The Importance of Cognitive Executive Functions in Gait Recovery After Total Hip Arthroplasty

Published:January 06, 2020DOI:



      To determine the influence of cognitive functioning on gait recovery after total hip arthroplasty.


      Prospective cohort study.


      Rehabilitation hospital.


      Patients (N=40) who underwent a total hip arthroplasty, with normal cognitive functioning and without any other relevant medical condition, were recruited and studied before surgery and at the beginning and the end of the rehabilitation program.

      Main Outcome Measures

      Gait speed (10-Meter Walk Test [10MWT]) and gait functional mobility (Timed Up and Go [TUG] test), measured at the time of discharge from the rehabilitation unit, were the primary outcomes. The candidate predictors were the cognitive and psychological variables collected in the presurgery phase, together with other potentially informative measures such as age, education, perceived pain, body mass index, presurgical gait speed and functional mobility.


      Our results suggest the existence of a direct relationship between cognitive functioning, with specific reference to high-level frontal executive functions, and the postoperative gait progress: the better the cognitive functioning in the preoperative phase, the better the course of recovery in terms of gait speed and functional mobility.
      In particular, the performance of the Frontal Assessment Battery test, together with age, perceived pain. Presurgical gait speed and functional mobility, was the best predictor of recovery of walking measured by 10MWT and TUG.


      The present study highlights the importance of cognitive functioning, together with clinical and demographic features, in the postsurgical recovery of walking, even in the absence of cognitive decline.
      In particular, these data show the crucial role of higher-order cognitive processes, such as executive functions, involved in the formulation of motor plans and their integration with proprioceptive and visual cues.


      List of abbreviations:

