Name: community-based adapted tango dancing for individuals with parkinson's disease and older adults
Uploaded: 2014-12-09T13:00:00
Duration: 9 min 19 s
Description: Watch this Scientific Journal Video about Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults at JoVE.com

We would like to thank the teachers, Ronda and Manuel Patino, and Gabriela Lopez of Tango Rio, Erik Renz, Sarah Kelley Kerr, Mark Needelman and Shelley Brooks. We also acknowledge volunteers Adrienne Wimberly, Allison Bascas, Marco Coelho, Dabin Choi, Carly DiLeo, Margaret Fang, Kevin Huang, Twinkle Mehta, Malije Obi, Mina Taheb, Diana Tiwari, Kedra Woodard, Dawa Tsering, Sabine Povian, Dhondup Tso King, Mylinh Vo, Rebecca Dillard and Marisa Warner. We acknowledge Medlock Gardens retirement community for providing space for the adapted tango workshop, Clairmont Oaks retirement community and Wesley Woods Towers for providing space for the interventions and we thank the administrative staff of each institution. We acknowledge Dr. William De L&#8217;Aune for statistical assistance. The study was supported by the Dan and Merrie Boone Foundation, the Emory Center for Injury Control, and the Emory Center for Health in Aging. This study was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Emory School of Medicine Discovery Program supported KE McKee, and Department of VA R&#38;D Service Career Development Awards (E7108M and N0870W) supported ME Hackney. We would also like to thank Mr. Aaron Bozzorg.&#160;

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Financial Disclosure/Conflict of Interest: There are no conflicts of interest to report.
Funding Sources: Dan and Merrie Boone Foundation, Emory Center for Injury Control, Emory Center for Health in Aging, Department of VA R&#38;D Service Career Development Awards to ME Hackney (E7108M and N0870W), National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Engaging in habitual exercise remains overwhelmingly poor in the general older adult population: only 1 in 8 older adults engage in strength or balance-challenging activities. 31 Recently, exercise has gained approval as a complementary approach to accompany conventional medicine. To further &#8216;aging in place&#8217; and maintain independence in a growing older population, the widespread implementation of evidence-based exercise programs is necessary. Additionally, given that pharmacological and surgical approaches incompletely address motor and cognitive challenges of the growing PD population, access to complementary therapies, like adapted tango, is necessary. Since 2006, this adapted tango program has been iterated, refined and tested several times, but only at academic centers, not in a community-based setting. 10,13 The methods described above provide a guide to dissemination of adapted tango to the community in such a way that the fidelity, efficacy, safety, and enjoyment of the program are preserved.
Translating health behavior research into sustainable applications is frequently overlooked 32 and underfunded. 33 This methodological guide may allow wider dissemination of adapted tango thus providing access to needed therapy for numerous community dwelling older adults and individuals with balance impairments. Key to dissemination of adapted tango are the selection of appropriate teacher trainees, proper safety training, ample volunteer/family member recruitment, and rigorous assessment of participants before and after completion of the program.
Without a qualified pool of teacher trainees, the adapted tango program will not function. Trainees must possess not only dance knowledge and skill but also a willingness to work outside the traditional realm of able-bodied dance. Teacher trainee enthusiasm, patience, and attention to detail (especially safety) cannot be overstated. One of the main barriers to a multitude of engaging exercise activities for older adults and those with balance impairments is the inability to guarantee safety. Indeed, safety cannot be guaranteed within the adapted tango curricula but if the measures described above regarding volunteer recruitment, participant file review, and partnering are followed, adverse events would be kept to a minimum.
Rigorous assessment of participants before and after the tango program with validated standard measures is necessary to demonstrate that community-based tango is as efficacious as that conducted in academic centers. One of the main limitations of the study as we have implemented it here is the small sample size. Although we were able to show dissemination did not compromise effect size, this should be replicated in future larger studies. The replicated demonstration of efficacy may lead to increased awareness of the benefits of complementary therapy and foster further accessibility to those in need.
The adapted tango dance manual (unpublished), adapted tango class syllabus, this text, and accompanying video are designed to allow individuals in diverse communities to implement this program. Yet, successful utilization of these print and video resources assumes some baseline knowledge of dance, older adults, movement disorders, and fall risk. The above protocol also assumes prior knowledge or familiarity with pre-and-post assessment tests. While all of these tests are cited in validated research papers available to the wider community, implementation of each research measure from a written description alone would be daunting. However, many of these tests are commonly utilized within the physical therapy community. Therefore, it may be advantageous to partner with a physical therapist when attempting to implement this program. Physical therapy involvement could help with implementing pre and post testing, fine-tuning fall prevention strategies and further dissemination/implementation of the program itself, with added expertise to ensure safety.
As stated earlier, implementation of a dancing exercise program for individuals with balance impairments is a big risk and represents a potentially unsafe situation if proper measures are not taken. Future dissemination of this program will necessitate strict safety standards to ensure community leaders and community facilities are willing to host such a program. Integral to safety is also the recruitment of volunteers and family members to partner during the class. While urban areas generally contain an abundance of pre-medical and other health profession students, rural areas lacking major academic centers may find volunteer recruitment more difficult. In this scenario we suggest reaching out to local schools/churches/clubs to enlist able-bodied youth in community service projects to partner for these dance classes.
Lack of mechanistic understanding may prevent more rapid evolution of dance/exercise as a complementary medicine. However, several mechanisms may explain the generally positive changes in physical function produced by adapted tango. The creativity involved in a dance form through exposure to novel steps, and choreographic patterns could tap into mechanisms of neural plasticity. A recent study of adapted tango noted improvement in PD disease severity 29 leading to speculation about potential neuroprotective or neurorestorative effects of adapted tango. The positive functional gains of older adults undergoing regular aerobic activity may be explained by plasticity-related changes in synaptogenesis, angiogenesis and neurogenesis. 34 Future research should delineate ideal frequency, duration and intensity of dance sessions to obtain and retain gains in function.
Individuals with PD were considerably more likely to comply with therapy and finish the program than were older adults, which is curious given that individuals with PD are less active than age-matched peers without PD. 35 Further, the PD group came from the community and needed to travel to the classes; whilst the older adults received the therapy at their senior living communities. As PD remains a condition with many intractable symptoms, those with PD may be more likely to comply with therapy suggestions, including novel, and appealing non-pharmacological treatments. Older adults lost to attrition may have felt less urgency to adopt a new exercise habit. Traditional exercise programs for older adults suffer more than 30% attrition, 36 which is comparable to the rate observed here for the older adult cohort.
The etiology of high satisfaction with the program is likely multifactorial. Music, which has been found to activate specific neural pathways associated with emotion, might reduce stress and enhance social relationships. 37In a randomized controlled trial of Tango over 2 weeks (meeting 1.5 hr and 4 times per week) with middle-aged adults with self-referred symptoms of anxiety, and depression, significant improvements in their symptoms were noted at post-test, and maintained at a 1 month follow-up and similar improvements were noted in the same population after 8 weeks of tango dance. 38 Because social dance often involves meeting regularly to work in pairs or groups for honing skill and/or to enjoy the activity, dance may encourage teamwork that can allow the cultivation of friendships and larger community involvement. Further, therapies involving the arts and self-expression, both emotional and physical, may be especially helpful for managing motor and cognitive symptoms resulting from aging-related morbidities. Therapies that 1) allow the patient to regain and exert control on their body and 2) involve extensive social interaction have been shown to be effective at improving quality of life. 39 Future research should evaluate the role of a regained locus of control and consider depression and cognitive impairment as they relate to interventional success.
Limitations with dissemination media (ie: text and video), safety concerns, and potential difficulty in recruiting teachers and volunteers may limit further dissemination of adapted tango. As this study was primarily methodological in focus, hypothesis testing to determine the significance of results was not performed, but will be necessary to perform in future work. The effect sizes in this work for the mobility measures were relatively small, which does call into question the true efficacy of this form of therapy. Evaluating measures of cognition, psychosocial function and quality of life, not performed here, are needed.
That the program was safely implemented by novice teachers in the community and for individuals with varied impairments and a large age range (36-95 years) suggests the generalizability of the program, and flexibility for addressing multiple needs. Rehabilitation to restore and/or improve function in people with PD and older adults must be efficient and effective. Creating sustained behavioral change through targeted and effective programs may be most effective at addressing functional independence issues for older adults with and without movement disorders. 40 Although effect sizes are often compromised during dissemination, 32 this study suggests that adapted tango could be disseminated in the community under the instruction of non-clinically trained individuals, with only minimally attenuated effect sizes. More research is needed to refine dissemination methods while maintaining program fidelity.

