A recent randomised clinical trial published in Developmental Medicine & Child Neurology assessed whether injections of botulinumtoxin-A in calf muscles benefit children with cerebral palsy.
“We hypothesised that injections with botulinumtoxin-A in the calf muscles would make walking easier, caused by improved ankle joint functioning following spasticity reduction,” the authors wrote.
In the trial, one botulinumtoxin-A treatment was not superior to placebo in making walking easier (measured as a reduction in energy cost or improved walking capacity); however, there was some evidence of a delayed improvement in energy cost. Moreover, there was some evidence of a decrease in calf pain intensity. No serious adverse events related to botulinumtoxin-A treatment were recorded.
New research from Macquarie University’s Spinal Pain Research Group shows that walking has the potential to change the way low back pain is managed, making effective interventions accessible to more people than ever before. The results of the trial, which combined walking with education, are published in The Lancet.
About 800 million people worldwide have low back pain, which is a leading cause of disability and reduced quality of life. Recurrences of low back pain are very common, with seven in 10 people who recover from an episode going on to have a recurrence within a year.
Professor of Physiotherapy Mark Hancock and his research team have been investigating ways to shift the emphasis from treatment to prevention to improve the management of back pain, an approach that empowers individuals to manage their own health and reduces the cost to society and the healthcare system.
Far from the bed rest recommended for back pain in the past, current best practice includes the combination of exercise and education, both to treat current pain and to prevent future episodes.
While beneficial, some forms of exercise are not accessible or affordable to many people due to their high cost, complexity and need for supervision.
A simpler, more accessible method
The world-first WalkBack trial examined whether a programme of walking combined with education could be effective in preventing recurrences of low back pain.
The trial followed 701 adults who had recently recovered from an episode of low back pain, randomly allocating participants to either an individualised walking program facilitated by a physiotherapist and six education sessions across six months, or to a no-intervention control group.
The participants’ progress was then followed for between one and three years to collect information about any new recurrences of low back pain they experienced.
The researchers’ primary aim was to compare the two groups for the number of days before participants experienced a recurrence of back pain that impacted daily activities or required care from a healthcare provider.
They also evaluated the cost effectiveness of the intervention, including costs related to work absenteeism and healthcare services.
Longer pain-free periods
The paper’s senior author, Professor Hancock, says what they discovered could have a profound impact on how low back pain is managed.
“The intervention group had fewer occurrences of activity-limiting pain compared to the control group, and a longer average period before they had a recurrence, with a median of 208 days compared to 112 days,” Professor Hancock says. “The risk of having a recurrence that required seeking care was nearly halved in those in the intervention group.
“Walking is a low-cost, widely accessible and simple exercise that almost anyone can engage in, regardless of age, geographic location or socio-economic status.
“We don’t know exactly why walking is so good for preventing back pain, but it is likely to include the combination of gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and the release of ‘feel-good’ endorphins.
“And of course, we also know that walking comes with many other health benefits, including cardiovascular health, improved bone density, maintenance of a healthy weight and improved mental health.”
Professor Hancock said the amount of walking each person completed was individualised based on a range of factors including their age, physical capacity, preferences and available time. Participants were given a rough guide to build up to 30 minutes, five times a week over a six-month period.
After three months, Professor Hancock said most of the people who took part were walking three to five days a week for an average of 130 minutes.
“You don’t need to be walking five or 10 kilometres every day to get these benefits,” Professor Hancock says.
A cost-effective option
The paper’s lead author, Postdoctoral Fellow Dr Natasha Pocovi, says in addition to providing participants with longer pain-free periods, they found the program was also cost effective.
“It not only improved people’s quality of life, but it reduced their need both to seek healthcare support and the amount of time taken off work by approximately half,” Dr Pocovi says.
“The exercise-based interventions to prevent back pain that have been explored previously are typically group-based and need close clinical supervision and expensive equipment, so they are much less accessible to the majority of patients.
“Our study has shown that this effective and accessible means of exercise has the potential to be successfully implemented on a much larger scale than other forms of exercise.”
To build on these findings, the team now hopes to explore how they can integrate the preventive approach into the routine care of patients who experience recurrent low back pain.
The over-the-counter supplement nicotinamide riboside, a form of vitamin B3, increased the walking endurance of patients with peripheral artery disease, a chronic leg condition for which there are few effective treatments.
