Abstract
Objectives
For several years, the concept of “physiological senile gait” has been strongly contested and seems to be associated with abnormal gait. Indeed, some changes characteristic of senile gait appear early on in subjects with neurodegenerative pathologies. The aim of this article was to determine how recent contributions can improve the study of gait in old populations. This paper is a thematic review of recent contributions from medical imaging techniques as well as instrumental gait analysis techniques in older adults. This article did not focus on Parkinson’s disease or other specific diseases bearing certain gait disturbances, since they belong to literature focusing on these particular disorders.
Material and methods
This work was not intended as a systematic review but only as a thematic one conducted by geriatricians in order review the recent literature in order to better apprehend how new technics could be implemented within their clinical practice. Articles were selected in online Medline and Cochrane Library databases, and some were previously identified by the authors.
Results
This paper highlights the most recent contributions in magnetic resonance imaging, functional magnetic resonance imagery, positron emission tomography and instrumental gait analyzing devices better understanding the underlying gait mechanisms in elderly populations.
Conclusions
This thematic review suggests that gait could be considered as a marker of “successful aging”. Its evaluation associated to longitudinal follow-up could be useful to predict cognitive and functional changes in frail older adults.
Résumé
Objectif
Depuis quelques années, le concept de « démarche sénile physiologique » est fortement contesté. Certaines modifications de la marche présentes chez le sujet âgé semblent le plus souvent être associées à des processus pathologiques débutants. Cet article propose une revue thématique des apports récents obtenus par les techniques d’imagerie médicale et les techniques instrumentales d’analyse de la marche appliquées aux personnes âgées. La maladie de Parkinson ainsi que d’autres pathologies incluant des modifications de la marche déjà décrites lors de publications spécifiques, ne sont pas spécifiquement évoquées dans cet article.
Matériel et méthodes
Les références citées dans cet article ont été en partie sélectionnées en recherchant dans la Cochrane Library et dans Medline. Certains articles utilisés étaient déjà connus des auteurs. Cet article ne prétend pas être une revue systématique mais une revue thématique faite récemment par des gériatres cliniciens afin de rassembler les données récentes de la littérature et envisager leur intégration lors de leur pratique quotidienne.
Résultats
Cet article résume les contributions récentes de l’imagerie par résonance magnétique structurelle et fonctionnelle, de la tomographie par émission de positons et des instruments d’analyse des paramètres de marche permettant une meilleure connaissance des mécanismes sous-jacents de la démarche chez les personnes âgées.
Conclusion
La qualité de la marche pourrait être considérée comme un marqueur de « vieillissement réussi » et l’analyse de sa détérioration pourrait aider à prévoir les changements cognitifs et fonctionnels y afférant.
1
English version
1.1
Introduction
Over the last few years, studying gait in older adults has raised a great deal of interest. Indeed, gait changes can lead to falls increasing the risk of institutionalization, functional decline and onset of comorbidities . Therefore, gait changes in older adults can be considered as a frailty marker. Recent studies have underlined that changes in certain gait parameters could be considered as a sign of cognitive frailty . Therefore, the concept of a “physiological senile gait” has been strongly argued and the question in fact remains: Is the “physiological senile gait” truly physiologically norm or could it reflect the onset of some pathological disorders, such as cognitive ones, leading to falls? Furthermore, could there be a cut-off discriminating healthy older adults from frail ones?
It is well known that gait results from a motor command stemming from the central nervous system and is executed by the peripheral nervous system. The execution of this motor command involves not only the vestibular and peripheral nervous systems but also good quality osteoarticular and muscle features, without forgetting the cardiovascular system. Clinical features are the first step to evaluate gait, including thorough medical history (surgeries, treatments, and preexisting diseases), physical examination and other clinical tests, these elements are essential to understand the locomotor abilities in elderly populations. Nevertheless, nowadays there are two core components for analyzing in-depth gait features: anatomical and functional analysis of the central nervous system in charge of managing motor commands and measures of gait spatiotemporal parameters. In fact, motor command organization can be studied through imaging techniques such as magnetic resonance imaging (MRI), functional MRI (fMRI) and positron emission tomography (PET). The tests and tools for gait analysis used in daily clinical practice have shown their limits compared to instrumental gait analysis . Walkway and accelerometric methods allow analyzing spatiotemporal gait parameters and these techniques have recently been used in old populations. The purpose of this article is to comment new, useful and promising techniques for gait analysis in elderly subjects. This article did not specifically focus on Parkinson’s disease or other pathologies where gait changes have already been defined in specific domains within the literature.
