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Cognition and Gait:
Integrating skills for safer mobility
Presented by: Nina Geier, M.S., M.P.T., CBIST
Senior Director for Central Jersey
Bancroft Brain Injury Rehabilitation
Our Mission
Bancroft provides opportunities to children and adults with
diverse challenges to maximize their potential.
Our Vision
A community where every individual has a voice, a purpose
and a rightful place in society.
Our Core Values
Responsible Empathetic Supportive Passionate Empowered Committed Trustworthy
RESPECT
Purpose
This webinar will discuss the importance of integrating
cognitive and motor skills to achieve safe ambulation
following traumatic brain injury (TBI). It will examine the
relationship between specific cognitive abilities (e.g.,
attention, executive functions) and gait. Strategies will be
presented to address cognition as it relates to safe
ambulation in home and community environments.
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Objectives
As a result of this Webinar, the participant will be able to:
• describe the cognitive processes that impact functional ambulation.
• demonstrate understanding of some research related to the integration
of cognition and gait.
• develop an understanding of the integration of the multiple systems
(e.g., sensory, motor, and cognitive) necessary for balance and safe
ambulation.
• identify strategies and interventions to address the cognitive skills
needed for safe ambulation in home and community environments.
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Gait and Balance Deficits following
Traumatic Brain Injury (TBI)
Symptoms of impaired balance and altered coordination have been
particularly troublesome, with as many as 30% of patients complaining
of these problems after TBI.
…effective coordination of activities and balance involves a complex
interaction of the sensory, motor-programming, and musculoskeletal
systems. Even minor impairments in integrating this information can
lead to significant disability.
(Basford JR, Chou L, Kaufman K, Brey, RH, Walker A, Malec JF, Moessner AM, Brown AW. An Assessment of
Gait and Balance Deficits After Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation,
March 2003; vol 84.)
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Balance Problems after TBI
According to Traumatic Brain Injury Model System Consumer
Information:
• Balance is the ability to keep your body centered over your feet.
• The ability to maintain your balance is determined by many factors,
including physical strength , coordination, senses, and cognitive ability.
• Between 30% and 65% of people with TBI experience dizziness and
disequilibrium.
(Balance Problems after Traumatic Brain Injury, Traumatic Brain Injury Model System Consumer Information,
Model Systems Knowledge Translation Center , 2011.)
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Systems Involved in Balance
Integration of somatosensory (proprioceptive, cutaneous, and joint),
visual, and vestibular systems.
(Sourced on June 12, 2014 from NeuroCom; www.resourcesonbalance.com)
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Common Cognitive Problems
following TBI
• Attention
• Memory
• Executive Functions
•Planning
•Organizing
•Problem-solving
•Decision-making
•Anticipating
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Attention
Impairments of attention are common after TBI, and include
reductions of processing speed, difficulty sustaining the
focus of attention (e.g., maintaining concentration or a
train of thought), and limitations in the ability to regulate
the allocation of attention in complex situations (e.g.,
shifting attention to multiple speakers, or between several
ongoing tasks).
(Cicerone KD. Cognitive Rehabilitation. In Zasler ND, Katz DI, Zafonte RD (eds.). Brain Injury Medicine: principles
and practice, Demos Medical Publishing, 2007.)
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Executive Functions
… have often been defined in terms of complex cognitive
activities such as planning, judgment, decision-making and
anticipation that require the coordination of multiple subprocesses to organize behavior and achieve particular
goals.
(Eslinger PJ, Zappala G, Chakara F, Barrett, A.. Cognitive Impairments After TBI In Zasler ND, Katz DI,
Zafonte RD (eds.). Brain Injury Medicine: principles and practice, Demos Medical Publishing, 2007.)
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Executive Functions
Associated cognitive operations include working memory,
prospective memory, strategic planning, cognitive
flexibility, abstract reasoning, and self-monitoring.
(Eslinger PJ, Zappala G, Chakara F, Barrett, A.. Cognitive Impairments After TBI In Zasler ND, Katz DI,
Zafonte RD (eds.). Brain Injury Medicine: principles and practice, Demos Medical Publishing, 2007.)
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Current State of Research
There is a limited amount of research on interventions that address the
integration of cognitive and motor skills in balance/gait for individuals
with Traumatic or Acquired Brain Injury…
…some research is available on dual task interventions for individuals with
progressive neurological conditions (e.g., Parkinson’s Disease,
Alzheimer’s)
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Effect of Cognitive Load on Gait
Recent research has shown that cognitive load has an effect on gait,
especially noticeable in people with neurodegenerative disorders.
Since the dual task conditions impose a higher attentional demand, the
performance in one or both tasks can be impaired if the attentional
reserve capacity available is challenged.
Recent studies have shown a relationship between dual task interference
and fall risk.
(Martin E, Bajcsy R. Analysis of the Effect of Cognitive Load on Gait with off-the-shelf Accelerometers in Cognitive
2011: The Third International Conference on Advanced Cognitive Technologies and Applications; 2011.)