A correction to the author list has been made for the article <a href="http://www.jove.com/video/52066">Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults</a>. There was an error with the author, Madeleine Hackney's, name. The author's name has been updated to:
Madeleine E. Hackney
from:
Madeleine Hackney

A correction to the author list has been made for the article <a href="http://www.jove.com/video/52066">Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults</a>.

Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults

Older adults and individuals with Parkinson&#8217;s Disease (PD) suffer decreased quality of life (QOL), 1-3 poor mobility, and high risk of falls 4 secondary to their motor and cognitive impairments. Physical activities that challenge mobility have beneficial effects on balance and can increase self-efficacy in performing activities of daily living (ADLs). 5 Specifically, exercise programs that 1) incorporate dynamic balance practice and 2) involve motor adaptation according to task and environmental demands can rehabilitate balance impairment.6
Dance has recently garnered attention as a potentially effective exercise therapy to address balance impairments. Frequent participation in partnered dance is associated with superior balance, gait, and reaction time in older dancers compared to age-matched non-dancers.7 In institutional settings, adapted Argentine tango (adapted tango) has improved mobility, balance and QOL in those with PD,8-12 stroke,13 and older individuals with visual impairment.14 Adapted tango is designed to address motor impairments including those specific to individuals with PD, i.e., bradykinesia, shortened stride length, backward instability, turning issues, and freezing of gait.
Composed of simple step elements, adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Participants focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics. Within the context of adapted tango, partner dancing is a sophisticated, yet accessible system of tactile communication that conveys motor intentions and goals between a &#8216;leader&#8217; (planner of movement) and &#8216;follower&#8217; (externally cued mover).
To ensure engaging, effective exercise programs like adapted tango are accessible by community-dwelling older adults, individuals with PD, and others with motor impairments, adapted tango must be disseminated beyond the academic research setting and into the community. Few evidence-based exercise programs are being systematically disseminated through delivery systems.15 This has resulted in insufficient numbers of adequately trained fitness personnel to provide community-based exercise activities suited to the unique needs of individuals with motor impairments. 16 This paper outlines methodology for dissemination of adapted tango, including standardization of an evidence-based curriculum and comprehensive training of dance teachers without clinical qualifications.
The adapted tango program described here incorporates key, novel elements based upon curricula developed through an empirical approach in several studies. 9,11-13,17 Uniquely, the program described here implemented an uninvestigated dose of 20, 1.5h biweekly sessions, which meets recommendations that older adults exceed 150 min of weekly exercise, 18 and provides additional learning time for individuals with PD to overcome motor learning challenges. 19 The program also expanded the rhythmic training component to harness the known movement facilitation effects of auditory cueing for PD. 20-22
The teacher training workshop focuses on the mechanics of teaching adapted tango, and includes didactic and experiential instruction regarding teaching populations with sensory and motor impairments (e.g., older adults and individuals with PD). A manual composed for this workshop provides a description of the five sections of the Adapted Tango class, a complete syllabus that describes the plan for each lesson (including rhythms, steps of the day, and embellishments) as well as information about people with movement disorders and motor impairments, fall risk and prevention. Classroom management, partnering and rhythmic training are also described in detail.
Any attempt to disseminate academically developed methodology into a community-based setting should include measures to ensure that program quality, safety and participant satisfaction are not sacrificed. Herein the methodology for assessing feasibility, efficacy and generalizability of a disseminated program are described. These measure include 1) evaluation of teacher trainees for teaching the adapted tango syllabus, as per instructions provided in the manual and 15 hr workshop, 2) measurement of adverse events and falls in and out of the class, 3) investigation of participant attrition and satisfaction 4) comparison of the feasibility, adherence and efficacy measures between older adults and individuals with PD, and 5) changes in mobility compared to results from previous studies.8,9,12
A successful dissemination should allow teacher trainees to deliver classes with very low incidence of adverse events (i.e., less than or equal to 1 event during a 12 week course of instruction or 48 classes). Additionally mobility improvements, as demonstrated by decreased fall risk, improved functional mobility, and increased lower body strength should be similar to those from prior studies.8 Finally, a well delivered program should have low attrition, (&#62;80% compliance), and be acceptable for individuals with PD as well as older and oldest-old individuals (85+ years) residing in senior independent living communities.