In a preliminary, randomised, double-blind clinical trial led by Northwestern University and University of Florida scientists, patients who took nicotinamide riboside daily for six months increased their timed walking distance by more than 17.3m, compared to a placebo group. As expected, walking speed declined in the placebo group, because peripheral artery disease causes progressive declines in walking performance.
“This is a signal that nicotinamide riboside could help these patients,” said Christiaan Leeuwenburgh, PhD, a UF professor of physiology and aging and senior author of the clinical trial report. “We are hoping to conduct a larger follow-up trial to verify our findings.”
Along with other researchers, Leeuwenburgh, whose research specialises in anti-aging treatments, collaborated with Mary M. McDermott, MD, a physician and professor of medicine at Northwestern University and an expert in peripheral artery disease.
The scientists recruited 90 people with an average age of 71 who had peripheral artery disease, or PAD, to test the effects of nicotinamide riboside. The supplement is increasingly popular as an anti-aging treatment (sales exceeded $60 million in 2022 in the US alone) but there has been scant evidence of any benefit in healthy people. Nicotinamide riboside is a precursor for the essential compound NAD, which plays roles in the body related to energy generation, improved blood flow and DNA repair.
Because PAD is associated with problems generating energy within muscle cells, McDermott and Leeuwenburgh thought that nicotinamide riboside, by improving energy generation, could help improve walking in people with the disease.
And indeed that’s what they found. Participants taking the supplement walked an average of 7m more in a six-minute walking test after six months, while those taking a placebo walked 10.3m less. Those who took at least 75% of the pills they were supposed to take performed even better, adding more than 30m to their walking distance, compared to people who took a placebo.
(The researchers also tested if resveratrol, a compound best known for being in red wine, could boost the effects of nicotinamide riboside; they found no additional benefits.)
PAD affects more than 8.5 million Americans over the age of 40. Caused by the buildup of fatty deposits in arteries, and associated with diabetes and smoking, the disease reduces blood flow to the limbs, especially the legs. Walking often becomes painful, and the disease typically causes declines in walking ability over time. Supervised walking exercise is first line therapy for PAD, but most people with the condition do not have access to supervised exercise.
In addition to a larger trial focused on patients suffering from PAD, Leeuwenburgh hopes to test the effects of nicotinamide riboside on walking performance in healthy older adults.
“We need to test it on a healthy older population before we recommend healthy people take it,” he said.
The ability to walk one kilometre comfortably can help predict fracture risk, according to researchers at the Garvan Institute of Medical Research. The findings, published in JAMA Network Open, suggest that simply asking a patient about walking limitation could allow clinicians to identify those in need of further bone health screening and prescribe interventions that could prevent fractures from occurring.
“We’ve discovered that trouble walking even short distances appears closely tied to higher fracture risk over the following five years,” says lead author of the study, Professor Jacqueline Center, Head of Garvan’s Clinical Studies and Epidemiology Lab.
“Just a few simple questions about how far someone can walk could give doctors an early warning sign to check bone health.”
The researchers examined data on nearly 267 000 adults aged 45 and older from the Sax Institute’s 45 and Up Study, a major ongoing research initiative that has been tracking health outcomes in adults in the Australian state of New South Wales for more than 15 years.
Participants were asked if health issues limited their ability to walk various distances, with answer options of ‘not at all,’ ‘a little,’ or ‘a lot’. The group was then followed for five years to track fracture outcomes.
The researchers found that one in five adults reported some walking limitation at the beginning of the study.
Those with more difficulty walking were significantly more likely to experience a fracture during follow-up. For example, women who said they were limited ‘a lot’ in walking one kilometre had a 60% higher fracture risk than women with no limitation.
For men, the increased risk was over 100%.
“We saw a clear ‘dose-response’ pattern, where greater walking limitation meant higher fracture risk. This suggests a direct relationship between low walking ability and weaker bones,” says first author of the study Dr Dana Bliuc, Senior Research Officer at Garvan.
Approximately 60% of all fractures in the study were attributable to some level of walking limitation.
The link remained strong even after accounting for other factors like age, falls, prior fractures, and weight, and the findings were consistent across different fracture sites like hips, vertebrae, arms, and legs.
“In this generally healthy community-based population, we still found one in five people had trouble walking a kilometre,” says Professor Center.
“We think this simple assessment could help identify many more at-risk individuals who may benefit from bone density screening or preventative treatment.”
Osteoporosis medications, lifestyle changes, and other interventions are available to improve bone strength and avoid first or repeat fractures.
