Recovering Automatic Walking
The Science of Automatic Movement Recovery
Recovering automatic walking after a stroke or traumatic brain injury can be hard work. While many people set this goal, they may not be training in the correct manner to achieve automaticity. The truth is that the consistent practice of walking will not always restore this automatic level. Recovering automatic walking requires a detailed understanding of each person’s situation and a program that targets functional mobility and specific types of attention to achieve this state.
So what is automatic movement? It is defined as the ability to move without occupying significant attention to the details required and it has 3 distinct characteristics:
1. Fluid Movement
2. High Frequency of Reflexive Movement Corrections
3. Low Cost of Attention
Understanding these characteristics means that, to achieve the goal of automatic walking, rehabilitation is best delivered under ideal conditions for performance and learning and it requires training in a manner that decreases the overall attentional cost of walking. Our previous articles on OPTIMAL Motor Learning (see the bottom of this article for links) explain the effectiveness of utilizing ideal conditions to create fluid movement and high frequency movement corrections but why is a low cost of attention so important? Why can’t we just pay attention to walking all the time?
Simply stated, there is a high price to be paid for high attentional needs during walking. Research has shown that the need to pay constant attention to walking strategies and balance results in a higher incidence of falls, anxiety, and even increased activation of additional muscles that should not be involved in walking. A task’s attentional cost involves the capacities of our brain’s working memory and attention. Attention is the way we take information in from our environment and our working memory is how our brain makes sense of it. If capacity for attention and working memory are overloaded while walking then performance will suffer. This means that if all our focus is needed for walking/balance and we try to do something else at the same time (like speaking to someone, getting something from a purse/pocket, or using a cell phone), our ability to walk with control and balance will be compromised.
When training to improve attention we must understand that not all attention is created equal. Each type is unique and can be addressed differently. Four different types of attention are:
1. Divided Attention – the ability to attend to two tasks simultaneously
2. Sustained Attention – the ability to endure attention for periods of time
3. Selective Attention – the ability to filter out unwanted stimulation and focus on the important
4. Alternating Attention – the ability to shift attention back and forth
When it comes to re-learning automatic walking, rehabilitation experts need to be able to assess and treat the specific types of attentional deficits in the context of walking and balance. While sustained attention can be improved through persistent practice, the other three types require a more unique approach such as dual task training.
Dual Task Training
Dual task training is defined as performing two different tasks at the same time. If the two tasks overload a person’s attention and working memory, then performance on either task will decline. The concept of training a person to walk and simultaneously perform another task at the same time can force the brain to shift the tasks of walking and balance into a more automatic section of the brain. Pushing the task into this automatic section of the brain lowers its cost of conscious attention, improves fluidity of movement, and increases the frequency of reflexive movement corrections. This can be a lot of fun in a safe environment and can be added into home programs for faster carryover of automaticity.
The two most common ways of dual tasking during walking are cognitive and manual. Cognitive will involve occupying the mind with a second task and manual will involve using the hands and upper extremities for the second task.
Examples of Cognitive Dual Tasking while walking on a treadmill can be:
Naming as many items in a category as possible (i.e. football teams, types of cereal, etc.)
Counting backwards from a given number by increments of 3’s or 7’s
Spelling 5 to 7 letter words backwards
Seeing 10 unrelated words and then being asked to recite as many as possible a few min later
Having a conversation
Examples of Manual Dual Tasking can be walking and:
Throwing/catching a ball
Using a cell phone
Taking off a purse and retrieving something from it
Counting out the appropriate change from your pocket
Sorting playing cards or photographs
In order to train at a level that overloads the system, tasks have to be difficult enough to make performance decline but still be possible. This starts to force one of the tasks into automaticity while still showing the participant that the activity is possible. If just walking isn’t hard enough then adding obstacles or increasing speed of walking might need to be employed. A skilled physical therapist will understand how to grade dual task activities appropriately and set safe, effective home programs that improve automaticity. Attentional cost can even be objectively measured by a skilled therapist to track progress.
Overloading the neural system in training can decrease the amount of attention needed for walking and balance. This can free up functional capacity for a person to attend to oncoming obstacles, conversation, or just simply using a cell phone to send a message while walking. Lowering the attentional cost of walking has even been proven to improve reflexive movements that maintain and correct balance. More importantly, it can decrease a person’s risk of falling, improve fluid movement, and decrease the amount of perceived effort involved during ambulation.
If your goal is to restore walking to an automatic level then you may want to take another look at your therapeutic training program. Are you safely overloading your system with multiple tasks to ensure that your brain is adapting toward your goal? If not, it may be time modify the program to address attention and dual tasking. Restoring automatic movement is not something that just happens through consistent practice, it is earned through completion of therapeutic programs that focus on attention, dual tasking, and ideal learning conditions.
For more information on creating ideal conditions for performance and learning, see our previous articles on OPTIMAL Motor Learning: