We acknowledge our participants and the experts with whom we consulted on the methodology developed in this walking program.

This protocol was approved by the Emory Institutional Review Board and the Atlanta Veterans Administration Research &#38; Development Committee. All participants signed an informed consent document prior to participation.
1. Participant recruitment
<ol>
	<li>Recruit older adults and individuals with PD and prodromal Alzheimer&#39;s disease (pAD) through flyers, registries, referrals, PD newsletters, educational meetings, webinars, support groups, older adult living communities, and websites (see Table 1 for participant information).</li>
	<li>Ensure the participants with PD have been diagnosed with &#34;idiopathic&#34; Parkinson&#39;s and positively respond to dopaminergic therapy7. Ensure that those with pAD have mild cognitive impairment with subjective memory loss.</li>
	<li>Confirm that participants with either PD or pAD have no other neurological insult and can ambulate 3 meters or more with and without assistance.</li>
</ol>
2. Safety training
<ol>
	<li>Train staff, instructors, care partners, and volunteers through an in-person experiential balance management class, a systematic approach to understanding balance, by presenting information about the three systems underlying balance: vestibular, visual, and somatosensory.
	<ol>
		<li>Introduce principles such as the base of support, the center of gravity, and limits of stability. Perform exercises such as (1) standing while shifting to the edges of one&#39;s feet and maintaining balance, (2) closing the eyes while standing and shifting weight from foot to foot, (3) observing a partner shift their weight until the partner has to take a step and learning to use body weight to support the weight of a partner.</li>
		<li>Use the balance management exercises from the previously mentioned balance management class (step 2.1.1) to increase the team&#39;s ability to detect and prevent potential falls in a rehabilitative movement class.</li>
		<li>Provide ongoing education to staff given by the principal investigator (PI) and staff physical therapists regarding protecting participants with specific gait and balance impairments.</li>
	</ol>
	</li>
</ol>
3. Technological considerations
<ol>
	<li>Identify and use any commercially available fitness app (see the Table of Materials) that can track time, distance, steps, pace, elevation, and other parameters needed for goal setting and to show progress.</li>
	<li>Identify a team meeting platform with video and sound capabilities (see the Table of Materials) for the virtual warm up.</li>
	<li>Use a one-tap mobile or conference call line for the virtual walk and cool down.</li>
	<li>Utilize heart rate monitors (see the Table of Materials) to track the heart rate throughout the walk.</li>
	<li>Create detailed written and picture instructions for using the fitness app, video team meeting platform, and conference call line. Email the instructions to all new participants 2 days prior to the walk day. Give technical support to all participants prior to and throughout the walks.</li>
</ol>
4. Overground walk environment
<ol>
	<li>Plan and inspect a safe outdoor walking route in terms of the convenience, safety, and appropriateness for older adults with sensory and motor impairments prior to the in-person walk in the local neighborhood, town, or near the older adult center.
	<ol>
		<li>Make a note of rest spots, benches, and shade, which can be useful during the walk, any uneven surfaces and curbs, which may present safety issues, and other important environmental assets or hazards. Consider the amount of traffic in the area and the overall quality of the sidewalks and/or walking paths.</li>
	</ol>
	</li>
	<li>Ensure that there is an appropriate, older adult-safe walking environment, including limited traffic, clear and even sidewalks, benches or other rest spots, shade, and mostly level ground. Some small inclines and declines may be tolerable, but check for ramps for those participants using rolling walkers.</li>
</ol>
5. Participant screening for virtual versus in-person walking groups
<ol>
	<li>Request that the participants complete a questionnaire regarding their age, education, medical history, fall history, use of assistive devices such as canes/walkers, and current medications during their initial testing session or prior to the first walk. Review the form with all the participants to ensure completeness/accuracy. 