<table border="0" cellpadding="0" cellspacing="0" width="64">
	<tbody>
		<tr height="20" style="height:15.0pt">
			<td height="20" style="height:15.0pt;width:48pt" width="64">Materials and Equipment</td>
		</tr>
		<tr height="20" style="height:15.0pt">
			<td height="20" style="height:15.0pt"></td>
		</tr>
		<tr height="20" style="height:15.0pt">
			<td height="20" style="height:15.0pt">Sound Equipment</td>
		</tr>
		<tr height="20" style="height:15.0pt">
			<td height="20" style="height:15.0pt">Space to hold dance classes</td>
		</tr>
	</tbody>
</table>

community-based adapted tango dancing for individuals with parkinson's disease and older adults

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple step elements. Adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics likely underlie adapted tango&#8217;s demonstrated efficacy for improving mobility and balance. In this paper, we describe the methodology to disseminate the adapted tango teaching methods to dance instructor trainees and to implement the adapted tango by the trainees in the community for older adults and individuals with Parkinson&#8217;s Disease (PD). Efficacy in improving mobility (measured with the Timed Up and Go, Tandem stance, Berg Balance Scale, Gait Speed and 30 sec chair stand), safety and fidelity of the program is maximized through targeted instructor and volunteer training and a structured detailed syllabus outlining class practices and progression.