1.2
Method
The aim of this article was not to conduct a systematic review of the literature with precise inclusion or exclusion criteria, but instead to propose a thematic review based the most recent articles and those already known by the authors. The literature selection was based on:
- •
their contribution to the cover a large overview input within a large review of gait analysis;
- •
experience of the working team in gait studies;
- •
practical aspect of the knowledge contained within the article. In a second time, the references of each article were studied and some articles were selected by this way.
To select the most recent articles, we carried out a search in the Cochrane Library using the keywords “gait AND older”. This resulted in eight articles but in fact, only two were focused on gait (specifically gait rehabilitation) in older adults. In the same database, using the keywords “gait AND elderly”, only one article was found and this article only concerned gait rehabilitation. No articles were found on the input of medical imaging and instrumental gait analysis.
We searched for articles in MEDLINE with the same keywords and limited our search to “items with links to full text, Human, English, French and Age > 65 years published within the last 10 years”. We found more than 900 references. The most interesting references were selected based on the previously reported criteria. Forty-seven abstract were initially considered to amount to a final of 12 articles.
1.3
Results
1.3.1
Medical imaging contribution
1.3.1.1
Magnetic resonance imaging
Table 1 lists the following commented studies. Zimmerman highlighted a correlation between the anatomical structures of the hippocampus and changes in gait parameters. In a group of 48 cognitively healthy older adults, mean age of 81 years, hippocampus volume was measured using volumetric MRI and its metabolism evaluated by proton nuclear magnetic resonance spectrometry. A correlation between step length and hippocampal volume was unveiled, as well as a relationship between step length variability and hippocampal metabolism. Some studies reported a relationship between vascular lesions and gait changes . A recent study evaluated mobility in 331 adults with no history of strokes and not affected by dementia or Parkinson’s disease. In this group of healthy older adults, the vascular lesions in the white matter and subclinical strokes were associated with slower gait speed, shorter stride length and longer double support time . Furthermore, the same study indicated a relationship between a greater step length variability and higher prevalence of infarcts, including basal ganglia infarcts .
| First authors and references | Observations |
|---|---|
| Zimmerman et al., Brain Res, 2009 | Correlation between steps length and the hippocampal volume and between the variability of the steps length and the hippocampal metabolism |
| Onen et al., Neurosci Lett 355, 2004 Onen et al., Brain Res, 2008 | Relationship vascular lesions in specific regions and gait disorders in MCI |
| Onen, J Neuroradiol, 2005 | Role of microangiopathy and circulation of cerebral spinal fluid and gait disorders in MCI |
| Rosano et al., Neuroepidemiology, 2006 | Vascular lesion in white matter and subclinical strokes are associated with slower gait speed, shorter stride length and longer double support time |
| Rosano et al., Neuroepidemiology, 2007 | Infarcts in basal ganglia are associated with variability of step length |
| Pugh and Lipsitz, Neurobiol Aging, 2002 | Age itself is associated with microangiopathy |
| Henry-Feugeas et al., Clin Interven Aging, 2008 | Role of arteriosclerotic brain lesions in the development of dementia in patients with MCI |
| Guerini et al., Arch Phys Med Rehabil, 2008 | Subcortical hypoperfusion interrupting long loops reflexes of deep white-matter motor tracts and descending motor fibers arising from medial cortical areas |
Morphological MRI has also promoted the “vascular” theory to explain gait changes in relations to cognitive disorders linked with aging. Age itself has been related to microangiopathy. In two similar publications, the role of arteriosclerotic brain lesions in the development of dementia in patients with mild cognitive impairment (MCI) has been demonstrated .
In previous studies, vascular lesions have been identified as a significant risk factor for developing gait changes and/or cognitive decline. The risk of falls depends on how vascular lesions are distributed in the frontal region in charge of executive functions and organization of motor commands. Another study highlights the relevance of subcortical lesions not only in frontal regions but also in seven specific regions: frontal, temporal, parietal, and occipital lobes, basal ganglia, internal capsule, external capsule and cerebellum. A multivariate analysis reported that subcortical vascular lesions were the sole significant predictor for the risk of falls in elderly populations. According to the authors, this could be related to the subcortical hypoperfusion interrupting long loop reflexes critical for gait and balance mediated by deep white matter sensory and motor tracts as wells as descending motor fibers arising from medial cortical areas .