	NOTE: Participants are not deemed appropriate for virtual walking classes due to safety considerations if they have a score of 4 or higher or if they answer &#34;yes&#34; to any of the first three key questions on the Stay Independent Screener8, if the participant scores a 2 or higher on item 3 of the New Freezing of Gait Questionnaire9, if an assistive device is used regularly, or if the participant reports falling more than once per month.</li>
	<li>Use other fitness metrics to assess the fitness to maintain safety and to evaluate progress (e.g., heart rate monitoring, VO2 submaximal assessment, 6 min walk test, Mini Best test, and vascular function measurement using a commercially available device)10,11,12 (see the Table of Materials).</li>
</ol>
6. Schedule the participants for a walk
<ol>
	<li>Host virtual and in-person walks simultaneously with the number of staff necessary to fill the lead, co-lead, and back-marker positions, as well as any other staff needed for safety/assistance.</li>
	<li>Schedule the walks at a time of day that is appropriate for the group.</li>
	<li>Schedule the walks twice per week for 12 weeks, ensuring a minimum of 20 walks in total. After 12 weeks, invite the participants to walk once per week. The walk presented in this study was 90 min, including the warm up, walk, and cool down.</li>
	<li>Email the virtual walk group instructions to participants 2 days prior to the day of the walk. The instructions are below:
	<ol>
		<li>Use an invitation with a link to a one-tap mobile or other video or conference call line.</li>
		<li>Provide new participants with instructions on how to use the technology and fitness tracking app, as well as regarding safety and appropriate attire.</li>
	</ol>
	</li>
</ol>
7. Staff roles and responsibilities
<ol>
	<li>Group lead responsibilities
	<ol>
		<li>Identify participants who have similar walking abilities before the walk. Assign back-markers/staff to participants who are deemed a high fall risk to protect them during the warm up, walk, and cool down.</li>
		<li>Introduce the self and the co-leader at the beginning of the session, along with other staff members. Educate the participants on the Borg Rate of Perceived Exertion (RPE) 10-point scale13, which is used to determine the participant&#39;s perceptions of their physical effort. Briefly discuss the session&#39;s agenda.</li>
		<li>Lead a total body warm up using cues for safety, effort, and time/repetitions.</li>
		<li>Monitor the remote participants during the warm up to ensure proper form, alignment, and safety.</li>
		<li>Motivate the participants. Tell them they are doing well if they participate. Congratulate all the participants on their efforts.</li>
		<li>Pay attention to the time for the warm ups, breaks, walks, and cool downs.</li>
		<li>Assess the participants continuously during one-tap mobile/conference call during the walk for safety, intensity, and form.</li>
		<li>Provide verbal cues for posture and gait mechanics (Table 2) after each RPE update and if a participant has not been heard speaking for a long period of time (to ensure we do not lose contact with a participant).</li>
		<li>Encourage rest and hydration breaks.</li>
		<li>Ask the participants about their walking environment (e.g., sidewalks, hills, etc.) and their walking form (posture). Check in with the participants frequently about safety concerns and how they can monitor and maintain good biomechanics of gait.</li>
		<li>Lead the cool-down after the walk on the one-tap mobile or conference call line.</li>
		<li>Answer any questions regarding the technology, walking form, intensity, goals, etc.</li>
		<li>Take over responsibilities if the co-leader becomes disconnected for any reason.</li>
	</ol>
	</li>
	<li>Co-lead responsibilities
	<ol>
		<li>Email the participant information and instructions for the fitness tracking app and team meeting links to all the participants 2 days prior to the walk.</li>
		<li>Take attendance at the start of the meeting. If a participant is not in attendance, call the participant to check on them.</li>
		<li>Assist the participants with the use of technology during the practice team meeting video calls.</li>
		<li>Assist the participants during the transition between the video call and the one-tap mobile call during the 5 min break.</li>
		<li>Assist the participants with the setting up, usage, and starting/stopping of the fitness tracking app.</li>
		<li>Ask and record the participants&#39; RPE and heart rates pre-warm up, post-warm up, and at the 15 min, 30 min, and 45 min time points of the walk.</li>
		<li>Manually record the RPE, heart rates, steps, distance walked, elevation, and average pace for the participants at the 45 min time point of the walk.</li>
		<li>Enter the data into any commercially available database survey software immediately or as soon as possible after collecting the data.</li>
		<li>Take over group leader responsibilities should the group leader become disconnected from the call for any reason.</li>
	</ol>
	</li>
	<li>Back-marker/other staff responsibilities
	<ol>
		<li>Ensure all the participants&#39; safety, particularly for the participants who have slower walking speeds, use an assistive device, or have a heightened fall risk, postural instability, or freezing of gait. Staff may be paired one-on-one or even two-on-one with participants who have been deemed a high fall risk.</li>
		<li>Ensure participants are walking along the same route and no participants become lost on the route. Watch for traffic carefully, and alert the group to oncoming traffic.</li>
		<li>Assist with any additional responsibilities as requested by the group leader or co-leader.</li>
		<li>Socialize with the participants during the walk.</li>
	</ol>
	</li>
</ol>
8. Virtual and in-person walk: Preparation steps
<ol>
	<li>Virtual walk procedure
	<ol>
		<li>At 15-20 min prior to the class time, log into the video team meeting. Educate new participants on the RPE scale. Lead a warm up for 25 min. Take the RPE pre- and post-warm up (co-leader).</li>
		<li>The warm up is performed by the group leader with whole-body large-amplitude movements incorporating posture, weight shifting, rotation, and stepping. Lead the warm up in both seated and standing positions with cues for safety, effort, amplitude, and form. Verbally ensure the safety of the participants.</li>
		<li>Implement a break for 5 min to prepare the participants for the walk. Assist the participants in logging on to the approved fitness tracking app and one-tap mobile or other conference call line.</li>
		<li>Instruct the participants in proper posture and gait mechanics after every RPE check-in and through the walk. See Table 2 for a complete list of cues. Ask the participants to be mindful of their environments and to describe their surroundings.</li>
		<li>Limit the walking group to four to six participants. Strongly encourage the participants to bring a caregiver or a walking buddy to their walks. Discuss with the participants the location and terrain of the walks prior to the first walk to ensure safety and familiarity with the chosen area.</li>
		<li>Take and record the participant&#39;s RPE at 15 min, 30 min, and 45 min.</li>
		<li>Ask the participants to stop their fitness tracking app after 45 min and participate in a 5-10 min guided cool down from the instructor delivered through the audio function.</li>
	</ol>
	</li>
	<li>In-person walk procedure
	<ol>
		<li>Arrive at an established walking location wearing a mask. Screen the participants for COVID-19, and assist with wearable HR and fitness tracking technology. Educate new participants on the RPE scale and agenda.</li>
		<li>Lead a warm up with whole-body large-amplitude movements incorporating posture, weight shifting, rotation, and stepping. Lead both seated and standing exercises with cues for safety, effort, amplitude, and form. Have an assigned staff member protect the participants with balance impairments to ensure their safety.</li>
		<li>Record the RPE and HR pre- and post-warm up.</li>
		<li>Implement a break for 5 min to prepare the participants for the walk. Assist the participants in starting the walking app technology.</li>
		<li>Divide the walking group into smaller groups based on speed, ability, and fall risk. Assign each walking group a leader, a back-marker, and/or other study staff, with one person in each group remaining on the audio call. The leader of the group with the greatest walking mobility leads the virtual walking group.</li>
		<li>Record the RPE and HR at the 15 min, 30 min, and 45 min time points.</li>
		<li>Give posture and gait cues at the beginning of the walk at 15 min, 30 min, and 45 min. Safety is of the utmost importance. Participants who are considered a high fall risk will have at least one person walking with them for safety and guarding. These individuals should be closely monitored for fatigue. Give cues for environmental hazards and encourage rest breaks and the use of assistive devices.</li>
		<li>Ask the participants to stop their walking app at the 45 min time point and participate in a 5-10 min guided cool down.</li>
		<li>Administer a satisfaction questionnaire intermittently (approximately every 10 classes) to determine the level of enjoyment the participants are experiencing.</li>
	</ol>
	</li>
</ol>
9. Participant post-evaluation
<ol>
	<li>Measure the chosen fitness metrics, as noted in step 5.2, to determine the change in the participants&#39; fitness over the course of the walking program.</li>
	<li>Administer a participant satisfaction survey.</li>
</ol>

