02 0.18 0.32 0.76* 0.540.730.59 0.690.420.020.05 0.49* 0.48* 0.26 0.07 0.35

Standard deviation of movement distance in frontal direction (cm)

acromion −0.26 −0.11 0.30 −0.45 0.240.320.300.30−0.45 −0.35 −0.35 −0.64* 0.18 −0.02 −0.15 0.34

knee −0.47 −0.45 −0.05 −0.49 0.490.81*0.720.23 −0.31 −0.13 −0.05 −0.48* 0.49* −0.21 −0.15 0.27

ankle −0.52 −0.39 −0.20 −0.81* 0.350.530.48−0.12 −0.26 −0.02 −0.06 −0.48* 0.49* −0.37 −0.29 0.11

Standard deviation of movement distance in sagittal direction (cm)

acromion −0.08 0.19 0.30 −0.76* 0.44 0.84*0.83*0.73 −0.31 −0.15 −0.19 −0.50* 0.64* −0.12 −0.20 0.17

knee −0.07 0.14 0.13 −0.77* −0.11 −0.41 −0.370.22 0.15 0.18 −0.22 −0.52* −0.37 −0.07 −0.22−0.50

ankle −0.08 0.22 0.28 −0.78* 0.08 0.240.120.350.430.13−0.10 −0.50* 0.48* −0.06 0.48*0.18

*p < 0.05, FR: functional reach.

the independence score of daily living was composed of

item groups related closely to physical function factors

[16,21]. Hence, it may have shown relationships with

gait parameters on both surfaces. However, it is noted

that the gait parameters with significant correlations dif-

fered between both walkway conditions. Potter et al. [21]

reported that a relationship was found between Barthel

ADL score and walking speed. However, this relation-

ship depends largely on the physical fitness level of the

older population. Because walking five meters on a nor-

mal surface was an easy task for the elderly in this study,

it is hard to attribute individual differences in gait by

their physical fitness level. Therefore, it may have shown

a poor relationship with the independence score of daily

living.

Conversely, because walking on soft surface poses

high difficulty, a significant relationship with walking

velocity may have been found. Means [9] and Means and

O’Sullivan [22] reported that walking at a high difficulty

level such as navigating an obstacle is superior in the

improvement ratio of physical function to walking nor-

mally for older people living in community-dwelling.

Therefore, walking on a soft surface walkway may be

effective as exercise for fall prevention. In addition,

those displaying greater ankle movements in the sagittal

direction on a normal surface tended to have a higher

independence score of daily living. Foot height during

the swing phase decreases with age and physical function

decline [23]. In this study, the ankle movement of the

sagittal and frontal directions in the normal surface cor-

related with toe flexion strength in females, thus it may

important to improve toe flexion strength for the inde-

pendence of daily living. Moreover, gait parameters on

the normal surface in females, as compared with that on

the soft surface, correlated with leg strength. This sug-

gests that the greater movement of joint points during

normal walking is affected by leg strength. These results

may mean that persons with superior leg strengths walk

forcefully on a normal surface.

On the other hand, almost gait parameters on soft sur-

faces correlated with a functional reach test in both sexes.

This test was proposed to evaluate dynamic balance for

older people [24]. As stated above, walking on a soft

surface which prolonged the swing phase (the one-leg

support phase) requires better balance ability. Walking

on a low rebound urethane foam mattress makes it diffi-

cult to kick the ground when beginning walking and to

elevate a leg due to soft surface. In case of normal walk-

ing, forcefully kicking the ground contributes to gain

rapid and forceful movement. However, forcefully kick-

ing the ground on the soft surface is needed large balance

ability. Because the ankle movement in the sagittal di-

rection on a soft surface correlated positively with func-

tional reach, persons with superior functional reach may

be able to elevate foot during swing phase. In fall pre-

vention exercise schools, it is recommended to improve

iliopsoas and femoral muscles to avoid stumbling over

an obstacle [25,26]. However, it will also be important to

propose exercise to positively move the center gravity of

the body. Such exercises include the functional reach

action which helps to keep body stable while walking on

an irregular surface.

Further studies will be examined to clarify motion

properties using kinematic analysis of other fall trigger

S. Demura et al. / Advances in Aging Research 2 (2013) 57-64 63

actions such as slips and missteps which require a step-

ping strategy.

5. CONCLUSION

In conclusion, gait properties on soft surfaces which

change the plantar aspect during foot contact differ from

those on a normal surface. Body sway of the acromion in

the frontal direction on a soft surface is larger than that

of knee and ankle joints. Walking on a soft surface may

cause an unanticipated inverted pendulum sway support-

ing a foot contact point because of the disturbance by the

sagging walkway. Gait on the soft surface requires bal-

ance ability (functional reach) rather than leg strength.

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