To sum up, it would seem that morphological MRI has unveiled a correlation between presence of vascular lesions, atrophy and hippocampal metabolism to changes in gait and subsequent relations to the cognitive evolution of older adults with MCI.
1.3.1.2
Functional imaging
Table 2 lists the studies discussed. Structures involved in gait control can be evaluated with techniques such as single photon emission tomography with technetium (HMPAO-SPECT), near-infrared spectroscopy (NRIS), transcranial magnetic stimulation (TMS), electro-encephalography (EEG), fMRI and PET. Depending on technical limitations, fMRI and PET are the techniques most often used and this is why we chose to only focus on these techniques. Furthermore, some studies reported in this paragraph concern young subjects because evaluations have yet to be conducted in older adults. Functional MRI does not use a radioactive tracer, but instead it is the concentration of desoxyhemoglobine which reflects a rise in the activation level. This technique distinguishes the cortical or subcortical regions activated during the task requested by the examiner however, fMRI (requiring for the patient to remain still) is not able to study brain activation directly during the real task, but rather the secondary activation obtained when imagining this task. In 2006, Bakker et al. demonstrated that characteristics (time needed) involved in the motor imagery of walking compared to real walking under the same conditions (path length and path width) in young people. They concluded to a high temporal correspondence between real and imagined walking and unveiled the possibility of studying the central components of gait with this technique. To our knowledge, only two studies comparing young and older people have been conducted. One study demonstrated that older subjects overestimated the duration of imagined movements , while the other study showed that the imagined performance was faster than the real physical performances . In these studies, the first step could have been to systematically consider the comparison between time needed to perform the real task and time required for imagining that same task. Furthermore, considering the available scientific literature, the population studied by functional imaging must be completely defined and the conclusions may not be extrapolated to other populations. In 2003, Malouin et al. , in a PET study assessing six healthy adults (mean age: 55.9 years) compared brain activation during motor imagery of locomotor-related tasks and reported the involvement of the pre-supplementary motor area (pre-SMA) as well as the leg area of the motor cortex in conditions requiring locomotor movements (walking, initiating gait and walking over an obstacle). This study also suggested that the basal ganglia played a role in locomotor movements, which are automatic by nature. In 2004, Jahn et al. , in a study focusing on 13 healthy young subjects (mean age: 27.3 years), compared cerebral activation during standing, walking and running. Standing was associated with activation in both thalami (more to the right), the left putamen, left frontal gyrus and cerebellar vermis and there were no deactivation areas. Walking demonstrated activation in additional motor areas like SMA, parahippocampal gyrus and fusiform gyrus as well as occipital visual areas, inferior frontal gyrus, left putamen and the vermis as well as the anterior lobe hemisphere of the cerebellum. When subjects imagined themselves walking, there was an activation in the vermis, (next to the area activated during walking) and in the pontomedullary area, furthermore a decreased activation of the fusiform gyrus and parahippocampal gyrus was highlighted (just like during walking). In 2008, in a study evaluating nineteen healthy young adults (mean age: 33.5 years), the same authors asked the subjects to represent themselves walking along a curved line, using the same method published in their previous study, and they validated the importance of the activation in the parahippocampal and fusiform gyrus when visual navigation was required to perform a precise walking task. However, deactivations were noted in the superior and medial temporal gyrus. Jahn et al. suggested that this deactivation could decrease the importance of vestibular afferents and avoid a possible conflict between visual and vestibular inputs . This modulation of the information coming from the vestibular system was confirmed in a study by Deshpande and Patla using galvanic vestibular stimulation (GVS) to the mastoid bone, the authors noted the effect of vestibular disruptions in the locomotor performance of young (nine healthy subjects aged 20–35 years) and healthy older adults (age 65–85 years) . This study showed that in young populations, the vestibular stimuli can be down-regulated in favor of better visual stimuli. However, this down regulation does decline with in age and thus older adults are more prone to impaired balance when vestibular and visual stimuli differ. Similarly, it has been demonstrated that the mechanism of cortical inhibitory reciprocal interaction between the sensory systems as observed during locomotion and stance phases does decline with age . These data seem relevant when studying gait in older adults with sensory impairments.