However, screening rates currently remain low, meaning many miss out on fracture risk assessments.
Finding easy but accurate ways to detect at-risk people is an important target for research.
“Fracture risk assessment generally relies on a bone density test, which many people have not had when seeing their doctor,” says Professor Center.
“Asking about walking ability takes just seconds and could be a free, non-invasive way to tell if someone needs their bones checked.”
The researchers stress that walking limitation may have many causes beyond weak bones, from heart disease to arthritis.
However, a difficulty in walking even short distances appears closely tied to fracture risk independently.
“We hope these findings will encourage clinicians to consider walking ability as a red flag for possible bone health issues. For patients, if you can’t walk a full kilometre comfortably, it may be wise to ask your doctor about getting your bones checked,” says Dr Bliuc.
Freezing is one of the most common and debilitating symptoms of Parkinson’s disease, when they suddenly lose the ability to move their feet, often mid-stride, resulting in a series of staccato stutter steps that get shorter until the person stops altogether. These episodes are one of the biggest contributors to falls among people living with Parkinson’s disease.
Today, freezing is treated with a range of pharmacological, surgical or behavioural therapies, none of which are particularly effective. What if there was a way to stop freezing altogether?
In a Nature Medicine report, researchers used a soft, wearable robot to help a person living with Parkinson’s walk without freezing. The robotic garment, worn around the hips and thighs, gives a gentle push to the hips as the leg swings, helping the patient achieve a longer stride. The device completely eliminated the participant’s freezing while walking indoors, allowing them to walk faster and further.
“We found that just a small amount of mechanical assistance from our soft robotic apparel delivered instantaneous effects and consistently improved walking across a range of conditions for the individual in our study,” said Conor Walsh, professor at SEAS and co-corresponding author of the study.
For over a decade, Walsh’s Biodesign Lab at SEAS has been developing assistive and rehabilitative robotic technologies to improve mobility for individuals’ post-stroke and those living with ALS or other diseases that impact mobility. Some of that technology, specifically an exosuit for post-stroke gait retraining, received support to develop and commercialise the technology.
“Leveraging soft wearable robots to prevent freezing of gait in patients with Parkinson’s required a collaboration between engineers, rehabilitation scientists, physical therapists, biomechanists and apparel designers,” said Walsh, whose team collaborated closely with that of Terry Ellis, Professor and Physical Therapy Department Chair and Director of the Center for Neurorehabilitation at Boston University.
The team spent six months working with a 73-year-old man with Parkinson’s disease, who, despite using both surgical and pharmacologic treatments, endured substantial and incapacitating freezing episodes more than 10 times a day, causing him to fall frequently. These episodes prevented him from walking around his community and forced him to rely on a scooter to get around outside.
In previous research, Walsh and his team leveraged human-in-the-loop optimization to demonstrate that a soft, wearable device could be used to augment hip flexion and assist in swinging the leg forward to provide an efficient approach to reduce energy expenditure during walking in healthy individuals.
Here, the researchers used the same approach but to address freezing. The wearable device uses cable-driven actuators and sensors worn around the waist and thighs. Using motion data collected by the sensors, algorithms estimate the phase of the gait and generate assistive forces in tandem with muscle movement.
The effect was instantaneous. Without any special training, the patient was able to walk without any freezing indoors and with only occasional episodes outdoors. He was also able to walk and talk without freezing, a rarity without the device.
“Our team was really excited to see the impact of the technology on the participant’s walking,” said Jinsoo Kim, former PhD student at SEAS and co-lead author on the study.
During the study visits, the participant told researchers: “The suit helps me take longer steps and when it is not active, I notice I drag my feet much more. It has really helped me, and I feel it is a positive step forward. It could help me to walk longer and maintain the quality of my life.”
“Our study participants who volunteer their time are real partners,” said Walsh. “Because mobility is difficult, it was a real challenge for this individual to even come into the lab, but we benefited so much from his perspective and feedback.”
The device could also be used to better understand the mechanisms of gait freezing, which is poorly understood.
“Because we don’t really understand freezing, we don’t really know why this approach works so well,” said Ellis. “But this work suggests the potential benefits of a ‘bottom-up’ rather than ‘top-down’ solution to treating gait freezing. We see that restoring almost-normal biomechanics alters the peripheral dynamics of gait and may influence the central processing of gait control.”
In a study published in Current Biology, people with early Alzheimer’s disease were found to have difficulty turning when walking. The new study used virtual reality and a computational model to further explore the intricacies of navigational errors previously observed in Alzheimer’s disease.
