Motor Learning Versus Standard Walking Exercise in Older

Adults with Subclinical Gait Dysfunction: A Randomized

Clinical Trial
Jennifer S. Brach, PhD, PT,* Jessie M. Van Swearingen, PhD, PT,* Subashan Perera, PhD,†
David M. Wert, PhD, PT,* and Stephanie Studenski, MD, MPH†

Key words: exercise; motor learning; clinical trial

OBJECTIVES: To compare the effect of motor learning
with that of standard exercise on measures of mobility and
perceived function and disability.
DESIGN: Single-blind randomized trial.
SETTING: University research center.
PARTICIPANTS: Older adults (n = 40) with a mean age
of 77.1  6.0, normal walking speed (≥1.0 m/s), and I ndependent functioning is at the core of successful aging,
and independent mobility is critical to independent func-
tion. Exercise for older adults is recommended because it
impaired motor skills (Figure of 8 walk time >8 seconds).
promotes physical and mental health and may improve
INTERVENTIONS: The motor learning program incor-
mobility and prevent walking difficulty.1 Walking places
porated goal-oriented stepping and walking to promote
demands on the musculoskeletal (muscles, bones, joints),
timing and coordination within the phases of the gait
cardiopulmonary (heart, lungs), and nervous (brain, spinal
cycle. The standard program employed endurance training
cord, peripheral nerves) systems.2,3 Although musculoskel-
by treadmill walking. Both included strength training and
were offered twice weekly for 1 hour for 12 weeks. etal and cardiopulmonary impairments are widely recog-
nized in older persons, neurological impairments, clinically
MEASUREMENTS: Primary outcomes were mobility per-
overt as well as subtle, are also increasingly common with
formance (gait efficiency, motor skill in walking, gait
age.3–5 It is likely that some combination of impairments
speed, walking endurance); secondary outcomes were per-
in the musculoskeletal, cardiopulmonary, and nervous sys-
ceived function and disability (Late-Life Function and Dis-
tems contributes to late-life mobility decline.3
ability Instrument).
Current exercise recommendations for health promo-
RESULTS: Thirty-eight of 40 participants completed the tion target strength and flexibility of the musculoskeletal
trial (motor learning, n = 18; standard, n = 20). The system and endurance in the cardiopulmonary system but
motor learning group improved more than the standard rarely address the nervous system.6 Neurological exercise
group in gait speed (0.13 vs 0.05 m/s, P = .008) and
focuses on motor learning through goal-oriented repetitive
motor skill ( 2.2 vs 0.89 seconds, P < .001). Both
practice and has been applied in neurological disorders
groups improved in walking endurance (28.3 and 22.9 m,
such as stroke and Parkinson’s disease,7–9 as well as in
P = .14). Changes in gait efficiency and perceived function
developing skills in sports and recreation.10 It was hypoth-
and disability were not different between the groups
esized that motor learning would improve walking by
(P > .10).
applying task-specific exercises to challenge the brain to
CONCLUSION: In older adults with subclinical gait dys- adapt to a well-controlled and environmentally responsive
function, motor learning exercise improved some parame-
sequence and timing of movements within the postures
ters of mobility performance more than standard exercise.
and phases of gait. Improvements in walking occur by
J Am Geriatr Soc 61:1879–1886, 2013.
restoring the pattern of brain and neuromuscular activation
that optimize the ability to meet walking demands.11–15
Because subclinical neurological abnormalities are com-
From the *Department of Physical Therapy, and †Division of Geriatric mon with aging, neurologically oriented motor learning
Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. exercise might address an important missing aspect of
Address correspondence to Jennifer S. Brach, Department of Physical exercise to promote independent mobility in late life.
Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA A task-oriented motor learning exercise program that
15260. E-mail: jbrach@pitt.edu incorporates elements of motor learning often used in neuro-
DOI: 10.1111/jgs.12506 logical rehabilitation was developed into an exercise

