Smartphone- and Paper-Based Delivery of Balance Intervention for Older Adults Are Equally Effective, Enjoyable, and of High Fidelity: A Randomized Controlled Trial.

Home-based rehabilitation programs for older adults have demonstrated effectiveness, desirability, and reduced burden. However, the feasibility and effectiveness of balance-intervention training delivered through traditional paper-versus novel smartphone-based methods is unknown. Therefore, the purpose of this study was to evaluate if a home-based balance-intervention program could equally improve balance performance when delivered via smartphone or paper among adults over the age of 65. A total of 31 older adults were randomized into either a paper or phone group and completed a 4-week asynchronous self-guided balance intervention across 12 sessions for approximately 30 min per session. Baseline, 4-week, and 8-week walking and standing balance evaluations were performed, with exercise duration and adherence recorded. Additional self-reported measures were collected regarding the enjoyment, usability, difficulty, and length of the exercise program. Twenty-nine participants completed the balance program and three assessments, with no group differences found for any outcome measure. Older adults demonstrated an approximately 0.06 m/s faster gait velocity and modified balance strategies during walking and standing conditions following the intervention protocol. Participants further self-reported similar enjoyment, difficulty, and exercise effectiveness. Results of this study demonstrated the potential to safely deliver home-based interventions as well as the feasibility and effectiveness of delivering balance intervention through a smartphone-based application.

Three-Day Remote Monitoring of Gait Among Young and Older Adults Using Participants' Personal Smartphones.

Conventional one-time gait analyses do not evaluate walking across more than a few steps, cannot monitor changes longitudinally, and do not reflect performance in real-life environments. To successfully quantify age-related gait decrement, technology that can continuously monitor gait is vital. This study examined the feasibility and validity for participant smartphones to remotely assess gait. In addition, the authors investigated whether smartphone-derived measures could differentiate between young and older adults (fallers and nonfallers). A total of 63 adults completed clinical and gait assessment in the laboratory and donned their smartphones for 3 days in the real-life environment. A custom-built Android application collected triaxial accelerations with spatiotemporal gait measures computed and compared between groups. Across 11 brands and 10 Android versions, smartphone-derived gait parameters were valid. Furthermore, results indicated age-related differences in walking during the 3-day assessment. However, no disparities were found between older adult groups. Smartphone-based evaluations may improve real-life screening of adults with gait deficits.

Smartphone Monitoring of Gait and Balance During Irregular Surface Walking and Obstacle Crossing.

As gait adaptation is vital for successful locomotion, the development of field-based tools to quantify gait in challenging real-world environments are crucial. The aims of this study were to assess the reliability and validity of a smartphone-based gait and balance assessment while walking on unobstructed and obstructed terrains using two phone placements. Furthermore, age-related differences in smartphone-derived gait strategies when navigating different walking conditions and environments were evaluated. By providing a method for evaluating gait in the simulated free-living environment, results of this study can elucidate the strategies young and older adults utilize to navigate obstructed and unobstructed walking paths. A total of 24 young and older adults ambulated indoors and outdoors under three conditions: level walking, irregular surface walking, and obstacle crossing. Android smartphones placed on the body and in a bag computed spatiotemporal gait (i.e., velocity, step time, step length, and cadence) and balance (i.e., center of mass (COM) displacement), with motion capture and video used to validate parameters in the laboratory and free-living environments, respectively. Reliability was evaluated using the intraclass correlation coefficient and validity was evaluated using Pearson's correlation and Bland-Altman analysis. A three-way ANOVA was used to assess outcome measures across group, condition, and environment. Results showed that smartphones were reliable and valid for measuring gait across all conditions, phone placements, and environments (ICC2,1: 0.606-0.965; Pearson's r: 0.72-1.00). Although body and bag placement demonstrated similar results for spatiotemporal parameters, accurate vertical COM displacement could only be obtained from the body placement. Older adults demonstrated a longer step time and lower cadence only during obstacle crossing, when compared to young adults. Furthermore, environmental differences in walking strategy were observed only during irregular surface walking. In particular, participants utilized a faster gait speed and a longer step length in the free-living environment, compared to the laboratory environment. In conclusion, smartphones demonstrate the potential for remote patient monitoring and home health care. Along with being easy-to-use, inexpensive, and portable, smartphones can accurately evaluate gait during both unobstructed and obstructed walking, indoors and outdoors.

Slower reaction and response times and impaired hand-eye coordination in individuals with neck pain.