The methods detailed above describe rigorous evaluation of adapted tango dissemination in an effort to ensure quality programming becomes available to community dwelling individuals with balance impairments. When this adapted tango program was implemented in community based settings around the Atlanta, GA metro area over the summer of 2012, it was found to be feasible, efficacious and generalizable, although effect sizes were generally small. Nine dance instructors without clinical qualifications participated in 15 hr of training, consisting of: a 12 hr workshop on adapted tango methods, PD-specific motor impairments, and fall prevention, followed by an additional 3 hr of individual training from the senior author. Teacher-trainees had 2-25 years of experience teaching dance and &#62;1 year working with older adults in a fitness/dance setting. Based upon their demonstrated proficiency with safety concepts and adapted tango methods, seven teacher-trainees were selected to teach Tango in five different senior living communities located in the greater Atlanta metro area. The PI (MEH) attended each of the classes at least three times. Each of the teachers delivered the expected syllabus on the expected day, in the correct order. Two non-injurious falls&#8212;involving two self-reported frequent fallers&#8212;occurred out of 48 offered tango classes for individuals with PD and 2 non-injurious falls occurred out of 144 offered tango classes for older adults. In these instances participants resumed dancing after a short break. Altogether, the teacher trainees taught 192 classes in adapted tango according to the methods described in the Adapted Tango Manual.
Several student volunteers, who dedicated 600+ volunteer hours to efforts related to Tango, were relatively easily recruited through undergraduate and graduate pre-health list serves. All volunteers underwent fall-prevention training and were assessed for safe practices before being allowed to partner with the highest fall risk participants. In attendance, each class for those with PD averaged M = 5.5, SD = 2 volunteers and M = 3.9, SD = 2 caregivers, friends, and relatives. Data regarding precise number of volunteers per older adult class is unavailable but fewer volunteers and fewer caregivers, friends, relatives attended the older adult classes.
Some data for those with PD have been previously published.29 Eighty-eight participants (age range: 36-95 years) were recruited for participation in the adapted tango classes (PD: n = 25; older adults: n = 63). Table 1 shows the baseline characteristics of the participants initially assigned to adapted tango. Sixty-seven participants (PD: n = 23, older adults: n = 44) completed 20 lessons in 10-12 weeks. Overall adherence was 76.1% but there was a significant difference between PD participants with 92% adherence (previously reported)29 and older adults with 70% adherence (p = 0.028). PD and older adult participants who did not complete the program cited illness, family commitments, other time commitments, and lack of interest as reasons for their withdrawal.
Efficacy Measures. Mobility and balance gains were similar to those observed in prior studies of adapted tango conducted in controlled academic settings.14 However, effect sizes were generally small. The changes noted are detailed here. Both groups were able to complete more rises during the 30 second chair stand and received higher scores on the BBS at post testing with gains maintained at follow-up. Gait speed and tandem stance for individuals with PD did not increase substantially at post-testing but demonstrated some increase at follow-up testing. Older adults demonstrated faster gait speed, faster TUG performance, and longer time in tandem stance from pre-to-post with gains maintained at follow-up. Figure 1 demonstrates efficacy outcomes in terms of mean change and effect sizes for each group. Cohen&#39;s d effects sizes of 0.41 and above are considered &#39;practically significant&#39;.30
Falls. Amongst the Older adult cohort, 122 falls were reported in 21,900 person days in the year prior at a rate of 0.0056 falls per person-day. Twelve falls were reported in 3,612 person days in the 12 week intervention period at a rate of .0033 falls per person-day and 7 falls were reported in 3,444 person days in the 12 weeks post-intervention at a rate of 0.0020 falls per person-day. Amongst the PD cohort, because of an outlier who fell 3-4 times per day, 1,289 falls were reported in 8,760 person days in the year prior at a rate of 0.1471 falls per person-day. One hundred twelve falls were reported in 1,932 person days in the 12 week intervention period at a rate of .0580 falls per person-day and 140 falls were reported in 1,764 person days in the 12 weeks post-intervention at a rate of 0.0794 falls per person-day.
At baseline, a greater proportion of the PD sample fell in the year before the study than older adults (i.e., 60% versus 38%). Falls outside of class during the 3 month class period and in the 3 months after the class were rare, although a greater proportion of those with PD experienced a fall compared to the older adult cohort. Figure 2 compares percentages of the groups who did or did not report falls in the year prior, during the intervention, and in the ten-twelve weeks after the intervention.
Satisfaction. The program was well received as per the Exit Questionnaire, and both PD and older adult participants strongly agreed they enjoyed the class and would continue classes if given the opportunity. They agreed they noted improved coordination, walking, strength, endurance, and balance and were more physically and mentally active. The only marginally significant difference between those with PD and the older adults was that older adults more strongly agreed they noted balance improvements (p = 0.075). Numerical ranking responses regarding enjoyment of the program from an exit questionnaire administered to all participants at the conclusion of the program are detailed in Table 2. Table 3 provides a summary of open-ended responses to questions soliciting feedback about the program. Participants in both groups in particular praised the quality of the instruction, the energy of the instructors, the format of the class, the attention received, and feedback given. Many participants appreciated the opportunity to meet new people and among those with PD, the opportunity to forge new friendships with other individuals with PD. A few participants wished there had been more dance while others found the class duration too long. The most frequent recommendation for future classes was to spend more time dancing.
<img alt="Figure 1" fo:content-width="3in" src="/files/ftp_upload/52066/52066fig1highres.jpg" width="400" /> 
Figure 1: Change in Mobility &#38; Balance Efficacy Measures. PD: Parkinson&#39;s disease; OA: Older Adults. The values presented are mean change scores +/- the standard deviation of change. Change score values are calculated as &#39;post minus pre&#39; and &#39;follow-up minus pre&#39; for gait speed, 30-s Chair Stand, Tandem Stance and the Berg Balance Scale. Change score values are calculated as &#39;pre minus post&#39; and &#39;pre minus follow-up&#39; for the Timed Up &#38; Go. Positive change indicates improvement on the outcome. Cohen&#39;s d estimates of effect size are placed above each group&#39;s change score. Cohen&#39;s d effects sizes of .41 and above are considered &#39;practically significant&#39;. 30 <a href="https://www.jove.com/files/ftp_upload/52066/52066fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" fo:content-width="5in" src="/files/ftp_upload/52066/52066fig2highres.jpg" width="500" /> 
Figure 2: Fall Incidence Outside of Class Before, During, and After the Intervention. The percentage of the sample considered Fallers (with a history of at least one fall in the prior year) and Non-Fallers (no history of falls in the prior year) within the PD group (red bars), and the Older Adults group (pink bars) are depicted, along with the percentages of the sample who did or did not report a fall outside of class during the ten-twelve week interventional period and in the ten-twelve weeks following cessation of the intervention. The p values are the levels of significance between groups determined with Chi square tests. Although those with PD were on average younger than the older adult cohort, they were more likely to experience falls during the study. <a href="https://www.jove.com/files/ftp_upload/52066/52066fig2highres.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="0" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td></td>
