Daniel Schoene

Discriminative ability and predictive validity of the Timed Up and Go test in identifying older people who fall: systematic review and meta-analysis

To investigate the discriminative ability and diagnostic accuracy of the Timed Up and Go Test (TUG) as a clinical screening instrument for identifying older people at risk of falling.

A randomized controlled pilot study of home-based step training in older people using videogame technology

Background Stepping impairments are associated with physical and cognitive decline in older adults and increased fall risk. Exercise interventions can reduce fall risk, but adherence is often low. A new exergame involving step training may provide an enjoyable exercise alternative for preventing falls in older people. Purpose To assess the feasibility and safety of unsupervised, home-based step pad training and determine the effectiveness of this intervention on stepping performance and associated fall risk in older people. Design Single-blinded two-arm randomized controlled trial comparing step pad training with control (no-intervention). Setting/Participants Thirty-seven older adults residing in independent-living units of a retirement village in Sydney, Australia. Intervention Intervention group (IG) participants were provided with a computerized step pad system connected to their TVs and played a step game as often as they liked (with a recommended dose of 2–3 sessions per week for 15–20 minutes each) for eight weeks. In addition, IG participants were asked to complete a choice stepping reaction time (CSRT) task once each week. Main Outcome Measures CSRT, the Physiological Profile Assessment (PPA), neuropsychological and functional mobility measures were assessed at baseline and eight week follow-up. Results Thirty-two participants completed the study (86.5%). IG participants played a median 2.75 sessions/week and no adverse events were reported. Compared to the control group, the IG significantly improved their CSRT (F31,1 = 18.203, p<.001), PPA composite scores (F31,1 = 12.706, p = 0.001), as well as the postural sway (F31,1 = 4.226, p = 0.049) and contrast sensitivity (F31,1 = 4.415, p = 0.044) PPA sub-component scores. In addition, the IG improved significantly in their dual-task ability as assessed by a timed up and go test/verbal fluency task (F31,1 = 4.226, p = 0.049). Conclusions Step pad training can be safely undertaken at home to improve physical and cognitive parameters of fall risk in older people without major cognitive and physical impairments. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12611001081909.

Performance-based physical function in older community-dwelling persons: a systematic review of instruments

BACKGROUND Identification of older persons at risk for the loss of independence, onset of (co)-morbidity or functional limitations through screening/assessment is of interest for the public health-care system. To date several different measurement instruments for overall physical function are frequently used in practice, but little information about their psychometric properties is available. Objectives and METHODS Our aim was to assess instruments with an overall score related to functional status and/or physical performance on content and psychometric properties. Electronic databases (Medline, EMBASE, AMED, Cochrane Library and CINAHL) were searched, using MeSH terms and relevant keywords. Studies, published in English, were included if their primary or secondary purpose was to evaluate the measurement properties of measurement instruments for overall physical function in community-dwelling older persons aged 60 years and older. Reliability, validity, responsiveness and practicability were evaluated, adhering to a specified protocol. RESULTS In total 78 articles describing 12 different functional assessment instruments were included and data extracted. Seven instruments, including their modified versions, were evaluated for reliability. Nine instruments, including their modified versions, were evaluated with regard to validity. CONCLUSION In conclusion, the Short Physical Performance Battery can be recommended most highly in terms of validity, reliability and responsiveness, followed by the Physical Performance Test and Continuous Scale Physical Functional Performance.

Use of virtual reality technique for the training of motor control in the elderly