<ol>
	<li>Brach, J. S., Vanswearingen, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interventions+to+improve+walking+in+older+adults.">Interventions to improve walking in older adults.</a> Current Translational Geriatrics and Experimental Gerontology Reports. 2 (4), (2013).</li><li>Mirelman, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gait+impairments+in+Parkinson's+disease.">Gait impairments in Parkinson's disease.</a> Lancet Neurology. 18 (7), 697-708 (2019).</li><li>Lopez, J., Perez-Rojo, G., Noriega, C., Martinez-Huertas, J. A., Velasco, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Longitudinal+impact+of+the+COVID-19+pandemic+on+older+adults'+wellbeing.">Longitudinal impact of the COVID-19 pandemic on older adults' wellbeing.</a> Frontiers in Psychiatry. 13, 837533 (2022).</li><li>Cunningham, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Why+physical+activity+matters+for+older+adults+in+a+time+of+pandemic.">Why physical activity matters for older adults in a time of pandemic.</a> European Review of Aging and Physical Activity. 17, 16 (2020).</li><li>Chodzko-Zajko, W. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+College+of+Sports+Medicine+position+stand.+Exercise+and+physical+activity+for+older+adults.">American College of Sports Medicine position stand. Exercise and physical activity for older adults.</a> Medicine and Science in Sports and Exercise. 41 (7), 1510-1530 (2009).</li><li>Target Heart Rate and Estimated Maximum Heart Rate. Centers for Disease Control and Prevention Available from: <a target="_blank" href="https://www.cdc.gov/pysicalactivity/basics/measuring/heartrate.htm#:~:text=For%20moderate%2Dintersity%20physical%20activity">https://www.cdc.gov/pysicalactivity/basics/measuring/heartrate.htm#:~:text=For%20moderate%2Dintersity%20physical%20activity</a> (2022)</li><li>Frank, C., Chiu, R., Lee, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Parkinson+disease+primer,+part+2:+Management+of+motor+and+nonmotor+symptoms.">Parkinson disease primer, part 2: Management of motor and nonmotor symptoms.</a> Canadian Family Physician. 69 (2), 91-96 (2023).</li><li>Stay Independent: Learn More about Fall Prevention. Centers for Disease Control and Prevention Available from: <a target="_blank" href="https://stacks.cdc.gov/view/cdc/53418">https://stacks.cdc.gov/view/cdc/53418</a> (2017)</li><li>Giladi, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validation+of+the+freezing+of+gait+questionnaire+in+patients+with+Parkinson's+disease.">Validation of the freezing of gait questionnaire in patients with Parkinson's disease.</a> Movement Disorders. 24 (5), 655-661 (2009).</li><li>Gill, T. M., DiPietro, L., Krumholz, H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+exercise+stress+testing+and+safety+monitoring+for+older+persons+starting+an+exercise+program.">Role of exercise stress testing and safety monitoring for older persons starting an exercise program.</a> Journal of the American Medical Association. 284 (3), 342-349 (2000).</li><li>Steffen, T. M., Hacker, T. A., Mollinger, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Age-+and+gender-related+test+performance+in+community-dwelling+elderly+people:+Six-Minute+Walk+Test,+Berg+Balance+Scale,+Timed+Up+&amp;+Go+Test,+and+gait+speeds.">Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up &amp; Go Test, and gait speeds.</a> Physical Therapy. 82 (2), 128-137 (2002).</li><li>Magnani, P. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+the+BESTest+and+the+Mini-BESTest+for+fall+risk+prediction+in+community-dwelling+older+adults+between+60+and+102+years+of+age.">Use of the BESTest and the Mini-BESTest for fall risk prediction in community-dwelling older adults between 60 and 102 years of age.</a> Journal of Geriatric Physical Therapy. 43 (4), 179-184 (2020).</li><li>Borg, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Borg's Perceived Exertion and Pain Scales. , (1998).</li><li>Sabino-Carvalho, J. L., Teixeira, A. L., Samora, M., Daher, M., Vianna, L. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Blunted+cardiovascular+responses+to+exercise+in+Parkinson's+disease+patients:+Role+of+the+muscle+metaboreflex.">Blunted cardiovascular responses to exercise in Parkinson's disease patients: Role of the muscle metaboreflex.</a> Journal of Neurophysiology. 120 (4), 1516-1524 (2018).</li></ol>

