65921
ied GerontologyAgmon et al.
JAG34310.1177/0733464812465921J
Original Article
The Effects of EnhanceFitness (EF) Training on Dual-Task Walking in Older Adults
Journal of Applied Gerontology 2015, V ol. 34(3) NP128–NP142 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464812465921 jag.sagepub.com
Maayan Agmon1,Valerie E. Kelly2, Rebecca G. Logsdon2, Huong Nguyen2, and Basia Belza2
Abstract Decline in dual-task walking performance is associated with increased risk of falls among older adults. The objective of this study is to determine whether 18 hr of participation in EnhanceFitness (EF), an evidence-based group exercise program, improves dual-task walking performance among community-dwelling older adults. Twenty-eight healthy, community-dwelling older adults were evaluated before participating in EF and after 18 hr of participation. Gait speed was evaluated under single task and dual tasks using the TUG (Timed Up and Go) and 1-min walk tests. Dual-task costs (DTC), the relative cost of dual-task performance compared to single-task performance, were calculated for both cognitive and motor tasks. Postural control and executive functions were evaluated as well. After 18 hr of EF, dual-task walking performance improved. Single-task performance improved as well as postural control and executive function. There was no significant change in DTC across all measurements, except for the cognitive task of the TUG. Keywords dual task, walking, older adults 1
University of Haifa, Haifa, Israel University of Washington, Seattle, WA, USA
2
Corresponding Author: Maayan Agmon, University of Haifa, Haifa, Israel. Email: [email protected]
Downloaded from jag.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 1, 2015
Agmon et al.
NP129
Introduction Falls and their consequences, including functional decline, hip fractures, and fear of future falls, are major concerns among older adults. Studies show that most falls occur when the person is performing concurrent tasks, such as talking while walking, or carrying an item while climbing steps (Bloem, Valkenburg, Slabbekoorn, & van Dijk, 2001). The ability to perform two tasks simultaneously, each of which could be performed independently, is called “dual-task” performance. Research shows that even simple physical tasks such as quiet standing appear to involve a degree of cognitive control (Horak, 2006; Lajoie, Teasdale, Bard, & Fleury, 1993; Shumway-Cook & Woollacott, 2007). An investigation of the relationship between cognition and postural control using a dual-task paradigm to compare the performance of young and older adults found a reduction in dualtask postural control performance among older adults (Lacour, Bernard-Demanze, & Dumitrescu, 2008). Furthermore, research has shown that dual-task performance is particularly influenced by “executive” cognitive abilities (Woollacott & Shumway-Cook, 2002; Yogev-Seligmann, Hausdorff, & Giladi, 2008). The association between postural control, dual-task performance, and executive function is important in understanding factors that contribute to falls among older adults because each of these areas has been shown to decline among older adults (Beauchet, Annweiler, Allali, Berrut, & Dubost, 2008). Dual-task performance may be modifiable with training, and thus may be a target for intervention with older adults at risk for falls (Bisson, Contant, Sveistrup, & Lajoie, 2007; Silsupadol, Lugade et al., 2009; Silsupadol, ShumwayCook et al., 2009; Silsupadol, Siu, Shumway-Cook, & Woollacott, 2006; Trombetti et al., 2010; You et al., 2009). Prior studies have measured the effect of single-task, nonspecific exercise interventions, such as Tai-Chi (Hall, Miszko, & Wolf, 2009), virtual reality (Bisson et al., 2007; Lajoie, 2003), and regular exercise (Melzer, Marx, & Kurz, 2009) on dual-task performance. Their main conclusion was that training postural control under single-task conditions may improve postural control under single-task conditions but does not transfer to dual-task performance. Other studies investigating the effect of dual-task training on dualtask performance found that dual-task training is more effective than single-task training in improving dual-task performance (Bisson et al., 2007; Lajoie, 2003; Silsupadol, Lugade et al., 2009; Silsupadol, Shumway-Cook et al., 2009; Toulotte, Thevenon, & Fabre, 2006; Trombetti et al., 2010; You et al., 2009). However, it is not clear whether individual training or training in a group setting is better for improving dual-task processing, or what optimal doses and durations are required to improve and retain dual-task walking performance among healthy older adults.
Downloaded from jag.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 1, 2015
NP130
Journal of Applied Gerontology 34(3)
The goal of this study is to explore whether an evidence-based group exercise program (EnhanceFitness [EF]) that has demonstrated improvement in balance, muscle strength, flexibility, and endurance (Belza, Shumway-Cook, Phelan, Williams, & Snyder, 2006) is also effective at improving dual-task walking performance. We hypothesized that the balance exercises that are part of the EF protocol might lead to improvement in dual-task walking performance. Furthermore, we hypothesized that, by virtue of the group setting, participants are challenged to divide their attention between the exercise and other distractions in the environment and that improvements in postural control achieved in a group setting would positively affect dual-task walking performance.