Virtual augmented exercise, an emerging technology that can help to promote physical activity and combine the strengths of indoor and outdoor exercise, has recently been proposed as having the potential to increase exercise behavior in older adults. By creating a strong presence in a virtual, interactive environment, distraction can be taken to greater levels while maintaining the benefits of indoor exercises which may result in a shift from negative to positive thoughts about exercise. Recent findings on young participants show that virtual reality training enhances mood, thus, increasing enjoyment and energy. For older adults virtual, interactive environments can influence postural control and fall events by stimulating the sensory cues that are responsible in maintaining balance and orientation. However, the potential of virtual reality training has yet to be explored for older adults. This manuscript describes the potential of dance pad training protocols in the elderly and reports on the theoretical rationale of combining physical game-like exercises with sensory and cognitive challenges in a virtual environment.ZusammenfassungEine durch virtuelle Realität ergänzte Bewegungsausführung stellt eine neue und sich schnell entwickelnde Technologie dar. Sie fördert die Lust zur Bewegung, vereinigt die Vorteile von Indoor- und Outdooraktivitäten und vermag sogar das Bewegungsverhalten von älteren Menschen zu verbessern. Eine starke Ablenkung von der eigentlichen Bewegungsausführung, verursacht durch ein überzeugendes Gefühl des Eintauchens in eine virtuell-interaktive Umgebung, kann dazu führen, dass sich die Meinung über Bewegung vom Negativen zum Positiven hin wendet. Neuste Erkenntnisse mit jungen Personen zeigen, dass das Training in einer virtuellen Umgebung Vergnügen bereitet, die Gemütslage und den Energielevel anhebt. Bei älteren Menschen kann eine virtuell-interaktive Umgebung die Haltungskontrolle beeinflussen und auch als Sturzprophylaxe dienen, in dem sie die sensorischen Bereiche stimuliert, die für die Kontrolle des Gleichgewichts und der Orientierung zuständig sind. Dennoch muss das Potenzial eines Trainings in einer virtuellen Umgebung bei älteren Menschen noch weiter erforscht werden. Dieser Artikel beschreibt die Möglichkeiten eines Einsatzes von elektronischen Tanzmatten bei älteren Menschen und erklärt die theoretischen Hintergründe der Kombination von körperlicher Aktivität mit gleichzeitigen sensorisch-kognitiven Aufgaben in einer virtuellen Umgebung.

A novel Dance Dance Revolution (DDR) system for in-home training of stepping ability: Basic parameters of system use by older adults

Objective This series of studies was conducted to develop and establish characteristics of exercise videogame play in older adults. The videogame was a modified version of the popular Dance Dance Revolution (DDR; Konomi). Methods Participants aged ≥70 were asked to make simple step movements in response to vertically drifting arrows presented on a video screen. Step responses were detected by a modified USB DDR mat, and characteristics of stepping performance such as step timing, percentage of missed target steps and percentage of correct steps were recorded by purpose-built software. Drift speed and step rate of visual stimuli were modified to increase task difficulty. Results Significant linear relationships between stepping performance and stimulus characteristics were observed. Performance of older adults decreased as stimulus speed and step rate were increased. Optimal step performance occurred for a stimulus speed of 17° of visual angle per second and a step rate of one step every 2 s. At fast drift speeds (up to 35°/s), participants were more than 200 ms too slow in coordinating their steps with the visual stimulus. Younger adults were better able to perform the stepping task across a wider range of drift speeds than older adults. Conclusion The findings suggest that older adults are able to interact with video games based upon DDR but that stepping performance is determined by characteristics of game play such as arrow drift speed and step rate. These novel “exergames” suggest a low-cost method by which older adults can be engaged in exercises that challenge balance and which can be conducted in their own homes.

Use of virtual reality technique for the training of motor control in the elderly. Some theoretical considerations.