			<td></td>
			<td>Individuals with PD</td>
			<td>Older Adults</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td>n=25</td>
			<td>n=63</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td>M (SD)</td>
			<td>M (SD)</td>
		</tr>
		<tr>
			<td colspan="2">Sex</td>
			<td>12 F; 13 M</td>
			<td>49F; 14M</td>
		</tr>
		<tr>
			<td colspan="2">Age (years)</td>
			<td>68.4 (7.5)</td>
			<td>82.3 (8.8)</td>
		</tr>
		<tr>
			<td colspan="2">Education (years)</td>
			<td>16.5 (2.1)</td>
			<td>14.2 (3.1)</td>
		</tr>
		<tr>
			<td colspan="2">Number Co-morbidities</td>
			<td>3.3 (1.7)</td>
			<td>3.2 (1.9)</td>
		</tr>
		<tr>
			<td colspan="2">Number Prescription Medications</td>
			<td>5.4 (4.5)</td>
			<td>3.3 (2.0)</td>
		</tr>
		<tr>
			<td colspan="2">Use of Assistive Device (%)</td>
			<td>29%</td>
			<td>69%</td>
		</tr>
		<tr>
			<td colspan="2">Fear of Falling (FoF)</td>
			<td>3.0 (1.5)</td>
			<td>2.9 (1.7)</td>
		</tr>
		<tr>
			<td colspan="2">Quality of Life (QoL)</td>
			<td>5.2 (0.9)</td>
			<td>5.4 (1.2)</td>
		</tr>
		<tr>
			<td colspan="2">Composite Physical Function (CPF) (/24)</td>
			<td>20.3 (4.9)</td>
			<td>17.8 (4.7)</td>
		</tr>
		<tr>
			<td colspan="2">Montreal Cognitive Assessment (MoCA) (/30)</td>
			<td>26.0 (2.8)</td>
			<td>22.5 (4.0)</td>
		</tr>
		<tr>
			<td colspan="2">Beck Depression Inventory-II (BDI-II) (/63)</td>
			<td>12.1 (9.6)</td>
			<td>6.6 (4.7)</td>
		</tr>
		<tr>
			<td colspan="2">UPDRS Motor Subscale III (n=24)</td>
			<td>28.1 (6.9)</td>
			<td>~</td>
		</tr>
		<tr>
			<td colspan="2">Gait Speed (m/s)</td>
			<td>0.97(.24)</td>
			<td>0.88(.23)</td>
		</tr>
		<tr>
			<td colspan="2">30 s Chair Stand (Number of Rises)</td>
			<td>11.5(4)</td>
			<td>7.9(5)</td>
		</tr>
		<tr>
			<td colspan="2">Berg Balance Scale (/56 points)</td>
			<td>51.2(4.5)</td>
			<td>46.1(8.7)</td>
		</tr>
		<tr>
			<td colspan="2">Tandem Stance (s)</td>
			<td>26.1(26)</td>
			<td>8.3(16)</td>
		</tr>
		<tr>
			<td colspan="2">Timed Up and Go (s)</td>
			<td>11.9(8)</td>
			<td>12.9(5)</td>
		</tr>
	</tbody>
</table>
Table 1: Adapted Tango Baseline Participant Demographics &#38; Outcome Measure Baselines. Participant-reported co-morbidities included arthritis, diabetes, high blood pressure, heart problems and osteoporosis, among others. FoF &#38; QoL are based upon participant ratings regarding worry about falling / quality of life from 1 (low) to 7 (high). For the Composite Physical Function Index, the Montreal Cognitive Assessment, and the Berg Balance Scale higher values indicate greater physical function, cognitive ability, and balance respectively. For BDI-II, higher values indicate greater depression.
<table border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td></td>
			<td>Total Sample (n=67)</td>
			<td>PD (n=23)</td>
			<td>Older Adult (n=44)</td>
			<td>p value</td>
		</tr>
		<tr>
			<td>Enjoyment</td>
			<td>1[1,1]</td>
			<td>1[1,1]</td>
			<td>1[1,1]</td>
			<td>0.725</td>
		</tr>
		<tr>
			<td>Balance</td>
			<td>2[1,3]</td>
			<td>2[2,3]</td>
			<td>2[1,3]</td>
			<td>0.075</td>
		</tr>
		<tr>
			<td>Walking</td>
			<td>2[1,3]</td>
			<td>2[2,3]</td>
			<td>2[1,3]</td>
			<td>0.427</td>
		</tr>
		<tr>
			<td>Mood</td>
			<td>2[1,3]</td>
			<td>2[1.25,2]</td>
			<td>2[1,3]</td>
			<td>0.713</td>
		</tr>
		<tr>
			<td>Coordination</td>
			<td>2[1,3]</td>
			<td>2[2,3]</td>
			<td>2[1,3]</td>
			<td>0.766</td>
		</tr>
		<tr>
			<td>Strength</td>
			<td>2[1,3]</td>
			<td>2.5[2,3]</td>
			<td>2[1,3]</td>
			<td>0.328</td>
		</tr>
		<tr>
			<td>Endurance</td>
			<td>2[1,3]</td>
			<td>2[2,3]</td>
			<td>2[1,3]</td>
			<td>0.783</td>
		</tr>
		<tr>
			<td>Continuing</td>
			<td>1[1,2]</td>
			<td>1.5[1,2]</td>
			<td>1[1,2]</td>
			<td>0.988</td>
		</tr>
		<tr>
			<td>Physically More Active</td>
			<td>2[1,3]</td>
			<td>2[1.25,3]</td>
			<td>2[1,3]</td>
			<td>0.876</td>
		</tr>
		<tr>
			<td>Mentally More Active</td>
			<td>2[1,3]</td>
			<td>2[1,3]</td>
			<td>2[1,3]</td>
			<td>0.659</td>
		</tr>
	</tbody>
</table>
Table 2: Participant Satisfaction. Participants indicated level of agreement (1 = strongly agree to 5 = strongly disagree) with statements regarding the class and improvements in their physical and mental well-being. Values are represented as Median [1st, 3rd quartile]. There were no differences between those with PD and older adults in self-reported satisfaction.
<table border="0" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td></td>
			<td>PD </td>
			<td>Older Adults</td>
		</tr>
		<tr>
			<td>What did you like best?</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Instructors and helpers&#8212;11</td>
			<td>Instructors and helpers&#8212;18</td>
		</tr>
		<tr>
			<td></td>
			<td>Being able to socialize&#8212;11</td>
			<td>Exercise&#8212;16</td>
		</tr>
		<tr>
			<td></td>
			<td>Opportunity to dance&#8212;3</td>
			<td>Opportunity to dance&#8212;14</td>
		</tr>
		<tr>
			<td></td>
			<td>Structured/Scheduled activity&#8212;1</td>
			<td>Being able to socialize&#8212;12</td>
		</tr>
		<tr>
			<td></td>
			<td>Feeling of accomplishment&#8212;1</td>
			<td>Bodily improvements (balance, walking, energy etc.)&#8212;6</td>
		</tr>
		<tr>
			<td></td>
			<td>Bodily improvements (balance, walking, energy etc.)&#8212;1</td>
			<td>Being &#39;challenged to think &#38; act&#39;&#8212;1</td>
		</tr>
		<tr>
			<td></td>
			<td>Flexibility with attendance&#8212;1</td>
			<td>All of it&#8212;1</td>
		</tr>
		<tr>
			<td></td>
			<td>Handouts with brief descriptions&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td>What did you like least?</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>More dancing, less exercise requested&#8212;4</td>
			<td>Duration too long&#8212;11</td>
		</tr>
		<tr>
			<td></td>
			<td>Nothing&#8212;3</td>
			<td>Nothing&#8212;8</td>
		</tr>
		<tr>
			<td></td>
			<td>Travel &#38; Distance&#8212;3</td>
			<td>Other&#8212;5</td>
		</tr>
		<tr>
			<td></td>
			<td>Attendance and Record Keeping Pressure&#8212;2</td>
			<td>Program duration (20 lessons) too short&#8212;4</td>
		</tr>
		<tr>
			<td></td>
			<td>Transportation to class dependant on others&#8212;1</td>
			<td>Hearing/Audio&#8212;2</td>
		</tr>
		<tr>
			<td></td>
			<td>Music system did not work well&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Warm up too long&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Too overprotected at times&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Number of chairs in the room made me fearful of running into them&#8212;1</td>
		</tr>
		<tr>
			<td></td>
			<td>Not enough emphasis on keeping up with the music&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Female partners (felt safer with male partners)&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Duration of individual classes (1.5 h) too long&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td>Recommendations</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Nothing&#8212;5</td>
			<td>Nothing&#8212;11</td>
		</tr>
		<tr>
			<td></td>
			<td>More Dancing&#8212;5</td>
			<td>Have more volunteer partners available&#8212;10</td>
		</tr>
		<tr>
			<td></td>
			<td>Shorter classes or more breaks&#8212;2</td>
			<td>Other&#8212;6</td>
		</tr>
		<tr>
			<td></td>
			<td>Include other Latin dances such as the cha cha&#8212;1</td>
			<td>Shorter classes&#8212;5</td>
		</tr>
		<tr>
			<td></td>
			<td>Provide tango music to listen to at home&#8212;1</td>
			<td>Visual Stimuli and Materials&#8212;4</td>
		</tr>
		<tr>
			<td></td>
			<td>Fewer chairs in room&#8212;1</td>
			<td>Program Duration (10-12 weeks) too short&#8212;3</td>
		</tr>
		<tr>
			<td></td>
			<td>Make-up class options&#8212;1</td>
			<td>Positioning and Point of View of Instructor&#8212;3</td>
		</tr>
		<tr>
			<td></td>
			<td>Better volunteer awareness of PD limitations&#8212;1</td>
			<td>More Movement&#8212;2</td>
		</tr>
		<tr>
			<td></td>
			<td>Have a focus group to share experiences&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Allow more opportunities to take notes&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Use name tags for the first few classes&#8212;1</td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Recruit more male volunteers to partner&#8212;1</td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 3: Participant Feedback. Participants completed an open-ended Exit Questionnaire regarding what they liked best and least about the class and suggestions for improvement. Their responses are summarized here.