JAGS 61:1879–1886, 2013

© 2013, Copyright the Authors
Journal compilation © 2013, The American Geriatrics Society 0002-8614/13/$15.00
1880 BRACH ET AL. NOVEMBER 2013–VOL. 61, NO. 11 JAGS

program to promote walking in older adults. The program or neurological conditions that were exclusion criteria.
includes goal-oriented stepping and walking patterns to pro- Participants had to be medically stable (excluded if
mote the timing and coordination of stepping integrated with reported dyspnea at rest or during activities, hospitaliza-
the phases of the gait cycle. The ultimate goal of the training tion in the past 6 months for acute illness or injury, or a
is to promote skill in walking. Adults who are skilled walkers progressive neuromuscular disorder such as Parkinson’s
have an energy-efficient gait, tire less easily, and as a result, disease) to be able to participate in the exercise program
are more likely to walk more, participate in more activities, (excluded if reported persistent lower extremity or back
and report less disability.16 In prior work, the effect of motor pain, fixed or fused lower extremity joints, resting systolic
learning walking exercise was compared with that of stan- blood pressure ≥200 mmHg, diastolic blood pressure
dard exercise in older adults with walking difficulty (defined ≥100 mmHg, or resting heart rate >100 beats per minute
as slow and variable gait). Motor learning exercise promoted or <40 beats per minute), and have a Mini-Mental State
greater gains in gait efficiency, gait speed, and self-perceived Examination22 score of 24 or greater. All participants had
walking ability.17 Although that population was similar to physician clearance to participate in a moderate-intensity
persons with neurological disorders, the potential effect of exercise program.
motor learning on the population of older persons who walk
at a normal speed but have evidence of subclinical neurologi-
cal deficits has not been explored. If motor learning training Sample Size and Randomization
for walking improves mobility in older adults with such sub- Because this was a pilot intervention trial, sample size
clinical gait dysfunction (gait speed ≥1.0 m/s but impaired (n = 40) was based on available resources rather than
motor skill in walking), it might make sense to incorporate statistical power. The study’s biostatistician (SP) generated
motor learning into exercise programs aimed at primary pre- the randomization sequence using a high-quality pseudo-
vention of future mobility disability. random deviate generator in SAS (SAS Institute, Inc., Cary,
The goal of this randomized clinical trial was to com- NC). The study coordinator randomly assigned partici-
pare motor learning with standard walking exercise in pants to motor learning or standard interventions in a 1:1
older adults with subclinical walking difficulty. It was ratio. A blocked randomization scheme was used to force
hypothesized that both forms of exercise would improve continued approximate balance between the numbers of
walking speed and endurance but that the motor learning subjects in each arm during recruitment. The block size
group would demonstrate greater improvements in motor was randomly four or six to prevent personnel from
skill and gait efficiency. predicting treatment arm.

METHODS Interventions
Overview Overview
The 12-week single-blind randomized pilot intervention Each protocol-driven, physical therapist–led intervention
trial compared two exercise interventions in older adults for one to two participants lasted 60 minutes twice a week
with subclinical gait dysfunction. The University of Pitts- for 12 weeks. The interventions were conducted at differ-
burgh institutional review board approved the Program to ent times to avoid cross-contamination. The protocols
Improve Mobility in the Elderly, and all subjects provided defined each activity and gave standards for progression
informed consent. The study was registered at ClinicalTri- based on accuracy and ease of performance. The treating
als.gov (PRO09080228). therapist documented treatment intensity at each session
that was periodically reviewed to ensure treatment pro-
Participants gression and fidelity. To equalize the time in treatment
between the two intervention arms, both programs
Eligible older adults had subclinical gait dysfunction, included a brief warm-up period (walking, lower extremity
defined as near-normal gait speed (≥1.0 m/s) and impaired active range of motion such as ankle pumps, knee exten-
motor skill in walking. Gait speed was assessed using an sion, hip extension, and gentle stretches for lower extrem-
instrumented walkway. Subjects completed two trials, and ity and trunk muscles) and strength training. The strength
the mean gait speed of the two trials was calculated and training was conducted on stacked weight equipment (leg
used to determine eligibility. Motor skill in walking was extension and curl combo, leg press machine, and multihip
assessed using the Figure of 8 Walk Test.18 The Figure of combo; Magnum Fitness Systems, South Milwaukee, WI)
8 Walk Test, which is associated with measures of move- and included knee extension, knee flexion, leg press, hip
ment control and planning during walking, has been vali- abduction, and hip extension. When subjects were able to
dated as a measure of walking skill.18–20 A score of complete two sets of 15 repetitions with minimal effort
8.7 seconds or longer has been identified as an indicator of (rating of perceived exertion (RPE) <10), resistance was
impaired function in community-dwelling older adults,21 increased for progression of the exercises.
and a mean of 7.3 seconds has been reported in healthy
young adults. Based on these preliminary findings, a score
Motor Learning Exercise
of 8 seconds or longer was selected as an initial indicator
of impaired motor skill in walking. In addition to the warm-up and strength training described
All participants underwent a brief screening examina- above, subjects in the motor learning group received 20
tion to identify any overt musculoskeletal, cardiopulmonary, to 30 minutes of motor learning exercises. The motor
JAGS NOVEMBER 2013–VOL. 61, NO. 11 MOTOR LEARNING VERSUS STANDARD EXERCISE 1881