| First author, technics and references | Observations |
|---|---|
| Bakker et al., J Neural Transm, 2007 | fMRI and PETscan are most often used to study gait |
| Bakker et al., fMRI, Exp Brain Res, 2007 | High temporal correspondence between real and imagined walk in young people |
| Personnier et al., Neurosci Lett, 2010 | Old people are at risk of overestimating the duration of imagined movements |
| Beauchet et al., J Neurol Sci, 2010 | Old people are at risk of underestimating the duration of imagined movements |
| Malouin et al., PETscan, Hum Brain Mapp, 2003 | Role of the pre-supplementary motor area, leg area of the motor cortex and basal ganglia in voluntary locomotor movements |
| Jahn et al., fMRI, Neuroimage, 2004 | Standing: activation in thalami, left putamen, left frontal gyri and vermis Walking: activation in SMA, parahippocampal and fusiform gyri, occipital visual areas, inferior frontal gyri, left putamen and vermis |
| Jahn K, fMRI, Brain Res, 2008 | Importance of activity in parahippocampic and fusiform gyri when precised gait is needed |
| Deshpande and Patla, Galvanic vestibular stimulations, Brain Res, 2007 | Decreasing down regulation capacity of vestibular information with age |
| Zwergal et al., fMRI, Neurobiol Aging, 2012 | Cortical inhibition and interaction between sensory systems during locomotion and stance declines with age |
| La Fouchère, fMRI and PET, Neuroimage, 2010 | Role of basal ganglia in the initiation of gait |
| Vidoni et al., fMRI, J Neurol Phys Ther, 2012 | Decreased activation in accessory motor regions, supplementary motor area and cerebellum in early stages of Alzheimer’s disease and increased coactivation in primary motor cortex of bilateral motor and visual regions in AD subjects |
Finally, the author compared the results from two functional imaging techniques: fMRI and, 18F-FDG PET, and validated the role of basal ganglia in gait initiation (GI) in a population that included sixteen healthy adults (age range: 51–73, mean age: 61.3 ± 7.8 years) .
Briefly and according to the author’s research, the stance phase seems modulated by the brainstem and the cerebellum while specific area have various well-defined roles during gait: the brainstem seems to involved in gat initiation and ending, the cortical areas, basal ganglia and thalami are implicated in GI and changes in direction.
The basal ganglia and cortical areas are responsible for gait changes for following specific direction or avoiding obstacles. The cerebellum seems to command gait rhythm and velocity. Cortical areas like SMA are involved the cognitive control of gait and its importance increases with age. In fact, while older adults are less able to down-regulate vestibular inputs, the cortical component seems more important during directed gait and changes of direction. According to the recent literature, the activity of the cortical network increases with age and thus could explain difficulties in performing dual tasks. A recent study has reported that the network organizing gait evolves along a person’s lifetime and according to certain specific disorders . Then, in the early stages of Alzheimer’s disease (AD), patients exhibit a decreased activation in the accessory motor areas, the supplementary motor area and the cerebellum in comparison to subjects without dementia. At the same time AD subjects show an increased coactivation of bilateral motor and visual regions with the primary motor cortex.
Considering the actual literature, available studies most often concern younger people. Very few have focus on older adults and especially elderly populations with cognitive disorders. This lack of data could be explained by the difficulties in convincing older adults to try these technics, as they are not easy to reach and the techniques are complicated to implement. Another difficulty seems to lie in the interpretation of the results as these cannot be extrapolated to other populations, furthermore carrying out a comparison between “healthy” older adults and adults with specific disorders is quite difficult and most often includes bias.