Watch this Scientific Journal Video about Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults at JoVE.com

Adapted tango has demonstrated efficacy for improving mobility and balance. We describe the dissemination of adapted tango teaching methods to dance instructor trainees and the implementation of adapted tango by the trainees in the community for improving mobility and balance in older adults and individuals with Parkinson&#8217;s disease.

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple ...

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Assessment of Sensorimotor Function in Mouse Models of Parkinson's Disease

Sensitive and reliable behavioral outcome measures are essential to the evaluation of potential therapeutic treatments in preclinical trials for many neurodegenerative diseases. In Parkinson's disease, sensorimotor tests sensitive to varying degrees of nigrostriatal dysfunction are fundamental for testing the efficacy of potential therapeutics. Reliable and quite elegant sensorimotor measures exist for rats, however many of these tests measure sensorimotor asymmetry within the rat and are not entirely suitable for the newer genetic mouse models of PD. We have put together a battery of sensorimotor tests inspired by the sensitive tests in rats and adapted for mice. The test battery highlighted in this study is chosen for a) its sensitivity in a wide variety of mouse models of PD, b) its ease in implementing into a study, and c) its low expense. These tests have proven useful in characterizing novel genetic mouse models of PD as well as in testing potential disease-modifying therapies.

In Parkinson's disease and movement disorders in general, sensitive and reliable behavioral assays are essential for testing novel potential therapeutics. Here, we describe a manageable battery of sensorimotor tests for mice that are sensitive to varying degrees of injury to the nigrostriatal system and useful for preclinical studies.

Sensitive and  reliable behavioral outcome measures are essential to the evaluation of  potential therapeutic treatments in preclinical trials for many  ...

Measuring Attentional Biases for Threat in Children and Adults

Investigators have long been interested in the human propensity for the rapid detection of threatening stimuli. However, until recently, research in this domain has focused almost exclusively on adult participants, completely ignoring the topic of threat detection over the course of development. One of the biggest reasons for the lack of developmental work in this area is likely the absence of a reliable paradigm that can measure perceptual biases for threat in children. To address this issue, we recently designed a modified visual search paradigm similar to the standard adult paradigm that is appropriate for studying threat detection in preschool-aged participants. Here we describe this new procedure. In the general paradigm, we present participants with matrices of color photographs, and ask them to find and touch a target on the screen. Latency to touch the target is recorded. Using a touch-screen monitor makes the procedure simple and easy, allowing us to collect data in participants ranging from 3 years of age to adults. Thus far, the paradigm has consistently shown that both adults and children detect threatening stimuli (e.g., snakes, spiders, angry/fearful faces) more quickly than neutral stimuli (e.g., flowers, mushrooms, happy/neutral faces). Altogether, this procedure provides an important new tool for researchers interested in studying the development of attentional biases for threat.

Here we describe a touch-screen visual search paradigm that can be used to study threat detection across the lifespan. The paradigm has already been used in various studies demonstrating that both children and adults detect threatening stimuli like snakes, spiders, and angry faces faster than non-threatening stimuli.

Investigators have long been interested in the human propensity for the rapid detection of threatening stimuli. However, until recently, research in this ...

Substantiating Appropriate Motion Capture Techniques for the Assessment of Nordic Walking Gait and Posture in Older Adults

Nordic walking (NW) has become a safe and simple form of exercise in recent years, and in studying this gait pattern, various data collection techniques have been employed, each with positives and negatives. The aim was to determine the effect of NW on older adult gait and posture and to determine optimal use of different data collection systems in both short and long duration analysis. Gait and posture during NW and normal walking were assessed in 17 healthy older adults (age: 69 &#177; 7.3). Participants performed two trials of 6 Minute Walk Tests (6MWT) (1 with poles (WP) and 1 without poles (NP)) and 6 trials of a 5m walk (3 WP and 3 NP). Motion was recorded using two systems, a 6-sensor accelerometry system and an 8-camera 3-dimensional motion capture system, in order to quantify spatial-temporal, kinematic, and kinetic parameters.
With both systems, participants demonstrated increased stride length and double support and decreased gait speed and cadence WP compared to NP (p &#60;0.05). Also, with motion capture, larger single support time was found WP (p &#60;0.05). With 3-D capture, smaller hip power generation and moments of force were found at heel contact and pre-swing as well as smaller knee power absorption at heel contact, pre-swing, and terminal swing WP compared to NP, when assessed over one cycle (p &#60;0.05). Also, WP yielded smaller moments of force at heel contact and terminal swing along with larger moments at mid-stance of a gait cycle (p &#60;0.05). No changes were found for posture.
NW seems appropriate for promoting a normal gait pattern in older adults. Three-dimensional motion capture should primarily be used during short duration gait analysis (i.e. single gait cycle), while accelerometry systems should be primarily employed in instances requiring longer duration analysis such as during the 6MWT.