BACKGROUND: Neck pain is associated with sensorimotor dysfunction. Research is sparse of the effect of neck pain on reaction and response times and hand-eye coordination. OBJECTIVES: To investigate hand and foot reaction and response times and hand-eye coordination in individuals with neck pain and to determine any relationships with clinical features of neck pain. METHODS: Sixty individuals with neck pain and 60 controls of similar age and gender were recruited. Tests of simple reaction and response time were measured on the dominant hand and foot. Hand-eye coordination was measured by tracing a variety of coordination patterns with different levels of difficulty. Clinical features measured were intensity and duration of pain, and neck disability. RESULTS: Hand and foot reaction and response times were significantly slower in the neck pain group compared to controls (all p < 0.001). The neck pain group took longer to trace the hand-eye coordination task at the hardest level (p = 0.03). Neck disability scores correlated with hand reaction time (r = 0.4, p = 0.005) and time taken in hand-eye coordination tasks (r = 0.2 for all levels, p < 0.05). Reaction and response times were correlated with time taken in the hand-eye coordination test (r = 0.2-0.4, p < 0.01). CONCLUSIONS: Individuals with neck pain had slower hand and foot reaction and response times and impaired hand-eye coordination, suggesting deficits in sensorimotor function. Training speed, as a function of acuity, and hand-eye coordination might be considered in clinical assessment. Further research is needed to identify potential underlying mechanisms of the slower and less well coordinated movement.

Development and Usability Testing of an Emergency Alert Device for Elderly People and People with Disabilities.

The objectives of this study were to develop and evaluate the effectiveness of an emergency alert device for elderly people and people with disabilities by usability testing. There were two phases in this study: (1) development of a prototype for an emergency alert device and (2) usability testing of the device. Results presented development of the prototype, which comprised parts for sending and receiving signals. There were two kinds of alarms for emergency calls known as conscious and unconscious alerts. Participants in the usability testing phase included 12 specialists and 161 users that comprised 146 elderly people or people with disabilities and 15 caregivers or community health volunteers. The instruments used were a rating scale, usability checklist, and individual interviews regarding the usability, general appearance, and use of the device. The users agreed with the overall aspects regarding usability of the device, its general appearance, and use ( X ¯ ± SD = 4.24 ± 0.88, 4.11 ± 0.90, and 4.37 ± 0.83, respectively). Most of the participants, both specialists and users, gave their perspectives on improving the size, color of the letters displayed, type of wristband, and method for sending signals.

Smartphone-Based Assessment of Gait During Straight Walking, Turning, and Walking Speed Modulation in Laboratory and Free-Living Environments.

As turns and walking speed modulation are crucial for functional mobility, development of a field-based tool to objectively evaluate non-steady-state gait is essential. This study aimed to quantify spatiotemporal gait using three Android smartphones during steady-state walking, turns, and gait speed modulation in laboratory and free-living environments. In total, 24 adults ambulated along a 10-m walkway in both environments under seven conditions: straight walking, 90° left or right turn, and modulating gait speed from usual-slow, usual-fast, slow-fast, and fast-slow. Two smartphones were attached to the body, with another phone placed in a shoulder bag. Gait velocity, step time, step length, cadence, and symmetry were computed from smartphone-based tri-axial accelerometers and validated with motion capture and video, in laboratory and free-living environments, respectively. Validity was assessed using Pearson's correlation and Bland-Altman analysis. Gait velocity results revealed moderate to very high validity across all walking conditions, smartphone models, smartphone locations, and environments. Correlations for gait velocity ranged between 0.87-0.91 and 0.79-0.83 for straight walking, 0.86-0.95 and 0.86-0.89 for turning, and 0.51-0.90 and 0.67-0.89 for speed modulation trials, in laboratory and free-living environments, respectively. Step time, step length, and cadence demonstrated high to very high correlations for straight walking and turns. However, symmetry results revealed high correlations only during straight walking in the laboratory. Conditions that included slow walking showed negligible to moderate validity with a high bias. In conclusion, smartphones can be employed as field-based devices to assess steady-state walking, turning, and speed modulation across environment, model, and placement when walking faster than 0.5 m/s.

Cognitive and visual demands, but not gross motor demand, of concurrent smartphone use affect laboratory and free-living gait among young and older adults.