learning program17 was based on the principles that enhance walked on a treadmill at a self-selected pace while oxygen
“skill” or smooth, automatic movement control.11,23–27 This consumption data was collected using open circuit spirom-
previously described program17 used goal-oriented, pro- etry and analysis of expired gases using a portable meta-
gressively more difficult stepping and walking patterns to bolic measurement system (VO2000; Medgraphics,
promote the timing and coordination of stepping inte- Minneapolis, MN). All participants were familiarized with
grated with the phases of the gait cycle.11,24,25,27 Concep- treadmill walking until comfortable walking on the tread-
tually, the exercise was intended to achieve its effects by mill before the baseline measurement. The mean rate of
shifting the center of pressure posterolaterally and then oxygen consumption and carbon dioxide production was
forward, encouraging hip extension before stepping, load- determined over 3 minutes after reaching steady state.33,34
ing the trailing limb, coordinating activation of the abduc- The energy cost of walking (mL of O2/kg/m) represents an
tors of the soon-to-be-swung leg with adductors of the estimate of energy expenditure per unit of gait speed35–37
stance limb, and shifting the center of pressure in medial and relates to metabolic equivalents (METs). Because the
stance to unload the stepping limb.28–30 Progression of energy cost of walking is standardized according to walk-
exercises was based on separately increasing the speed, ing speed, it is time independent, is repeatable, reflects the
amplitude, or accuracy of performance before undertaking physiological cost of gait,33,34 is little influenced by fit-
a more-complex task.31 For example, the progression of ness,34 and can be compared between individuals and over
stepping patterns was self-paced step forward and across, time, regardless of changes in gait speed.34,37
increase stepping speed, alternate side of stepping, and Motor Skill in Walking. The Figure of 8 Walk was
alternate forward and backward stepping. Walking used as a measure of motor skill in walking. The test
patterns incorporated patterns of muscle coordination and involved walking a figure 8 pattern around two markers
interlimb timing into walking. Walking patterns progressed placed 5 feet apart. Performance was scored based on
by altering speed, amplitude (e.g., narrowing oval width), the time needed to complete the figure 8 walk and the
or accuracy of performance (e.g., without straying from number of steps. No added value has been found for
the desired path) and then to complex walking patterns the qualitative portion of the Figure of 8 Walk, so only
involving walking past others and with upper extremity the quantitative measures are reported. The Figure of 8
object manipulation tasks, such as carrying or bouncing a Walk has established interrater reliability (intraclass cor-
ball.27 Treadmill walking reinforced the rhythmic stepping relation coefficient (ICC) = 0.90 for time, ICC = 0.92
and was completed at preferred walking speed with brief for number of steps) and validity by comparison with
intervals of increased speed. measures of gait, motor control, and function.18 Less
time and fewer steps are an indicator of greater skill in
Standard Exercise walking.
Gait Speed. Participants walked at their usual, self-
In addition to the warm-up and strength training described selected speed on a 4-m instrumented walkway (GaitMat
above, subjects in the standard group underwent endurance II, E.Q. Inc., Chalfont, PA) with 2-m noninstrumented sec-
training. The endurance training consisted of treadmill tions at either end to allow for acceleration and decelera-
walking at a submaximal workload with a self-reported tion. After two practice trials, participants completed four
RPE of 10 to 13 (somewhat hard). When subjects were able trials that were used for data collection. Gait speed was
to tolerate a RPE of 10 to 13 for 15 minutes, the workload averaged over the four trials. The test–retest reliability of
was increased by first increasing the duration (up to gait speed measured using the GaitMat according to ICC
30 minutes) and then by increasing walking speed. The goal is 0.98.38
was to achieve 30 minutes of continuous treadmill walking Walking Endurance. The 6-Minute Walk Test (6MWT)
at a somewhat hard level of exertion. of distance walked (meters) in 6 minutes, including time
For safety, all participants (motor learning and stan- for rest as needed, was used to assess walking endurance.39
dard groups) were told they should stop walking immedi- The 6MWT has established psychometric properties, test–
ately if they felt they could not continue (symptom retest reliability (Pearson correlation coefficient (r) = 0.95)
limited), they or the physical therapist observed shortness in older adults,40,41 and construct validity for graded exer-
of breath, they demonstrated problems in the walking pat- cise test and functional classification.42
tern (e.g., toe drags on the floor during the swing-through Lower Extremity Strength Related to Mobility. The
phase of gait), or they reported or the physical therapist repeated chair rise component of the Short Physical Perfor-
observed any of the general indications for stopping nondi- mance Battery43 was used as a measure of lower extremity
agnostic exercise tests as recommended by the American strength. Participants were timed as they completed five
College of Sports Medicine.32 repeated chair rises without the use of the upper extremi-
ties. Time to complete the five chair rises was recorded.
Outcomes
Assessors masked to the intervention group assessed all out- Function and Disability
come measures before and after the 12-week intervention.
Late-Life Function and Disability Instrument
Mobility The Late-Life Function and Disability Instrument (LLFDI),
Gait Efficiency. The energy cost of walking reflects a pair of self-reported measures that assess physical func-
the energy used for all bodily actions during walking and tion and disability in older adults with acute or chronic
was used as an indicator of gait efficiency.33 Participants problems and is designed to be more sensitive to change
1882 BRACH ET AL. NOVEMBER 2013–VOL. 61, NO. 11 JAGS