The aim was to substantiate optimal use of data collection techniques for Nordic walking gait and posture analysis. Three-dimensional motion capture should be used during short duration analysis (i.e. single gait cycle), while accelerometry should be employed for longer duration analysis (i.e. repeated cycles) like a 6 Minute Walk Test.

Nordic walking (NW) has become a safe and simple form of exercise in recent years, and in studying this gait pattern, various data collection techniques ...

Psychophysical Tracking Method to Measure Taste Preferences in Children and Adults

The Monell two-series, forced-choice, paired-comparison tracking method provides a reliable measure of sweet taste preferences from childhood to adulthood. The method, which is identical for children, adolescents, and adults, is of short duration (&#60; 15 min), does not rely on sustained attention or place demands on memory (which would yield spurious age differences), and minimizes the impact of language development, making this method amenable to the cognitive limitations of pediatric populations. In this whole-mouth tasting method, subjects are asked to taste (without swallowing) pairs of solutions of different sucrose concentrations and to point to the solution they prefer. Each subsequent pair contains the participant&#39;s preceding preferred concentration and an adjacent stimulus concentration. The procedure continues until the subject chooses either a given concentration of sucrose when paired with both a higher and a lower concentration, or the highest or lowest concentration two consecutive times. Subjects are prevented from reaching response criteria on the basis of first or second position bias by the two-series design of the method, which counterbalances the order of solution presentation within each pair between the series (the weaker concentration is presented first in Series 1, second in Series 2). The geometric mean of the two sucrose concentrations chosen in Series 1 and 2 is an estimate of the participant&#39;s most preferred level of sucrose. Sucrose preference as determined with this laboratory-based measure has been shown to be associated with preference for sugars in foods and beverages and with taste receptor genotype, family history of alcoholism, and race/ethnicity, as well as depressive symptomatology among pediatric populations. The method has real-world relevance and has been applied to determine most preferred level of other tastes (e.g., salt), making it a valuable psychophysical tool.

Sweet taste has powerful hedonic appeal among people of all ages, particularly children. Described herein is a reliable and valid method that can be used to determine the level of sweetness most preferred, making it a valuable psychophysical tool for scientists.

The Monell two-series, forced-choice, paired-comparison tracking method provides a reliable measure of sweet taste preferences from childhood to ...

A Community-based Stress Management Program: Using Wearable Devices to Assess Whole Body Physiological Responses in Non-laboratory Settings

A pragmatic breath-based intervention to benefit human performance and stress management is timely and valuable to individuals seeking holistic approaches for emotional regulation and optimizing compensatory reserve mechanisms. This protocol is designed to not only teach mind-body awareness but also to provide feedback utilizing physiological data and survey results. The primary findings of this study showed that heart coherence and alpha variables were significantly correlated after four weeks of the breath-based meditation stress protocol. Meditation and rhythmic breathing produced significant increases in alpha brain activity. These brain physiological responses conformed to the Pleth Variability Index (PVI) changes, suggesting the ability of the human body to enter into a meditative state and effectively manage stress. When assessed after four weeks of daily practicing the techniques employed in the stress management protocol, based on the Five Facet Mindfulness Questionnaire, subjects improved in applying mindfulness skills. The overall mindfulness score, Pleth variability index (PVI), and perfusion index (PI) increased after the 4-week intervention period. Results from electroencephalography (brain waves) were consistent with a meditative state during the post-study follow-up session. This provides evidence that wearable devices are feasible for data collection during a breath-based stress management intervention. This protocol can be easily and efficiently implemented into any study design in which physiological data are desired in a non-laboratory-based setting.

Stress is an unavoidable and persistent component of life and holistic approaches for its management are being considered. A standardized methodology was created to demonstrate the feasibility of a breath-based stress management protocol that can be used with commercially available portable technology.

A pragmatic breath-based intervention to benefit human performance and stress management is timely and valuable to individuals seeking holistic approaches ...

Behavioral Assessments of Spontaneous Locomotion in a Murine MPTP-induced Parkinson's Disease Model

Parkinson&#8217;s disease (PD) is a common neurodegenerative disorder disease, causing the phenomenon of shaking, rigidity, slowness of movement and dementia. 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) can lead to some Parkinson&#8217;s-like symptoms by destroying dopaminergic neurons in the substantia nigra of the brain. It has been thus used to establish PD models in various animal studies. Here, mice receive MPTP injections (20 mg/kg/day) for seven days and the behavioral tests are performed on the eighth day. This model is adapted efficiently in the study of PD. The behavioral tests here include the cylinder test and the open field test. The cylinder experiment is used to detect the animals&#8217; ability to lift their front paws when put into a different environment. As the PD model mice show arching&#8212;the mouse arches its back&#8212;the number of paw liftings decrease. This test is easy to execute. The open field test is used to detect the amount of time the mice spend on running, walking, and remaining immobile. We analyze animals&#8217; movements in open field using software and obtain data. Lastly, we use L-DOPA, one of the most commonly used PD drugs, as one example to show how to apply this model to the study of PD drugs. Our results indicate that MPTP neurotoxicity induces motor deficit which can be mitigated by L-DOPA.

We describe establishment of a murine model for Parkinson's disease using MPTP, and behavioral assessments using cylinder and open field tests to measure motor function. We then use L-DOPA as one example to show how to apply this model in the study of PD drugs.

Parkinson&#8217;s disease (PD) is a common neurodegenerative disorder disease, causing the phenomenon of shaking, rigidity, slowness of movement and ...

