Effect of Backward Walking on Balance and Gait in Healthy Elderly

Good balance in elderly who are living independently, capably, and proactively is an essential factor for cooking, traveling, doing household work, shopping, and activities of daily living.[1] Balance is essential for keeping going in a position, continuing to exist stable while going from one position to another, conducting daily living activities, and going freely in the community.[2]

Balance and postural stability are the general terms used to narrate the dynamic action by which the body’s position is preserved in equilibrium. When the body’s center of mass (COM) or center of gravity (COG) is sustained over the base of support (BOS), it results in maximum balance.[3]

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It is a combination of vision, proprioception, vestibular sensation, the strength of muscle, and reaction time. As age increases, there is an accelerating mislaying of work of these systems which can subscribe to a balance shortfall.[4]The potential to balance can be hampered by disease, medications, and the task of aging.[5]

There are several factors that lead to impairment in balance in the elderly population, some of the factors are been discussed below. In a study, it is shown that elderly people have reduced flexibility and range of motion, which would hamper their ability to recover balance following an external disturbance.[5]

In a study “lower- extremity muscle force and balance performance in adults aged 65 years and older” it was suggested that the force-generating capacity of the distal musculature is important in the maintenance of balance in older adults.[6]Hence it is important to focus on the strength of the lower limb muscles as well for the improvement of balance in elderly.

India comprises the second largest geriatric population, which is about 1/8th of the total geriatric population of the world. As per the census 2011, 103.2 million people in India were of the age of 60 years or more, count for 8.6% of the total population. Among many health matters that are faced by the elderly, falls are a major issue.[7]

Falls are one of the most major issues in the elderly and have been considered the “geriatric giant”.[8]There are several exercise programs that are useful for fall prevention in the elderly. Some of them are the Otago home exercise program, a multi-system group exercise program incorporating a circuit of activities, Tai Chi balance training, pilates mat exercise, and virtual reality game exercise.[3]

Backward walking is something different from forward walking. During backward walking the leg reverses its movement direction and also travels in the opposite direction with virtually the same path as in forward walking.[9] A pre-stretch of the hamstring is seen prior to thigh reversal because of greater hip flexion and lesser hip extension in backward walking. Hence backward walking helps in providing stimulus to increase hamstring flexibility and reducing low back pain in persons with hamstring tightness.[10]

Backward walking appears to be a novel task. During backward walking, hip extension and flexion of the knee are greater as compared to forward walking. Increased extension of the hip joint and associated lumbar spine extension increasingly load the facet joints opening up the disc space, and resulting in the reduction of compressive force in the intervertebral disc. Hence backward walking intervention remarkably improve low back range of motion and leads to a reduction in low back pain.[11]

During backward walking, older adults displayed a notably improved range of motion of the ankle joint and stability. Ankle kinematics may be responsible for the result benefits related to decreasing the occurrence of falls in older adults and other populations at risk for falls following backward walking.[12] The demonstration has been done that backward walking helps in improving quadriceps strength and power and also decreases patellofemoral joint reaction force at the knee joints.[13]

During Backward walking there is enhanced cardiopulmonary demand as compared to forward walking at the same speed. It is also suggested that backward walking enhances energy expenditure to such a level that is sufficient to maintain cardiopulmonary fitness.[9] Backward walking is also responsible for improving balance in school-aged boys. As backward walking origin neural adaptations and progressive training induce adaptation of soleus H-reflex. During backward walking muscle synergy or neuromotor control, reorganization occurs in the lower limbs which could be the cause of improvement in balance.[14]

As backward walking improves muscle flexibility, lower limb range of motion, core muscle strength, and lower limb strength, these may lead to improvement in balance. Also, backward walking is cost-effective, easy to perform, and doesn’t require much assistance once the technique is being learned by the individual. Hence the objective of the study was to assess the effect of backward walking on balance and gait in healthy elder people.

Ethical clearance was taken from the Institution Sub Ethics committee. In this randomized controlled trial, 34 participants were randomly selected from the community as per inclusion and exclusion criteria. Simple random allocation was done to divide participants into two groups using the chit method. Written informed consent was taken from all the participants. The sample size was calculated using the software Primer, where it was derived to be 16 participants in each group with desired power: 0.800 and alpha: 0.05and it was calculated using previously done studies with mean and standard deviation as 18.1, 10.5 respectively. Considering the 5% dropout chance, 34 participants were recruited for the study.[15] The study setting was Dr. D.Y. Patil college of physiotherapy OPD, Pune, India. 34 participants in age groups between 60-70 years and of both genders, who were walking independently, (45-50 score on the berg balance scale ) and with a cognition level (of 24 and above on the mini-mental scale) were included in the study. Individuals with recent fractures and surgeries of lower limb and spine (past 6 months), neurological conditions (Parkinson’s, stroke, vertigo), use of any assistive walking device, visual and hearing impairment, medications that interfere with balance (antihistamine, Anti-depressant) were excluded from the study. Total 32participants (16 in each