We have no conflicts of interest to report.

The methods detailed above describe a safe and feasible way to implement a low-cost, salient, over-ground walking program for older adults with neurodegenerative diseases1,2. The virtual classes were shown to be effective in contributing to physical and mental well-being and quality of life during a period of social isolation due to COVID-193. Once the quarantine measures were lifted and COVID-19 vaccines became readily available, the part...

Older adults with neurodegenerative diseases, specifically Parkinson&#39;s disease (PD), have poor mobility, a high risk of falls, decreased quality of life (QOL), and generally decreased activity levels. More specifically, walking difficulties among older adults and people with PD are common, leading to decreased independence and increased morbidity and mortality1. Age-related changes in gait include altered gait biomechanics, slower gait speeds, and decreased coordination. In PD, bradykinesia and hypokinesia, along with timing and coordination problems, contribute to gait changes2.
In addition, older adults have been affected by the onset of the global COVID-19 pandemic in March 20203. Many countries implemented &#34;isolation and quarantine&#34; and &#34;social distancing&#34; to limit the spread of the virus. Given the high mortality and morbidity rate of older people due to COVID-19, strict social distancing and isolation rules remained in effect for older people for approximately one&#160;year until the vaccine became available. Unintended consequences of social distancing and social isolation for older adults include a marked decline in physical activity and a decreased daily step count. For example, many older adults were unable to participate in either daily functional physical activities, such as running errands and social engagements, or formal daily exercise programs for one&#160;year or longer. This trend is disconcerting given that many older adults were not achieving the recommended daily amount of physical activity pre-pandemic4.
Physical activity participation among older adults and people with PD has been widely researched and has been shown to have physical, psychological, and cognitive benefits for older adults5. Improving strength, balance, and endurance can reduce the risk of falls, enhance independence, and improve quality of life. A simple, salient, and low-cost form of exercise is walking. The guidelines for physical activity in older adults suggest 150 min of moderate-intensity exercise, such as brisk walking, per week to obtain health benefits. A heart rate of 64%-76% of the maximum heart rate or a rate of perceived exertion (RPE) between 4 and 6 on the 10-point Borg Rate of Perceived Exertion scale can be used to define moderate walking intensity6.
The method presented in this work is a hybrid in-person/virtual walking group format for older adults with and without balance impairment due to neurodegenerative disease. The increased use of online technology-based platforms and the increased technological familiarity among older adults have facilitated the use of this method. The technique was developed during the pandemic, from Summer to Fall of 2020, over several months, and the development process included holding weekly working group meetings of experts to build consensus regarding the methods. These working group meetings preceded the piloting of the method. An advantage of the hybrid method is the ability to involve older adults from distant geographical locations who are at low risk of falls (requiring less supervision) while also supervising those at higher risk of falls or other adverse events. Safety concerns are also addressed extensively in this work.
The purpose of this method is to provide guidelines, recommendations, and procedures to rehabilitation specialists and fitness instructors for the safe and feasible delivery of virtual and in-person walking classes to older adults with neurodegenerative diseases in order to improve older adult physical function and social connectivity and, thus, quality of life.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Chest strap heart rate monitor</td>
			<td>Polar</td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>Computer with video/sound</td>
			<td></td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>Fitness tracking app</td>
			<td>Any commercially available app</td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>iPAD</td>
			<td>Apple IPAD</td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>Pressure management device</td>
			<td>Atcor Medical, Australia</td>
			<td>SphygmoCor</td>
			<td></td>
		</tr>
		<tr>
			<td>Smartphone</td>
			<td>Apple or Android</td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>Standard chair</td>
			<td></td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>Team meeting platform</td>
			<td>Zoom&#160;</td>
			<td>NA</td>
			<td></td>
		</tr>
	</tbody>
</table>

walk with me hybrid virtual/in-person walking for older adults with neurodegenerative disease

This study presents a protocol for virtual and in-person walking groups for older adults with neurodegenerative diseases and addresses the decline in physical activity and social connectivity during the pandemic. Physical activity, specifically moderate-intensity walking, has been shown to have multiple health benefits for older adults. This methodology was created during the COVID-19 pandemic, contributing to lower physical activity levels and social isolation in older adults. Both the in-person and virtual classes utilize technology such as fitness tracking apps and video platforms. Data are presented from two groups of older adults with neurodegenerative disease: people with prodromal Alzheimer's disease and people with Parkinson's disease. Participants in the virtual classes were screened for balance impairments before the walk, and any person deemed at risk for falls was not eligible to participate virtually. As COVID vaccines became available and restrictions were lifted, in-person walking groups became feasible. Staff and caregivers were trained in balance management, roles/responsibilities, and delivering walking cues. Both walks, virtual and in-person, consisted of a warm up, a walk, and a cool down, and posture, gait, and safety cues were given throughout. Measures of the rate of perceived exertion (RPE) and heart rate (HR) were taken pre-warm up, post-warm up, and at 15 min, 30 min, and 45 min time points. Participants also used a walking application (app) on their phones to record the distance walked and the number of steps taken. The study showed a positive correlation between HR and RPE in both groups. The participants in the virtual group rated the walking group favorably in terms of improving their quality of life during a period of social isolation and contributing to physical, mental, and emotional well-being. The methodology shows a safe and feasible way to implement virtual and in-person walking groups for older adults with neurological diseases.