      10MWT (10-Meter Walk Test), AIC (Akaike information criterion), BDI (Beck Depression Inventory), DSB (Digit Span Backward), FAB (Frontal Assessment Battery), MMSE (Mini-Mental State Examination), STAI-X (State-Trait Anxiety Inventory), THA (total hip arthroplasty), TUG (timed Up and Go), VAS (visual analog scales)
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        • la Fougere C.
        • Zwergal A.
        • Rominger A.
        • et al.
        Real versus imagined locomotion: a [18F]-FDG PET-fMRI comparison.
        Neuroimage. 2010; 50: 1589-1598
        • Jahn K.
        • Deutschlander A.
        • Stephan T.
        • Strupp M.
        • Wiesmann M.
        • Brandt T.
        Brain activation patterns during imagined stance and locomotion in functional magnetic resonance imaging.
        Neuroimage. 2004; 22: 1722-1731
        • Jahn K.
        • Deutschländer A.
        • Stephan T.
        • et al.
        Imaging human supraspinal locomotor centers in brainstem and cerebellum.
        Neuroimage. 2008; 39: 786-792
        • Jahn K.
        • Deutschländer A.
        • Stephan T.
        • et al.
        Supraspinal locomotor control in quadrupeds and humans.
        Prog Brain Res. 2008; 171: 353-362
        • Sacheli L.M.
        • Zapparoli L.
        • De Santis C.
        • et al.
        Mental steps: Differential activation of internal pacemakers in motor imagery and in mental imitation of gait.
        Hum Brain Mapp. 2017; 38: 5195-5216
        • Hausdorff J.M.
        • Yogev G.
        • Springer S.
        • Simon E.S.
        • Giladi N.
        Walking is more like catching than tapping: gait in the elderly as a complex cognitive task.
        Exp Brain Res. 2005; 164: 541-548
        • Morris R.
        • Lord S.
        • Bunce J.
        • Burn D.
        • Rochester L.
        Gait and cognition: mapping the global and discrete relationships in ageing and neurodegenerative disease.
        Neurosci Biobehav Rev. 2016; 64: 326-345
        • Demnitz N.
        • Esser P.
        • Dawes H.
        • et al.
        A systematic review and meta-analysis of cross-sectional studies examining the relationship between mobility and cognition in healthy older adults.
        Gait Posture. 2016; 50: 164-174
        • Hunter S.W.
        • Bobos P.
        • Frengopoulos C.
        • Macpherson A.
        • Viana R.
        • Payne M.W.
        Cognition predicts mobility change in lower extremity amputees between discharge from rehabilitation and 4-month follow-up: a prospective cohort study.
        Arch Phys Med Rehabil. 2019; 100: 2129-2135
        • Taylor-Piliae R.E.
        • Latt L.D.
        • Hepworth J.T.
        • Coull B.M.
        Predictors of gait velocity among community-dwelling stroke survivors.
        Gait Posture. 2012; 35: 395-399
        • Buecking B.
        • Eschbach D.
        • Knobe M.
        • et al.
        Predictors of noninstitutionalized survival 1 year after hip fracture: a prospective observational study to develop the Marburg Rehabilitation Tool for Hip fractures (MaRTHi).
        Medicine (Baltimore). 2017; 96e7820
        • Benedetti M.G.
        • Ginex V.
        • Mariani E.
        • et al.
        Cognitive impairment is a negative short-term and long-term prognostic factor in elderly patients with hip fracture.
        Eur J Phys Rehabil Med. 2015; 51: 815-823
        • Ariza-Vega P.
        • Lozano-Lozano M.
        • Olmedo-Requena R.
        • Martín-Martín L.
        • Jiménez-Moleón J.J.
        Influence of cognitive impairment on mobility recovery of patients with hip fracture.
        Am J Phys Med Rehabil. 2017; 96: 109-115
        • Forer S.
        • Granger C.
        Functional independence measure.
        The Buffalo General Hospital State University of New York at Buffalo, Buffalo1987
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: the Barthel Index.
        Md State Med J. 1965; 14: 61-65
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        • Mini-mental state
        A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Pfeiffer E.
        A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients.
        J Am Geriatr Soc. 1975; 23: 433-441
        • Dubois B.
        • Slachevsky A.
        • Litvan I.
        • Pillon B.
        The FAB: a Frontal Assessment Battery at bedside.
        Neurology. 2000; 55: 1621-1626
        • Monaco M.
        • Costa A.
        • Caltagirone C.
        • Carlesimo G.A.
        Forward and backward span for verbal and visuo-spatial data: standardization and normative data from an Italian adult population.
        Neurol Sci. 2013; 34: 749-754
        • Caffarra P.
        • Vezzadini G.
        • Dieci F.
        • Zonato F.
        • Venneri A.
        Rey-Osterrieth complex figure: normative values in an Italian population sample.
        Neurol Sci. 2002; 22: 443-447
        • Spielberger C.D.
        State-Trait anxiety inventory.
        The Corsini encyclopedia of psychology. John Wiley & Sons, Inc, Hoboken2010
        • Beck A.T.
        • Steer R.A.
        • Brown G.K.
        Manual for the Beck Depression Inventory-II.
        Psychological Corporation, San Antonio1996
        • Hershkovitz A.
        • Kalandariov Z.
        • Hermush V.
        • Weiss R.
        • Brill S.
        Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture.
        Arch Phys Med Rehabil. 2007; 88: 916-921
        • Nasreddine Z.S.
        • Phillips N.A.
        • Bédirian V.
        • et al.
        The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
        J Am Geriatr Soc. 2005; 53: 695-699
        • Yogev-Seligmann G.
        • Hausdorff J.M.
        • Giladi N.
        The role of executive function and attention in gait.
        Mov Disord. 2008; 23 (quiz 472): 329-342
        • Maidan I.
        • Shustak S.
        • Sharon T.
        • et al.
        Prefrontal cortex activation during obstacle negotiation: what's the effect size and timing?.
        Brain Cogn. 2018; 122: 45-51
        • Gaalema D.E.
        • Dube S.
        • Potter A.
        • et al.
        The effect of executive function on adherence with a cardiac secondary prevention program and its interaction with an incentive-based intervention.
        Prev Med. 2019; : 105865
        • Stroop J.R.
        Studies of interference in serial verbal reactions.
        J Exp Psychol. 1935; 18: 643-662
        • Hiyama Y.
        • Kamitani T.
        • Wada O.
        Association between disease-specific anxiety at discharge and functional outcome in patients after total knee arthroplasty.
        Knee. 2019; 26: 477-483
        • Masaracchio M.
        • Hanney W.J.
        • Liu X.
        • Kolber M.
        • Kirker K.
        Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: a systematic review with meta-analysis.
        PLoS One. 2017; 12e0178295