1.3.2
Contribution of the spatio-temporal parameters of gait
The Table 3 lists the studies discussed below.
| Author, references | Observations |
|---|---|
| Bridenbaugh and Kressig, Gerontology, 2011 | Instrumental method more precise than clinical tests |
| Wang et al., J Neural Transm, 2009 | Attentional component of gait increase with age |
| Verghese et al., J Gerontol A Biol Sci Med Sci, 2009 | Gait speed and variability of gait are two marker of risk to fall |
| Hausdorff et al., Arch Phys Med Rehabil, 2001 | An increase of 0.017 m in the length of the step in a cycle of step doubles the risk to fall |
| Maki, J Am Geriatr Soc, 1997 | Variability of gait is a marker of fear of falling not a marker of fall risk |
| Beauchet et al., JAGS, 2008 Dubost et al., Hum Mov Sci, 2006 | Interest of study the speed and the length of the step and the variability of gait during dual task considering the risk of falls |
| Allali et al., Dement Geriatr Cogn Disord, 2008 | Importance of executive functions considering the variability of the gait |
| Sheridan et al., JAGS, 2003 | Importance of divided attention capacities considering the variability of the gait |
| Holtzer et al., Neuropsychology, 2007 | Importance of cognitive functions considering the variability of gait speed |
| Allali et al., Mov Disord, 2010 | Specific gait’s profile considering people with AD or fronto-temporal dementia |
| Verghese et al., J Neurol Neurosurg Psychiatry, 2007 | Modifications of gait’s profile could help to predict the cognitive evolution of MCI |
| Bautmans et al., Gait Posture, 2011 | Reliability between the results obtained by Dynaport ® and GaitRite ® when based on two walks over 18 m and correlation with falls and functional status in older subjects |
| Gillain et al., Ann Phys Rehabil Med, 2009 | An accelerometric device allows to highlight specific gait’s profiles according to the cognitive status of older subjects |
Today, to conduct a precise study on spatiotemporal gait’s parameters there is a choice between treadmills (i.e., GaitRite ® ) or accelerometer devices (i.e., Locométrix ® or Dynaport ® ). Many teams have used the GaitRite ® system (however other types of treadmills are available). This treadmill comes in different distances and is equipped with pressure sensors to measure spatiotemporal parameters. Collected data consist in speed, number of gait cycles, step length and width as well as duration of the double stance period. Then, by calculating the variables’ coefficient of variation (CV) and comparing each gait cycle to the other, it is possible to express gait “variability”.
As well-detailed in a recent review regarding the relevance of gait analysis, these technics help to improve the precision of gait profiles, much better than clinical tests alone could . Then, in the last ten years, studies which have used these techniques have reported that with age walking requires more attention .
Some authors have shown that gait speed and variability are two predictors for the risk of falls in older adults ; a variation of 0.017 m in step length within a gait cycle actually increases this risk twofold . A few years ago, Brian Maki using footswitches, reported that decreased speed, reduced step length and increased duration of the double stance period were independent fall predictors. However in the same study the author highlighted that step-to-step variability was not related to the risk of falls but rather associated with the fear of falling . Unfortunately, a comparison between these three studies remains difficult without a complete and detailed description of the three different populations and the patients’ potential history of falls prior to the evaluation.
Using GaitRite ® , numerous authors have demonstrated the relevance of analyzing gait during dual task, i.e. asking the subject to walk while simultaneously completing a cognitive task. Three parameters, gait speed step length and variability of gait parameters, seem good predictors for the risk of falls in this condition .
Other teams have studied older adults at the onset of cognitive disorders or Alzheimer’s disease and have reported the influence of memory and executive functions but also the importance of divided attention capacities on the variability of gait parameters, mainly gait speed . Most recently, a significant relationship was reported between an increased CV for step time (i.e., time needed to complete a gait cycle) in older adults with frontotemporal dementia, compared to older adults suffering from AD and to healthy subjects .
In a survey of 400 subjects without cognitive disorders, a cognitive assessment and instrumental study of their gait parameters were performed at the beginning of the study and after 5 years. At the 5-year visit, the authors described a significant correlation ( P = 0.02) between the evolution of gait speed, step length and global decline in cognitive and executive functions, once variables had been adjusted for age, sex and level of education .
A recent study reported the reliability of the results obtained using a triaxial accelerometer device (Dynaport ® ) based on two 18- meter walking courses. Furthermore, the results obtained were correlated with falls and functional status in older adults. In this context, our team analyzed gait parameters with a triaxial portable accelerometer, the Locométrix ® . This device, fitted around the patient’s waist with an elastic belt, recorded the accelerations in the antero-posterior, medio-lateral and cranio-caudal axes. Gait parameters were analyzed in a population of healthy older adults, adults with MCI and adults with Alzheimer’s disease (AD). In all three groups, the subjects had to walk along a straight, 40-meter long corridor, in a simple task (walking) and dual task (walking while counting backwards). In both conditions, the Locométrix ® differentiated the three populations based on their gait profile related to their cognitive status .