Pilot virtual walking group 
During COVID-19, an expert working group of seven individuals created and implemented the virtual walking protocol with eight pilot participants. The working group consisted of a PI, a physical therapist, an exercise physiologist, a lab manager, two research study coordinators, and a graduate student. The working group met virtually every week to form a consensus on the methods preceding the pilot of the methods. To pilot the methods, participants from the PD and older a...

Watch this Scientific Journal Video about Walk with Me Hybrid Virtual/In-Person Walking for Older Adults with Neurodegenerative Disease at JoVE.com

Walk with Me Hybrid Virtual/In-Person Walking for Older Adults with Neurodegenerative Disease

The present protocol aims to inform rehabilitation specialists and fitness instructors in safe, feasible, and evidence-based methods of delivering virtual and in-person walking classes to older adults with neurodegenerative diseases.

This study presents a protocol for virtual and in-person walking groups for older adults with neurodegenerative diseases and addresses the decline in ...

walk-with-me-hybrid-virtualin-person-walking-for-older-adults-with

Research

JoVE Journal

Behavior

773 Views.  Emory University School of Medicine. The present protocol aims to inform rehabilitation specialists and fitness instructors in safe, feasible, and evidence-based methods of delivering virtual and in-person walking classes to older adults with neurodegenerative diseases. 

Video: Walk with Me Hybrid Virtual/In-Person Walking for Older Adults with Neurodegenerative Disease

Behavioral Phenotyping of Murine Disease Models with the Integrated Behavioral Station (INBEST)

Due to rapid advances in genetic engineering, small rodents have become the preferred subjects in many disciplines of biomedical research. In studies of chronic CNS disorders, there is an increasing demand for murine models with high validity at the behavioral level. However, multiple pathogenic mechanisms and complex functional deficits often impose challenges to reliably measure and interpret behavior of chronically sick mice. Therefore, the assessment of peripheral pathology and a behavioral profile at several time points using a battery of tests are required. Video-tracking, behavioral spectroscopy, and remote acquisition of physiological measures are emerging technologies that allow for comprehensive, accurate, and unbiased behavioral analysis in a home-base-like setting. This report describes a refined phenotyping protocol, which includes a custom-made monitoring apparatus (Integrated Behavioral Station, INBEST) that focuses on prolonged measurements of basic functional outputs, such as spontaneous activity, food/water intake and motivated behavior in a relatively stress-free environment. Technical and conceptual improvements in INBEST design may further promote reproducibility and standardization of behavioral studies.

Behavioral Phenotyping of Murine Disease Models with the Integrated Behavioral Station INBEST

Prolonged and comprehensive monitoring of mice in a home-cage environment provides a deeper understanding of aberrant behavior in murine models of brain diseases. This paper describes the Integrated Behavioral Station (INBEST) as the key component of contemporary behavioral analysis.

Due to rapid advances in genetic engineering, small rodents have become the preferred subjects in many disciplines of biomedical research. In studies of ...

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.

Community-based Adapted Tango Dancing for Individuals with Parkinson&#039;s Disease and Older Adults

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 ...

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 ...

The 4 Mountains Test: A Short Test of Spatial Memory with High Sensitivity for the Diagnosis of Pre-dementia Alzheimer's Disease

This protocol describes the administration of the 4 Mountains Test (4MT), a short test of spatial memory, in which memory for the topographical layout of four mountains within a computer-generated landscape is tested using a delayed match-to-sample paradigm. Allocentric spatial memory is assessed by altering the viewpoint, colors and textures between the initially presented and target images.
Allocentric spatial memory is a key function of the hippocampus, one of the earliest brain regions to be affected in Alzheimer&#39;s disease (AD) and impairment of hippocampal function predates the onset of dementia. It was hypothesized that performance on the 4MT would aid the diagnosis of predementia AD, which manifests clinically as Mild Cognitive Impairment (MCI).
The 4MT was applied to patients with MCI, stratified further based on cerebrospinal fluid (CSF) AD biomarker status (10 MCI biomarker positive, 9 MCI biomarker negative), and with mild AD dementia, as well as healthy controls. Comparator tests included tests of episodic memory and attention widely accepted as sensitive measures of early AD. Behavioral data were correlated with quantitative MRI measures of the hippocampus, precuneus and posterior cingulate gyrus.
4MT scores were significantly different between the two MCI groups (p = 0.001), with a test score of &#8804;8/15 associated with 100% sensitivity and 78% specificity for the classification of MCI with positive AD biomarkers, i.e., predementia AD. 4MT test scores correlated with hippocampal volume (r = 0.42) and cortical thickness of the precuneus (r = 0.55).
In conclusion, the 4MT is effective in identifying the early stages of AD. The short duration, easy application and scoring, and favorable psychometric properties of the 4MT fulfil the need for a simple but accurate diagnostic test for predementia AD.