The purpose of this study was to investigate the effectiveness of a backward walking exercise program on balance and gait in healthy elderly aged 60-70 years. Results showed that there was a highly significant improvement in the score of the timed up-and-go test. This shows that backward walking gives effective improvement in balance scores on the TUG outcome measure for most of the subjects. Balance gets affected with ankle flexibility and strength, so as ankle range and strength improves, balance improves. Backward walking improves ankle flexibility and strength. So study done by Janet S. Dufek, showed the beneficial effect of backward walking on balance.[12]Study done by Manisha Rathi et al (2014) shows that backward walking improved quadriceps strength significantly, as backward walking reduces compression forces on the patellofemoral joint and reduces the absorption of force at knee joint. This occurs due to reduced eccentric function of the quadriceps strength. It has been demonstrated that backward walking improves quadriceps strength.[9] Core strength is required for maintaining balance and backward walking improves core strength hence backward walking is effective in improving balance[16]

It is also suggested that hamstring flexibility and perhaps low back flexibility may increase when walking backward. As backward walking provides stimulus for increasing the length of the hamstring muscle. [11]

Similarly, Teres liu-Ambrose (2008) showed that the Otago home-based program which consists of resistance training and balance retraining showed significant improvement when assessed on timed up and go test and physiological profile and hence improved executive functioning and therefore reduces the risk of falls in older people.[15] A study done by Ladda Thiamwong (2013) concluded that 12 weeks of simple balance training program is effective in improving the balance of rural older adults when assessed on time up and go test. Fear of falling was also decreased in people who received balance training.[1]

When the balance was measured by using a multi-directional reach test (MDRT) results showed that there is a significant improvement in all the directions,e. forward direction, backward direction, left lateral, and right lateral direction followed by the backward walking program.

Similarly, Robert A. Newton concluded from his study that when the elderly performed the MDRT in a free surrounding which does not have the support of the wall. Whereas while performing FRT (functional reach test) subjects had the support of a wall for reaching a forward direction. This fact that there was no support of wall in MDRT could have led to a reduced mean measured in MDRT (8.89 in) as comparative to mean values observed in FRT (10.9 in.).[17]

The present study also showed that when gait speed assessment was done after 4 weeks of the backward walking program, it is found that backward walking showed significant improvement in improving gait speed.

A study done by Lien Quach (2011) has shown that there is a relationship between gait speed and risk of falls in community-dwelling older adults. He suggested that people walking with faster and slower gait speeds are at risk of falls. Such that people with slower gait are more prone for inside falls, whereas people with faster gait are at high risk of outside falls, presumably where they are uncovered to environmental danger. Lastly, a reduction in gait speed is an important risk factor for future falls. It is well-recognized that a slow gait is related to risk of falls. The decrease in gait speed may give a signal for a reduction in physical functioning, risk for diseases, or reduction in motor control centers in the frontal lobe.[18]

D. L. Sturnieks (2008) showed that older adults tend to walk slowly as compared to younger populations. He told it's not clear whether the reduction in speed is due to physical limitations or an adaptive strategy for safety improvement. These spatiotemporal gait patterns are more profoundly found in fallers than non-fallers. As age advances, kinetic and kinematic alteration occurs in older people such as reduction in hip range of motion, increased anterior pelvic tilt, reduced ankle power generation capacity, increased hip extension.[4]

In contradiction to this study, Wei-Ya Hao (2011) showed that followed by 12 weeks of a backward walking program in school-aged boys, the gait speed decreased as compared to forward walking.[15]

When step length and stride length assessment was done after 4 weeks of the backward walking program, it is found that backward walking showed significant improvement in improving step length. Similar results were observed by Elizabeth T. in her study (2007).[19]

Thus in our study, we found that all subjects were able to perform backward walking. There were no complaints of falls or any kind of discomfort while performing backward walking. Thus, our study conclude that backward walking was effective in improving balance and gait in healthy elderly.

In this study, a small sample size was taken. A short duration of backward walking was given to subjects thrice a week. There was no follow-up taken on whether the participants are continuing the exercises or not and the effects will remain further. Further study can be done with a long duration of backward walking. Studies can be done to know the effect of backward walking on people who complain of impaired balance. Future studies can be done on backward walking with footwear and without footwear to understand the effect of backward walking on joint forces on the incline surfaces.