Virtual augmented exercise, an emerging technology that can help to promote physical activity and combine the strengths of indoor and outdoor exercise, has recently been proposed as having the potential to increase exercise behavior in older adults. By creating a strong presence in a virtual, interactive environment, distraction can be taken to greater levels while maintaining the benefits of indoor exercises which may result in a shift from negative to positive thoughts about exercise. Recent findings on young participants show that virtual reality training enhances mood, thus, increasing enjoyment and energy. For older adults virtual, interactive environments can influence postural control and fall events by stimulating the sensory cues that are responsible in maintaining balance and orientation. However, the potential of virtual reality training has yet to be explored for older adults. This manuscript describes the potential of dance pad training protocols in the elderly and reports on the theoretical rationale of combining physical game-like exercises with sensory and cognitive challenges in a virtual environment.ZusammenfassungEine durch virtuelle Realität ergänzte Bewegungsausführung stellt eine neue und sich schnell entwickelnde Technologie dar. Sie fördert die Lust zur Bewegung, vereinigt die Vorteile von Indoor- und Outdooraktivitäten und vermag sogar das Bewegungsverhalten von älteren Menschen zu verbessern. Eine starke Ablenkung von der eigentlichen Bewegungsausführung, verursacht durch ein überzeugendes Gefühl des Eintauchens in eine virtuell-interaktive Umgebung, kann dazu führen, dass sich die Meinung über Bewegung vom Negativen zum Positiven hin wendet. Neuste Erkenntnisse mit jungen Personen zeigen, dass das Training in einer virtuellen Umgebung Vergnügen bereitet, die Gemütslage und den Energielevel anhebt. Bei älteren Menschen kann eine virtuell-interaktive Umgebung die Haltungskontrolle beeinflussen und auch als Sturzprophylaxe dienen, in dem sie die sensorischen Bereiche stimuliert, die für die Kontrolle des Gleichgewichts und der Orientierung zuständig sind. Dennoch muss das Potenzial eines Trainings in einer virtuellen Umgebung bei älteren Menschen noch weiter erforscht werden. Dieser Artikel beschreibt die Möglichkeiten eines Einsatzes von elektronischen Tanzmatten bei älteren Menschen und erklärt die theoretischen Hintergründe der Kombination von körperlicher Aktivität mit gleichzeitigen sensorisch-kognitiven Aufgaben in einer virtuellen Umgebung.

A Novel Video Game-Based Device for Measuring Stepping Performance and Fall Risk in Older People

OBJECTIVE To determine whether a dance mat test of choice stepping reaction time (CSRT) is reliable and can detect differences in fall risk in older adults. DESIGN Randomized order, crossover comparison. SETTING Balance laboratory, medical research institute, and retirement village. PARTICIPANTS Older (mean age, 78.87±5.90y; range, 65-90y) independent-living people (N=47) able to walk in place without assistance. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Reaction (RT), movement, and response times of dance pad--based stepping tests, Physiological Profile Assessment (PPA) score, Digit Symbol Substitution Test (DSST) score, time to complete the Trail Making Test (TMT) A+B, Fall Efficacy Scale International (FES-I) score, Activities-specific Balance Confidence (ABC) Scale score, and Incidental and Planned Exercise Questionnaire (IPEQ) incidental IPEQ activity subscore. RESULTS Test-retest reliability of the dance mat CSRT response time was high (intraclass correlation coefficient model 3,k=.90; 95% confidence interval [CI], .82-.94; P<.001) and correlated highly with the existing laboratory-based measure (r=.86; 95% CI, .75-.92; P<.001). Concurrent validity was shown by significant correlations between response time and measures of fall risk (PPA: r=.42; 95% CI, .15-.63; P<.01; TMT A: r=.61; 95% CI, .39-.77; TMT B: r=.55; 95% CI, .31-.72; DSST: r=-.53; 95% CI, -.71 to -.28; P<.001; FES-I: Spearman ρ=.50; 95% CI, .25-.69; ABC Scale: Spearman ρ=-.58; 95% CI, -.74 to -.35; P<.01). Participants with moderate/high fall-risk scores (PPA score >1) had significantly slower response times than people with low/mild fall-risk scores (PPA score <1) at 1146±182 and 1010±132ms, respectively (P=.005), and multiple fallers and single/nonfallers showed significant differences in RT (883±137 vs 770±100ms; P=.009) and response time (1180±195 vs 1031±145ms; P=0.017). CONCLUSIONS The new dance mat device is a valid and reliable tool for assessing stepping ability and fall risk in older community-dwelling people. Because it is highly portable, it can be used in clinic settings and the homes of older people as both an assessment and training device.