The 4 Mountains Test: A Short Test of Spatial Memory with High Sensitivity for the Diagnosis of Pre-dementia Alzheimer&#039;s Disease

This article describes the 4 Mountains Test (4MT), a hippocampus-dependent test of working allocentric spatial memory. The hippocampus is affected early in Alzheimer's disease (AD) and this article outlines the 4MT methodology and results of patient testing, which demonstrates the value of the 4MT in the diagnosis of pre-dementia AD.

This protocol describes the administration of the 4 Mountains Test (4MT), a short test of spatial memory, in which memory for the topographical layout of ...

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 ...

A Behavioral Test Battery for the Repeated Assessment of Motor Skills, Mood, and Cognition in Mice

Pharmacological and toxicological studies in neurodegeneration require comprehensive behavioral analysis in mice because motor dysfunctions and dysfunctions in mood and cognition are common and often shared symptoms in neurodegenerative diseases. Shown here is a behavioral test battery for motor, mood, and cognition, which can be repeatedly tested in a longitudinal study. This battery assesses the overall behavioral phenotype in mice by examining each domain of behavior with at least two independent well-accepted tests (i.e., open-field test and rotarod test for motor function, social interaction test, elevated plus maze test, and forced swim test for emotional function, and Morris water maze test and novel object recognition test for cognitive function). Therefore, this sensitive and comprehensive test battery is a powerful tool for the study of behavioral alternation in neurodegeneration.

A comprehensive behavioral test battery of motor skills, mood&#8212;including social interaction, depression, and anxiety&#8212;and cognition is designed for the repeated assessment of neurodegeneration-related behavioral changes in mice.

Pharmacological and toxicological studies in neurodegeneration require comprehensive behavioral analysis in mice because motor dysfunctions and ...

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 ...

Home-Based Prescribed Pulmonary Exercise in Patients with Stable Chronic Obstructive Pulmonary Disease

As a systemic disease, chronic obstructive pulmonary disease (COPD) affects the respiratory system, inducing restless and exercise dyspnea. It also impacts exercise capacity and forms a vicious circle in which it further aggravates the condition of patients and accelerates disease progression. As a functional holistic exercise, traditional Chinese exercises (TCE) play an important role in the rehabilitation of COPD on the basis of adjusting the breath and performing coordinated movements. This study investigates the effects of prescribed pulmonary exercises (which are modified from TCE) on exercise capacity of upper and lower limbs, endurance exercise capacity, and quality of life in stable COPD patients. The goal is to determine the accessibility of these prescribed exercises in COPD rehabilitation. Participants are randomly divided into a non-exercise control group (CG) or prescribed pulmonary exercise group (PG) at a ratio of 1: 1. The PG receives intervention for 60 min twice per day, 7 days a week, for a total of 3 months. The intensity is measured using the Borg category-ratio 10 scale and with a heart-rate monitor. Then, an exercise capacity test and quality of life questionnaire are scheduled at 1 week before and after the formal intervention. After 3 months of intervention, the 30 s arm curl test, 30 s sit-to-stand test, 6 min walking test, and quality of life show significant improvement in COPD patients (p &#60; 0.05). These findings indicate that prescribed pulmonary exercises can be applied as alternative, convenient, and effective home- and community-based exercises for stable COPD patients.

Presented here is a protocol to investigate the effects of home-based prescribed pulmonary exercise in stable chronic obstructive pulmonary disease (COPD) patients, which is modified based on traditional Chinese exercises according to dyspnea and limited exercise capacity observed in COPD patients.

As a systemic disease, chronic obstructive pulmonary disease (COPD) affects the respiratory system, inducing restless and exercise dyspnea. It also ...

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 ...