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In other words, if walking is the problem then the intervention should primarily focus on the task of walking through motor skill-based exercise and not on an impairment-based exercise intervention alone. 45- 47 How do the most skilled movers at their sport prepare for their sport specific skilled tasks? While sport specific skilled movers may exercise to build a foundation of muscle strength, flexibility and endurance capacity for their sport, no athlete steps to the plate with a bat in hand, raises the basketball to the hoop, or tees up the golf ball without substantial task-oriented exercise training. Taking a lesson from the sports world and from neurorehabilitation, task-oriented motor skill exercise is the essential component of exercise training to improve motor task performance. The loss of motor skill related, high energy cost of walking (eg inefficient) is a major factor in the age-related decline in physical function and activity for older adults. 42- 44 We argue the timing and coordination problems are evidence of the loss of motor skill in walking, more so than a decrease in physiological reserve capacities for walking alone. Whether contributors to or consequences of the age-related walking problems, walking is slow, 17 less stable, 40 inefficient, 41 and the timing and coordination of stepping with postures and phases of gait is poor. 28- 39 The questions are: “Why are the results suboptimal?” and “Can we do better?”. These multifactorial impairment-based programs have resulted in only modest improvements in walking (eg an approximate 5% increase in gait speed, with a range of 0-16%). strengthening, endurance and flexibility programs) focusing on improving the underlying impairments of the systems involved.
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Interventions to improve walking have historically been multifactorial (i.e. 9 For example, the reduced hip extension blocks the mechanical accumulation of potential energy in the limb tissues during stance to release during swing to fuel the limb forward movement, while also eliminating the hip extension, movementrelated feedback stepping signal for the transition from stance to step. The biomechanical and movement control problems appear to interact. reduced rate of forward momentum, 17 stride length and time variability, 18, 19 and timing issues, including a loss of the rhythm, hesitancy, and difficulty transitioning from stance to swing. flexed trunk posture, 11 decreased hip extension in mid to late stance, 12, 13 and decreased ankle plantarflexion and power at push off 11, 13- 16) and movement control is disrupted (i.e. 6- 10 Typically the biomechanics are altered (i.e. The constellation of deficits characteristic of age-related walking problems contributes to inefficient gait. The walking disability develops gradually, and although many older adults are referred (or self-refer) to a geriatric specialist because of the mobility problem, the reason for the walking difficulties often cannot be identified. 6 The changes that occur in walking with age are likely the result of multiple small changes in several different systems more so than the result of one catastrophic event such as a stroke or hip fracture. 1- 5 Walking is a complex task that places demands on the musculoskeletal, cardiopulmonary, and nervous systems. Walking difficulty is a common, costly problem in older adults and it contributes to loss of independence, higher rates of morbidity and increased mortality. In this article we: 1) briefly review the current literature regarding impairment-based interventions for improving mobility, 2) discuss why the results have been only modest, and 3) suggest an alternative approach to intervention (i.e. Taking a lesson from the sports world and from neurorehabilitation, task-oriented motor learning exercise is an essential component of training to improve motor skill and may be a beneficial approach to improving walking in older adults. We argue the timing and coordination problems are evidence of the loss of motor skill in walking. In older adults, walking is slow, less stable, inefficient, and the timing and coordination of stepping with postures and phases of gait is poor. These impairment-based programs have resulted in only modest improvements in walking. strengthening, endurance and flexibility programs) focusing on improving the underlying impairments. Interventions to improve walking in older adults have historically been multifactorial (i.e.