Researchers, led by Professor Neil Burgess and colleagues in the Space and Memory group at the UCL Institute of Cognitive Neuroscience, grouped participants into three categories: healthy younger participants (31 total), healthy elderly participants (36 total) and patients with mild cognitive impairment (43 total). They then asked them to complete a task while wearing virtual reality goggles, which allowed them to make real movements.
In the trial, participants walked an outbound route guided by numbered cones, consisting of two straight legs connected by a turn. They then had to return to their starting position unguided.
The task was performed under three different environmental conditions aimed at stressing the participant’s navigational skills: an unchanged virtual environment, the ground details being replaced by a plain texture, and the temporary removal of all landmarks from the virtual reality world.
The researchers found that people with early Alzheimer’s consistently overestimated the turns on the route and showed increased variability in their sense of direction. However, these specific impairments were not observed in the healthy older participants or people with mild cognitive impairment, who did not show underlying signs of Alzheimer’s.
This suggests that these navigational errors are specific to Alzheimer’s disease – rather than an extension of healthy ageing or general cognitive decline – and could help with diagnosis.
Joint first author, Dr Andrea Castegnaro (UCL Institute of Cognitive Neuroscience), said: “Our findings offer a new avenue for the early diagnosis of Alzheimer’s disease by focusing on specific navigational errors. However, we know that more work is needed to confirm these early findings.
Dr Castegnaro added, “Cognitive assessments are still needed to understand when the first cognitive impairments develop, and when it comes to existing spatial memory tests used in clinics, those often rely on verbal competence. Our tests aim to offer a more practical tool that doesn’t rely on language or cultural background.”
Altered gait is common in patients with Parkinson’s disease (PD), and the usefulness of treatments is limited. Researchers in Japan have developed a novel transcranial stimulation method using external electrodes, the team demonstrated significant gait improvements in PD patients. The results, which also showed improvements for other neurological disorders, are published in the Journal of Neurology, Neurosurgery & Psychiatry.
Motor function declines characterises PD, particularly in relation to gait disorders, manifesting as decreased step length, reduced arm swing, slow movements, rigidity, and postural instability, which are prevalent among patients with PD. While non-pharmacological approaches like transcranial direct current stimulation show promise in improving motor function, recent research focuses on gait-combined closed-loop stimulation, which synchronises brain stimulation with the individual’s gait rhythm. proposes a novel intervention for gait improvement, thus creating new hope for patients with PD.
“We recently developed a novel neuromodulation approach using gait-combined closed-loop transcranial electrical stimulation (tES) and demonstrated promising gait improvements in patients who are post-stroke. Here, we tested the efficacy of this intervention in patients with Parkinsonian gait disturbances,” explains lead author Ippei Nojima from Shinshu University and Nagoya City University, Japan.
To this end, the clinical researchers from Japan recruited 23 patients with PD or Parkinson’s syndrome. All study participants were randomly assigned to receive either the active treatment or sham treatment.
During the course of the trial, a low-current electrode (up to 2mA) was externally affixed to the occipital region of the head. A reference electrode was then placed in the neck region to establish a stable electrical reference point and to complete the electrical circuit. The treatment included performing tES on the cerebellum in a non-invasive manner. The brain side showing severe impact was specifically targeted during the electrotherapy.
“Gait disturbance lowers activities of daily living in patients with PD and related disorders. However, the effectiveness of pharmacological, surgical, and rehabilitative treatments is limited. Our novel intervention might be able to improve physical function for not just patients with PD but also for those with other disabilities,” comments senior author Yoshino Ueki from the Department of Rehabilitation Medicine at Nagoya City University.
The cerebellum plays a key role in gate control, so electrical stimulation of this region is likely to exert therapeutic benefits. The therapy showed encouraging results after just ten repetitions. The treatment group showed a significant improvement in gait parameters including speed, gait symmetry, and stride length.
Professor Nojima said, “These findings showed that gait-combined closed-loop tES over the cerebellum improved Parkinsonian gait disturbances, possibly through the modulation of brain networks generating gait rhythms.”
Interestingly, no patient dropped out during the study. Moreover, patients from both the groups (treatment and sham) showed good and comparable compliance. Side effects such as skin irritation, vertigo, or odd sensations/perceptions were also not observed in any of the volunteering patients. This study has special significance, considering the fact that Japan is witnessing a sharp rise in its elderly population.