than similar measures, was selected as the function and

RESULTS
disability outcome measure.44,45 The function component
has 32 items in three areas: basic lower extremity, Of 110 people initially screened over the telephone, 64
advanced lower extremity, and upper extremity. The dis- underwent onsite screening. Forty-one participants met all
ability component has 25 items in four domains: personal criteria, 40 were randomized (one subject deferred), and
role, social role, instrumental role, and management role. 38 completed the study (Figure 1). The two dropouts
The ICC for test–retest reliability ranged from 0.91 to developed medical conditions unrelated to the study and
0.98 for the function subscales and from 0.68 to 0.82 for walked more slowly than those who completed the study.
the disability domains.44,45 Although these two subjects had a gait speed of 1.0 m/s or
greater during their screening visit, their baseline testing
gait speeds were <1.0 m/s (0.73 and 0.98 m/s).
Data Analysis
Participants had a mean age of 77.1, normal gait
All statistical analyses were performed using SAS version speed (mean gait speed 1.18 m/s), and impaired motor
9.3 (SAS Institute, Inc.). Participant characteristics and skill in walking (mean Figure 8 time 9.2 seconds; Table 1).
baseline measurements of the arms were compared using Although subjects had a normal gait speed, their baseline
t-tests for continuous variables and chi-square tests for energy cost of walking was 0.22 mL/kg/m, nearly 50%
categorical variables. Paired-sample t-tests were used to greater than the 0.15 mL/kg/m energy cost of normal
assess significance of change in outcomes measures within walking in young adults.47 Baseline mean LLFDI score
each arm. To obtain adjusted comparison of outcomes was similar to that of community-dwelling older adults
between treatment arms, an analysis of covariance model without mobility limitations.48
was fitted using change form baseline to follow-up in each Participants in the two treatment arms were similar on
outcome as the response variable, treatment arm as the all baseline measures (Tables 1–3). Although not statisti-
main factor of interest, and baseline value of the outcome cally significant, baseline gait speed was 0.08 m/s faster in
as a covariate. the motor learning than the standard group, which is con-
Outcomes for gait efficiency, the main mobility out- sidered to be a small but meaningful difference.49 All 38
come, were examined in greater detail. To determine individuals who completed the study participated in at
whether the change in gait efficiency was clinically mean- least 22 exercise sessions, with 37 participants (97%) com-
ingful, a meaningful difference was estimated from the pleting all 24 sessions.
baseline sample energy cost of walking using Cohen mod- The motor learning group had greater improvements
erate effect size criteria (e.g., moderate effect = 0.5 9 than the standard group in motor skill and a greater
baseline standard deviation of energy cost).46 Likewise, reduction in time to complete the Figure of 8 test (adjusted
before and after the intervention, the percentage of sub- group difference (standard error (SE)) 1.39 seconds
jects who had an energy cost of walking of 0.15 mL/kg/m (0.29 seconds), P < .001) and number of steps taken dur-
or less, which is considered normal for adults, was exam- ing the Figure of 8 test (adjusted group difference (SE)
ined according to treatment arm.47 1.09 (0.49), P = .03)—both indicators of improved