The instrumental gait analysis seems quite relevant for discriminating one or several spatiotemporal variables that could increase the risk of falling and help identify subjects with cognitive disorders based on their gait profile and thus discern those at risk of developing dementia.
These methods for studying gait parameters have shown that age was not the only element to explain gait variability. In fact, factors such as cognitive disorders, histories history of falls, given walking speed and gait conditions (single or dual task) do have an impact on gait in older populations and remain useful indicators to evaluate the risk of falls or predict cognitive evolution. Then, considering these parameters and in order to assess gait it is essential to refine gait conditions, population characteristics (not only age but history of falls, medications, comorbidities, sensory impairments, neurologic disorders…), required walking speed and evaluation technic used. It seems important to note that results from a study with a specific technic conducted on a specific population and using a specific protocol cannot be extrapolated to other situations. In light of the above, teams who are studying gait do encounter some general difficulties in geriatric populations: design of the study and finding a balance between the need to highlight some results with a strong statistical power and the relevance of underling this result in a “real-life” population.
1.3.3
Gait initiation
More recently, several teams have tried with various techniques to study the precise onset of GI. Indeed, this moment seems particularly dangerous for older adults presenting a risk of falls. GI is a voluntary transition from a stable double stance position to a continuously unstable posture when walking, which requires anticipatory postural adjustments to shift the center of mass towards the supporting side to lift-up the leg . As showed by single-photon or positron emission tomography or repetitive transcranial magnetic stimulation GI requires the activation of the SMA and basal ganglia also seem to be playing a crucial role as demonstrated in subjects with in Parkinson’s disease (PD) subject . GI is often evaluated using force platforms. In the past years, several teams have studied GI in a population of healthy older adults , in older people with fear of falling , fallers , subjects with PD and AD . GI seems to vary according to the population studied. Further studies should be conducted to validate and refine these observations.
1.4
Discussion and conclusion
Several studies have reported the relevance of gait assessment in older populations. New imaging techniques and instrumental analyses enable to underline the relationship between anatomy and metabolism of the central structures and spatiotemporal gait parameters. Gait seems to be an indicator of “successful aging” by predicting cognitive and functional changes. Unfortunately, and despite very useful elements provided by these new techniques, they remain quite confidential, restrained to an experimental setting and are not widely available in clinical practice. Step length, gait speed and variability seem essential indicators of gait quality. Moreover, studying gait in dual task condition could bring information on the risk of falls, and cognitive reserve allocated for gait organization. Furthermore, in this elderly population it seems quite relevant to conduct systematic gait evaluations in single and dual task conditions associated with a long-term follow-up.
Finally, GI seems a crucial element to evaluate safety in older adults. Studying this specific moment, could better refine the underlying mechanisms involved in gait and balance and work towards improving them.
In our opinion, clinical tests remain essential for evaluating quickly and efficiently the gait and balance of older adults, available tests include the 10-meter walking test to evaluate speed, the Timed-up-and-go test, the short physical performance battery including the Sit-to-Stand test, the Berg or Tinetti balance tests test should remain the best way to perform a quick useful study of the balance of older subjects. Concerning dual task condition, the Stop walking when talking test represent a very good predictor of risk . Indeed, comparing gait speed in single and dual task is a relevant screening tool to evaluate the risk of falls; with a low 40% sensitivity but a high 96% specificity .