BACKGROUND: As smartphones are an integral part of daily activities, understanding the underlying mechanism associated with concurrent cell phone use while walking may help reduce the risks of injury. RESEARCH QUESTION: This study examined the effect of cognitive, visual, and gross motor demands while using a phone during gait among young and older adults in the laboratory and free-living environments. METHODS: Twelve young and twelve older adults walked along a 10-m walkway under five conditions: single-task walking (Walk), walking and bi-manually holding a phone (Walk-Hold), walking while looking at a phone held in front of the participants (Walk-Look), walking while answering questions (Walk-Answer), and walking while texting (Walk-Text). All conditions were performed in laboratory and free-living environments. Gait velocity, step time, step length, and cadence were obtained using a smartphone with a built-in accelerometer attached to the body. The dual-task cost (DTC) was also assessed. A three-way ANOVA was utilized for all parameters. RESULTS: While no three-way interactions were found for any parameter, group × condition interactions were significant for gait velocity, step time, step length, cadence and their corresponding DTC. Decreased gait velocity, step length and cadence, with increased step time was demonstrated during Walk-Look, Walk-Answer, and Walk-Text, compared to Walk and Walk-Hold. While older adults markedly changed their gait during Walk-Answer and Walk-Text, these changes were less pronounced among young adults. SIGNIFICANCE: Visual and cognitive demand while concurrently using a phone influenced gait, especially among the elderly. Environment did not accentuate gait alterations during concurrent phone use. Therefore, smartphone technology should be developed to detect dual-task walking and temporarily modify functionality to reduce risk of injury from divided attention.

Reliability and validity of a smartphone-based assessment of gait parameters across walking speed and smartphone locations: Body, bag, belt, hand, and pocket.

The assessment of spatiotemporal gait parameters is a useful clinical indicator of health status. Unfortunately, most assessment tools require controlled laboratory environments which can be expensive and time consuming. As smartphones with embedded sensors are becoming ubiquitous, this technology can provide a cost-effective, easily deployable method for assessing gait. Therefore, the purpose of this study was to assess the reliability and validity of a smartphone-based accelerometer in quantifying spatiotemporal gait parameters when attached to the body or in a bag, belt, hand, and pocket. Thirty-four healthy adults were asked to walk at self-selected comfortable, slow, and fast speeds over a 10-m walkway while carrying a smartphone. Step length, step time, gait velocity, and cadence were computed from smartphone-based accelerometers and validated with GAITRite. Across all walking speeds, smartphone data had excellent reliability (ICC2,1≥0.90) for the body and belt locations, with bag, hand, and pocket locations having good to excellent reliability (ICC2,1≥0.69). Correlations between the smartphone-based and GAITRite-based systems were very high for the body (r=0.89, 0.98, 0.96, and 0.87 for step length, step time, gait velocity, and cadence, respectively). Similarly, Bland-Altman analysis demonstrated that the bias approached zero, particularly in the body, bag, and belt conditions under comfortable and fast speeds. Thus, smartphone-based assessments of gait are most valid when placed on the body, in a bag, or on a belt. The use of a smartphone to assess gait can provide relevant data to clinicians without encumbering the user and allow for data collection in the free-living environment.

Home-based interventions improve trained, but not novel, dual-task balance performance in older adults: A randomized controlled trial.

The purpose of this study was to compare the efficacy of four different home-based interventions on dual-task balance performance and to determine the generalizability of the four trainings to untrained tasks. Sixty older adults, aged 65 and older, were randomly assigned to one of four home-based interventions: single-task motor training, single-task cognitive training, dual-task motor-cognitive training, and dual-task cognitive-cognitive training. Participants received 60-min individualized training sessions, 3 times a week for 4 weeks. Prior to and following the training program, participants were asked to walk under two single-task conditions (i.e. narrow walking and obstacle crossing) and two dual-task conditions (i.e. a trained narrow walking while performing verbal fluency task and an untrained obstacle crossing while counting backward by 3s task). A nine-camera motion capture system was used to collect the trajectories of 32 reflective markers placed on bony landmarks of participants. Three-dimensional kinematics of the whole body center of mass and base of support were computed. Results from the extrapolated center of mass displacement indicated that motor-cognitive training was more effective than the single-task motor training to improve dual-task balance performance (p=0.04, ES=0.11). Interestingly, balance performance under both single-task and dual-task conditions can also be improved through a non-motor, single-task cognitive training program (p=0.01, ES=0.13, and p=0.01, ES=0.11, respectively). However, improved dual-task processing skills during training were not transferred to the novel dual task (p=0.15, ES=0.09). This is the first study demonstrating that home-based dual-task training can be effectively implemented to improve balance performance during gait in older adults.

Why does older adults' balance become less stable when walking and performing a secondary task? Examination of attentional switching abilities.