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What is Dual Task
Performance?
• Performance of two tasks that require equal amounts of
attention
• Carrying out two competing tasks simultaneously
• Can be a combination of cognitive and motor tasks, two
cognitive tasks, or two motor tasks
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Research on Gait in Other Diagnostic
Groups: Parkinson’s Disease
It is known that cognitive function, especially executive
function and attention play a role in gait and falls.
However, it is not known how cognitive impairments relate
to objective measures of balance and gait in neurological
disorders…
(Peterson A, Lobb B, Mancini M, Horak F. The Relationship between Cognitive Testing and Gait and Balance
Measures in Parkinson's Disease. Neurology , February 12, 2013; 80[Meeting Abstracts 1]: P04.169.)
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Research in Other Diagnostic Groups:
Parkinson’s Disease (continued)
Methods:
• Subjects underwent cognitive, gait, and balance testing in the "on" state.
Pearson correlations were used to correlate gait and balance measures and
cognitive test performance.
•
Gait/balance testing: Timed Up and Go (iTUG), Sensory Organization Test
(SOT), Motor Control Test (MCT), Neurocom Equitest.
•
Cognitive measures: global function (MOCA), memory (WMS-III Logical
Memory), executive (trails A & B, Stroop, WAIS-III letter-number sequencing,
digit symbol), visual spatial (JoLo), attention (Stroop, WAIS-R digit span
forwards and backwards), and language (Boston naming, verbal fluency f's,
animals, vegetables).
(Peterson A, Lobb B, Mancini M, Horak F. The Relationship between Cognitive Testing and Gait and Balance
Measures in Parkinson's Disease. Neurology , February 12, 2013; 80[Meeting Abstracts 1]: P04.169.)
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Research in Other Diagnostic Groups:
Parkinson’s Disease (continued)
Results:
Data supports the relationship between objective gait and balance
measures and cognitive function, specifically executive function in
patients with [Parkinson’s Disease].
(Peterson A, Lobb B, Mancini M, Horak F. The Relationship between Cognitive Testing and Gait and Balance
Measures in Parkinson's Disease. Neurology , February 12, 2013; 80[Meeting Abstracts 1]: P04.169.)
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Research in the TBI/ABI
Population
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Cognitive Interference
In healthy individuals, people are able to perform motor tasks and higher
cognitive functions at the same time.
Motor tasks (e.g., walking) have been thought to be immune from
interference of cognitive processing because they have been considered
“automatic” and do not require central cognitive resources.
However, after acquired brain injury, the availability and use of various
modalities (e.g., cognition and movement) may be quite different than
in healthy individuals.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Interference between gait and
cognitive tasks
Interference between cognitive tasks and motor control
activities such as gait is a problem in neurological
rehabilitation settings.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Interference between gait and
cognitive tasks
Interference between cognition and locomotor tasks may be
important in assessing neurological patients’ ability to
function independently, and in designing therapies for both
cognitive and motor rehabilitation.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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The Effect of Dual Tasks
Concurrent performance of two cognitive tasks (e.g., reading
while monitoring a conversation) often leads to a
deterioration in the performance of either or both tasks.
Motor tasks (e.g., walking) were thought to be immune from
this interference because they are “automatic” and not
requiring central cognitive resources.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Are Healthy People Immune to
Distractions?
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Are Healthy People Immune to
Distractions?
….a story about an Australian woman who walked off a
pier because she was more intent on checking out
Facebook than watching where she was going. That
incident joins the pantheon of examples of distracted
walking, including the viral video of a young woman
plunging into a mall fountain because she was engrossed in
her small screen.
(Sourced on June 2, 2014 from http://www.pewresearch.org/fact-tank/2014/01/02/more-than-halfof-cell-owners-affected-by-distracted-walking/)
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What happens after brain injury?
• Use of the areas of the brain subserving cognition and
movement may be quite different from that of healthy
individuals
• An individual may be able to perform cognitive tasks in
isolation…and, a motor task in isolation….BUT,
• Concurrent performance of cognitive and motor tasks may
result in severe impairment in one or both modalities
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Theories about Decreased Dual-Task
Performance following Brain Injury
• Overall cognitive capacity (e.g., attention, memory,
executive functions) may decrease after brain injury.
• Cognitive motor interference may arise because motor
control ceases to be automatic after acquired brain injury.
• Previously automatic actions may revert to the status of
“controlled” processes and may place heavy demands on
available cognitive resources.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Why is this important to rehab?
• Typical therapy sessions involve concurrent performance of cognitive
and motor tasks (e.g., listening to therapists instructions while
practicing walking; managing internal or external distractions).
• Treatment may be designed to minimize dual task activities
OR
may be designed to challenge an individual to practice dual tasking.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Why is this important to rehab?
(continued)
• The level of dual task interference may need to be varied between
individuals.
• Assessment of dual task abilities may provide better insight into an
individual’s ability to function in everyday, real-life activities than single
task conditions of typical neurological assessments.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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How can interference be studied?