In choosing a systematic method for gait assessment, the most important thing would be to select some easy to perform test, reproducible under the same conditions and well known by the examiner in order to be systematically repeated. Finally, a hand grip test or Martin’s vigorimeter could be relevant to evaluate muscle mass in elderly populations and predict the evolution of their and future functional status. In the future, the use of these new technics, enhancing “central” or “peripheral” markers with a predictive value for functional and cognitive decline, might improve the detection of people at risk of falling and enable teams to propose multidisciplinary screening evaluation and monitoring follow-ups. These studies might permit the design of adapted and specific gait but also cognitive rehabilitation protocols, in a population of frail older adults.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
2
Version française
2.1
Introduction
Au cours de ces dernières années, l’étude de la marche chez le sujet âgé a suscité beaucoup d’attention. En effet, une altération de la marche peut entraîner des chutes et augmenter le risque de placement, de déclin cognitif et la survenue de comorbidités . C’est pourquoi les changements de la marche peuvent être considérés comme un indicateur de fragilité. Des travaux récents montrent que les altérations de certains paramètres de la marche peuvent être considérées comme un signe de fragilité cognitive . Le concept de « démarche sénile physiologique » est donc contesté. Le questionnement actuel du clinicien est : – La « démarche sénile physiologique » est vraiment physiologiquement normale ou est-elle le reflet d’un processus pathologique débutant, comme un trouble cognitif, pouvant entraîner des chutes ? – Et qu’en est-il d’un éventuel seuil permettant de différencier la personne âgée en bonne santé de la personne âgée fragile ?
Il est admis que la marche est le résultat d’une commande motrice émanant du système nerveux central et exécutée au niveau du système nerveux périphérique. L’exécution de la commande motrice est possible grâce à l’implication du système vestibulaire, du système nerveux périphérique et du système cardiovasculaire mais également par une bonne qualité musculaire et ostéoarticulaire.
Pour étudier la marche, il est nécessaire d’étudier les aspects cliniques. Une liste exhaustive des antécédents (chirurgies, traitements médicaux, conditions préexistantes), examen physique et tests cliniques sont essentiels à la compréhension de la mobilité de la personne âgée. De plus, il existe deux voies d’analyse de l’organisation spécifique de la marche : l’analyse anatomique et fonctionnelle du système nerveux central qui organise la commande motrice et la mesure des paramètres spatiotemporels de la marche. L’organisation de la commande motrice peut actuellement être précisée grâce aux techniques d’imagerie par résonance magnétique (IRM), IRM fonctionnelle (IRMf), et tomographie par émission de positons (PET). Quant à l’étude précise des paramètres de marche, les tests cliniques utilisés en pratique quotidienne ont rapidement montré leurs limites comparé aux analyses instrumentales des paramètres de marche . En effet, les tapis de marche et les accéléromètres permettant l’analyse des paramètres spatiotemporels de la marche, ont été récemment utilisés chez le sujet âgé.
L’objectif de cet article est de discuter des nouvelles techniques d’analyse de la marche chez le sujet âgé. La maladie de Parkinson ainsi que d’autres pathologies incluant des modifications de la marche déjà décrites lors de publications spécifiques, ne sont pas abordées.
2.2
Méthode
Le but de cet article n’est pas de mener une revue systématique de la littérature. Les auteurs proposent ici une revue thématique basée sur les articles récents et d’autres précédemment connus des auteurs. Les articles ont été sélectionnés selon :
- •
leur contribution à une large revue thématique ;
- •
l’expertise des principaux auteurs concernant l’étude de la marche ;
- •
l’aspect pratique des connaissances et découvertes citées dans l’article.
Ensuite, les auteurs ont analysé la bibliographie de chaque article afin de sélectionner d’autres références contributives. Les recherches bibliographiques ont été menées au sein de la Cochrane Library avec les mots clés « gait AND older » (marche ET âgé). Nous avons identifié ainsi huit articles dont deux décrivaient spécifiquement la rééducation de la marche chez la personne âgée. Dans la même base de données et en utilisant les mots « gait AND elderly » (marche ET personnes âgées), nous n’avons retrouvé qu’un seule article portant sur la rééducation fonctionnelle uniquement. Aucun article n’a été retrouvé sur la contribution de l’imagerie et des techniques d’analyse instrumentale de la marche. Les auteurs ont ensuite cherché via MEDLINE avec les mêmes mots clés en limitant avec « articles complets uniquement, Humains, Anglais, Français, Âge : +65 ans, publiés au cours des dix dernières années ».
Nous avons retrouvé plus de 900 références. Les plus intéressantes étaient sélectionnées en fonction des critères décrits plus haut. Initialement, 47 résumés furent considérés et seulement 12 articles finalement retenus.
2.3
Résultats
2.3.1
Apport de l’imagerie
2.3.1.1
L’imagerie à résonance magnétique
Le Tableau 1 résume les différentes études décrites.
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