Single and dual task tests of gait speed are equivalent in the prediction of falls in older people: a systematic review and meta-analysis

Although simple assessments of gait speed have been shown to predict falls as well as hospitalisation, functional decline and mortality in older people, dual task gait speed paradigms have been increasingly evaluated with respect to fall prediction. Some studies have found that dual task walking paradigms can predict falls in older people. A systematic review and meta-analysis was conducted to determine whether dual task walking paradigms involving a secondary cognitive task have greater ability to predict falls than single walking tasks. The meta-analytic findings indicate single and dual task tests of gait speed are equivalent in the prediction of falls in older people and sub-group analyses revealed similar findings for studies that included only cognitively impaired participants, slow walkers or used secondary mental-tracking or verbal fluency tasks.

Step training improves reaction time, gait and balance and reduces falls in older people: a systematic review and meta-analysis

Objective To examine the effects of stepping interventions on fall risk factors and fall incidence in older people. Data source Electronic databases (PubMed, EMBASE, CINAHL, Cochrane, CENTRAL) and reference lists of included articles from inception to March 2015. Study selection Randomised (RCT) or clinical controlled trials (CCT) of volitional and reactive stepping interventions that included older (minimum age 60) people providing data on falls or fall risk factors. Results Meta-analyses of seven RCTs (n=660) showed that the stepping interventions significantly reduced the rate of falls (rate ratio=0.48, 95% CI 0.36 to 0.65, p<0.0001, I2=0%) and the proportion of fallers (risk ratio=0.51, 95% CI 0.38 to 0.68, p<0.0001, I2=0%). Subgroup analyses stratified by reactive and volitional stepping interventions revealed a similar efficacy for rate of falls and proportion of fallers. A meta-analysis of two RCTs (n=62) showed that stepping interventions significantly reduced laboratory-induced falls, and meta-analysis findings of up to five RCTs and CCTs (n=36–416) revealed that stepping interventions significantly improved simple and choice stepping reaction time, single leg stance, timed up and go performance (p<0.05), but not measures of strength. Conclusions The findings indicate that both reactive and volitional stepping interventions reduce falls among older adults by approximately 50%. This clinically significant reduction may be due to improvements in reaction time, gait, balance and balance recovery but not in strength. Further high-quality studies aimed at maximising the effectiveness and feasibility of stepping interventions are required. Systematic reviews registration number CRD42015017357.

Interactive Cognitive-Motor Step Training Improves Cognitive Risk Factors of Falling in Older Adults – A Randomized Controlled Trial

Purpose Interactive cognitive-motor training (ICMT) requires individuals to perform both gross motor movements and complex information processing. This study investigated the effectiveness of ICMT on cognitive functions associated with falls in older adults. Methods A single-blinded randomized controlled trial was conducted in community-dwelling older adults (N = 90, mean age 81.5±7) without major cognitive impairment. Participants in the intervention group (IG) played four stepping games that required them to divide attention, inhibit irrelevant stimuli, switch between tasks, rotate objects and make rapid decisions. The recommended minimum dose was three 20-minute sessions per week over a period of 16 weeks unsupervised at home. Participants in the control group (CG) received an evidence-based brochure on fall prevention. Measures of processing speed, attention/executive function (EF), visuo-spatial ability, concerns about falling and depression were assessed before and after the intervention. Results Eighty-one participants (90%) attended re-assessment. There were no improvements with respect to the Stroop Stepping Test (primary outcome) in the intervention group. Compared to the CG, the IG improved significantly in measures of processing speed, visuo-spatial ability and concern about falling. Significant interactions were observed for measures of EF and divided attention, indicating group differences varied for different levels of the covariate with larger improvements in IG participants with poorer baseline performance. The interaction for depression showed no change for the IG but an increase in the CG for those with low depressive symptoms at baseline. Additionally, low and high-adherer groups differed in their baseline performance and responded differently to the intervention. Compared to high adherers, low adherers improved more in processing speed and visual scanning while high-adherers improved more in tasks related to EF. Conclusions This study shows that unsupervised stepping ICMT led to improvements in specific cognitive functions associated with falls in older people. Low adherers improved in less complex functions while high-adherers improved in EF. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12613000671763