Method Participants Thirty community-dwelling older adults, who had not started any new exercise routine for at least 2 months prior to the study were recruited and enrolled in EF classes. Two participants dropped out of the study 2 weeks into the EF program due to serious medical conditions, unrelated to the training protocol. Inclusion criteria were (a) age 60 or older, (b) able to walk 10 meters independently, (c) new to EF, and (d) could speak, understand, and read English. Exclusion criteria were (a) any active and untreated symptomatic illness that might limit the participant’s ability to adhere to the program; (b) presence of neurologic or musculoskeletal diagnosis, such as cerebral vascular accident (CVA), Parkinson’s disease, Alzheimer’s disease, or multiple sclerosis; (c) severe orthopedic restrictions such as acute back pain or a total hip replacement within 3 months prior to the study; and (d) significant hearing or vision loss. The study was approved by the Institutional Review Board of the University of Washington. Written informed consent was obtained from all participants.
Study Design and Procedures This study used a single group pre- and post-test design. Participants were assessed at baseline and after completing 18 hr of EF over 6 to 10 weeks. EF classes took place in community settings, lasted 1 hr and were conducted mostly with participants standing. Cognitive function was measured with the Montreal Cognitive Assessment (MoCA) at baseline (Nasreddine et al., 2005). The main outcome of the study was dual-task walking performance. Secondary outcomes included postural control and executive functioning. Baseline and final tests were conducted by two physical therapists, with the same person conducting both assessments for each participant.
Downloaded from jag.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 1, 2015
Agmon et al.
NP131
Intervention. EF is a community-based supervised group exercise class that meets 3 times per week for 1 hr in various community locations, with an average class size of 14 participants. EF has been shown to provide significant improvement in gait velocity, lower- and upper-extremity muscle strength, and self-rated health status and quality of life (Belza et al., 2006). The required components of EF classes are (a) warm-up (5-8 min), (b) cardiovascular endurance (20 min), (c) cool-down phase (3-5 min), (d) strength training (20 min), (e) stretching (8-10 min), and (f) balance and posture exercises (included within different exercises). There is no specific element of EF that targets dual-task training. The exercises that address balance include walking with head turns, quick stops, marching, tiptoe walking, heel walking, heel-to-toe walking, stepping over objects, sit-tostand, ankle sways, and twisting side to side. We anticipated that the balance exercises, by their nature, present many competing stimuli, which require participants to divide their attention. Thus, we hypothesized that EF may improve dualtask performance even though it is not targeted directly. Measures of dual-task walking performance. The main outcome, dual-task walking performance, was evaluated for both the Timed-Up-and-Go (TUG) test and the 1-min walk test as follows.
(a) Single-task TUG: Participants were asked to stand up from a chair, walk 3 meters, turn, walk back, and sit down. Performance was measured as the time to complete the test in seconds. Older adults with a TUG time of
ied GerontologyAgmon et al.
JAG34310.1177/0733464812465921J
Original Article
The Effects of EnhanceFitness (EF) Training on Dual-Task Walking in Older Adults
Journal of Applied Gerontology 2015, V ol. 34(3) NP128–NP142 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464812465921 jag.sagepub.com
Maayan Agmon1,Valerie E. Kelly2, Rebecca G. Logsdon2, Huong Nguyen2, and Basia Belza2
Abstract Decline in dual-task walking performance is associated with increased risk of falls among older adults. The objective of this study is to determine whether 18 hr of participation in EnhanceFitness (EF), an evidence-based group exercise program, improves dual-task walking performance among community-dwelling older adults. Twenty-eight healthy, community-dwelling older adults were evaluated before participating in EF and after 18 hr of participation. Gait speed was evaluated under single task and dual tasks using the TUG (Timed Up and Go) and 1-min walk tests. Dual-task costs (DTC), the relative cost of dual-task performance compared to single-task performance, were calculated for both cognitive and motor tasks. Postural control and executive functions were evaluated as well. After 18 hr of EF, dual-task walking performance improved. Single-task performance improved as well as postural control and executive function. There was no significant change in DTC across all measurements, except for the cognitive task of the TUG. Keywords dual task, walking, older adults 1
University of Haifa, Haifa, Israel University of Washington, Seattle, WA, USA
2
Corresponding Author: Maayan Agmon, University of Haifa, Haifa, Israel. Email: [email protected]
Downloaded from jag.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 1, 2015
Agmon et al.