Contrary to previous belief, fewer numbers of daily steps are necessary for health benefits to appear, according to the largest analysis to investigate this. The study, published in theEuropean Journal of Preventive Cardiology, found that walking at least 3967 steps a day started to reduce the risk of dying from any cause, and 2337 steps a day reduced the risk of dying from cardiovascular disease.
The new analysis included 226 889 people from 17 different studies around the world. It showed that the risk of dying from any cause or from cardiovascular disease decreases significantly with every 500 to 1000 extra steps you walk. An increase of 1000 steps a day was associated with a 15% reduction in the risk of dying from any cause, and an increase of 500 steps a day was associated with a 7% reduction in dying from cardiovascular disease.
The researchers, led by Maciej Banach, Professor of Cardiology at the Medical University of Lodz, Poland, and Adjunct Professor at the Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, found that even if people walked as many as 20 000 steps a day, the health benefits continued to increase, with no upper limit found yet.
“Our study confirms that the more you walk, the better,” says Prof Banach. “We found that this applied to both men and women, irrespective of age, and irrespective of whether you live in a temperate, sub-tropical or sub-polar region of the world, or a region with a mixture of climates. In addition, our analysis indicates that as little as 4000 steps a day are needed to significantly reduce deaths from any cause, and even fewer to reduce deaths from cardiovascular disease.”
According to World Health Organization data, insufficient physical activity is the fourth most frequent cause of death in the world, with 3.2 million deaths a year related to physical inactivity. The COVID-19 pandemic also resulted in a reduction in physical activity, and activity levels have not recovered two years on from it.
Dr Ibadete Bytyçi from the University Clinical Centre of Kosovo, Pristina, Kosovo, senior author of the paper, says: “Until now, it’s not been clear what is the optimal number of steps, both in terms of the cut-off points over which we can start to see health benefits, and the upper limit, if any, and the role this plays in people’s health. However, I should emphasise that there were limited data available on step counts up to 20 000 a day, and so these results need to be confirmed in larger groups of people.”
This meta-analysis is the first not only to assess the effect of walking up to 20 000 steps a day, but also to look at whether there are any differences depending on age, sex or where in the world people live.
The studies analysed by the researchers followed up participants for a median (average) of seven years. The mean (average) age was 64, and 49% of participants were female.
In people aged 60 years or older, the size of the reduction in risk of death was smaller than that seen in people aged younger than 60 years. In the older adults, there was a 42% reduction in risk seen in those who walked 6000–10 000 steps a day, while there was a 49% reduction in risk in younger adults who walked 7000–13 000 steps a day.
Prof Banach says: “In a world where we have more and more advanced drugs to target specific conditions such as cardiovascular disease, I believe we should always emphasise that lifestyle changes, including diet and exercise, which was a main hero of our analysis, might be at least as, or even more effective in reducing cardiovascular risk and prolonging lives. We still need good studies to investigate whether these benefits may exist for intensive types of exertion, such as marathon running and iron man challenges, and in different populations of different ages, and with different associated health problems. However, it seems that, as with pharmacological treatments, we should always think about personalising lifestyle changes.”
Strengths of the meta-analysis include its size and that it was not restricted to looking at studies limited to a maximum of 16 000 steps a day. Limitations include the observational nature of the study. The impact of step counts was not tested on people with different diseases; all the participants were generally healthy when they entered the studies analysed. The researchers were not able to account for differences in race and socioeconomic status, and the methods for counting steps were not identical in all the studies included in this meta-analysis.
Among 25 183 women aged 50 to 79 years, there were 1455 cases of hospitalisation for heart failure during a median follow-up of 16.9 years. Compared with women who walked at a casual pace, those who walked at an average pace or fast pace had 27% and 34% lower risks of heart failure, respectively.
Fast walking for less than 1 hour per week was associated with the same risk reduction of heart failure as average or casual walking for more than 2 hours per week.
“This study confirms other studies demonstrating the importance of walking speed on mortality and other cardiovascular outcomes,” said senior author Charles B. Eaton, MD, MS, of the Warren Alpert Medical School of Brown University. “Given that limited time for exercise is frequently given as a barrier to regular physical activity, walking faster but for less time might provide similar health benefits as the recommended 150 minutes per week of moderate physical activity.”
Further study is warranted to determine whether interventions to increase the walking pace in older adults will reduce heart failure risk and whether fast pace will compensate for the short duration of walking.