110 Assessed for Eligibility

by Phone Screen
46 Failed Phone Screen
Not interested n=32
Deceased n=1
Unwilling to travel n=5
Persistent pain n=4
Recent hospitalization n=3
< 65 years of age n=1
64 Assessed for Eligibility
by Clinic Screen
23 Failed Clinic screen
Gait speed < 1.0 m/s n=8
Figure of 8 < 8.0 sec n=15
1 Declined Participation
40 Randomized

20 Assigned to Motor Learning 20 Assigned to Standard Exercise

0 lost to follow-up 0 lost to follow-up

2 Discontinued Intervention 0 Discontinued Intervention

18 included in analysis 20 included in analysis

Figure 1. Study flowchart.

JAGS NOVEMBER 2013–VOL. 61, NO. 11 MOTOR LEARNING VERSUS STANDARD EXERCISE 1883

P-Valueb
Table 1. Baseline Characteristics According to Treat-

<.001

.008
.13

.03

.14
.59
ment Group
Motor

Group Difference
Learning, Standard,

(Standard Error)
n = 18 n = 20 P-value

(0.02)
(0.29)
(0.49)
(0.04)
(10.3)
(0.69)
Characteristic

Adjusted
Age, mean  SD 75.7  5.5 78.5  6.2 .16

0.03
1.39
1.09
0.11
15.4
0.38
Female, n (%) 10 (55.6) 13 (68.4) .42
White, n (%) 18 (100) 19 (95) .32
Married, n (%) 12 (67) 9 (47) .36
Graduate education, 10 (56) 11 (58) .99

P-Valuea
n (%)

.0001
Chronic conditions,

.31

.08
.13
.03
.27
n (%)
Cardiac disease 2 (11) 1 (5) .49
Musculoskeletal 12 (67) 18 (90) .08

0.06

0.14
42.8
0.8
2.1

2.8
conditions

Change







Vision problems 13 (72) 18 (90) .16

0.02
0.89
0.85
0.05
22.9
0.8
Diabetes mellitus 4 (22) 2 (10) .30
Cancer 8 (44) 5 (25) .21

Standard, n = 20
Lung disease 4 (22) 2 (10) .30
Gait speed, m/s, 1.22  0.16 1.14  0.15 .79

Postintervention
mean  SD

0.04

0.14
40.0
1.0
1.8

2.3
Mean  SD
Figure of 8 Test, 9.1  0.93 9.3  0.92 .97







seconds,

416.6
8.4
0.20

15.2
1.19

11.7
mean  SD

Table 2. Pre- and Postintervention Performance-Based Outcomes According to Treatment Group

SD = standard deviation.

Preintervention

0.04

0.15
65.6
0.9
2.1

2.3
motor skill. The motor learning group also had greater







improvement in gait speed than the standard group

0.22

16.1
1.14

12.6
393.7
9.3
(Table 2). Because of equipment malfunction or poor data
quality, seven of the 38 individuals who completed the
study were missing baseline or postintervention data on
P-Valuea

the energy cost of walking. Missing data were equally dis-

<.001
.001
.001
.001
.06

.43
tributed between treatment groups (motor learning group
n = 3, standard group n = 4). The adjusted difference in
change in energy cost of walking between the groups was
0.07

0.11
29.6
0.03 mL/kg/m (P = .13). Changes in walking endurance
1.1
1.5

2.4
Change

(6MWT), chair rise time, and perceived function and dis-








ability were not different between the groups (P > .10).

2.2
1.5

0.5
0.04

0.13
28.3
Motor Learning, n = 18

Motor skill in walking, gait speed, and walking endur-

ance improved in the motor learning group, whereas only
Postintervention

one indicator of motor skill in walking (Figure of 8 time)

0.05

0.15
55.0
1.0
1.5

2.2

and walking endurance improved within the standard

Mean  SD

group (Table 2). Chair rise time did not change








significantly in either group. The motor learning group but

0.17

13.8
1.35

10.9
448.6
6.9

not the standard exercise group had improvements in the

instrumental role and management disability domains of
the LLFDI (Table 3). The function component of the
Preintervention

0.05

0.16
53.1

LLFDI did not change with either intervention (Table 3).

Motor learning, n = 15; standard, n = 16.
0.9
1.7

3.2

A moderate effect size for energy cost of walking was








determined to be 0.03 mL/kg/m (e.g., moderate effect =

9.1
0.21

15.3
1.22

11.3
420.3

0.5 9 0.05). After the motor learning intervention, the

group mean energy cost decreased by 0.04 mL/kg/m to
Between-group comparison.
Within-group comparison.

0.17 mL/kg/m. It is likely that the 0.04 mL/kg/m change

SD = standard deviation.
Energy cost, mL/kg/mc

6-Minute Walk Test, m

that the motor learning group exhibited is a meaningful

5 chair rise, seconds
Figure of 8, seconds

change. This is in contrast to the standard exercise group,

Figure of 8, steps
Outcome

Gait speed, m/s

which improved only 0.02 mL/kg/m with the intervention.

At baseline, only 6% of the subjects in the motor learning
(1/15) and standard (1/16) groups had an energy cost
of walking that was normal. After the interventions, 33%
(5/15) of the subjects in the motor learning group had a
b
a

c
1884 BRACH ET AL. NOVEMBER 2013–VOL. 61, NO. 11 JAGS

P-Valueb
normal energy cost of walking, compared with only

.60
.49
.57
.50

.78
.63
.68
.43
.49
.14
12.5% (2/16) of the subjects in the standard exercise
group (Figure 2).

Difference (Standard
Adjusted Group
DISCUSSION

(1.42)
(3.14)
(1.93)
(2.49)

(1.82)
(4.88)
(1.98)
(3.34)
(3.55)
(2.98)
Motor learning exercise improved markers of walking
Error)

more than standard exercise in older adults with subclini-

0.75
2.17
1.10
1.69

0.50
2.39
0.82
2.66
2.46
4.48
cal gait dysfunction, defined as generally adequate gait
speed but impaired motor skill in walking. The motor
learning program resulted in greater improvements in
walking skill and gait speed. In addition, when the findings
P-Valuea

were examined within groups, only the motor learning

.35
.98
.69
.23

.44
.67
.30
.12
.14
.26
group improved in self-reported disability.
The energy cost of walking was high in this popula-
13.6

11.4
tion of older adults with generally adequate walking speed,
3.2
6.3
4.4
8.0

7.6

7.6
8.4
8.8
Change

suggesting that there were inefficiencies in their gait pat-

Table 3. Pre- and Postintervention Self-Reported Function and Disability Outcomes According to Treatment Group












terns. Gaits with altered timing and postures, which are
0.4
2.3

1.5
1.4
2.0
3.4
3.3
3.3
0.72
0.04

often the result of neurological or orthopedic conditions,

Standard, n = 20

can double or triple the cost of walking.50–52 Motor learn-

ing interventions that focus on the timing and coordination
Postintervention

11.0
10.1
10.7

12.6
16.8
14.6
15.2
15.1
13.6

of movement during gait have reduced the energy cost of

Mean  SD

7.8

walking.53 In contrast to previous studies and the hypothe-













sis of the current study, the motor learning group did not
63.8
74.3
57.1
79.7

56.8
64.4
54.1
77.6
77.5
88.2

demonstrate significant improvements in gait efficiency.

