Cognition and Gait: Integrating skills for safer mobility

1. 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

2. Our Mission Bancroft provides opportunities to children and adults with diverse challenges to maximize their potential. Our Core Values Responsible Empathetic Supportive Passionate Empowered Committed Trustworthy R E S P E C T Our Vision A community where every individual has a voice, a purpose and a rightful place in society.

3. 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.

5. 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.

6. 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. • (BasfordJR, 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.)

7. 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.)

8. 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)

9. Common Cognitive Problems following TBI • Attention • Memory • Executive Functions • Planning • Organizing • Problem-solving • Decision-making • Anticipating

10. 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.)

11. 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 sub-processes to organize behavior and achieve particular goals. • (Eslinger PJ, Zappala G, Chakara F, Barrett, A.. Cognitive Impairments After TBI In Zasler ND, Katz DI, • ZafonteRD (eds.). Brain Injury Medicine: principles and practice, Demos Medical Publishing, 2007.)

12. Executive Functions • Associated cognitive operations include working memory, prospective memory, strategic planning, cognitive flexibility, abstract reasoning, and self-monitoring. • (EslingerPJ, 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.)

13. 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)

14. 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.)

15. 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

16. 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.)

17. 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), NeurocomEquitest. • 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.)

18. 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.)

19. Research in the TBI/ABI Population

20. 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.)

21. 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.)

23. 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.)

24. 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.)

25. Are Healthy People Immune to Distractions?

26. 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-half-of-cell-owners-affected-by-distracted-walking/)

27. 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.)

28. 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.)

29. 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.)

30. 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.)

31. 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.)

32. 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.)

33. 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.)

34. 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.)

35. Clinical Implications • The clinical implications of the relationship between gait and cognitionare 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.)

36. 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 sub-processes to organize behavior and achieve particular goals. • (Eslinger PJ, Zappala G, Chakara F, Barrett, A.. Cognitive Impairments After TBI In Zasler ND, Katz DI, • ZafonteRD (eds.). Brain Injury Medicine: principles and practice, Demos Medical Publishing, 2007.)

37. Executive Functions • Associated cognitive operations include working memory, prospective memory, strategic planning, cognitive flexibility, abstract reasoning, and self-monitoring. • (EslingerPJ, 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.)

38. 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.

39. Integration of Assessments from Interdisciplinary Team • Neuropsychological Assessment • Physical Therapy Evaluation • Occupational Therapy Evaluation • Speech Therapy Evaluation

40. 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.

41. 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.

42. Treatment Considerations • Environmental modifications • Home (lighting, noise, clutter, “traffic pattern”)

43. Treatment Considerations • Community (travel patterns, peak shopping/travel times, curb cuts, traffic lights, stairs, elevators, escalators, weather-related issues)

45. 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.

46. 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.

47. QUESTIONS