Previous research using dual-task paradigms indicates balance-impaired older adults (BIOAs) are less able to flexibly shift attentional focus between a cognitive and motor task than healthy older adults (HOA). Shifting attention is a component of executive function. Task switch tests assess executive attention function. This multivariate study asked if BIOAs demonstrate greater task switching deficits than HOAs. A group of 39 HOA (65-80 years) and BIOA (65-87 years) subjects performed a visuo-spatial task switch. A sub-group of subjects performed a dual-task obstacle avoidance paradigm. All participants completed the Berg Balance Scale (BBS) and Timed Up and Go (TUG). We assessed differences by group for: (1) visuo-spatial task switch reaction times (switch/no-switch), and performance on the BBS and TUG. Our balance groups differed significantly on BBS score (p<.001) and switch reaction time (p=.032), but not the TUG. This confirmed our hypothesis that neuromuscular and executive attention function differs between these two groups. For our BIOA sub-group, gait velocity correlated negatively with performance on the switch condition (p=.036). This suggests that BIOA efficiency of attentional allocation in dual task settings should be further explored.

Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trial.

OBJECTIVE: To compare the effect of 3 different approaches to balance training on dual-task balance performance in older adults with balance impairment. DESIGN: A double-blind, randomized controlled trial. SETTING: University research laboratory. PARTICIPANTS: Older adults (N=23) with balance impairment (mean age, 74.8y). They scored 52 or less on the Berg Balance Scale (BBS) and/or walked with a self-selected gait speed of 1.1m/s or less. INTERVENTIONS: Participants were randomly assigned to 1 of 3 interventions: single-task training, dual-task training with fixed-priority instructions, and dual-task training with variable-priority instructions. Participants received 45-minute individualized training sessions, 3 times a week for 4 weeks. MAIN OUTCOME MEASURES: Gait speed under single-task and dual-task conditions was obtained at baseline, the second week, the end of training, and the twelfth week after the end of training. Other measures, including the BBS and the Activities-specific Balance Confidence (ABC) Scale, were collected at baseline and after training. RESULTS: Participants in all groups improved on the BBS (P<.001; effect size [ES]=.72), and walked significantly faster after training (P=.02; ES=.27). When a cognitive task was added, however, only participants who received dual-task training with fixed-priority instructions and dual-task training with variable-priority instructions exhibited significant improvements in gait speed (P<.001, ES=.57; and P<.001, ES=.46, respectively). In addition, only the dual-task training with variable-priority instructions group demonstrated a dual-task training effect at the second week of training and maintained the training effect at the 12-week follow-up. Only the single-task training group showed a significant increase on the ABC after training (P<.001; ES=.61). CONCLUSIONS: Dual-task training is effective in improving gait speed under dual-task conditions in elderly participants with balance impairment. Training balance under single-task conditions may not generalize to balance control during dual-task contexts. Explicit instruction regarding attentional focus is an important factor contributing to the rate of learning and the retention of the dual-task training effect.

Training-related changes in dual-task walking performance of elderly persons with balance impairment: a double-blind, randomized controlled trial.

The purpose of this study was to compare the efficiency of three different balance training strategies in an effort to understand the mechanisms underlying training-related changes in dual-task balance performance of older adults with balance impairment. Elderly individuals with balance impairment, age 65 and older, were randomly assigned to one of three individualized training programs: single-task (ST) balance training; dual-task training with fixed-priority (FP) instruction; and dual-task training with variable-priority (VP) instruction. Balance control during gait, under practiced and novel conditions, was assessed by calculating the center of mass and ankle joint center inclination angles in the frontal plane. A smaller angle indicated better balance performance. Other outcomes included gait velocity, stride length, verbal reaction time, and rate of response. All measures were collected at baseline and the end of the 4-week training. Results indicated that all training strategies were equally effective (P>.05) at improving balance performance (smaller inclination angle) under single-task contexts. However, the VP training strategy was more effective (P=.04) in improving both balance and cognitive performance under dual-task conditions than either the ST or the FP training strategies. Improved dual-task processing skills did not transfer to a novel dual-task condition. Results support Kramer et al.'s proposal that VP training improves both single-task automatization and the development of task-coordination skills.

Training of balance under single- and dual-task conditions in older adults with balance impairment.

BACKGROUND AND PURPOSE: Traditionally, rehabilitation programs emphasize training balance under single-task conditions to improve balance and reduce risk for falls. The purpose of this case report is to describe 3 balance training approaches in older adults with impaired balance. CASE DESCRIPTIONS: Three patients were randomly assigned to 1 of 3 interventions: (1) single-task balance training, (2) dual-task training under a fixed-priority instructional set, and (3) dual-task training under a variable-priority instructional set. OUTCOMES: The patients who received balance training under dual-task conditions showed dual-task training benefits; these training benefits were maintained for 3 months. The patient who received variable-priority training showed improvement on novel dual tasks. DISCUSSION: Older adults may be able to improve their balance under dual-task conditions only following specific types of balance training. This case report gives insight on how this intervention might be combined with more traditional physical therapy intervention.