Methods:
• Participants were adults (N=50) with acquired
non-progressive brain injury (plus 10 healthy controls)
• Pressure pads taped to ball and heel of each foot
• Measured number of strides, median duration, and
variability in duration of stride time
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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How can interference be studied?
• Cognitive Interference included:
•Spoken word generation task (ex: name “things to eat”, “things in the
house”)
•Mental arithmetic task with auditory presentation (ex: 5+6=11…yes or no)
•Verbal paired associate monitoring task (ex: “dog”… “bone”)
•Visuospatial decision task (ex: “10 past 3”… are the clock hands on the same
of opposite side of clock?)
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Results
In healthy controls:
• Dual task decrements in both gait and in cognitive scores
were generally small or absent.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Results
In individuals with acquired brain injury:
• Dual task interference produced significant impairment of
both gait and cognitive function.
• Dual task decrement was not strongly related to lesion site.
• Decrements did not differ dramatically across the four
cognitive tasks studied.
• Significant slowing of the gait cycle and a reduction in
cognitive task scores were found when doing tasks
simultaneously.
(Haggard P, Cockburn J, Cock J, Fordham C, Wade D. Interference between gait and cognitive tasks in a
rehabilitating neurological population. Journal of Neurology and Neurosurgical Psychiatry 2000; 69: 479-486.)
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Clinical Implications
The clinical implications of the relationship between gait and
cognition are that gait assessment should be considered as
a part of the routine assessment of cognitive function and
conversely, cognitive function and specifically executive
function should be assessed in patients with gait disorders.
(Allal G, van der Meulen M, Assal F. Gait and cognition: the impact of executive function. Department of
Neurology, University Hospital Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland.)
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Executive Functions
… have often been defined in terms of complex cognitive
activities such as planning, judgment, decision-making and
anticipation that require the coordination of multiple subprocesses to organize behavior and achieve particular
goals.
(Eslinger PJ, Zappala G, Chakara F, Barrett, A.. Cognitive Impairments After TBI In Zasler ND, Katz DI,
Zafonte RD (eds.). Brain Injury Medicine: principles and practice, Demos Medical Publishing, 2007.)
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Executive Functions
Associated cognitive operations include working memory,
prospective memory, strategic planning, cognitive
flexibility, abstract reasoning, and self-monitoring.
(Eslinger PJ, Zappala G, Chakara F, Barrett, A.. Cognitive Impairments After TBI In Zasler ND, Katz DI,
Zafonte RD (eds.). Brain Injury Medicine: principles and practice, Demos Medical Publishing, 2007.)
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Impact of Executive Function
• Modulating speed, base of support, stride length, etc.
• Navigating around environmental obstacles
• Self-awareness of limitations for meeting environmental
demands
• Decision-making for crossing streets, etc.
• Problem-solving alternate ways to manage barriers,
obstacles, etc.
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Integration of Assessments
from Interdisciplinary Team
•
•
•
•
Neuropsychological Assessment
Physical Therapy Evaluation
Occupational Therapy Evaluation
Speech Therapy Evaluation
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Neuropsychological Assessment
Summaries may include critical information. For example:
Areas of challenge included processing speed (efficiency of performance,
accuracy, and visual-motor coordination), visual-spatial skills (creating
a design with plastic shapes), executive functioning, and motor
functioning. On more complex tasks, attention to detail and ability to
utilize effective problem solving skills appeared to be a challenge.
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Treatment Considerations
• Gait training in a quiet PT gym vs. a demanding environment (e.g.,
complex distractions, variable surfaces, noise); progressive increases in
demands.
• Modulate verbal instructions during gait training based on the amount
of interference (decreased performance) from the cognitive load.
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Treatment Considerations
• Environmental modifications
• Home (lighting, noise, clutter, “traffic pattern”)
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Treatment Considerations
• Community (travel patterns, peak shopping/travel times, curb
cuts, traffic lights, stairs, elevators, escalators, weather-related
issues)
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Treatment Considerations
• Address concurrent movement and cognition during daily living tasks,
and modify tasks to minimize interference.
• Collaborate with psychology/counseling to address emotional issues
(e.g., anxiety, frustration tolerance).
• Develop strategies (e.g., environmental cues, guidelines) and rules for
specific environments.
• Do not expect generalization across environments.
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Documentation of Effect of
Cognitive Issues on Gait/Safety
Example:
PS is able to walk greater than 500 feet with close supervision on level
surfaces in a low-stimulating clinical environment. Gait deviations
include decreased right weight shift and shortened left step length.
In complex environments in the community, PS becomes distracted and
requires verbal cues to attend to environmental barriers (e.g., curbs,
uneven surfaces). PS requires occasional assistance to regain balance
when he has not planned adequately to navigate around such barriers.
A strategy has been introduced for PS to “stop, look, and listen” when
approaching crosswalks in order to improve attention to crossing light
and environmental demands.
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QUESTIONS
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