Using a Real-Time Locating System to Measure Walking Activity Associated with Wandering Behaviors Among Institutionalized Older Adults

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for wandering behaviors. The benefits of a RTLS are objective and continuous measurements of activity. Self-report methods of activity, especially wandering, by health care staff are vulnerable to floor effects and recall bias, and continuous clinical or research observation over the long-term can be time-consuming and expensive. Health care staff also fail to recognize the onset and/or duration of wandering behaviors, which are associated with a variety of adverse health outcomes in this population but amenable to intervention. RTLS technologies can measure the walking activity of institutionalized residents with cognitive impairment over time with a high degree of accuracy. This is particularly useful for the study of wandering, defined as walking for at least 60 seconds with few (if any) breaks in activity. Wandering is associated with disease progression, hospitalizations, falls and death. Previous work suggests older adults with poor balance ability and high sustained walking activity may be particularly susceptible to poor health outcomes. RTLS&#39;s are used to assess cognitive impairment and factors associated with gait and balance; however, supplemental paper and pencil gait/balance tools may be used to further refine risk profiles. This project discusses the use of a RTLS to measure walking activity and also gait quality and balance ability measures on this population.

This paper discusses the use of a continuous and objective real-time locating system to measure walking activity associated with wandering behaviors, focusing on older adults with cognitive impairment. Walking activity is measured by walking distance, sustained walking distance, and sustained gait speed. Also assessed are gait quality and balance ability.

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for ...

Lexical Decision Task for Studying Written Word Recognition in Adults with and without Dementia or Mild Cognitive Impairment

Older adults are slower at recognizing visual objects than younger adults. The same is true for recognizing that a letter string is a real word. People with Alzheimer&#39;s disease (AD) or Mild Cognitive Impairment (MCI) demonstrate even longer responses in written word recognition than elderly controls. Despite the general tendency towards slower recognition in aging and neurocognitive disorders, certain characteristics of words influence word recognition speed regardless of age or neuropathology (e.g., a word&#8217;s frequency of use). We present here a protocol for examining the influence of lexical characteristics on word recognition response times in a simple lexical decision experiment administered to younger and older adults and people with MCI or AD. In this experiment, participants are asked to decide as quickly and accurately as possible whether a given letter string is an actual word or not. We also describe mixed-effects models and principal components analysis that can be used to detect the influence of different types of lexical variables or individual characteristics of participants on word recognition speed.

This article describes how to implement a simple lexical decision experiment to assess written word recognition in neurologically healthy participants and in individuals with dementia and cognitive decline. We also provide a detailed description of reaction time analysis using principal components analysis (PCA) and mixed-effects modeling.

Older adults are slower at recognizing visual objects than younger adults. The same is true for recognizing that a letter string is a real word. People ...

Dynamic Digital Biomarkers of Motor and Cognitive Function in Parkinson's Disease

As Parkinson&#8217;s disease (PD) is a heterogeneous disorder, personalized medicine is truly required to optimize care. In their current form, standard scores from paper and pencil symptom- measures traditionally used to track disease progression are too coarse (discrete) to capture the granularity of the clinical phenomena under consideration, in the face of tremendous symptom diversity. For this reason, sensors, wearables, and mobile devices are increasingly incorporated into PD research and routine care. These digital measures, while more precise, yield data that are less standardized and interpretable than traditional measures, and consequently, the two types of data remain largely siloed. Both of these issues present barriers to the broad clinical application of the field&#8217;s most precise assessment tools. This protocol addresses both problems. Using traditional tasks to measure cognition and motor control, we test the participant, while co-registering biophysical signals unobtrusively using wearables. We then integrate the scores from traditional paper-and-pencil methods with the digital data that we continuously register. We offer a new standardized data type and unifying statistical platform that enables the dynamic tracking of change in the person&#8217;s stochastic signatures under different conditions that probe different functional levels of neuromotor control, ranging from voluntary to autonomic. The protocol and standardized statistical framework offer dynamic digital biomarkers of physical and cognitive function in PD that correspond to validated clinical scales, while significantly improving their precision.&#160;

This protocol offers a digitization of portions of traditional clinical tasks commonly used to measure cognition and motor control in Parkinson&#8217;s disease. Clinical tasks are digitized while biophysical rhythms are co-registered from different functional levels of the nervous systems, ranging from voluntary, spontaneous, automatic to autonomic.

As Parkinson&#8217;s disease (PD) is a heterogeneous disorder, personalized medicine is truly required to optimize care. In their current form, standard ...

Highlighting and Reducing the Impact of Negative Aging Stereotypes During Older Adults' Cognitive Testing

As life expectancy increases, aging has become a major health challenge, resulting in a huge effort to better discriminate between normal and pathological cognitive decline. It is thus essential that cognitive tests and their administration are as fair as possible. However, an important source of bias during cognitive testing comes from negative aging stereotypes that can impair the memory performance of older adults and inflate age differences on cognitive tasks. The fear of confirming negative aging stereotypes creates an extra pressure among older adults which interferes with their intellectual functioning and leads them to perform below their true abilities. Here, we present a protocol that highlights simple but efficient interventions to alleviate this age-based stereotype threat effect. The first study showed that simply informing older participants about the presence of younger participants (threat condition) led older adults to underperform on a standardized memory test compared with younger participants, and that this performance difference was eliminated when the test was presented as age-fair (reduced-threat condition). The second study replicated these findings on short cognitive tests used to screen for predementia in clinical settings and showed that teaching older adults about stereotype threat inoculated them against its effects. These results provide useful recommendations about how to improve older adults' memory assessment both in Iab studies and in clinical settings.

Here, we present a protocol designed to show how negative aging stereotypes can impair memory performance of older adults during cognitive testing and how to reduce this deleterious effect. This method can help older people to perform at an optimal level during testing in both lab studies and clinical settings.

As life expectancy increases, aging has become a major health challenge, resulting in a huge effort to better discriminate between normal and pathological ...