NP129
Introduction Falls and their consequences, including functional decline, hip fractures, and fear of future falls, are major concerns among older adults. Studies show that most falls occur when the person is performing concurrent tasks, such as talking while walking, or carrying an item while climbing steps (Bloem, Valkenburg, Slabbekoorn, & van Dijk, 2001). The ability to perform two tasks simultaneously, each of which could be performed independently, is called “dual-task” performance. Research shows that even simple physical tasks such as quiet standing appear to involve a degree of cognitive control (Horak, 2006; Lajoie, Teasdale, Bard, & Fleury, 1993; Shumway-Cook & Woollacott, 2007). An investigation of the relationship between cognition and postural control using a dual-task paradigm to compare the performance of young and older adults found a reduction in dualtask postural control performance among older adults (Lacour, Bernard-Demanze, & Dumitrescu, 2008). Furthermore, research has shown that dual-task performance is particularly influenced by “executive” cognitive abilities (Woollacott & Shumway-Cook, 2002; Yogev-Seligmann, Hausdorff, & Giladi, 2008). The association between postural control, dual-task performance, and executive function is important in understanding factors that contribute to falls among older adults because each of these areas has been shown to decline among older adults (Beauchet, Annweiler, Allali, Berrut, & Dubost, 2008). Dual-task performance may be modifiable with training, and thus may be a target for intervention with older adults at risk for falls (Bisson, Contant, Sveistrup, & Lajoie, 2007; Silsupadol, Lugade et al., 2009; Silsupadol, ShumwayCook et al., 2009; Silsupadol, Siu, Shumway-Cook, & Woollacott, 2006; Trombetti et al., 2010; You et al., 2009). Prior studies have measured the effect of single-task, nonspecific exercise interventions, such as Tai-Chi (Hall, Miszko, & Wolf, 2009), virtual reality (Bisson et al., 2007; Lajoie, 2003), and regular exercise (Melzer, Marx, & Kurz, 2009) on dual-task performance. Their main conclusion was that training postural control under single-task conditions may improve postural control under single-task conditions but does not transfer to dual-task performance. Other studies investigating the effect of dual-task training on dualtask performance found that dual-task training is more effective than single-task training in improving dual-task performance (Bisson et al., 2007; Lajoie, 2003; Silsupadol, Lugade et al., 2009; Silsupadol, Shumway-Cook et al., 2009; Toulotte, Thevenon, & Fabre, 2006; Trombetti et al., 2010; You et al., 2009). However, it is not clear whether individual training or training in a group setting is better for improving dual-task processing, or what optimal doses and durations are required to improve and retain dual-task walking performance among healthy older adults.
Downloaded from jag.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 1, 2015
NP130
Journal of Applied Gerontology 34(3)
The goal of this study is to explore whether an evidence-based group exercise program (EnhanceFitness [EF]) that has demonstrated improvement in balance, muscle strength, flexibility, and endurance (Belza, Shumway-Cook, Phelan, Williams, & Snyder, 2006) is also effective at improving dual-task walking performance. We hypothesized that the balance exercises that are part of the EF protocol might lead to improvement in dual-task walking performance. Furthermore, we hypothesized that, by virtue of the group setting, participants are challenged to divide their attention between the exercise and other distractions in the environment and that improvements in postural control achieved in a group setting would positively affect dual-task walking performance.
Method Participants Thirty community-dwelling older adults, who had not started any new exercise routine for at least 2 months prior to the study were recruited and enrolled in EF classes. Two participants dropped out of the study 2 weeks into the EF program due to serious medical conditions, unrelated to the training protocol. Inclusion criteria were (a) age 60 or older, (b) able to walk 10 meters independently, (c) new to EF, and (d) could speak, understand, and read English. Exclusion criteria were (a) any active and untreated symptomatic illness that might limit the participant’s ability to adhere to the program; (b) presence of neurologic or musculoskeletal diagnosis, such as cerebral vascular accident (CVA), Parkinson’s disease, Alzheimer’s disease, or multiple sclerosis; (c) severe orthopedic restrictions such as acute back pain or a total hip replacement within 3 months prior to the study; and (d) significant hearing or vision loss. The study was approved by the Institutional Review Board of the University of Washington. Written informed consent was obtained from all participants.
Study Design and Procedures This study used a single group pre- and post-test design. Participants were assessed at baseline and after completing 18 hr of EF over 6 to 10 weeks. EF classes took place in community settings, lasted 1 hr and were conducted mostly with participants standing. Cognitive function was measured with the Montreal Cognitive Assessment (MoCA) at baseline (Nasreddine et al., 2005). The main outcome of the study was dual-task walking performance. Secondary outcomes included postural control and executive functioning. Baseline and final tests were conducted by two physical therapists, with the same person conducting both assessments for each participant.
Downloaded from jag.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 1, 2015
Agmon et al.
NP131
Intervention. EF is a community-based supervised group exercise class that meets 3 times per week for 1 hr in various community locations, with an average class size of 14 participants. EF has been shown to provide significant improvement in gait velocity, lower- and upper-extremity muscle strength, and self-rated health status and quality of life (Belza et al., 2006). The required components of EF classes are (a) warm-up (5-8 min), (b) cardiovascular endurance (20 min), (c) cool-down phase (3-5 min), (d) strength training (20 min), (e) stretching (8-10 min), and (f) balance and posture exercises (included within different exercises). There is no specific element of EF that targets dual-task training. The exercises that address balance include walking with head turns, quick stops, marching, tiptoe walking, heel walking, heel-to-toe walking, stepping over objects, sit-tostand, ankle sways, and twisting side to side. We anticipated that the balance exercises, by their nature, present many competing stimuli, which require participants to divide their attention. Thus, we hypothesized that EF may improve dualtask performance even though it is not targeted directly. Measures of dual-task walking performance. The main outcome, dual-task walking performance, was evaluated for both the Timed-Up-and-Go (TUG) test and the 1-min walk test as follows.
(a) Single-task TUG: Participants were asked to stand up from a chair, walk 3 meters, turn, walk back, and sit down. Performance was measured as the time to complete the test in seconds. Older adults with a TUG time of