Although the improvements were not statistically signifi-
cant (P = .06), it is likely that they were clinically mean-
Preintervention

ingful. This pilot study had limited power to detect a

10.2
11.8
11.1

10.3

15.1
15.0
15.7
8.5

6.7

9.5

meaningful difference. The absolute difference in energy













cost of 0.03 mL/kg/m is probably a moderate effect size,

64.5
74.3
57.5
82.0

55.3
63.0
52.1
74.3
74.2
84.9

and the difference in the proportion that achieved normal

energy cost is potentially clinically relevant.
The motor learning intervention also affected partici-
P-Valuea

SD = standard deviation; LLFDI = Late-Life Function and Disability Instrument, score range 0–100.

pation in daily activities (LLFDI disability domain). The

.005
.91
.62
.62
.25

.21
.31
.21
.05
.08

findings of the current study are similar to the effect of a

similar motor learning exercise program in older adults
with slow and variable gait16 in which self-reported
12.5

10.1

14.7

11.7
12.6
5.5

7.2

3.3

3.7

9.4
Change

function and disability also improved. Mechanistically, it













is to be expected that improvements in gait efficiency

Motor Learning, n = 18

1.5

2.8

1.0
3.6
1.1
6.0
5.6
7.3
0.15

0.87

would result in less fatigue and that, as a result, older

adults would participate in more activities and report less
Postintervention

disability.16
15.1
13.9

18.4

13.3
13.8

Intervention strategies challenge the brain to improve

8.9

8.1

6.8

7.7

9.7
Mean  SD

walking performance in different ways. An impairment-













based intervention, such as the standard strength and

64.0
78.4
56.9
76.7

56.4
68.7
53.2
80.4
80.3
93.3
Preintervention

14.2
12.4
11.6

13.0

12.1
12.3
11.6
8.8

5.7

7.9











63.9
76.9
56.1
79.5

55.4
65.1
52.1
74.5
74.7
86.1
Advanced lower extremity

Between-group comparison.
Within-group comparison.
Basic lower extremity

Management role
Instrumental role
Outcome

Upper extremity

Personal role
LLFDI disability
LLFDI function

Social role
Frequency

Limitation
Overall

Figure 2. Percentage of subjects with normal energy cost of

walking before and after the intervention according to treat-
ment arm.
b
a
JAGS NOVEMBER 2013–VOL. 61, NO. 11 MOTOR LEARNING VERSUS STANDARD EXERCISE 1885

endurance program, challenges the brain to use increased may be an important new addition to exercise programs
capacity in body systems to compensate for gait difficul- for older adults that include primarily endurance and
ties. Walking performance probably improves secondary to strength training.
greater ability to produce muscle forces, to move joints
through a greater range of motion, and to deliver more ACKNOWLEDGMENTS
oxygenated blood to the active tissues. The use of greater
capacity of body systems for walking makes the outcome A portion of this work was presented at the American
of the impairment-based intervention approach potentially Geriatric Society meeting, May 2012, Seattle, Washington.
inefficient and difficult to sustain. A motor learning–based Conflict of Interest: Jennifer Brach, Subashan Perera,
approach challenges the brain to adapt and learn the and Stephanie Studenski were supported by the Pittsburgh
sequence of movements and timing with the postures Older Americans Independence Center (NIA P30
and phases of gait to improve walking. Improvements AG024827), Jennifer Brach was supported by a Beeson
in walking occur by restoring the pattern of brain and Career Development Award (NIA K23 AG026766), and
neuromuscular activation that optimizes the use of capaci- Subashan Perera received salary support from a research
ties to meet the demands of the task of walking.14,15 The grant from InRange Systems, Inc. to the University of
task-oriented focus of the motor learning–based approach Pittsburgh.
has the potential to lead not only to an efficient and auto- Author Contributions: Conception and design: Brach,
matic motor sequence pattern for walking, but also to Van Swearingen, Studenski. Acquisition of data: Brach,
reward-based adaptive changes in the brain that may be Wert. Analysis of data: Brach, Perera. Interpretation of
sustainable.11 data: Brach, Van Swearingen, Perera, Wert, Studenski.
Observational studies have shown a link between gait Drafting and revising the article for important intellectual
speed and disability or survival.43,54–56 It is unknown content: All. Final approval of the article: All.
whether interventions that increase gait speed prevent or Sponsor’s Role: The funding organization did not play
delay disability or increase survival. Exercise interventions, a role in the collection, management, analysis, or interpre-
such as motor learning exercise, that substantially improve tation of the data or in the preparation, review, or
gait speed should be investigated for their potential effect approval of the manuscript.
on disability and survival in older adults.
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